Mid-term failure rates, timing, and mechanisms for osteochondral allograft transplantation in the knee: Characterizing risk factors and identifying modifiable variables

Background

Knee osteochondral allograft transplantation (OCAT) is consistently successful, however, higher failure rates for multisurface and bipolar OCATs persist. Failure mechanisms have involved OCA erosion, delamination, degeneration, fracture, and/or fragmentation, and progression of joint disease, associated with older patient age, higher BMI, male sex, nicotine use, comorbidities, low chondrocyte viability, larger OCA volume, and bipolar OCAT.

Methods

Patient outcomes were prospectively followed after primary knee OCAT and analyzed for failure mechanisms categorized as OCA Cartilage, OCA Bone, Meniscus Allograft, Joint Disease Progression, or Unknown. Cases were included when OCAT was performed >5 years prior; all failure cases were included regardless of final follow-up (FFU) time. Failure and non-failure cohorts, and failure mechanism subcohorts, were compared based on patient sex, age, BMI, nicotine use, concurrent procedures, OCAT surgery type, and adherence.

Results

There were 186 cases in 184 patients (n = 112 males; mean age = 37.1 years; mean BMI = 28.5 kg/m2; mean FFU = 79 months). Initial failure rate was 23.1% (n = 43) with mechanisms attributed to OCA Bone (n = 15; 34.9%), Meniscus (n = 13; 30.2%), Joint Disease Progress (n = 11; 25.6%), OCA Cartilage (n = 2; 4.7%), or Unknown (n = 2; 4.7%). Risk factors included concurrent ligament reconstruction, ipsilateral osteotomy, and tibiofemoral bipolar + OCAT. However, older age and higher BMI, as well as potential barriers for post-operative adherence should be considered during patient selection.

Conclusions

Recent advances have mitigated key risk factors, such that reductions in knee OCAT failure rates with improvements in function, mental health, and quality of life have been more consistently realized.

Level of evidence

2, prospective cohort study.

Undenatured type II collagen for knee osteoarthritis

INTRODUCTION

Knee Osteoarthritis (OA) leads to significant pain and reduced function and affects patients' overall quality of life (QoL). Conservative modalities are the first line of management, resorting to surgery only if they fail. However, these modalities have limitations, and do not address the underlying cause of knee OA. The use of nutraceuticals, including native/undenatured type II collagen (UC-2), has evolved and shown promise in the conservative management of knee OA. This article highlights the mechanism of action, and qualitatively presents the pre-clinical, clinical and on-going scientific literature exploring the safety and efficacy of UC-2 for the management of knee OA.

METHODS

A search was performed using multiple databases (PubMed, Web of Science, Embase and Scopus) employing terms for UC-2 and Knee OA for articles published in English language, while adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. All pre-clinical and clinical studies utilizing UC-2 for knee OA were included. Studies not using UC-2 alone or not focusing on the management of knee OA were excluded.

RESULTS

Twelve studies (3 pre-clinical studies, 8 clinical studies and 1 study with both pre-clinical and clinical component) met our pre-defined search and inclusion criteria, and were included in this review.

DISCUSSION

UC-2 acts via a specific immune mediated mechanism, known as oral tolerance, which can lead to reduced inflammation and enhanced cartilage repair in the knee joint. In addition, administration of UC-2 (40 mg daily) is safe and efficacious in the short- and mid-term, reducing inflammation and pain, and improving function, range of motion (ROM) and overall QoL. Nonetheless, more adequately powered, prospective, multi-center, non-randomized and randomized controlled trials with longer follow-up are warranted to establish the long-term efficacy of UC-2 in knee OA patients and justify its routine clinical use.

All-inside ramp lesion repair via anterior portals and pie-crusting: Excellent outcomes and survivorship at one-year follow-up

Background

Ramp lesions, located in the posterior horn of the medial meniscus, are commonly associated with anterior cruciate ligament (ACL) injuries and contribute to knee instability if untreated. Traditional repair methods use posteromedial portals, but newer approaches, such as the all-inside technique through anterior arthroscopic portals with pie-crusting of the posterior oblique ligament (POL), offer improved access and reduced morbidity. This study aimed to assess the clinical outcomes, return-to-sport rates, and failure rates of this technique compared to established methods.

Materials and methods

A retrospective analysis included 54 patients (mean age: 29.1 years) who underwent ramp lesion repair using the all-inside technique between January 2019 and December 2022. Clinical outcomes were evaluated with the IKDC score, Lysholm score, and Tegner activity scale. Failure was defined as the need for revision surgery.

Results

At a mean follow-up of 30.7 months, patients had a mean IKDC score of 81.5 ± 7.1 and Lysholm score of 94.5 ± 7.4. The Tegner activity scale declined slightly from 7.2 ± 1.2 preoperatively to 6.8 ± 1.3 postoperatively. All patients returned to sport within 9.2 ± 2.5 months, with a failure rate of 12.9 % and an average revision time of 13.1 ± 8.2 months.

Conclusion

The all-inside technique for ramp lesion repair via anterior portals provides excellent clinical outcomes and return-to-sport rates, with failure rates comparable to other methods. This minimally invasive approach offers improved access, reduced morbidity, and a reliable option for managing ramp lesions in ACL-injured patients.

Level of evidence

IV.

Preoperative depression screening using PHQ-2 is associated with worse outcomes after ACL reconstruction

Purpose

To determine how screening positive for depression preoperatively can affect patient reported outcomes after anterior cruciate ligament reconstruction (ACLR).

Methods

Primary ACLR patients between May 2020-September 2022 with a PHQ-2 score prior to their surgery were retrospectively reviewed. Patients older than 13 years of age and with minimum 6-months of follow-up were included for analysis. Patients were categorized as PHQ(+) (PHQ-2 ≥2) or PHQ2(-) (PHQ-2 < 2). Demographics, preoperative and postoperative Patient Reported Outcome Information System (PROMIS) -Physical Function (PF) and Pain Interference (PI) scores, Patient Acceptable Symptomatic State (PASS), surgical clinical outcomes, and complications were collected and compared. Chi-square tests and independent t-tests were used for categorical and continuous variables, respectively.

Results

A total of 127 patients were analyzed, with 32 PHQ2(+) and 95 PHQ2(-). The PHQ2(+) group had a lower proportion responding "yes" to PASS preoperatively (6.5 % vs. 25.3 %, p = 0.03), at 9 months (47.4 % vs. 72.4 %, p = 0.05), and 12 months postoperatively (42.9 % vs 79.5 %, p = 0.009). PHQ2(+) reported worse PROMIS-PI scores preoperatively, at 6 months, and at 9 months. The PHQ2(+) group reported worse PROMIS-PF preoperatively, at 6 months, at and 12 months. The PHQ2(+) group had worse IKDC scores preoperatively at 9 months and at 12 months. Those screening positive for depression also demonstrated a higher incidence of postoperative complications (34.4 % vs. 9.5 %, p = 0.001) and reoperation rates (21.9 % vs. 4.2 %; p = 0.002).

Conclusion

A brief preoperative survey, such as the PHQ-2, can provide prognostic value for patient outcomes after ACLR.

Level of evidence

III-Retrospective cohort study.

Effect of Prior Bariatric Surgery on the Outcomes of Joint Arthroplasty: A Systematic Review and Meta-Analysis

OBJECTIVE

Obesity is a risk factor for joint arthroplasty complications. With this systematic review and meta-analysis, we assessed whether a positive history of bariatric surgery influences postoperative outcomes in patients undergoing various types of joint arthroplasty.

METHODS

We conducted a comprehensive search database such as Scopus, PubMed, Medline Ovid, CNKI, and CENTRAL for studies comparing outcomes between patients undergoing arthroplasty with and without a history of bariatric surgery. We extracted data on short-term medical complications, venous thromboembolism (VTE), periprosthetic infections, superficial wound infections, hospital stay length, and operative time. We used the data to conduct meta-analyses using random-effects models and subgroup analyses based on the type of arthroplasty.

RESULTS

Overall, 15 studies with nearly 150,000 participants were included. The analysis showed that prior bariatric surgery did not significantly affect overall medical complications post-arthroplasty, with OR of 0.968 (95%CI, 0.706-1.327). For VTE, the results similarly indicated no substantial difference, with an OR of 0.912 (95%CI, 0.644-1.291). In assessing periprosthetic infections, the OR was 0.754 (95%CI, 0.535-1.064), showing comparable rates between patients with and without a history of bariatric surgery.Regarding superficial wound infections, the analysis produced an OR of 2.390 (95%CI, 0.723-7.897), indicating variability but not statistical significance. Hospital stay length was reduced in patients with a history of bariatric surgery, reflected by SMD of -0.113 (95%CI, -0.221 to -0.005). Lastly, operative time also showed a significant reduction, with an SMD of -0.462 (95%CI, -0.865 to -0.059).

CONCLUSIONS

Prior bariatric surgery does not reduce the risk of short-term complications post-arthroplasty, but it seems to reduce the hospital stay length and operative time. The effects vary significantly across different types of joint arthroplasty, suggesting a need for tailored preoperative assessments and care protocols.

PROTOCOL REGISTRATION

This systematic review and meta-analysis was registered at PROSPERO, with the number: CRD42024539052.

Human induced pluripotent stem cell-derived therapies for regeneration after central nervous system injury

In recent years, the progression of stem cell therapies has shown great promise in advancing the nascent field of regenerative medicine. Considering the non-regenerative nature of the mature central nervous system, the concept that "blank" cells could be reprogrammed and functionally integrated into host neural networks remained intriguing. Previous work has also demonstrated the ability of such cells to stimulate intrinsic growth programs in post-mitotic cells, such as neurons. While embryonic stem cells demonstrated great potential in treating central nervous system pathologies, ethical and technical concerns remained. These barriers, along with the clear necessity for this type of treatment, ultimately prompted the advent of induced pluripotent stem cells. The advantage of pluripotent cells in central nervous system regeneration is multifaceted, permitting differentiation into neural stem cells, neural progenitor cells, glia, and various neuronal subpopulations. The precise spatiotemporal application of extrinsic growth factors in vitro, in addition to microenvironmental signaling in vivo, influences the efficiency of this directed differentiation. While the pluri- or multipotency of these cells is appealing, it also poses the risk of unregulated differentiation and teratoma formation. Cells of the neuroectodermal lineage, such as neuronal subpopulations and glia, have been explored with varying degrees of success. Although the risk of cancer or teratoma formation is greatly reduced, each subpopulation varies in effectiveness and is influenced by a myriad of factors, such as the timing of the transplant, pathology type, and the ratio of accompanying progenitor cells. Furthermore, successful transplantation requires innovative approaches to develop delivery vectors that can mitigate cell death and support integration. Lastly, host immune responses to allogeneic grafts must be thoroughly characterized and further developed to reduce the need for immunosuppression. Translation to a clinical setting will involve careful consideration when assessing both physiologic and functional outcomes. This review will highlight both successes and challenges faced when using human induced pluripotent stem cell-derived cell transplantation therapies to promote endogenous regeneration.

