Offset restoration in total hip arthroplasty: Important: A current review

Normal vertical and horizontal offset is essential for hip biomechanics, muscle functioning and gait pattern. Total hip arthroplasty (THA) should aim to restore normal offset with implantation of femoral and acetabular components. This would be possible with proper preoperative planning, templating and ensuring implant options are available for offset restoration. Templating is essential for understanding the vertical and horizontal offset change, especially in hip arthritis presenting late with significant limb length discrepancy at THA. Planning should include appropriate soft tissue releases and the use of ideal implants to achieve restoration of horizontal and vertical offset. Under correction of horizontal offset at THA for fracture neck of femur could result in abductor fatigue, limp and increased wear. Restoration of horizontal offset is imperative at THA for a fractured neck of the femur to achieve optimal abductor function. Horizontal offset is necessary for optimal abductor muscle tension and function. Revision THA for acetabular bone loss would require hip center restoration with the acetabular and femoral offset correction to achieve limb length correction and abductor length. The inability to achieve vertical and horizontal offset correction could lead to dislocation or signs of abductor fatigue. Careful vertical and horizontal femur offset restoration is required for normal hip biomechanics, decreased wear and increased longevity.

Needle arthroscopic-assisted repair of tibio-fibular syndesmosis acute injury: A case report

BACKGROUND

Acute injuries to the tibiofibular syndesmosis, often associated with high ankle sprains or malleolar fractures, require precise diagnosis and treatment to prevent long-term complications. This case report explores the use of needle arthroscopy as a minimally invasive technique for the repair of tibiofibular syndesmosis injuries.

CASE SUMMARY

We report on a 40-year-old male patient who presented with a trimalleolar fracture and ankle subluxation following a high ankle sprain. Due to significant swelling and poor soft tissue quality, initial management involved external stabilization. Subsequently, needle arthroscopy was employed to assess and treat the tibiofibular syndesmosis injury. The procedure, performed under spinal anesthesia and fluoroscopic control, included nanoscopic evaluation of the ankle joint and reduction of the syndesmosis using a suture button. Follow-up assessments showed significant improvement in pain levels, range of motion, and functional scores. At 26 weeks post-procedure, the patient achieved full range of motion and pain-free status. Needle arthroscopy offers a promising alternative for the management of acute tibiofibular syndesmosis injuries, combining diagnostic and therapeutic capabilities with minimal invasiveness.

CONCLUSION

This technique may enhance clinical outcomes and reduce recovery times, warranting further investigation and integration into clinical practice.

Effects of human umbilical cord mesenchymal stem cell-derived exosomes in the rat osteoarthritis models

Mesenchymal stem cells (MSCs) offer great potential for treatment of osteoarthritis (OA) by promoting articular cartilage regeneration via paracrine secretion of exosomes; however, the underlying mechanisms are not fully understood. This study aimed to explore the therapeutic effects of exosomes secreted by human umbilical cord-derived MSCs (hUC-MSCs) in rat models of OA and reveal the underlying mechanisms. UC-MSCs and UC-MSC-exosomes were prepared and identified by transmission electron microscopy and flow cytometry. IL-1β-induced OA chondrocytes and the operation and collagenase-induced OA rat models were established. The results of micro-computed tomography, histology, and immunohistochemistry showed that UC-MSC-exosomes promoted cartilage regeneration in OA rats. ELISA results showed that the levels of synovial fluid cytokines, TNF-α, IL-1β, and IL-6, were lower in exosome therapy group than control group in both OA rat models. Exosome treatment significantly downregulated the expression of MMP-13 and ADAMTS-5 in chondrocytes stimulated by IL-1β, and upregulated collagen II expression. These findings suggest that hUC-MSC-exosomes offer a promising option for the therapy for OA.

Validity of the Musculoskeletal Tumor Society Score for lower extremity in patients with bone sarcoma or giant cell tumour of bone undergoing bone resection and reconstruction surgery in hip and knee

BACKGROUND

The Musculoskeletal Tumor Society Score (MSTS) is widely used to evaluate functioning following surgery for bone and soft-tissue sarcoma. However, concerns have been raised about its content validity due to the lack of patient involvement during item development. Additionally, literature reports inconsistent results regarding data quality and structural validity. This study aimed to evaluate content, structural and construct validity of the Danish version of the MSTS for lower extremity (MSTS-LE).

METHODS

The study included patients from three complete cohorts (n = 87) with bone sarcoma or giant cell tumour of bone who underwent bone resection and reconstruction surgery in hip and knee. Content validity was evaluated by linking MSTS items to frameworks of functioning, core outcome sets and semi-structured interviews. Data quality, internal consistency and factor analysis were used to assess the underlying structure of the MSTS. Construct validity was based on predefined hypotheses of correlation between the MSTS and concurrent measurements.

RESULTS

Content validity analysis revealed concerns regarding the MSTS. The MSTS did not sufficiently cover patient-important functions, the item Emotional acceptance could not be linked to the framework of functioning, the items Pain and Emotional acceptance pertained to domains beyond functioning and items' response options did not match items. A two-factor solution emerged, with the items Pain and Emotional acceptance loading highly on a second factor distinct from functioning. Internal consistency and construct validity showed values below accepted levels.

CONCLUSION

The Danish MSTS-LE demonstrated inadequate content validity, internal consistency, and construct validity. In addition, our analyses did not support unidimensionality of the MSTS. Consequently, the MSTS-LE is not a simple reflection of the construct of functioning and the interpretation of a sum score is problematic. Clinicians and researcher should exercise caution when relying solely on MSTS scores for assessing lower extremity function. Alternative outcome measurements of functioning should be considered for the evaluation of postoperative function in this patient group.

Real World Clinical Outcomes When Discontinuing Denosumab or Bisphosphonates in Patients with Surgically Managed Osteoporotic Vertebral Compression Fractures: A Population-Based Cohort Study

BACKGROUND CONTEXT

Osteoporotic vertebral compression fractures (OVCFs) are common fragility fractures. Patients who undergo surgical treatment for their initial OVCFs warrant particular attention because there is an elevated risk of subsequent vertebral fractures and other types of fragility fractures. However, the optimal osteoporosis treatment for this specific patient group is less investigated.