Concomitant hip arthroscopy and periacetabular osteotomy: Systematic review and meta-analysis of contemporary outcomes, survivorship, and complications with comparison to isolated periacetabular osteotomy

Objective

To evaluate outcomes, survivorship, and complication rates among patients who underwent concomitant periacetabular osteotomy (PAO) and hip arthroscopy and compare them to patients undergoing isolated PAO.

Design

Systematic review and meta-analysis.

Setting

Medline, EBSCO host, and Google Scholar databases were searched to identify all studies describing concomitant PAO and HA through May 9, 2023 (PROSPERO study protocol registration: CRD42023426191).

Patients

Patients who underwent concomitant PAO and hip arthroscopy compared to patients who underwent isolated PAO.

Interventions

Randomized controlled trials and cohort studies reporting clinical outcomes after concomitant PAO and hip arthroscopy.

Main outcome measures

Patient-reported outcome measures (PROMs), radiographic outcomes, range of motion scores, complications, re-operations, and survivorship.

Results

Thirteen studies reporting on a total of 697 patients (726 hips) were included. Significant improvements in PROMs and radiographic measures were demonstrated for most included studies. Pooled analyses demonstrated significant improvements in post-operative modified Harris Hip Score (mHHS) (mean difference (MD): 26.97, 95%CI: 30.19 to -23.75; p < 0.00001) and lateral-center edge angle (LCEA; MD: 13.94, 95%CI: 16.95 to -10.93; p < 0.0001) values. Patients undergoing combined procedures experienced 136 complications for 690 hips (19.71 %) with 29 (21.32 %) classified as major. There were 27 re-operations for 614 hips (4.40 %), and post-operative survivorship estimated at minimum 85 % after 3.5 years follow-up. However, for most outcome measures, there were no differences between concomitant procedures and isolated PAO.

Conclusions

Based on the available literature, patients undergoing concomitant PAO and hip arthroscopy experience excellent outcomes. However, there is limited evidence to indicate that performing both procedures result in different outcomes compared to PAO alone.

Evaluating barbed sutures: A porcine biomechanical comparison of Z-plasty and turndown flap according to Silfverskiöld

Introduction

It is not possible to add an infinite amount of suture material to tendon plasties and repairs in vivo. Each additional knot can reduce the tensile strength by up to 50 %. Therefore, barbed sutures, as a knotless suturing system, should be investigated as a potential alternative to traditional sutures to minimize knot-related weakening.

Material and methods

Superficial porcine flexors were randomized into five groups. A non-contact measurement was utilized. The Z-plasty and the turndown flap according to Silfverskiöld were used. The Stratafix barbed knotless suture was compared to regular smooth polydioxanone. The biomechanical protocol included a creep test, a cyclic test, and a tear-off test.

Results

The Z-plasty with Stratafix showed significantly improved maximum force compared to the Z-plasty with Polydioxanon (PDS 108.5 ± 22.2N, Stratafix 142.3 ± 23.5N, p < .01). The Z-plasty was significantly superior to the turndown flap in maximum Force (turndownflap with Stratafix 52.4 ± 14.6N, Z-plasty with Stratafix 108.5 ± 22.2N, p < .001).

Conclusion

The Stratafix barbed suture can significantly improve the Z-plasty in maximum tension by up to 32 % when compared to regular PDS. To formulate a more precise indication, biological factors must be further investigated.

Biomechanical behavior of fibula fracture fixation using the Stryker VariAx 2 system: A finite element analysis of lower limb load distribution

Aims

In this study, we used finite element analysis to evaluate the mechanical behavior of the lower extremity under three conditions: an intact fibula, a fractured fibula without fixation, and a fractured fibula stabilized using the Stryker VariAx 2 One-Third Tubular Plating System.

Methods

Three-dimensional solid models incorporating detailed representations of bones, ligaments, and tendons were developed from CT and MRI data. Loading conditions were imposed simulating an axial compressive load of 700 N applied to the upper extremity of the resected femur and a torsional load of 6000 Nmm applied to the proximal femur, and a fixed constraint was imposed on the foot, simulating physiological conditions encountered during gait.

Results

indicated that the absence of the fibula leads to significant increases in stress and angular displacement across key anatomical regions, including the tibia, femur, patella, and foot, underscoring the fibula's role in load sharing. Although reintroducing a fibular implant partially ameliorates these effects, the implant itself exhibits elevated stress compared to a natural fibula.

Conclusion

These findings highlight the need for careful preoperative planning and individualized treatment strategies in fibula fracture management, while also informing future improvements in implant design.

Osteotomy across arcuate line in ilium needs prudence in curved periacetabular osteotomy

Background

This study aimed to measure the optimal osteotomy angle and length, as well as the available width of the osteotomy site in the posterior column for the safe performance of periacetabular osteotomy.

Methods

Fifty-six hips in 41 patients who underwent curved periacetabular osteotomy were evaluated. Computed tomography data were subjected to multiplanar reconstruction to measure parameters in two reference planes: the functional pelvic plane and the anterior pelvic plane. The optimal osteotomy angle, osteotomy length, and available width of the posterior column were defined. We assessed the possible factors affecting the optimal osteotomy angle.

Results

The functional pelvic plane showed an average and maximum anterior pelvic tilt of 7.8° and 16.4°, respectively, from the anterior pelvic plane. The optimal osteotomy angles had comparable dispersions in the functional pelvic plane and anterior pelvic plane reference planes. Furthermore, as the rotation angle of the reconstructed axial views increased, i.e., the osteotomy site became closer to the arcuate line of the pelvis, the available width of the osteotomy site narrowed, and the length of the osteotomy site increased. We found significant correlations between the optimal osteotomy angle and sex, height, weight, body mass index, head lateralization index, and acetabular anteversion in all planes. The multiple regression analysis revealed that acetabular anteversion was significantly correlated with the optimal osteotomy angle in all planes, while height, weight, BMI, center edge angle, acetabular roof obliquity, and head lateralization index were correlated in some planes.

Conclusions

Osteotomies near the arcuate line of the pelvis are considered particularly risky because long-distance osteotomies must be performed within a narrow width. The optimal osteotomy angle is affected by many factors, including acetabular anteversion, which varies from case to case.

The top 50 cited publications relating to femoral shaft fractures - A bibliometric analysis of the literature

Background

Femoral shaft fractures (FSF's) represent common orthopaedic injuries, traditionally resulting from high-energy trauma in younger patients. Effective treatment is crucial for functional recovery, with significant social and economic implications. Despite extensive literature relating to FSF's, the quality of evidence and research trends remain unclear.

Methods

A bibliometric analysis was conducted using Web of Science (August 2024) to identify the top 50 most-cited publications related to FSF's. Publications were screened using specific inclusion and exclusion criteria, focusing on primary FSF-related research. Data including authorship, publishing institution, level of evidence (LOE), and study focus were analysed using VOSviewer software to explore bibliometric coupling, co-citation relationships and keyword co-occurrences.

Results

The 50 most-cited publications collectively received 9796 citations, with the highest cited paper accumulating 508 citations. Treatment outcomes (50 %) and epidemiology (32 %) were the predominant study focuses, while only 4 % addressed surgical techniques. Retrospective cohort and case-control studies constituted 84 % of the included papers, predominantly of level III evidence. The mean patient age was 37.96 years, with a majority being female (65.2 %). Hannover Medical School emerged as the most prolific institution, and the Journal of Bone and Joint Surgery published the highest number of articles. Co-occurrence analyses highlighted trends in osteoporosis and bisphosphonate-related FSFs.

Conclusions

FSF literature has expanded, focusing primarily on treatment outcomes and epidemiological risk factors. However, a significant proportion of studies are of low evidence, with limited prospective research and an underrepresentation of topics such as FSF complications and paediatric fractures. Future studies should aim to maximise research quality and address emerging themes, including gender-specific analyses and the management of atypical fractures in elderly male populations.

Strategies for preventing anterior cruciate ligament injuries in athletes: Insights from a scoping review

Background and aims

Anterior cruciate ligament (ACL) injuries significantly impact young athletes, leading to long-term physical, psychological, and socioeconomic consequences. There is an urgent need to develop effective preventive strategies. This scoping review aims to evaluate modifiable and non-modifiable risk factors for ACL injuries and assess existing preventive strategies.

Methods

A comprehensive literature search was performed on November 20, 2024, across databases including Embase, PubMed, Web of Science, Google Scholar, and Cochrane Library. Articles published between 2000 and 2024 focusing on ACL injury prevention were included, while editorial content, non-clinical studies, and non-English publications were excluded.

Results

The search yielded 322 articles, narrowing down to 94 after deduplication. After title screening, 46 studies progressed to full review, ultimately leading to the inclusion of 14 relevant manuscripts. Key findings indicate that ACL injuries result from various factors, with female athletes being 2.2 times more susceptible. Genetic predispositions linked to collagen-related SNPs and biomechanical patterns, such as landing techniques and knee positioning, were identified as significant contributors. Effective preventive programs integrated strength training, neuromuscular training, and advanced technology, including wearable devices and video analysis.

Conclusion

The study reinforces the importance of a personalized, multifaceted approach to ACL injury prevention, focusing on risk stratification and optimizing training strategies alongside technological advancements. Implementing these strategies can significantly mitigate the risk of ACL injuries in high-risk populations.

A Di-aptamer-functionalized scaffold promotes bone regeneration by facilitating the selective retention of MSCs and EPCs and then promoting crosstalk between osteogenesis and angiogenesis

The crosstalk between osteogenesis and angiogenesis plays an important role in promoting the formation of a microenvironment that supports bone regeneration. This suggests that the retention of endogenous osteogenic and angiogenic cells in the bone defect area can promote tissue-engineered bone (TEB) osteogenesis and cell-cell interactions. In this study, a Di-Aptamer-functionalized HA/β-TCP (Di-Aptamer-H/T) scaffold was prepared by sequential modification of APTES and sulfo-SMCC and connected with aptamer HM69 and EPC1. We confirmed that aptamers HM69 and EPC1 can specifically identify mesenchymal stem cells (MSCs) and endothelial progenitor cells (EPCs), respectively. This process triggers the expression of adhesion-related genes in these cells and allows these cells to selectively stay coupled to Di-Aptamer-H/T. The osteogenic differentiation ability of MSCs treated with Di-Aptamer-H/T in vitro was significantly increased. Similarly, the ability of Di-Aptamer-H/T-treated EPCs to form blood vessels was also enhanced. Notably, the osteogenic and angiogenic abilities of cocultured MSCs and EPCs treated with the Di-Aptamer-H/T scaffold were significantly better than those of cells cultured individually. In vivo, the results of micro-CT angiography, H&E staining, Masson's staining and histochemical staining further confirmed that Di-Aptamer-H/T formed new bones and vessels more readily than those treated with a single aptamer linked to HA/β-TCP or with HA/β-TCP alone. In brief, our study demonstrated that crosstalk between osteogenesis and angiogenesis is promoted by the Di-Aptamer-H/T scaffold, which serves as a potential treatment strategy for bone defects and can improve outcomes.

The use of exoskeleton robotic training on lower extremity function in spinal cord injuries: A systematic review

Objective

To perform a systematic review of the utility of exoskeleton robotic therapy on lower extremity recovery in Spinal Cord Injury (SCI) patients.

Methods

We used the Embase, Cochrane, and PubMed databases and searched from January 2012 to December 2023 for studies on exoskeleton robotic assist devices used in working with SCI patients. Only articles published in English were evaluated, and the retrieved articles were screened via our inclusion/exclusion criteria. We conducted our meta-analysis with the Cochrane Review Manager 5.4 (RevMan) software. Robotic assisted gait training and conventional gait training methodology were compared using Walking Index for Spinal Cord Injury II (WISCII), Spinal Cord Independence Measure III (SCIM III), and 6 Minute Walk Test (6MWT) as reported outcome measures.

Results

Eleven randomized clinical trials (RCTs) involving 552 total participants were included in the meta-analysis. The results of the meta-analysis indicated statistically significant improvement in SCIM III [MD 5.14, 95 % CI = (4.47, 5.810), P < 0.00001], WISCII [MD 2.31, 95 % CI = (2.13, 2.49), P < 0.00001] and 6MWT [MD 37.04, 95 % CI = (32.35, 41.74), P < 0.00001] in patients with SCI as compared to conventional gait training (CGT) therapy. Conclusion: Robotic Therapy could improve ambulation/quality of life in patients with spinal cord injuries compared to the standard treatment only, but future studies should include additional measures addressing quality of life and patient satisfaction.

Psychotropic comedication trends in long-term lithium treatment for older adults with bipolar disorder: A 10-year analysis

OBJECTIVES

The prescription of psychotropic comedications in patients with bipolar disorder (BD) evolved between 1995 and 2010. This study provides a comprehensive overview of prescription trends across various classes of psychotropic comedications, alongside lithium treatment, in older adults (aged ≥55 years) with BD, from 2010 to 2019.

METHODS

This naturalistic, retrospective cohort study included 166 older adults (mean age 67.4 years) treated with lithium. Medical files from a large mental healthcare provider in the Netherlands were used to construct Lifecharts. The average proportion of time that different classes of comedications were prescribed during follow-up was calculated.

RESULTS

Patients received psychotropic comedications next to lithium for 75.8 % of total follow-up time. Benzodiazepines were prescribed for 56.2 % of follow-up time, antidepressants for 31.6 %, atypical antipsychotics for 25.9 %, a second mood stabilizer for 18.4 %, and typical antipsychotics for 8.7 %. Most classes of comedications did not show significant changes in prescription trends over the 10-year observation period. Quetiapine at doses below 50 mg/day was prescribed significantly more over time (p = .033), its prescription duration increasing from 2.0 % of total follow-up time in 2010 to 8.1 % in 2019.

LIMITATIONS

Generalizability is limited due to focus on older lithium-treated BD patients, potential selection bias, and retrospective design.

CONCLUSIONS

Long-term lithium treatment in older adults is mostly combined with other psychotropic medications. Frequent and prolonged use of benzodiazepines and significant increase of low-dose quetiapine use are concerning, given their adverse effects and lack of long-term efficacy. Prescription trends observed before 2010 have largely stabilized.

PLAIN LANGUAGE SUMMARY

In this study, we examined what types of comedication were used alongside lithium in older adults with bipolar disorder between 2010 and 2019. For this purpose, we reviewed the medical records of 166 patients 55 years or older in the Netherlands. These patients were prescribed additional psychotropic medications along with lithium 75.8 % of the time. Benzodiazepines, often used to treat anxiety and sleep issues but not recommended for long-term use due to adverse effects, were the most frequently prescribed, namely 56.2 % of the time. Antidepressants were prescribed 31.6 % of the time, atypical antipsychotics 25.9 %, a second mood stabilizer 18.4 %, and typical antipsychotics 8.7 %. Although most prescription trends remained stable between 2010 and 2019, prescription time of low-dose quetiapine increased. We conclude that lithium maintenance treatment is mostly combined with other psychotropic comedications in older adults with bipolar disorder. Considering their potential adverse effects and lack of long-term benefits, the increasing use of low-dose quetiapine and the frequent long-term use of benzodiazepines are particularly concerning.

Surgical site soft tissue thickness as a predictor of complications following arthroplasty

Appreciation of soft-tissue thickness (STT) at surgical sites is an increasingly recognized aspect of arthroplasty procedures as it may potentially impacting postoperative outcomes. Recent research has focused on the predictive value of preoperative STT measurements for complications following various forms of arthroplasty, particularly infections, across procedures such as total knee, hip, shoulder, and ankle replacements. Several studies have indicated that increased STT is associated with a higher risk of complications, including infection and wound healing issues. The assessment of STT before surgery could play a crucial role in identifying patients at a higher risk of complications and may be instrumental in guiding preoperative planning to optimize outcomes in arthroplasty procedures. Standardized measurement techniques and further research are essential to enhance the reliability and clinical utility of STT assessment for arthroplasty surgery.

Demographic and training descriptive analysis of National and American Hockey League team physicians

Aims/objective

Assess the demographic/education backgrounds of team physicians (TPs) in the National Hockey League (NHL) and American Hockey League (AHL).

Materials/methods

Orthopedic Surgeon (O) and Primary Care (PC) TPs for each NHL and AHL team were recorded based on an internet search. Age, sex, and race were collected. Education and practice information were collected and included programs attended, program region, degree, fellowship completion, fellowship subspeciality, practice setting, and H-indices.

Results

Thirty-nine NHL O, 38 NHL PC, 39 AHL O, and 33 AHL PC TPs were identified. 100 % of O-NHL and -AHL TPs were male while 94.7 % and 87.9 % of NHL and AHL PC TPs were male, respectively. NHL TPs were 53.2 years old on average while AHL TPs were 50.8 years old (p = 0.11). Most TPs were Caucasian. More NHL O TPs were MDs (100 %) compared to NHL PC TPs (84.2 %; p = 0.011); similar trends were seen in the AHL. 66.7 % of NHL O TPs practice in academic settings, compared to 33.3 % of AHL O TPs (p = 0.030). NHL O TPs had the highest H-indices. The most represented residency/fellowship programs were Hospital for Special Surgery and Kerlan-Jobe.

Conclusion

NHL O TPs were more likely to have an MD, be fellowship trained, practice in an academic setting, and had higher H-indices compared to their NHL PC counterparts; similar trends were observed in the AHL. There was an overall lack of diversity amongst TPs in both leagues.

Risk factors for diabetic foot ulcer in diabetic patients at the Tehran diabetes clinic: a case-control study

Background and objective

: Diabetic foot ulcer (DFU) is one of the main health challenges of diabetes complications worldwide. A wide range of factors may increase the risk of DFU. This study aimed to investigate the risk factors of DFU among diabetic patients.

Methods

This case-control study was conducted on 800 diabetic patients at the Tehran diabetes clinic of the Endocrinology and Metabolism Research Institute in Iran. The case group included 400 diabetic patients diagnosed with DFU, while the control group included 400 diabetic patients without DFU. Data were collected through medical records, validated questionnaires, and clinical examinations. The association between factors and the risk of DFU was analyzed using both crude and adjusted logistic regression models, adjusting for confounders based on a directed acyclic graphs.

Results

The final adjusted model demonstrated significant direct associations between the risk of DFU with a longer duration of diabetes, a history of previous DFU, peripheral neuropathy, retinopathy, high blood pressure, severe kidney function loss, and good foot self-care. However, there were significant inverse associations between DFU risk with female gender, higher education levels, being married, use of oral diabetes drugs, higher hemoglobin levels, and high physical activity.

Conclusions

The risk of DFU was significantly associated with the following factors: diabetes duration, previous DFU history, peripheral neuropathy, retinopathy, blood pressure, kidney function, foot self-care, gender, education levels, marital status, diabetes drugs, hemoglobin levels, and physical activity. Further studies, especially ones in multicenter cohorts with a special focus on novel risk factors, are warranted to expand on our findings.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40200-025-01582-z.

Ultrasound-guided percutaneous screw fixation of sternal metastasis

Sternal metastasis often result in disabling pain, significant functional limitations, with potential consequences for the thoracic spine. This case report suggests a new approach combining ultrasound for initial guidance and fluoroscopy with cone-beam CT (CBCT) for screw fixation. The patient experienced immediate pain relief, a better mobility, and improved quality of life. This approach demonstrates a minimally invasive, radiation-sparing and time saving strategy for sternal screwing.

An overview of stem cells and cell products involved in trauma injury

Trauma injuries represent a significant public health burden worldwide, often leading to long-term disability and reduced quality of life. This review provides a comprehensive overview of the therapeutic potential of stem cells and cell products for traumatic injuries. The extraordinary characteristics of stem cells, such as self-renewal and transdifferentiation, make them definitive candidates for tissue regeneration. Mesenchymal stem cells (MSCs), neural stem cells (NSCs), and hematopoietic stem cells (HSCs) have been tested in preclinical studies for treating distinct traumatic injuries. Stem cell mechanisms of action are addressed through paracrine signaling, immunomodulation, differentiation, and neuroprotection. Cell products such as conditioned media, exosomes, and secretomes offer cell-free resources, thereby avoiding the risks of live cell transplantation. Clinical trials have reported many effective outcomes; however, variability exists across trauma types. Some challenges include tumorigenicity, standardized protocols, and regulatory issues. Collaboration and interdisciplinary research are being conducted to harness stem cells and products for trauma treatment. This emerging field is promising for improving patient recovery and quality of life after traumatic injuries.

Outcomes After Patellofemoral Arthroplasty With the Arthrex iBalance-A Third Generation Implant

Background

Patellofemoral arthroplasty (PFA) is an attractive option for patients who have isolated patellofemoral disease. This study aimed to assess the functional outcomes and revision rates of primary PFA with a third-generation implant with short- to medium-term follow-up.