PURPOSE

This study compares the risk of subsequent osteoporotic fractures and mortality rate for patients who are initiated with denosumab and bisphosphonates and determines the effect of adherence to treatment.

STUDY DESIGN

Retrospective nationwide cohort study PATIENT SAMPLE: A total of 2,858 patients who had surgically-managed osteoporotic vertebral compression fractures.

OUTCOME MEASURES

The risk of osteoporotic fractures, vertebral fractures, non-vertebral fractures and death.

METHODS

This is a retrospective nationwide cohort study that uses the National Health Insurance Research Database. Patients aged ≥50 years who were admitted for surgical interventions for OVCF between 2012 and 2016 and subsequently received denosumab or bisphosphonates for one year were included. Patients were stratified according to their anti-osteoporosis medications and adherence to treatment. A multivariable, time-varying Cox proportional hazards model was used to determine the risk of osteoporotic fractures, vertebral fractures, non-vertebral fractures and death.

RESULTS

A total of 2,858 patients were included in this study: 1,123 patients in the denosumab group and 1,735 patients in the bisphosphonates group. Compared to persistent denosumab users, the non-persistent denosumab users, persistent bisphosphonate users and non-persistent bisphosphonate users had a greater risk of osteoporotic fractures, with respective hazard ratios of 1.64 (95% confidence interval [CI], 1.16-2.32), 1.74 (95% CI, 1.25-2.42) and 1.53 (95% CI, 1.14-2.06). If osteoporotic fractures were divided into non-vertebral and vertebral fractures, none of the groups exhibited an increased risk of vertebral fractures compared to persistent denosumab users, with an HR of 1.00 (95% CI: 0.54-1.88) for non-persistent denosumab users, 1.64 (95% CI: 0.96-2.81) for persistent bisphosphonate users and 1.52 (95% CI: 0.95-2.43) for non-persistent bisphosphonate users. However, there was a significantly greater risk of non-vertebral fracture, with respective hazard ratios of 2.04 (95% CI, 1.33-3.11), 1.80 (95% CI, 1.18-2.76) and 1.56 (95% CI, 1.06-2.27) for non-persistent denosumab users, persistent bisphosphonate users and non-persistent users. Noteworthy, non-persistent denosumab users exhibited a significantly greater risk of mortality than persistent denosumab users, with a hazard ratio of 3.12 (95% CI, 2.22-4.38).

CONCLUSIONS

In terms of patients with OVCFs who require hospitalization and surgical intervention, those who receive ongoing denosumab treatment exhibit less risk of developing subsequent osteoporotic fractures than those who receive bisphosphonates or non-persistent denosumab treatment. However, discontinuation of denosumab is associated with a significantly increased risk of subsequent fractures and mortality. Therefore, adherence to the treatment is crucial for patients who are initiated with denosumab.

Current trends and hotspots of depressive disorders with colorectal cancer: A bibliometric and visual study

BACKGROUND

Depression is strongly associated with colorectal cancer (CRC). Few bibliometric analyses have systematically summarized the research focus and recent progress in this field.

AIM

To determine the research status and hotspots by bibliometric analysis of relevant publications on the relationship between CRC and depression.

METHODS

Articles on depression in CRC patients were collected from the Web of Science Core Collection. CiteSpace and VOSviewer software were used to visualize bibliometric networks.

RESULTS

From 2001 to 2022, Supportive Care in Cancer, the United States, Tilburg University, and Mols were the most productive and influential journal, country, institution, and author name. Co-occurrence cluster analysis of keywords placed quality of life, anxiety, and psychological stress in the center of the visual network diagram. Further clustering was performed for the clusters with studies of the relevant mechanism of action, which showed that: (1) Cytokines have a role essential for the occurrence and development of depressive disorders in CRC; (2) MicroRNAs have a role essential for the development of depressive disorders in CRC; (3) Some anticancer drugs have pro-depressant activity; and (4) Selective serotonin reuptake inhibitors have both antitumor and antidepressant activity.

CONCLUSION

Life quality and psychological nursing of the cancer population were key topics. The roles of cytokines and microRNAs, the pro-depression activity of anticancer drugs and their antitumor properties deserve in-depth study.

The Fragility Index is Typically Misinterpreted and of Low Value: Clinical Trials are Designed to be Fragile

The Fragility Index (FI) is defined as the number of patients whose outcome would need to change to reverse a statistically significant finding to a nonsignificant finding. The FI is nothing more than a repackaging of statistical significance based on the P value, perpetuating the (1) ignoring of results that are "not" statistically significant, (2) treating results that are statistically significant as certain, and (3) distracting from evaluation of clinical significance. A well-designed trial includes a sample size calculation to determine the minimum number of patients required to observe a difference between study groups (if a difference exists). By including this minimum number, clinical trials are designed to be fragile, yet subsequently criticized as such, leading readers to the incorrect conclusion that the studies are flawed. It's time to move past systematic reviews focused on the FI.

Effectiveness of therapeutic methods for Legg-Calvé-Perthes disease according to staging, limits of conservative treatment: a systematic review with meta-analysis

Legg-Calvé-Perthes disease (LCPD) is known as a self-limiting pediatric orthopedic pathology that affects the hip due to ischemia with consequent aseptic avascular necrosis of the femoral head. This is a systematic literature review carried out in the databases indexed in the Medical Literature Analysis and Retrieval System Online (MEDLINE) in accordance with the precepts established by the PRISMA methodology (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). The aim was to compare the effectiveness of treatment for Legg-Calvé-Perthes disease in relation to its staging: the limits of conservative treatment. Conservative treatment was used in four studies, and most patients under the age of 6.5 had Stulberg I and II results. Older patients, between eight and ten years old, had a relatively better classification when they underwent surgical treatment. In this context, the data collected did not show significant variations; however, it was possible to observe that conservative treatment was more effective in this population, while surgical treatment is better recommended at older ages.