Methods

We retrospectively reviewed the records of 49 patients (70 knees) undergoing PFA with the iBalance system by a single surgeon at a quaternary center between January 2015 and September 2022 for demographic and surgical data, as well as complications and revision rates. Patient-reported outcome scores were then collected.

Results

The population was majority female (81.6%) with a median age of 50 years. Four knees were revised to a total knee arthroplasty (5.7%) at an average time point of 2.3 years postoperatively (range: 1.3-3.5 years). The median Single Assessment Numeric Evaluation score at the time of follow-up was 82.5, while the median Kujala score was 72. Lower preoperative Kellgren-Lawrence grade was significantly associated with lower Knee Injury and Osteoarthritis Outcome Scores in all 5 domains (P < .05 for all). Additional procedures were required in 17 knees (24.3%), in most cases to improve patella tracking.

Conclusions

This study is, to our knowledge, the first to examine outcomes of the iBalance PFA system. The results show favorable patient-reported outcomes in this cohort consistent with other 2nd and 3rd generation PFA implants, along with a revision rate similar to its prosthetic peers.

Ultrasound-based radiomics and machine learning for enhanced diagnosis of knee osteoarthritis: Evaluation of diagnostic accuracy, sensitivity, specificity, and predictive value

Purpose

To evaluate the usefulness of radiomics features extracted from ultrasonographic images in diagnosing and predicting the severity of knee osteoarthritis (OA).

Methods

In this single-center, prospective, observational study, radiomics features were extracted from standing radiographs and ultrasonographic images of knees of patients aged 40-85 years with primary medial OA and without OA. Analysis was conducted using LIFEx software (version 7.2.n), ANOVA, and LASSO regression. The diagnostic accuracy of three different models, including a statistical model incorporating background factors and machine learning models, was evaluated.

Results

Among 491 limbs analyzed, 318 were OA and 173 were non-OA cases. The mean age was 72.7 (±8.7) and 62.6 (±11.3) years in the OA and non-OA groups, respectively. The OA group included 81 (25.5 %) men and 237 (74.5 %) women, whereas the non-OA group included 73 men (42.2 %) and 100 (57.8 %) women. A statistical model using the cutoff value of MORPHOLOGICAL_SurfaceToVolumeRatio (IBSI:2PR5) achieved a specificity of 0.98 and sensitivity of 0.47. Machine learning diagnostic models (Model 2) demonstrated areas under the curve (AUCs) of 0.88 (discriminant analysis) and 0.87 (logistic regression), with sensitivities of 0.80 and 0.81 and specificities of 0.82 and 0.80, respectively. For severity prediction, the statistical model using MORPHOLOGICAL_SurfaceToVolumeRatio (IBSI:2PR5) showed sensitivity and specificity values of 0.78 and 0.86, respectively, whereas machine learning models achieved an AUC of 0.92, sensitivity of 0.81, and specificity of 0.85 for severity prediction.

Conclusion

The use of radiomics features in diagnosing knee OA shows potential as a supportive tool for enhancing clinicians' decision-making.

Poor adherence rates to the minimum information for studies evaluating biologics in orthopaedics (MIBO) guidelines for clinical studies on platelet-rich plasma for osteochondral lesions of the talus: A systematic review

INTRODUCTION

The Minimum Information for Studies Evaluating Biologics in Orthopaedics (MIBO) guidelines were developed in 2017 in order to establish a standardized approach for reporting key characteristics in platelet rich plasma (PRP)-based studies. However, the adherence to the guidelines from authors publishing data on studies related to the use of PPR in the management of osteochondral lesions of the talus (OLTs) has not yet been determined. The purpose of this study was to analyze how well clinical trials on PRP interventions for OLTs adhered to the MIBO guidelines.

METHODS

PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were used to perform a systematic review of the PubMed, Embase and Cochrane Library databases. Inclusion criteria clinical studies that assessed PRP interventions for OLTs. The original 23 MIBO checklist items were separated and modified into a 46-point checklist. Adherence was determined by calculating the total percentage of checklist items that each article adequately and clearly reported from the 46-point checklist.

RESULTS

A total of 9 studies (356 patients) with a weighted mean age of 42.1 ± 6.1 years were included in this study. The weighted mean follow-up was 32.2 ± 8.7 months. Overall, only 42.8 % ± 5.2 % of the 46-point MIBO checklist items were reported per article with no articles displaying adherence rates of 100 %. No articles had adherence rates ≥ 50 %, 6 (66.7 %) had adherence rates between 40.0 % and 49.9 % and 3 (33.3 %) had adherence rates less than 39.9 %. There was no difference in mean adherence rates between studies published prior to publication of the MIBO guidelines in May 2017 (41.7 %) and after publication of the MIBO guidelines in May 2017 (44.0 %) (p = 0.6473). There was variation in adherence rates between categories with the "Postoperative Care" category having the highest adherence rate (83.3 %) while the "Activation" category and the "Whole Blood Processing" had the lowest adherence rates (5.6 %).

CONCLUSION

This systematic review demonstrated that clinical studies evaluating outcomes following the use of PRP in the setting of OLTs poorly adhered to MIBO guidelines. None of the included studies had adherence rates ≥ 50 % and only 1 of the 12 MIBO categories had adherence rates ≥ 80 %. Interestingly, there was no difference in the mean adherence rates in studies conducted before and after publication of the MIBO guidelines in May 2017. This study underscores the need for superior reporting of critical data related to PRP in studies evaluating outcomes in patients with OLTs augmented with PRP.

Survey of postoperative practices for lumbar spinal stenosis surgery among canadian spinal surgeons and rehabilitation professionals

Background

Postoperative rehabilitation for lumbar spine stenosis (LSS) surgery has been shown to improve functional status postoperatively. However, there is a lack of clinical guidelines on postsurgical recommendations, movement restrictions and rehabilitation practices, which can lead to variations in care. The purpose of this study was to describe current postoperative LSS surgery practices of spine surgeons, physiotherapists, and chiropractors in Canada related to movement restrictions, exercise recommendations and rehabilitation.

Methods

The cross-sectional online survey was distributed to spine surgeons, physiotherapists and chiropractors through newsletters and emails from professional colleges and associations. The surveys involved 3 clinical vignettes of patients with LSS, each with a different type of surgical intervention. Participants were asked to reflect on the cases and provide information on their postoperative practices.

Results

Twenty-six spine surgeons and 151 rehabilitation professionals responded to the survey. Many of the spine surgeons in this study do not (35%) or occasionally refer (27%) their post-LSS surgery patients to outpatient postoperative rehabilitation and do not believe such programs are necessary for all patients (65.4%). There was significant variation on which restrictions should be applied and the length of time that restrictions should be used across all movements and conditions. Rehabilitation professionals observed movement restrictions that aligned with surgeons' recommendations in Cases 1 (decompression) and 3 (long fusion). However, in Case 2 (laminectomy with 1-3 level fusion), they noted more restrictions (eg, pushing, pulling, lifting) than those prescribed by surgeons. The range of exercise recommendations and treatment modalities rehabilitation professionals prescribe vary widely.

Conclusions

There is currently wide variation in care, demonstrating the need to build consensus among spine surgeons and rehabilitation professionals regarding the most optimal postoperative management. In addition, the reasoning behind imposed restrictions should be considered along with surgery-specific factors in refining current postoperative care pathways for the studied patient population.

The value of MRI radiomics in distinguishing different types of spinal infections

BACKGROUND

In clinical practice, the three most prevalent forms of infectious spondylitis are tuberculous spondylitis (TS), brucellosis spondylitis (BS), and pyogenic spondylitis (PS). It is possible to successfully lessen neurological and spinal damage by detecting them early. In the medical field, radiomics has been applied extensively. It is crucial to find out if MRI imaging can be used to diagnose spinal infections early.

PURPOSE

To explore the diagnostic value of establishing models based on MRI radiomics for different spinal infections.

METHODS

This retrospective study collected clinical and magnetic resonance imaging information on a total of 136 patients diagnosed with spondylitis in April 2019 and August 2023, who were classified into specific spinal infections (TS or BS) and non-specific spinal infections (PS) based on treatment. 3D Slicer software was used to outline the region of interest (ROI) and extracted ROI features. All patients were randomly divided into a training set and a test set (7:3), and after standardized, the t-test and LASSO were sequentially performed in the training set to extract the optimal radiomic features. These features were used to calculate the Radscore and construct the features classifier model and evaluated by test set. Univariate and multivariate logistic regression of Radscore and clinical features to identify predictors contributing to the diagnosis were used to plot nomograms, the area under the receiver operating characteristic curve (AUC), calibration curves, and decision curve analysis (DCA) to assess the nomogram. The same approach described above was used to diagnose both subgroups of BS and TS in SSI.

RESULTS

321 radiological features were extracted from the three different sequences. The remaining 7 optimal radiomics features were used to calculate the Radscore and establish three feature classifier models, with RF having the best performance (AUC=1 and 0.86). And after univariate and multivariate logistic regression, the final nomogram constructed by Radscore and had good discriminatory performance in the training set and the test set (AUC =0.924 and 0.868), and the calibration curve and DCA showed good clinical efficacy. In the subgroup, the AUC of the training and test sets was 0.929and0.863.

CONCLUSION

The diagnostic model based on MR radiomics can gradually differentiate tuberculous spondylitis, brucellosis spondylitis, and pyogenic spondylitis.

Surgical management of spinal metastases: A cross-continental study in the United States and the Netherlands

Background

There is currently no consensus on the optimal surgical treatment for patients with spinal metastases. Investigating regional variations in surgical management could provide valuable insights to optimize care and refine surgical practices globally.

Objective

To investigate differences in patient populations, surgical management, and perioperative outcomes among patients who underwent surgery for spinal metastases in either Boston (United States) or Utrecht (Netherlands).

Methods

727 patients surgically treated for spinal metastases in Boston (n=539) and Utrecht (n=188) between 2018-2022 were included. Data on patient characteristics, surgical management, perioperative outcomes, and survival were collected. The Mann-Whitney U test was used for continuous data, and Fisher's exact test for categorical data.

Results

In Boston, a higher percentage of patients had three or more spinal metastases (68% vs 59%; p=0.006) and brain metastases (16% vs 4.3%; p<0.001) at the time of surgery compared with Utrecht. Vertebrectomy/corpectomy with stabilization was performed in 54% of patients in Boston versus none in Utrecht (p<0.001), whereas percutaneous stabilization was performed in 1.3% of patients in Boston versus 39% in Utrecht (p<0.001). In Utrecht, patients received postoperative radiotherapy more frequently (70% vs 54%; p<0.001) and earlier (17 days [IQR:12-24] vs 29 days [IQR:23-39]; p<0.001). Postoperative neurological outcome, complications, reoperation rates, and survival did not differ between the two cohorts (all p>0.05).

Conclusions

Differences in patient populations and surgical management exist between tertiary hospitals on separate continents. Further research is needed to determine the optimal extent and timing of surgery to improve quality of life for patients with spinal metastases.

Trends of opioid use following anterior cervical discectomy and fusion: A 10-year longitudinal study of the Veterans Health Administration

Background

The United States Veteran Health Administration (VHA) cares for a substantial group of patients who are at higher risk of substance abuse in comparison to the general population. The purpose of this study was to (1) examine opioid consumption in the veteran population both pre- and postoperatively to anterior cervical discectomy and fusion (ACDF) and (2) understand the risk factors that are associated with sustained postoperative opioid use.

Methods

A retrospective database study was conducted using the Veterans Affairs Informatics and Computing Infrastructure database. Patients who underwent ACDF between 2010 and 2020 were identified and stratified into 3 groups based on their preoperative opioid usage prior to the procedure: opioid naïve, low preoperative opioid use (1-3 preoperative claims), and high preoperative opioid use (≥4 preoperative claims). Cumulative pre- and postoperative opioid usage for each patient was calculated in Morphine Milligram Equivalents (MME).

Results

A total of 7,894 patients were identified with 3,929 (49.7%) opioid naïve, 1,813 (23.0%) low preoperative opioid use, and 2,152 (27.3%) high opioid usage. The proportion of patients in the opioid-naïve cohort, low preoperative usage cohort, and high preoperative opioid usage cohort, that remained on opioids 1 year postoperatively was 13.1%, 31.3%, and 77.8%, respectively. At 1 year postoperatively, the median opioid MME significantly decreased pre- to postoperatively (25.0 vs. 0, p<.006). High preoperative opioid consumption was found to be the greatest risk factor for continued chronic opioid use (OR 17.1, p<.001).

Conclusions

Following ACDF procedures, opioid consumption significantly decreased; however, at 1 year, over one-third of patients remained on opioid therapy. A disproportionate number of patients who remained on chronic opioid therapy had high preoperative opioid consumption. Notably, increased scrutiny and policy changes regarding opioids, which began around 2017, resulted in a significant reduction in preoperative opioid use by 2020 compared to a decade earlier.

Outcomes of triple arthrodesis with IOFIX type fixation: A prospective study

BACKGROUND

The aim of this study was to evaluate the patient reported outcome measures (PROMS), radiological outcome and complications when performing a triple arthrodesis using the IOFIX system for the talonavicular and calcaneocuboid joints.

METHODS

Data was collected prospectively. Twenty-nine consecutive patients were reviewed 1 year postoperative. Outcomes analysed were rate of fusion, American Orthopaedic Foot and Ankle Society (AOFAS) score, Visual Analogue Scale (VAS), patient satisfaction and complications.

RESULTS

Complete fusion was achieved in 90 %. The mean preoperative AOFAS score improved from 42 (95 % confidence interval: 22-43) to 75 (95 % confidence interval 67-82) postoperative and the mean VAS improved from 6.5 (95 % confidence interval 4.9-8.6) to 4 (95 % confidence interval 3.1-4.9), p < 0.001. There was an early complication rate of 13 %. After 1 year 86 % were satisfied and there was a complication rate of 3 %.

CONCLUSIONS

This study suggests that the IOFIX system offers a reliable and performant alternative technique for patients undergoing a triple arthrodesis.

LEVEL OF EVIDENCE

Level II, prospective cohort study.

Postoperative complications and cost implications in sickle cell disease patients undergoing total hip arthroplasty: A national inpatient sample study

Background

Sickle cell disease (SCD) is a genetic condition affecting approximately 5 % of the global population, with significant prevalence in sub-Saharan Africa and an estimated 89,079 cases in the United States. Osteonecrosis, particularly of the femoral head (ONFH), is a common orthopaedic complication in SCD, often requiring total hip arthroplasty (THA) when conservative treatments fail. While THA can improve pain and function, it carries significant perioperative risks, with complication rates in patients with SCD as high as 67 %. This study aims to compare postoperative outcomes, medical costs, and the impact of different THA implant designs in patients with SCD versus a matched non-SCD cohort.

Methods

The study utilized the National Inpatient Sample (NIS) database. Postoperative outcomes in patients with and without SCD undergoing total hip arthroplasty between the fourth quarter of 2015 and 2020 were analyzed using propensity score matching and multivariable logistic regression modeling. Additionally, a subgroup analysis examined outcomes based on the use of cemented versus non-cemented implants.

Results

The study analyzed 2,830,040 hip arthroplasty patients, including 2535 with sickle cell disease (SCD), and after propensity score matching, found that patients with SCD had significantly higher rates of postoperative complications such as periprosthetic fractures, dislocations, infections, and acute kidney injury. Multivariate analysis confirmed SCD as an independent risk factor for these complications, along with increased hospital stays and higher charges. Additionally, patients with SCD receiving cemented implants experienced worse outcomes, including higher risks of periprosthetic fractures and infections, compared to those with non-cemented implants.

Conclusion

This study found that patients with sickle cell disease (SCD) undergoing total hip arthroplasty had significantly higher complication rates, increased healthcare costs, and longer hospital stays, with cemented implants posing greater risks compared to press-fit implants.

Conditioned medium derived from mesenchymal stem cells and spinal cord injury: A review of the current therapeutic capacities

Spinal cord injury (SCI) is a debilitating condition of the nervous system that imposes considerable challenges for subjects, such as bladder and bowel incontinence and infections. The standard therapeutic strategy is methylprednisolone utilization accompanied by surgical decompression. However, achieving an effective therapy with the minimum side effects for SCI is still a puzzle. Nowadays, mesenchymal stem cell (MSC) therapy has received much consideration in scientific communities in light of its pharmacological and therapeutic properties, for instance, anti-inflammatory, regenerative, analgesic, and immunomodulatory influences. Despite the mentioned advantages for MSCs, their tumorigenic potential is a limiting agent for its wide therapeutic application. Recent documents show that the use of conditioned medium (CM) derived from MSCs can largely solve these problems. CM encompasses neuroprotective growth factors and cytokines, such as stem cell factor (SCF), vascular endothelial growth factor (VEGF), and glial cell line-derived neurotrophic factor (GDNF). The persuasive evidence from experimental studies revealed that CM originating from MSCs can have a considerable role in the amelioration of SCI. Hence, in the current papers, we will review and summarize evidence indicating the anti-SCI mechanisms of MSC-derived CM by relying the current experimental data.

Intramuscular myxoma: unusual observation of spontaneous tumor size shrinkage

Soft tissue tumors, whether benign or malignant, may grow over time or remain stable, but they usually do not spontaneously decrease in size. However, there are exceptions, such as inflammatory conditions, desmoid tumors, or benign cysts. Intramuscular myxomas are benign soft tissue tumors that typically present as a solitary, slow-growing, painless mass. They are generally treated by surgical resection, after which recurrence is rare. Here, we present a brief series of three unusual cases of intramuscular myxomas that spontaneously decreased in size. They were located in the cervical region, the right lower extremity, and the paravertebral lumbar region. Imaging findings and percutaneous biopsies confirmed the diagnosis in all cases. Follow-up imaging showed a spontaneous reduction in lesion volume over time, far exceeding the amount of tissue sample removed during biopsy. This unusual observation of spontaneous shrinkage may call into question the subsequent therapeutic approach to these lesions.

Relationship Between the Elastic Modulus of the Novel Pedicle Screw-Plate System and Biomechanical Properties Under Osteoporotic Condition: A Power-Law Regression Analysis Based on Parametric Finite Element Simulations

BACKGROUND AND OBJECTIVE

The novel pedicle screw-plate system (NPSPS) is a new internal fixation method for the thoracic spine that we proposed, which has demonstrated effectiveness through clinical practice and biomechanical testing. Nevertheless, the optimal elastic modulus of NPSPS (NPSPS-E) remains debated, particularly for osteoporosis patients. We propose a more efficient method to predict the biomechanical effects of NPSPS across varying elastic moduli in osteoporosis using parametric finite element (FE) analysis, establishing the regression relationship between NPSPS-E and biomechanical properties.

METHODS

An FE surgical model of NPSPS under osteoporotic conditions was developed. The NPSPS-E was linearly varied from 3.6 GPa (polyether ether ketone) to 110 GPa (titanium alloy). Using power-law regression analysis, a functional equation was established to correlate NPSPS-E with biomechanical properties under osteoporotic condition.

RESULTS

Power-law equations and regression models were successfully established between NPSPS-E and biomechanical prediction indices under osteoporotic condition (P<0.0001). As NPSPS-E increased, the range of motion (ROM) of the T8-T10 spinal segments decreased from 0.51°-4.06° to 0.24°-1.45°. The mean von Mises stress in the T8-T10 vertebrae declined from 1.36 MPa-2.03 MPa to 1.15 MPa-1.79 MPa. Concurrently, the stress shielding ratios and the total stress ratios of the NPSPS increased from 3.66%-48.07% and 13.96%-26.96% to 10.70%-56.20% and 52.62%-64.40%, respectively.

CONCLUSION

The functional equations derived from these models serve as a predictive tool to directly estimate the biomechanical effects of NPSPS across a range of elastic modulus under osteoporotic conditions, thereby facilitating the design and optimization of NPSPS materials.

The biomedical applications of artificial intelligence: an overview of decades of research

A significant area of computer science called artificial intelligence (AI) is successfully applied to the analysis of intricate biological data and the extraction of substantial associations from datasets for a variety of biomedical uses. AI has attracted significant interest in biomedical research due to its features: (i) better patient care through early diagnosis and detection; (ii) enhanced workflow; (iii) lowering medical errors; (v) lowering medical costs; (vi) reducing morbidity and mortality; (vii) enhancing performance; (viii) enhancing precision; and (ix) time efficiency. Quantitative metrics are crucial for evaluating AI implementations, providing insights, enabling informed decisions, and measuring the impact of AI-driven initiatives, thereby enhancing transparency, accountability, and overall impact. The implementation of AI in biomedical fields faces challenges such as ethical and privacy concerns, lack of awareness, technology unreliability, and professional liability. A brief discussion is given of the AI techniques, which include Virtual screening (VS), DL, ML, Hidden Markov models (HMMs), Neural networks (NNs), Generative models (GMs), Molecular dynamics (MD), and Structure-activity relationship (SAR) models. The study explores the application of AI in biomedical fields, highlighting its enhanced predictive accuracy, treatment efficacy, diagnostic efficiency, faster decision-making, personalised treatment strategies, and precise medical interventions.