Ankle Osteoarthritis

Ankle osteoarthritis (OA) is less common than knee and hip OA, and 75% to 80% of all presentations are posttraumatic in nature, resulting from either ligamentous or bony injury to the ankle. While the ankle joint cartilage demonstrates capacity for self-restoration, the ankle joint is sensitive to aberrancies in biomechanics and the inflammatory milieu after an injury is thought to contribute to the onset of posttraumatic ankle OA. Conservative care for ankle OA is currently centered on pain reduction, and derivatives that may delay the progression of ankle OA are the subject of ongoing investigation. Surgical management for end-stage ankle OA currently focuses on ankle arthrodesis and total ankle arthroplasty. Specific indication for one procedure over the other is the topic of much debate. While total ankle arthroplasty has become more frequently used with the advent of newer generation systems, ankle arthrodesis may still be favored in younger patients with high-demand occupations.

Mitigating the Risks of Lower Extremity Injuries in Soccer: A Comprehensive Analysis of Lower Extremity Injury Rates in Soccer Between 2014 and 2023

Objective

With events such as the Copa America 2024, the 2026 World Cup, and the arrival of European stars in Major League Soccer (MLS), the already observed and forecasted rise of soccer in the United States (US) seems to be an inevitable outcome. Although regular participation in soccer features several benefits, including increasing cardiovascular health, decreasing stress, and promoting interpersonal relationships, the risk of injury, as is the case in any sport, is ever present. Although many sports that are popular in America feature high rates of concussion, rotator cuff injuries, and general upper extremity injuries, soccer, being more strenuous on the lower-half of the body, features a disproportionate rate of lower extremity injuries. An analysis of the frequencies of these injuries, relative to factors such as year of injury, age, gender, location of injury, and diagnosis of injury, may help organizational bodies and soccer leagues implement new regulations regarding the usage of protective equipment and rules regarding gameplay. This study aims to illuminate these takeaways in an effort to better patient care outcomes in soccer-related injuries.

Method

This paper utilized the National Electronic Injury Surveillance System Database (NEISS) to compile data on lower extremity soccer-related injuries within the defined study period, 2014-2023. Inclusion criteria for the study involved all patients presenting to the emergency department (ED) within the study period and within the defined age range of 0 to 69 years old, with injuries sustained from or related to soccer. Using NEISS, trends were elucidated discriminating based on year of injury, sex, age group, location of injury, and diagnosis group of injury.

Results

Within the defined study period of 10 years, from 2014-2023, there were approximately 843,063 total soccer-related lower extremity injuries which presented to various EDs across the US. Regarding majorities, the most injuries were sustained in 2014 (12.84% of total injuries), most patients sustaining injuries were male (66.6% of all patients), and within the age range of 10-19 years old (63.24% of all patients), with the most instances occurring at age 15. Lower extremity injuries were most reported to be affecting the ankle with 306,797 incidences (36.39% of total injuries seen) and the most frequent diagnosis group was reported to be strains/sprains with 396,420 (47.02% of total injuries seen) total occurrences.

Conclusion

This study analyzes the incidents of lower extremity injuries while participating in soccer for the last 10 years, 2014-2023. The study provides new data regarding the frequency of injuries and their relative rate with respect to year of injury, age group, sex, location of injury, and diagnosis. The results of this study show injury majorities and trends which can be used to dictate changes in regulation regarding gameplay and the utilization of protective equipment in order to mitigate injuries related to the lower extremities in soccer.

Mesenchymal stem cells biological and biotechnological advances: Implications for clinical applications

BACKGROUND

Mesenchymal stem cells (MSCs) are multipotent stem cells that are able to differentiate into multiple lineages including bone, cartilage, muscle and fat. They hold immunomodulatory properties and therapeutic ability to treat multiple diseases, including autoimmune and chronic degenerative diseases. In this article, we reviewed the different biological properties, applications and clinical trials of MSCs. Also, we discussed the basics of manufacturing conditions, quality control, and challenges facing MSCs in the clinical setting.

METHODS

Extensive review of the literature was conducted through the databases PubMed, Google Scholar, and Cochrane. Papers published since 2015 and covering the clinical applications and research of MSC therapy were considered. Furthermore, older papers were considered when referring to pioneering studies in the field.

RESULTS

The most widely studied stem cells in cell therapy and tissue repair are bone marrow-derived mesenchymal stem cells. Adipose tissue-derived stem cells became more common and to a lesser extent other stem cell sources e.g., foreskin derived MSCs. MSCs therapy were also studied in the setting of COVID-19 infections, ischemic strokes, autoimmune diseases, tumor development and graft rejection. Multiple obstacles, still face the standardization and optimization of MSC therapy such as the survival and the immunophenotype and the efficiency of transplanted cells. MSCs used in clinical settings displayed heterogeneity in their function despite their extraction from healthy donors and expression of similar surface markers.

CONCLUSION

Mesenchymal stem cells offer a rising therapeutic promise in various diseases. However, their potential use in clinical applications requires further investigation.

Less inflammatory response in the direct anterior than in the direct lateral approach in patients with femoral neck fractures receiving a total hip arthroplasty: exploratory results from a randomized controlled trial

BACKGROUND AND PURPOSE

It is still debatable which is the least invasive approach to the hip joint in arthroplasty for a femoral neck fracture (FNF). We compared the traditional direct lateral approach (DLA) with the direct anterior approach (DAA) regarding creatine kinase (CK), C-reactive protein (CRP), and hemoglobin (Hb).

METHODS

In a randomized controlled trial, 130 elderly patients with dislocated FNFs treated with total hip arthroplasty (THA) were included. CK, CRP, and Hb were measured preoperatively and on postoperative days 1 to 4 and were compared between the DAA and DLA groups using repeated measures mixed-effect models.

RESULTS

The CK level was significantly higher on the 1st postoperative day in the DLA group, 597 U/L (95% confidence interval [CI] 529-666) vs 461 U/L (CI 389-532), estimated mean difference (MD) 136 U/L (CI 38-235). The CRP levels were significantly higher on postoperative days 3 and 4 in the DLA group, 207 mg/L (CI 189-226) vs 161 mg/L (CI 143-180), estimated MD 46 mg/L (CI 19-72) and 162 mg/L (CI 144-181) vs 121 (CI 102-140), estimated MD 41 mg/L (CI 15-68). Blood loss, expressed as difference in Hb, did not differ between the groups.

CONCLUSION

In an elderly population with FNFs, we found that the DAA, compared with the DLA, results in less CK and CRP increase, but no change in Hb.

Transforaminal lumbar endoscopic discectomy: should we abandon it for L5-S1 foraminal and extraforaminal lumbar disc herniations? A prospective non-randomised study and literature review

PURPOSE

The aim of this study is to investigate the clinical outcomes of transforaminal lumbar endoscopic discectomy (TLED) in patients with L5-S1 lumbar disc herniation (LDH).

MATERIALS AND METHODS

Seventy-five consecutive individuals with diagnosed foraminal/extraforaminal L5-S1 LDH were included in this study. All patients underwent TLED, being subsequently evaluated in a 2-year follow-up period. Assessment was performed preoperatively and at 6 weeks and 3, 6, 12 and 24 months postoperatively. Visual Analogue Scale (distinctly applied for lower limb - VAS-LP and low back - VAS-BP pain) and Short-Form 36 (SF-36) Medical Health Survey Questionnaire were implemented to assess pain and health-related quality of life (HRQoL) of enrolled individuals, respectively.

RESULTS

No major perioperative complications were observed. Recorded values of all studied indices were demonstrated to feature a clinically and statistically significant amelioration at 6 weeks, presenting lesser improvement at 3 months with subsequent stabilisation. VAS-LP and VAS-BP values were displayed to reach a plateau in 6 months postoperatively, whereas all parameters of SF-36 continued to present a statistically significant improvement until the end of follow-up at 2 years.

CONCLUSIONS

TLED represent a safe and efficient technique in terms of diminishing perceived pain and improving HRQoL in patients with L5-S1 LDHs. However, specific patient- and technique-related circumstances on the ground of low surgical experience may limit its effectiveness in these patients.

Recent advances of bone tissue engineering: carbohydrate and ceramic materials, fundamental properties and advanced biofabrication strategies ‒ a comprehensive review

Bone is a dynamic tissue that can always regenerate itself through remodeling to maintain biofunctionality. This tissue performs several vital physiological functions. However, bone scaffolds are required for critical-size damages and fractures, and these can be addressed by bone tissue engineering. Bone tissue engineering (BTE) has the potential to develop scaffolds for repairing critical-size damaged bone. BTE is a multidisciplinary engineered scaffold with the desired properties for repairing damaged bone tissue. Herein, we have provided an overview of the common carbohydrate polymers, fundamental structural, physicochemical, and biological properties, and fabrication techniques for bone tissue engineering. We also discussed advanced biofabrication strategies and provided the limitations and prospects by highlighting significant issues in bone tissue engineering. There are several review articles available on bone tissue engineering. However, we have provided a state-of-the-art review article that discussed recent progress and trends within the last 3-5 years by emphasizing challenges and future perspectives.

Preliminary study of extracorporeal shock wave alleviating joint capsule fibrosis caused by internal bleeding of knee joint in rats

PURPOSE

Joint contracture is a common disease in clinical practice, joint bleeding is an important factor affecting the progression of joint contracture. This study aimed to explore the effect of extracorporeal shock wave on alleviating joint capsule fibrosis caused by intra-articular hemorrhage in rats.

METHODS

Forty two SD rats were randomly divided into seven groups. Perform simple fixation and fixation after blood injection separately. Measure the range of motion of each group's knee joints and calculate the corresponding degree of contraction. Use HE staining and Masson staining to detect the number of anterior joint capsule cells and collagen deposition. Detection of changes in Wnt1, β-catenin protein expression in joint capsule using Western blotting.

RESULTS

Compared to group C, the degree of knee joint contracture in M1 and M2 groups of rats increased, and collagen deposition, cell number and Wnt1, β-catenin protein expression also increased accordingly. Compared to M1 and M2 groups, the degree of knee contraction in E1 and E2 groups were reduced, while collagen deposition, cell number and Wnt1, β-catenin protein expression were decreased, and the degree of joint contracture in NR1 and NR2 groups showed no significant improvement. Compared to NR1 and NR2 groups, the degree of knee contraction in E1 and E2 groups were reduced, while collagen deposition, cell number and Wnt1, β-catenin protein expression were decreased.

CONCLUSIONS

Both rat models of knee joint contracture were successful, and joint bleeding can exacerbate joint contracture. Extracorporeal shock waves alleviate joint capsule fibrosis caused by intra-articular bleeding in rats.

Mechanisms and risk factors associated with spinal cord injury, facet fracture, and level of dislocation, in occupants with cervical spine dislocations sustained in motor vehicle crashes

OBJECTIVE

Motor vehicle crashes (MVCs) are the leading cause of cervical spine dislocation. The mechanisms underlying this injury are unclear, limiting the development of injury prevention devices and strategies. MVC databases contain occupant, medical, vehicle, and crash details that are not routinely collected elsewhere, providing a unique resource for investigating injury mechanisms and risk factors. In this study, a comprehensive standalone analysis of cervical spine dislocations captured in MVC databases was performed.

METHODS

Epidemiologic, biomechanical, and injury data were extracted from three MVC databases. Logistic regression models were developed to determine the occupant, vehicle, and crash characteristics, as well as the global (inertial or impact) and regional (flexion, compression, etc.) loading mechanisms associated with the level of cervical spine dislocation (axial or sub-axial), and the occurrence of spinal cord injury (SCI) or facet fracture concomitant to dislocation.

RESULTS

There was no association between global or regional injury mechanisms and the level of cervical spine dislocation. Sub-axial dislocations were typically due to head/face impact with the airbag or upper interior components, or a result of seatbelt restraint of the torso. Higher occupant age, lower BMI, partial/no ejection, and frontal and side configuration crashes (compared to rollovers) were associated with a higher likelihood of sub-axial, versus axial, dislocation. Amongst all dislocations, an increased likelihood of SCI was associated with impact injuries, airbag non-deployment, and complete ejection, while concomitant facet fracture was associated with the presence of regional compression. Severe crashes, partial ejections, and "utility vehicles" and "vans and trucks" (compared with "passenger vehicles") were associated with a higher risk of facet fracture concomitant to sub-axial dislocation.