Flavonoids and their role in oxidative stress, inflammation, and human diseases

Oxidative stress and chronic inflammation are important drivers in the pathogenesis and progression of many chronic diseases, such as cancers of the breast, kidney, lung, and others, autoimmune diseases (rheumatoid arthritis), cardiovascular diseases (hypertension, atherosclerosis, arrhythmia), neurodegenerative diseases (Alzheimer's disease, Parkinson's disease, Huntington's disease), mental disorders (depression, schizophrenia, bipolar disorder), gastrointestinal disorders (inflammatory bowel disease, colorectal cancer), and other disorders. With the increasing demand for less toxic and more tolerable therapies, flavonoids have the potential to effectively modulate the responsiveness to conventional therapy and radiotherapy. Flavonoids are polyphenolic compounds found in fruits, vegetables, grains, and plant-derived beverages. Six of the twelve structurally different flavonoid subgroups are of dietary significance and include anthocyanidins (e.g. pelargonidin, cyanidin), flavan-3-ols (e.g. epicatechin, epigallocatechin), flavonols (e.g. quercetin, kaempferol), flavones (e.g. luteolin, baicalein), flavanones (e.g. hesperetin, naringenin), and isoflavones (daidzein, genistein). The health benefits of flavonoids are related to their structural characteristics, such as the number and position of hydroxyl groups and the presence of C2C3 double bonds, which predetermine their ability to chelate metal ions, terminate ROS (e.g. hydroxyl radicals formed by the Fenton reaction), and interact with biological targets to trigger a biological response. Based on these structural characteristics, flavonoids can exert both antioxidant or prooxidant properties, modulate the activity of ROS-scavenging enzymes and the expression and activation of proinflammatory cytokines (e.g., interleukin-1beta (IL-1β), interleukin-6 (IL-6), and tumor necrosis factor-alpha (TNF-α)), induce apoptosis and autophagy, and target key signaling pathways, such as the nuclear factor erythroid 2-related factor 2 (Nrf2) and Bcl-2 family of proteins. This review aims to briefly discuss the mutually interconnected aspects of oxidative and inflammatory mechanisms, such as lipid peroxidation, protein oxidation, DNA damage, and the mechanism and resolution of inflammation. The major part of this article discusses the role of flavonoids in alleviating oxidative stress and inflammation, two common components of many human diseases. The results of epidemiological studies on flavonoids are also presented.

Micelle-to-Gel: Thermosensitive intra-articular hydrogels for osteoarthritis management

Osteoarthritis (OA) is a chronic and degenerative joint disease with a rising incidence worldwide. Current therapeutic approaches primarily focus on symptom relief through systemic administration, which raises safety concerns related to side effects and long-term use. In this context, the local administration of natural compounds with anti-inflammatory and anti-arthritic properties, such as β-Lapachone constitutes an interesting alternative. In this work, we prepared and characterized injectable thermosensitive hybrid hydrogels loaded with β-Lapachone. A comprehensive characterization of the hydrogel systems was performed, including micellar diameter, mechanical properties at different temperatures, the ability to control drug release and microstructure. The anti-inflammatory activity of the free drug, as well as that of the blank or loaded hydrogels was then evaluated ex vivo, using OA cartilage explants. Additionally, in vivo studies were carried out in a rabbit model of OA to assess their clinical potential. The results suggest that the hydrogel systems possess a composite microstructure integrating micelles, together with a temperature-responsive stiffness and the ability to modulate drug release. In addition, β-Lapachone-loaded hydrogels display an interesting immunomodulatory potential ex vivo, as they were able to efficiently reduce the secretion of several proinflammatory mediators, such as IL-6, MMP9, MMP13 and CXCL8. Furthermore, the drug-loaded hydrogels were found to improve in vivo cartilage and bone histomorphometric markers, such as subchondral bone thickness, as well as early signs of cartilage damage, such as the fibrillation index. Therefore, the developed β-Lapachone-loaded thermosensitive hydrogels constitute a promising alternative for OA management.

Surgical Antibiotic Prophylaxis Dosing in Adult Patients with Obesity: A Comprehensive Review of Pharmacokinetic and Pharmacodynamic Data

Surgical antibiotic prophylaxis is an important measure to prevent postoperative surgical site infections. Current guideline recommendations do not treat obesity specifically, although it can affect pharmacokinetics and pharmacodynamics. The objective of this review was to synthesize current evidence on the need for obesity-related dosing adjustments in surgical antibiotic prophylaxis. MEDLINE and Cochrane Library were searched for studies investigating antibiotic prophylaxis dosing in surgical patients with obesity. Outcomes of interest were pharmacokinetic parameters such as plasma and interstitial fluid concentrations, area under the concentration time curve in plasma and in interstitial fluid, and other pharmacokinetic measures. Thirty studies investigating cefazolin, cefoxitin, cefuroxime, piperacillin/tazobactam, meropenem, ertapenem, metronidazole, vancomycin, ciprofloxacin, and gentamicin were included in this analysis. Except for metronidazole, cefoxitin, and gentamicin, there is currently no evidence suggesting the need for dosing adjustments.

Lumbar localized fat distribution parameters are independent predictors of osteoporotic vertebral compression re-fractures (OVCRFs) following Percutaneous Kyphoplasty (PKP): a retrospective matched case-control study

OBJECTIVE

To investigate potential risk factors for osteoporotic vertebral compression re-fractures (OVCRFs) following percutaneous kyphoplasty (PKP).

MATERIALS AND METHODS

Patients who underwent PKP from January 2012 to January 2020 were included in this study within the same institution. Cases were defined as patients who experienced OVCRFs, while controls were matched based on corresponding clinical characteristics from those patients without OVCRFs. The lumbar localized fat distribution parameters, including the fat infiltration ratio (FIR) in muscles [multifidus (MF), erector spinae (ES), paravertebral muscles (PVM), and psoas major (PS)] and subcutaneous fat thickness (SFT), were compared between the two groups through radiological data. And other clinical data that may be relevant were also compared. Independent risk factors for OVCRFs after PKP were identified through a binary logistic regression analysis.

RESULT

A total of 1391 patients who underwent PKP were included in this study. 51 patients were categorized into the re-fracture group, and 102 patients were selected as matched controls from the remaining cohort. There were statistically significant differences between the two groups in metrics including MF-FIR, ES-FIR, PVM-FIR, PS-FIR, bone mineral density (BMD), body-mass index (BMI), SFT, hemoglobin (Hb), albumin (ALB), alkaline phosphatase (ALP), and triglycerides (TG) (P < 0.05). Binary logistic regression analysis demonstrated that PVM-FIR (P = 0.003), SFT (P < 0.001), BMD (P = 0.011), and ALP (P = 0.005) were independent predictors for the occurrence of OVCRFs.

CONCLUSION

This study discovered that lumbar localized fat distribution parameters including PVM-FIR and SFT are independent predictors of OVCRFs. Additionally, BMD and ALP were found to be independent predictors of OVCRFs.

Risk Factors for Developing Perthes Disease: A Comprehensive National Analysis Spanning 2 Decades

BACKGROUND

Perthes disease is an uncommon pediatric condition affecting the hip joint, causing varying degrees of femoral head necrosis. The underlying cause of Perthes remains unknown, thus it is crucial to identify risk factors associated with its development to aid in early diagnosis and intervention. This study aimed to analyze risk factors associated with Perthes in a large cohort.

METHODS

A case-control study was conducted using data from a U.S. national database from 2003 to 2023. Patients diagnosed with Perthes were compared with those without the disease. Variables potentially associated with Perthes were analyzed using multivariable logit models, and adjusted odds ratios (AOR) with 95% CI were calculated. Statistical significance was determined, and a P -value <0.05 was considered significant.

RESULTS

The study included 4034 patients with Perthes and 3,483,745 age-matched controls. The mean age of patients with Perthes was 8.38 years, compared with 8.35 years in the control group ( P =0.27). Significant risk factors identified included male sex (AOR: 3.14, P <0.001), white race (AOR: 2.16, P <0.001), and obesity (AOR: 2.21, P <0.001). Conversely, Black (AOR: 0.26, P <0.001), Hispanic (AOR: 0.53, P <0.001), and Asian (AOR: 0.55, P <0.001) races were associated with lower odds of developing Perthes. Additional significant risk factors included tobacco exposure (AOR: 1.25, P =0.02), hypertension (AOR: 1.64, P <0.001), and thrombophilia (AOR: 9.17, P <0.001).

CONCLUSIONS

This study is the largest study on Perthes disease in literature, identifying several independent risk factors, including male sex, white race, obesity, tobacco exposure, hypertension, obesity, and thrombophilia. Among children with Perthes, thrombophilia exhibited the highest adjusted odds ratio, despite its rarity. These findings offer valuable insights for further research aimed at elucidating the underlying etiology of Perthes disease, particularly with regards to the roles of vascular and metabolic pathways.

LEVEL OF EVIDENCE

Level III-prognostic case-control study.

Total ankle arthroplasty versus ankle arthrodesis in end-stage osteoarthritis: A meta-analysis of comparative outcomes

The treatments for end-stage ankle arthritis are challenging. Standard treatment methods include ankle arthrodesis (AA) and total ankle arthroplasty (TAA). This meta-analysis compares the outcomes of TAA and AA based on comparative studies. Literature databases include PubMed, Embase, and Google Scholar. Keywords related to the treatment of end-stage ankle osteoarthritis with AA compared to TAA were used. The outcome measurements include functional outcomes and revision rates. Review Manager 5.4 was used to conduct statistical analysis. A standard p-value of <0.05 indicated statistical significance. 27 comparison articles, including data from 12,341 patients, were included in the meta-analysis. 4917 patients underwent total ankle arthroplasty, while 7440 underwent ankle arthrodesis. The results showed a significant difference in the AOFAS score favoring TAA (p < 0.001). Dorsiflexion range of motion (ROM) also showed a significant difference in favor of TAA (p < 0.001). Additionally, the TAA group's plantarflexion ROM was significantly superior (p < 0.001). The overall SF-36 score, which measures quality of life, reported improved outcomes for patients who underwent TAA compared to those with AA (p < 0.001). The Activities of Daily Living, calculated by the Foot and Ankle Ability Measure (FAAM) score, also showed significant improvement in patients who had TAA compared to those who received AA (p < 0.001). When both the Activities of Daily Living and Sports subscales were combined, there was a significant improvement in the total FAAM score for TAA patients (p < 0.001). However, there was a significant difference in revision rates favoring AA (p < 0.001). This meta-analysis compared postoperative outcomes of ankle arthrodesis (AA) and total ankle arthroplasty (TAA) through patient-reported and functional measures. By synthesizing qualitative and quantitative data, we identified TAA as the superior intervention, demonstrating significant advantages in AOFAS scores, FAAM activities of daily living, FAAM total scores, SF-36 total scores, and range of motion. These findings aid in tailoring surgical decisions for end-stage ankle osteoarthritis, particularly when patient-specific factors such as anatomical suitability, comorbidities, or access to advanced care limit treatment options. Additionally, this study supports the recent trend of showing comparable revision rates between TAA and AA.