CONCLUSION

The findings of this study may be used to inform the loading modes to be simulated in future ex vivo or computational models seeking a better understanding of cervical spine dislocations.

Health-related outcomes with supervised exercise and myofascial release versus only supervised exercise in subacromial pain syndrome: a randomized controlled single-blind study

BACKGROUND

Myofascial tissue plays a critical role in shoulder joint mobility disorders. Myofascial release therapy (MFR) is frequently utilized to restore the extensibility of fascial tissue and is considered beneficial for various clinical conditions such as low back pain and ankle injuries. However, no studies have yet evaluated the effects of MFR on periscapular muscles activation and shoulder mobility in patients with subacromial pain syndrome(SAPS).

OBJECTIVE

The purpose of this study was to compare the effectiveness of MFR combined with supervised exercise(SE) and SE alone in patients with SAPS.

DESIGN

Assessor-blinded randomized controlled trial.

SETTING

Sir Run Run Shaw Hospital, Zhejiang University School of Medicine.

SUBJECTS

Subacromial pain syndrome patients.

METHODS

Fifty participants were divided into two groups: SE group and MFR + SE group, each group 25 cases. Both treatment methods were performed 5 times a week for 4 weeks.

MAIN MEASURES

Shoulder pain severity was assessed by visual analog scale (VAS); shoulder range of motion (ROM) by a goniometer; functionality by shoulder Pain and Disability Index (SPADI); and periscapular muscles activation by sEMG. All measurements were evaluated both pre- and post-treatment.

RESULTS

An ANOVA analysis indicated no significant group by time interactions for flexion ROM and resting VAS (p > 0.05). However, significant group by time interactions were found for SPADI, abduction and external rotation ROM, and activity VAS (p < 0.05). Post-hoc tests revealed significant improvements in SPADI, abduction and external rotation ROM, and activity VAS in both groups compared to pre-treatment (p < 0.05). Additionally, there were significant group by time interactions for the sEMG values of the upper trapezius and serratus anterior (p < 0.05). Post-hoc tests showed that compared to pre-treatment, the MFR + SE group had decreased upper trapezius sEMG values and increased serratus anterior sEMG values(p < 0.05), while the SE group showed increased serratus anterior sEMG values(p < 0.05). After the 4-week intervention, there were significant between-group differences in SPADI, abduction and external rotation ROM, activity VAS, and sEMG values of the upper trapezius and serratus anterior(p < 0.05).

CONCLUSION

Four weeks of MFR combined with SE can increase shoulder ROM, improve pain, and thus enhancing functional activities in patients with SAPS. Additionally, it can further improve the balance between the upper trapezius and serratus anterior to improve the dynamics of the periscapular muscles.

TRIAL REGISTRY NUMBER

ChiCTR2200061054. Date of registration 15/06/2022.

Effective Management of Methicillin-Resistant Shoulder Septic Arthritis Using Continuous Local Antibiotic Perfusion: A Case Study and Long-Term Follow-Up

BACKGROUND Septic arthritis of the shoulder is a rare and challenging condition to treat. Typically, arthroscopic debridement is the common approach. Specifically, septic arthritis of the shoulder caused by methicillin-resistant bacteria is extremely difficult to cure due to persistent infection and limited antibiotic options. However, recent studies have demonstrated that continuous local antibiotic perfusion (CLAP) can provide favorable results for bone and soft tissue infections. By administering the antibiotics required to suppress the biofilm, CLAP can effectively treat the infection while sparing the tissue. CASE REPORT A 46-year-old woman undergoing long-term hemodialysis treatment for congenital anomalies of the kidney and urinary tract experienced severe pain in the left shoulder joint during glucocorticoid treatment for amyloid arthritis of the right shoulder. Despite the absence of fever, significant swelling and fluid accumulation were observed in the left shoulder joint, leading to the performance of a puncture. A bacterial examination of the puncture fluid detected methicillin-resistant coagulase-negative Staphylococcus epidermidis (MRCNS). In this report, we present a case in which CLAP was administered for septic arthritis of the shoulder caused by methicillin-resistant bacteria. After irrigation debridement, the patient received intravenous antibiotics and CLAP. Following the initiation of treatment, the dosage of antibiotics was adjusted while performing therapeutic drug monitoring. An early improvement in the inflammatory response and sedation of the infection was observed, with no relapse after 2 years. CONCLUSIONS Septic arthritis can lead to serious functional impairment if left untreated. CLAP is a promising option for managing septic arthritis of the shoulder.

[Arthroplasty and oral health-an overview]

Despite limited evidence for a preoperative dental screening examination and needs-based focal rehabilitation, as well as the need for antibiotic prophylaxis prior to invasive dental procedures, oral health is and remains a relevant topic in arthroplasty. The aspect of oral health should not be neglected in the future in connection with periprosthetic infections and should continue to be the subject of intensive research. The frequency of conspicuous dental findings in middle and old age underlines the importance of this problem. A dental examination prior to arthroplasty implantation can generally contribute to minimizing the risk of arthroplasty infection. It would be desirable for further studies to provide evidence on this topic in order to make recommendations for action. Independently of this, the development of an interdisciplinary guideline (arthroplasty and dentistry) on this topic should be encouraged. This could help to ensure that standardized treatment procedures are integrated into everyday clinical practice across the board.

Feasibility of using diamond-like carbon films in total joint replacements: a review

Diamond-like Carbon (DLC) has been used as a coating material of choice for a variety of technological applications owing to its favorable bio-tribo-thermo-mechanical characteristics. Here, the possibility of bringing DLC into orthopedic joint implants is examined. With ever increasing number of patients suffering from osteoarthritis as well as with the ingress of the osteoarthritic joints' malaise into younger and more active demographics, there is a pressing need to augment the performance and integrity of conventional total joint replacements (TJRs). Contemporary joint replacement devices use metal-on-polymer articulations to restore function to worn, damaged or diseased cartilage. The wear of polymeric components has been addressed using crosslinking and antioxidants; however, in the context of the metallic components, complications pertaining to corrosion and metal ion release inside the body still persist. Through this review article, we explore the use of DLC coatings on metallic bearing surfaces and elucidate why this technology might be a viable solution for ongoing electrochemical challenges in orthopedics. The different characteristics of DLC coatings and their feasibility in TJRs are examined through assessment of tribo-material characterization methods. A holistic characterization of the coating-substrate interface and the wear performance of such systems are discussed. As with all biomaterials used in TJRs, we need mindful consideration of potential in-vivo challenges. We present a few caveats for DLC coatings including delamination, hydrophobicity, and other conflicting as well as outdating findings in the literature. We recommend prudently exploring DLC films as potential coatings on metallic TJR components to solve the problems pertaining to wear, metal ion release, and corrosion. Ultimately, we advise bringing DLC into clinical use only after addressing all challenges and concerns outlined in this article.

Agreement between non-invasive and invasive arterial blood pressure during surgery in the prone position: an error grid analysis

PURPOSE

Prone position has recently gained renewed importance as a treatment for acute respiratory distress syndrome and spine and brain surgeries. Our study aimed to perform an error grid analysis to examine the clinical discrepancies between arterial blood pressure (ABP) and non-invasive blood pressure (NIBP) in the prone position and to investigate the risk factors influencing these differences.

METHODS

Error grid analysis was performed retrospectively on 1389 pairs of 100 consecutive prone positioning cases. This analysis classifies the difference between the two methods into five clinically relevant zones, from "no risk" to "dangerous risk". Additionally, multivariable ordinal logistic regression analysis was conducted to evaluate the relationship between the risk zones of mean blood pressure (MBP), as classified by error grid analysis and the covariate of interest.

RESULTS

Error grid analysis showed that the proportions of measurement pairs in risk zones A-E for systolic blood pressure were 96.8%, 3.2%, 0.1%, 0%, and 0%, respectively. In contrast, the MBP proportions were 74.0%, 25.1%, 0.9%, 0.1%, and 0%. Multivariable ordinal logistic regression analysis revealed that the position of arms (next to the head) was a significant factor (adjusted odds ratio: 4.35, 95% CI: 2.38-8.33, P < 0.001).

CONCLUSION

Error grid analysis revealed a clinically unacceptable discrepancy between ABP and NIBP for MBP during prone positioning surgery. The position of the arms next to the head was associated with increased clinical discrepancy between the two MBP measurement methods.

Hepatocyte Growth Factor Delivery to Injured Cervical Spinal Cord Using an Engineered Biomaterial Protects Respiratory Neural Circuitry and Preserves Functional Diaphragm Innervation

A major portion of spinal cord injury (SCI) cases occur in the cervical region, where essential components of the respiratory neural circuitry are located. Phrenic motor neurons (PhMNs) housed at cervical spinal cord level C3-C5 directly innervate the diaphragm, and SCI-induced damage to these cells severely impairs respiratory function. In this study, we tested a biomaterial-based approach aimed at preserving this critical phrenic motor circuitry after cervical SCI by locally delivering hepatocyte growth factor (HGF). HGF is a potent mitogen that promotes survival, proliferation, migration, repair, and regeneration of a number of different cell and tissue types in response to injury. We developed a hydrogel-based HGF delivery system that can be injected into the intrathecal space for local delivery of high levels of HGF without damaging the spinal cord. Implantation of HGF hydrogel after unilateral C5 contusion-type SCI in rats preserved diaphragm function, as assessed by in vivo recordings of both compound muscle action potentials and inspiratory electromyography amplitudes. HGF hydrogel also preserved PhMN innervation of the diaphragm, as assessed by both retrograde PhMN tracing and detailed neuromuscular junction morphological analysis. Furthermore, HGF hydrogel significantly decreased lesion size and degeneration of cervical motor neuron cell bodies, as well as reduced levels surrounding the injury site of scar-associated chondroitin sulfate proteoglycan molecules that limit axon growth capacity. Our findings demonstrate that local biomaterial-based delivery of HGF hydrogel to injured cervical spinal cord is an effective strategy for preserving respiratory circuitry and diaphragm function.

Is a Plantarflexed First Ray the Primary Deformity In Children With Cavovarus Feet Secondary to Charcot-Marie-Tooth Disease? A Pedobarographic Analysis

BACKGROUND

Charcot-Marie-Tooth disease (CMT) is a common cause of cavovarus foot deformity in children. This deformity is often quoted as being forefoot driven, with a primary deformity of first ray plantarflexion driving the hindfoot into varus by virtue of the tripod effect of the foot, which was hypothesized by Coleman and is commonly assessed clinically using his eponymous block test. The primary goal of this study was to objectively investigate this hypothesis using dynamic pedobarography.

METHODS

A review of the gait lab archives at a large tertiary referral center was carried out to identify children with CMT who had foot photos and dynamic pedobarographic data. Two orthopaedic surgeons then determined the weight-bearing hindfoot alignment of these children using clinical photography. The order of contact during gait of the first metatarsal relative to the fifth metatarsal was then obtained from the dynamic pedobarographic data.

RESULTS

One hundred eighteen feet from 60 children with CMT met the study inclusion criteria. Sixty-eight varus feet were compared with 50 nonvarus feet. First ray contact occurred before fifth ray contact in only 39.7% of the varus feet compared with 34.0% of the nonvarus feet, which did not meet statistical significance (P=0.526).

CONCLUSIONS

In this cohort, dynamic pedobarography did not consistently demonstrate the first metatarsal contact occurring before the fifth metatarsal contact in children with varus feet secondary to CMT. While nearly 40% of the feet did make initial contact on the first ray, 60% of the feet landed in varus before the first ray made contact, leading us to believe that the foot is prepositioned in varus. This may be in part due to the progressive muscle imbalance and secondary deformity that has occurred. Surgical management of these children should take this.