Level of evidence

3.

Attitudes regarding barriers to entry and the learning curve associated with endoscopic decompression-only surgery: an international survey

BACKGROUND CONTEXT

Endoscopic spine decompression surgery (ESDS) offers numerous benefits, including reduced tissue damage, smaller incisions, shorter recovery times, and a lower risk of complications. However, its adoption among spine surgeons in the United States has been slow. The reluctance to adopt ESDS can be attributed to factors such as the learning curve, cost of equipment and training, and limited access to necessary resources.

PURPOSE

The primary objective of this study is to assess attitudes toward barriers to and reasons for not adopting ESDS. A secondary objective is to further identify the learning curves, challenges, and common concerns of surgeons considering ESDS adoption.

STUDY DESIGN/SETTING

An international survey of fellowship-trained spine surgeons from the Society for Minimally Invasive Spine Surgery (SMISS).

PATIENT SAMPLE

A total of 171 fellowship-trained spine surgeons from the Society for Minimally Invasive Spine Surgery voluntarily and anonymously responded to our survey via the RedCap platform. Surgeons were located across the globe, representing six regions.

OUTCOME MEASURES

Data on current region of practice, specialty training, time in practice, practice type, and surgical volume was obtained for each surgeon who responded to the survey. Additionally, we obtained data on perceived benefits, barriers to entry, and the learning curve of endoscopic techniques.

METHODS

A survey was distributed to fellowship-trained spine surgeons from the Society for Minimally Invasive Spine Surgery, with questions focusing on perceived benefits, barriers to adoption, and the learning curve of endoscopic techniques.

RESULTS

A total of 171 surgeons responded to the survey, representing six regions: North America (48.0%), Asia Pacific (28.7%), and Europe (11.7%). Respondents were trained in Orthopaedic Surgery (59.1%) and Neurological Surgery (35.7%). Experience varied, with 35.9% having over 20 years in practice. Most respondents were in Private Practice (59.6%) or Academic/University settings (39.2%), with the majority practicing in urban areas (67.8%). Surgeons were categorized into the EG (50.3%) who used endoscopic techniques and the NEG (49.7%) who did not. There were no significant differences in training types or work settings between the groups. For the NEG, 23.5% were exposed to endoscopic techniques during training, and 50.6% received specific training in practice, mainly through formal industry courses (76.7%). The primary barriers to adopting ESDS were lack of training (55.3%), unavailability of equipment (50.6%), and financial concerns. EG surgeons cited minimizing tissue trauma, improved access to foraminal pathology, and minimizing recovery time as critical factors for using ESDS. Challenges included concerns for incomplete decompression and the duration of surgery, with significant variation in perceived difficulty during the learning curve.

CONCLUSION

Despite the recognized benefits of ESDS, barriers such as training deficiencies and equipment costs hinder its widespread adoption. Addressing these barriers through enhanced training opportunities and hospital system support could increase the adoption of ESDS, benefiting both surgeons and patients by reducing recovery times and complications.

A Review of Syndesmosis Injuries and Preferred Treatment in Football Players

PURPOSE OF REVIEW

Syndesmotic injuries are common football injuries. The unique demands of football athletes create large magnitude rotational moments about the ankle, even during low impact maneuvers. This review explores the structure and function of the syndesmosis, assesses recent data in football athletes at the professional and collegiate levels regarding epidemiology, describes available treatment options, and provides example cases from the authors' institution. The review concludes with clinical and surgical pearls for the evaluation and treatment of syndesmotic injury.

RECENT FINDINGS

In general, flexible syndesmotic fixation has demonstrated similar clinical outcome scores as rigid fixation. Flexible fixation has demonstrated benefit over rigid fixation in terms of implant failure, hardware removal, and local irritation. Both flexible and rigid fixation remain viable options for treatment of syndesmotic injuries yet the indications for selecting a construct are often subjective. Certain cases of high-risk football players such as linemen may warrant careful consideration of rigid fixation options despite the clinical advantages of flexible fixation. During fixation, direct visualization techniques with open or arthroscopic assistance for reduction of the syndesmosis remain superior and enable diagnosis of chondral defects. Flexible and rigid syndesmotic fixation techniques are viable for treatment of unstable syndesmotic injuries in athletes. Recent literature favors flexible fixation. However, at-risk football athletes or those with length unstable fibula fractures may benefit from rigid or supplemental flexible fixation as opposed to traditional flexible fixation. We recommend direct visualization of reduction at the syndesmosis during surgical treatment of unstable ankle injuries.

A Systematic Review of Clinical Outcomes of Pedicled Flap Repairs of the Knee Extensor Mechanism

BACKGROUND

 Rupture of the extensor mechanism of the knee has severe functional morbidity, and repair can be complicated by infection, allograft degeneration, and recurrent rupture. Techniques of autologous tissue repair utilizing pedicled flaps such as the gastrocnemius offer vascularized methods of reconstruction, with potentially diminished complication rates. The goal of this study was to evaluate the functional outcomes and complications associated with pedicled flap repair of the knee extensor mechanism.

METHODS

 A systematic review was conducted following the Preferred Reporting Items for Systemic Reviews and Meta-Analyses guidelines. Publications that focused on local myocutaneous flaps as a means for reconstruction were included. Causes for knee extensor mechanism deficit, flap characteristics, ambulation rate, changes in range of motion pre- and postoperation, and postoperative complications were analyzed. Technique reports including primary suture repairs, synthetic mesh, and allograft use were excluded.

RESULTS

 An initial 119 studies were identified, with final review of 22 observational studies encompassing 128 cases of pedicled flap reconstructions. The gastrocnemius (88.2%, n = 113), quadriceps (6.3%, n = 8), and a combination of the vastus and gastrocnemius flaps (5.5%, n = 7), were the most frequently utilized flaps. Functional outcomes were favorable with 87.2% of patients achieving ambulation without external support. Variability in range of motion outcomes across different flap may be secondary to the patient characteristics as well as extent of initial injury.

CONCLUSION

 Autologous pedicle flap reconstruction of the knee extensor mechanism emerges as a viable option for cases characterized by extensive defects and insufficient soft tissue coverage, which are not amenable to direct suture repairs or allografts. Postoperative assessments revealed that the majority of patients experienced improved ambulation status, with no instances of deterioration noted among the patients.

Several factors predict the achievement of the patient acceptable symptom state and minimal clinically important difference for patient-reported outcome measures following anterior cruciate ligament reconstruction: A systematic review

PURPOSE

To summarize the predictors of the patient acceptable symptom state (PASS), minimal clinically important difference (MCID) and minimal important change (MIC) for patient-reported outcome measures (PROMs) following anterior cruciate ligament reconstruction (ACLR).

METHODS

MEDLINE, PubMed and Embase were searched from inception to 5 January 2024. The authors adhered to PRISMA/R-AMSTAR guidelines, and the Cochrane Handbook for Systematic Reviews of Interventions. Data on statistical associations between predictive factors and PROMs were extracted. Inverse odds ratios (ORs) and confidence intervals (reverse group comparison) were calculated when appropriate to ensure comparative consistency.

RESULTS

Thirteen studies comprising 21,235 patients (48.1% female) were included (mean age 29.3 years). Eight studies comprising 3857 patients identified predictors of PASS, including lateral extra-articular tenodesis (LET) (OR = 11.08, p = 0.01), hamstring tendon (HT) autografts (OR range: 2.02-2.63, p ≤ 0.011), age over 30 (OR range: 1.37-2.28, p ≤ 0.02), male sex (OR range: 1.03-1.32, p ≤ 0.01) and higher pre-operative PROMs (OR range: 1.04-1.21). Eight studies comprising 18,069 patients identified negative predictors of MCID or MIC, including female sex (OR = 0.93, p = 0.034), absence of HT autografts (OR = 0.70, p < 0.0001), higher pre-operative PROMs (OR = 0.76-0.84, p ≤ 0.01), meniscectomy (OR = 0.67, p = 0.014) and collision sports (OR = 0.02-0.60, p ≤ 0.05).

CONCLUSION

Higher pre-operative PROMs, age over 30, male sex, LETs and HT autografts predicted PASS achievement. Lower pre-operative PROMs, male sex, non-collision sports, and lack of meniscectomies predicted MCID/MIC achievement. This review provides a comprehensive understanding of the predictors of clinically significant post-ACLR outcomes, thus improving clinical decision-making and the management of patient expectations.

LEVEL OF EVIDENCE

Level IV.

Antibiofilm capacity of PMMA surfaces: A review of current knowledge

The emergence of microorganisms resistant to antimicrobial therapies, associated with the decline in the development of new drugs, including antibiotics, antifungals, and antivirals, highlights the need for alternative strategies to combat microorganisms that cause infections, especially multidrug-resistant bacteria. Polymethylmethacrylate (PMMA) is a material widely used in the biomedical field, with uses ranging from surgical implants, bone cements, and dental devices, to laboratory equipment and three-dimensional models for surgical planning. Despite its multiple applications, PMMA has the disadvantage of favoring microbial adhesion, due to the porous nature of the material, associated with poor bond strength, thermal instability and water sorption in the oral environment, which can contribute to infection development. To mitigate this problem, the scientific community is looking to modify PMMA to give it antimicrobial properties. This review presents possible approaches that include changes to the topography of PMMA, creating textured or nanostructured surfaces, and chemical modifications, such as incorporating antimicrobial agents into the PMMA matrix or surface treatments. Both strategies aim to hinder the adhesion and growth of microorganisms. In addition, combining these approaches seeks a synergistic effect and could become a promising mechanism for preventing infections.