MRI and single-cell RNA sequence results reveal the influence of anterior talofibular ligament injury on osteochondral lesions of the talus

Anterior talofibular ligament injuries and osteochondral lesions of the talus present unique challenges to orthopedic surgeons. This study aimed to investigate the relevant relationship between them by analyzing the Magnetic resonance imaging (MRI) results of clinical patients and single-cell RNA sequence (scRNA seq) results of healthy talus cartilage to discuss the risk factors. Data from 164 patients from 2018 to 2023 was retrospectively analyzed. The correlation analysis between ATFL injury grade and the Hepple stage of OLT determined by MRI was performed. Publicly available single-cell RNA datasets were collected. Single-cell RNA datasets from five volunteers of healthy talus cartilage were analyzed. ATFL injury grade was relevant with the Hepple stage of OLT (P < 0.05). The results of multivariate logistic regression analysis showed that injured area was the independent influencing factor of the incidence rate and the severity of OLT (P < 0.05). The Hepple stage of OLT was relevant with AOFAS and VAS (P < 0.05). Single-cell RNA sequence results showed that among the 9 subtypes of chondrocytes, the interaction strength between HTC-A and HTC-B is the highest. Their physical interactions are mainly achieved through the CD99 signaling pathway, and factor interactions are mainly achieved through the ANGPTL signaling pathway. Anterior talofibular ligament injury may lead to osteochondral lesions of the talus. Early medical intervention should be carried out for ligament injuries to restore joint stability and avoid cartilage damage.

Evaluation of orthobiological ozonized platelet-rich plasma therapy post-arthroscopic suturing and lone partial meniscectomy in the treatment of meniscal tears within degenerative knee osteoarthritis

BACKGROUND

Knee joint osteoarthritis (OA)-related meniscal tears are still sometimes treated in centers by arthroscopic partial meniscectomy (APM), which is then followed by a solitary physical therapy regimen.

OBJECTIVE

The present study was conducted to compare the efficacy of intra-articular injection of ozonized platelet-rich plasma (PRP) and hyaluronic acid following arthroscopic suturing, and APM to treat meniscal tear degenerative type.

METHODS

In a randomized trial of prospective comparative research, 104 patients, all of whom had meniscal tears due to OA of the knee, were randomly divided into two groups. The participants in Group A (55 patients) were given intra-articular ozonized PRP and hyaluronate therapeutics, following arthroscopic suturing of meniscal tear treatment (ASMT) of degenerative knee joint OA. Group B (49 patients) was prepared for APM alone. Both groups were followed by physical therapy and a follow up visit throughout 12, 24, and 36 months. The WOMAC and Lequesne scores were evaluated.

RESULTS

At every follow up visit for 6, 12, and 24, months, there was a significant decline in the mean of WOMAC and Lequesne scores in Groups A and B relative to baseline. Additionally, Group A significantly (P<0.0001) outperformed Group B at 12, 24, and 36 months for both Lequesne's and WOMAC scores. There were infection, stiffness, and widespread OA knee degeneration detected in Group B while no serious adverse effects were observed in Group A.

CONCLUSION

The study's findings demonstrated that physical and intra-articular orthobiological ozonized PRP and hyaluronate therapies were more effective than APM in treating degenerative knee joint OA.

A biomechanical study comparing the compression force and osseous area of contact of two screws fixation techniques used in ankle joint arthrodesis model

INTRODUCTION

Arthrodesis of a (diseased) ankle joint is usually performed to achieve pain relief and stability. One basic principle of arthrodesis techniques includes rigid fixation of the surfaces until union. It seems plausible that stable anchoring and homogeneous pressure distribution should be advantageous, however, it has not been investigated yet. The aim is to achieve uniform compression, as this is expected to produce favorable results for the bony fusion of the intended arthrodesis. Numerous implants with different biomechanical concepts can be used for ankle fusion. In this study, headless compression screws (HCS, DePuy Synthes, Zuchwil, Switzerland) were compared biomechanically to an alternative fixation System, the IOFix device (Extremity Medical, Parsippany, NJ, USA) in regard to the distribution of the compression force (area of contact) and peak compression in a sawbone arthrodesis-model (Sawbones® Pacific Research Laboratories, Vashon, WA, USA). This study aims to quantify the area of contact between the bone interface that can be obtained using headless compression screws compared to the IOFix. In current literature, it is assumed, that a large contact surface with sufficient pressure between the bones brings good clinical results. However, there are no clinical or biomechanical studies, that describe the optimal compression pressure for an arthrodesis.

MATERIAL AND METHODS

Two standardized sawbone blocks were placed above each other in a custom-made jig. IOFix and headless compression screws were inserted pairwise parallel to each other using a template for a uniform drilling pattern. All screws were inserted with a predefined torque of 0.5 Nm. Pressure transducers positioned between the two sawbone blocks were compressed for the measurement of peak compression force, compression distribution, and area of contact.

RESULTS

With the IOFix, the compression force was distributed over significantly larger areas compared to the contact area of the HCS screws, resulting in a more homogenous contact area over the entire arthrodesis surface. Maximum compression force showed no significant difference.

CONCLUSION

The IOFix system distributes the compression pressure over a much larger area, resulting in more evenly spread compression at the surface. Clinical studies must show whether this leads to a lower pseudarthrosis rate.

Clinical outcomes and survival rates of a uncemented modular revision stem system in hip arthroplasty: a 10-year single-institution study on a frail population

INTRODUCTION

The increasing prevalence of primary hip arthroplasty has led to a parallel rise in revision cases. Femoral revision often entails compromised bone integrity, requiring consideration of various solutions for optimal reconstructive options. Despite technological advancements, there is limited evidence on the clinical outcomes of the latest modular revision stems. This study aimed to evaluate the clinical outcomes and survival rates of next generation uncemented modular revision stem in patients undergoing hip revision surgery.

MATERIALS AND METHODS

This retrospective single-center study assessed the survival and failure causes of a specific uncemented modular stem in 48 patients undergoing hip revision surgery between 2012 and 2022. Data included preoperative parameters, surgical details, and postoperative outcomes measured through clinical and radiographic assessments. Forty-eight patients (25 males, 23 females; mean age 72 years) were included, with a mean Charlson Comorbidity Index of 5. Preoperative diagnoses varied, with periprosthetic joint infection (PJI) being the most common (45.8%), followed by periprosthetic fractures (27.1%). Partial revisions occurred in 60.4%, total revisions in 39.6%. According to Paprosky classification of femoral bone loss, type II and III were the most represented, respectively 35.4% and 50%.