Common sports-related nerve injuries seen by the electrodiagnostic medical consultant

The high physiologic demands of sports create dynamic stress on joints, soft tissues, and nerves which may lead to injuries in the athlete. Electrodiagnostic (EDx) assessment is essential to identify the correct diagnosis, localization, and prognosis, to guide management of sports-related neuropathies. A comprehensive review was performed to provide the EDx medical consultant with a practical approach to the common peripheral nerve disorders seen in athletes. Sports-related neuropathies reviewed include transient traumatic irritation of the brachial plexus and/or cervical nerve roots ("Burners and stingers,") suprascapular and axillary neuropathies, ulnar neuropathy at the elbow (UNE) in throwers, ulnar neuropathy at the hand/wrist in cyclists, multi-ligamentous knee injury, and foot/ankle neuropathies including tarsal tunnel syndrome. A thorough understanding of peripheral anatomy, possible entrapment sites, mechanisms of injury, and key physical examination findings is essential for correct diagnosis. EDx assessments beyond routine studies are generally required for sports-related neuropathy, which may not necessarily follow typical entrapment patterns. Adjunct diagnostic imaging, such as point-of-care ultrasound and magnetic resonance imaging, are helpful tools to identify associated musculoskeletal pathology such as compressive cysts or nerve entrapment, which may be amenable to interventional or surgical treatment. When no clear reversible structural pathology exists, management of sports-related neuropathy is athlete-specific and generally multi-modal, involving a combination of physical rehabilitation techniques to address muscle imbalances, load management, protective equipment, and interventional pain procedures.

No significant difference in skin contamination during anterior cruciate ligament reconstruction with and without preoperative skin cleaning

PURPOSE

This prospective study aimed to assess whether preoperative antiseptic skin cleansing reduces bacterial contamination and surgical site infections (SSI) following anterior cruciate ligament reconstruction (ACLR). We hypothesized that antiseptic cleaning would lower bacterial load, reducing contamination and early infections.

METHODS

One hundred and nineteen patients scheduled for ACLR were included in this prospective, nonrandomized study. Individuals were divided into two groups. Patients in the intervention group applied octenisan® wash lotion daily for three days before surgery and used the wash solution instead of their usual shower gel. Additionally, they swiped their leg with octenisan® soaked gloves on the morning of the operation. The control group followed their usual wash routine with no specific instructions. Fluid samples were taken before surgery from the irrigation bag and at 15-min intervals from the reservoir of the sterile surgical drape during the procedure. Suture material used for the ACL graft and meniscus repair were also collected for testing. The samples were subjected to a 14-day incubation period. Follow-up included outpatient visits at 6 weeks, 12 weeks and 6 months with a final evaluation at 12 months.

RESULTS

Contamination rates showed no significant difference between the control and intervention groups. The mean contamination rate in the control group was 6.4% (n = 22) and 6.6% (n = 24) in the intervention group (p = 0.28). At 12-month follow-up, 110 out of 119 participants were included (52 control, 58 intervention). T tests for age (p = 0.19), BMI (p = 0.66), and surgery duration (p = 0.38) showed no significant differences. No early SSI were observed in either group postoperatively.

CONCLUSION

Our results indicate that the use of antiseptic wash lotion and gloves does not influence the risk of bacterial contamination during surgery.

LEVEL OF EVIDENCE

Level III.

The effects and optimal dosage of traditional Chinese exercises on patients with chronic ankle instability: A systematic review and meta-analysis

BACKGROUND

The effectiveness of Traditional Chinese exercises in promoting functional recovery in patients with chronic ankle instability, as well as the potential impact of variables such as intervention type, duration, frequency, and cycle on treatment outcomes, still requires further investigation.

METHODS

Literature searches were conducted in multiple databases including China National Knowledge Infrastructure (CNKI), VIP, Wanfang, China Biomedical Literature Database (CBM), PubMed, EBSCO(Medline、CINAHL、SPORTDiscus), Embase, Cochrane Library, ProQuest, and Web of Science for randomized controlled trials assessing the effects of Traditional Chinese Exercises interventions on patients with Chronic Ankle Instability. The publication timeframe spanned from the inception of each database until January 20, 2025. Meta-analysis was performed using STATA 15 software on the included studies.

RESULTS

Twelve randomized controlled trials (RCTs) involving 323 patients were included in this analysis. Compared with the control group, Traditional Chinese exercises showed the following improvements: CAIT: WMD = 4.02, 95 % CI [3.22, 4.81], z = 9.90, P < 0.001.Balance: ANT: SMD = 0.38, 95 % CI [0.18, 0.59], z = 3.71, P = 0.003.PM: SMD = 0.49, 95 % CI [0.26, 0.70], z = 4.73, P < 0.001.PL: SMD = 0.67, 95 % CI [0.46, 0.88], z = 6.35, P < 0.001.C: SMD = 0.80, 95 % CI [0.35, 1.25], z = 3.51, P < 0.001.JPS:Plantarflexion: SMD = -0.58, 95 % CI [-0.94, -0.21], z = 3.09, P = 0.002.Inversion: SMD = -0.46, 95 % CI [-0.86, -0.06], z = 2.23, P = 0.025.Muscle Strength: Plantarflexion: SMD = 0.81, 95 % CI [0.43, 1.18], z = 4.25, P < 0.001.Inversion: SMD = 0.66, 95 % CI [0.25, 1.07], z = 3.16, P = 0.002.Eversion: SMD = 1.04, 95 % CI [0.62, 1.46], z = 4.82, P < 0.001.Subgroup Analysis: Tai Chi training conducted twice weekly for a 12-week intervention period, with 60-minute sessions, demonstrated the most effective improvements.

LEVEL OF EVIDENCE

The evidence level for the effects of Traditional Chinese exercises on Balance-ANT, Balance-PM, and Balance-PL balance directions in CAI patients is rated as "moderate."

CONCLUSION

Traditional Chinese exercise has been shown to significantly improve balance, muscle strength, and joint position sense in CAI patients. Based on the current findings, Tai Chi training appears to provide greater benefits for CAI patients. It is recommended that CAI patients participate in Tai Chi training twice a week, with each session lasting 60 minutes, over a 12-week period.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO database, CRD42024613359.

The future of wearable ergonomic devices in plastic surgery: A systematic review

BACKGROUND

Throughout the last decade, surgeons across specialties are increasingly using wearable support devices to minimize occupational discomfort during procedures. However, there is still a paucity of their use in plastic surgery. This review evaluates the types of ergonomic devices used across surgical specialties and their impact on pain reduction.

METHODS

A systematic search was conducted on October 23, 2024, using Embase, PubMed, Scopus, Web of Science, and Cumulative Index to Nursing and Allied Health Literature. Inclusion criteria required the utilization of a wearable ergonomic device by surgeons in peer-reviewed, original research. Two investigators independently conducted the screening, extraction, and synthesis of results.

RESULTS

Of the 954 reports identified, 11 articles were selected for analysis. The average study sample size was 13, with a range from 3 to 25 surgeons. The average time reported was 108 min, with a range from 10 to 383.5 min. The physical supporting devices included 6 upper extremity/body exoskeletons, 2 posture sensing and/or training devices, 1 lower extremity/body exoskeleton, 1 neck exoskeleton, one trunk exoskeleton, 1 exoskeleton-based radiation protection apron, and 1 external surgeon support system. These studies took place mainly in general surgery, with only one study in plastic surgery. All studies reported a positive surgeon experience using their respective device.

CONCLUSION

This review reveals that nearly half of the identified devices were upper body/upper extremity supporting devices, mainly used in general surgery with favorable experiences among the surgeons. This underscores the possibility of expanding the utilization of these devices further into plastic surgery and highlights the need for more research into plastic surgeons' experiences using these ergonomic tools in the operating room.

MRI deep learning models for assisted diagnosis of knee pathologies: a systematic review

OBJECTIVES

Despite showing encouraging outcomes, the precision of deep learning (DL) models using different convolutional neural networks (CNNs) for diagnosis remains under investigation. This systematic review aims to summarise the status of DL MRI models developed for assisting the diagnosis of a variety of knee abnormalities.

MATERIALS AND METHODS

Five databases were systematically searched, employing predefined terms such as 'Knee AND 3D AND MRI AND DL'. Selected inclusion criteria were used to screen publications by title, abstract, and full text. The synthesis of results was performed by two independent reviewers.

RESULTS

Fifty-four articles were included. The studies focused on anterior cruciate ligament injuries (n = 19, 36%), osteoarthritis (n = 9, 17%), meniscal injuries (n = 13, 24%), abnormal knee appearance (n = 11, 20%), and other (n = 2, 4%). The DL models in this review primarily used the following CNNs: ResNet (n = 11, 21%), VGG (n = 6, 11%), DenseNet (n = 4, 8%), and DarkNet (n = 3, 6%). DL models showed high-performance metrics compared to ground truth. DL models for the detection of a specific injury outperformed those by up to 4.5% for general abnormality detection.

CONCLUSION

Despite the varied study designs used among the reviewed articles, DL models showed promising outcomes in the assisted detection of selected knee pathologies by MRI. This review underscores the importance of validating these models with larger MRI datasets to close the existing gap between current DL model performance and clinical requirements.

KEY POINTS

Question What is the status of DL model availability for knee pathology detection in MRI and their clinical potential? Findings Pathology-specific DL models reported higher accuracy compared to DL models for the detection of general abnormalities of the knee. DL model performance was mainly influenced by the quantity and diversity of data available for model training. Clinical relevance These findings should encourage future developments to improve patient care, support personalised diagnosis and treatment, optimise costs, and advance artificial intelligence-based medical imaging practices.

Total knee arthroplasty reimbursement is declining overall and at a marginally faster rate amongst female orthopaedic surgeons: A Medicare analysis

Background

While the prevalence of total knee arthroplasty (TKA) is increasing, reimbursement is declining. The purpose of this study was to determine how surgeon gender influences procedure volume, reimbursement, practice style, and patient demographics for TKAs nationally and regionally between 2013 and 2021.

Methods

The Medicare Physician and Other Practitioners database was queried from 2013 to 2021 for procedure volume, TKA reimbursement, surgeon characteristics, and patient demographics for any surgeon who performed at least ten primary TKAs per year. Statistical tests were conducted to analyze differences based on surgeon gender, geography, and year.

Results

Of the 2,415,802 TKAs performed between 2013 and 2021, 1.5 % were billed by female surgeons. The number of TKAs performed annually increased by 29.1 % for female surgeons and decreased by 2.6 % for male surgeons. Between 2013 and 2021, reimbursement for TKAs decreased by 23.9 % for male surgeons and 26.2 % for female surgeons. In 2021, male surgeons were reimbursed $1017 per TKA while female surgeons were reimbursed $964 (p = 0.049). Male surgeons performed more TKAs annually in 2021 (Male: 39.3, Female: 30.9, p < 0.001), more total billable services (Male: 4148.0, Female: 2719.3, p < 0.001), and more unique billable services (Male: 70.7, Female: 55.3, p < 0.001) than female surgeons.

Conclusions

Female representation among surgeons who perform TKAs is increasing nationally. However, male surgeons treat more patients, perform more total billable services, and perform more unique billable services than female surgeons. TKA reimbursement is decreasing at a faster rate for female surgeons than male surgeons, although this is likely due to geographical differences.