RESULTS

At a mean follow-up of 4.6 years, stem survival was 92.5%. Complications (20%) included dislocation, PJI, fracture, and loosening; the overall reoperation rate was 12.5%. The SF-12 physical score was 43.6, while the mental score was 51.1. The HOOS score was 71.8, and the HHS score was 71.4. Radiographic analysis identified nonprogressive osteolysis in 15.1% of patients.

CONCLUSIONS

This study on this uncemented modular revision stem demonstrated favorable outcomes in an elder fragile population with moderate to severe femoral bone loss. The implant's modularity provides versatility in addressing various defects, without any implant breakage observed during the study period. Literature comparison highlighted similar outcomes despite sample size differences. The promising results warrant continued investigation into the long-term survivorship of this modular stem system.

Step-cut osteotomy for cubitus varus deformity with application of patient-specific instrument in children: a preliminary report

PURPOSE

The step-cut osteotomy has been recognized as a valuable approach for addressing cubitus varus deformity, albeit one that necessitates technical proficiency. This study aims to evaluate the efficacy of the modified step-cut osteotomy technique in conjunction with patient-specific instruments by clinical and radiological assessment.

METHODS

We conducted a retrospective review of patients who underwent modified step-cut osteotomy with the use of patient-specific instruments in conjunction with Kirschner wires fixation for the correction of cubitus varus deformity between April 2016 and April 2022. Follow-up was performed for a minimum of two years, during which pre-operative and post-operative clinical and radiological parameters were compared.

RESULTS

Fifteen patients were enrolled in this study. The mean pre-operative humeral-elbow-wrist (HEW) of the affected side was -21.7° (ranging from -14° to -34°), while the normal side was 9.4° (ranging from 5° to 15°). The post-operation HEW of affected side was 9° (ranging from 4° to 16°). There was no significant difference between the normal side and affected side after operation (p = 0.74). Pre-operative range of motion in the affected side was 130°, while the post-operative range of motion was 132°. Fourteen patients (93.3%) were pleased with the overall appearance of their elbow. None lazy-S deformity was observed in these cases. There were no major complications.

CONCLUSION

The modified step-cut osteotomy technique, utilizing patient-specific instrument in conjunction with Kirschner wires fixation was found to be a safe, reliable, and technically easy procedure for correcting cubitus varus deformity.

Calibration of Aseptic Loosening Simulation for Coatings Osteoinductive Effect

The risk of aseptic loosening in cementless hip stems can be reduced by improving osseointegration with osteoinductive coatings favoring long-term implant stability. Osseointegration is usually evaluated in vivo studies, which, however, do not reproduce the mechanically driven adaptation process. This study aims to develop an in silico model to predict implant osseointegration and the effect of induced micromotion on long-term stability, including a calibration of the material osteoinductivity with conventional in vivo studies. A Finite Element model of the tibia implanted with pins was generated, exploiting bone-to-implant contact measures of cylindrical titanium alloys implanted in rabbits' tibiae. The evolution of the contact status between bone and implant was modeled using a finite state machine, which updated the contact state at each iteration based on relative micromotion, shear and tensile stresses, and bone-to-implant distance. The model was calibrated with in vivo data by identifying the maximum bridgeable gap. Afterward, a push-out test was simulated to predict the axial load that caused the macroscopic mobilization of the pin. The bone-implant bridgeable gap ranged between 50 μm and 80 μm. Predicted push-out strength ranged from 19 N to 21 N (5.4 MPa-3.4 MPa) depending on final bone-to-implant contact. Push-out strength agrees with experimental measurements from a previous animal study (4 ± 1 MPa), carried out using the same implant material, coated, or uncoated. This method can partially replace in vivo studies and predict the long-term stability of cementless hip stems.

Unmasking Pott Disease: A Diagnostic Challenge Mimicking Metastatic Lung Cancer - A Case Report

BACKGROUND Tuberculosis spondylitis, also known as Pott disease, is a rare form of the ancient infectious disease tuberculosis. It bears a complex clinical and radiological profile, often necessitating an extensive differential diagnostic approach for accurate identification. The disease was named in honor of the first diagnosed patient, highlighting its historical significance. CASE REPORT We report a case involving a 69-year-old male initially admitted to the Pulmonology Department under the suspicion of a left lung tumor, as indicated by a chest X-ray. A subsequent CT scan revealed a tumor-hilar mass, enlarged subcarineal lymph nodes, and a pathological mass at the C6/C7 vertebral level. Despite negative tuberculosis tests, the patient was misdiagnosed with disseminated lung cancer with spinal metastases. Following radiotherapy targeting the cervical and thoracic spine, the definitive diagnosis of spinal tuberculosis was confirmed via histopathological examination from an open biopsy of the C6 and C7 vertebrae. CONCLUSIONS Tuberculosis can present with an insidious and misleading clinical picture, often mimicking other diseases such as cancer. Early and accurate diagnostic processes are crucial for effective treatment. This case underscores the importance of considering tuberculosis in the differential diagnosis, especially when clinical presentations are ambiguous.

Hydrogel-based therapeutic strategies for spinal cord injury repair: Recent advances and future prospects

Spinal cord injury (SCI) is a debilitating condition that can result in significant functional impairment and loss of quality of life. There is a growing interest in developing new therapies for SCI, and hydrogel-based multimodal therapeutic strategies have emerged as a promising approach. They offer several advantages for SCI repair, including biocompatibility, tunable mechanical properties, low immunogenicity, and the ability to deliver therapeutic agents. This article provides an overview of the recent advances in hydrogel-based therapy strategies for SCI repair, particularly within the past three years. We summarize the SCI hydrogels with varied characteristics such as phase-change hydrogels, self-healing hydrogel, oriented fibers hydrogel, and self-assembled microspheres hydrogel, as well as different functional hydrogels such as conductive hydrogels, stimuli-responsive hydrogels, adhesive hydrogel, antioxidant hydrogel, sustained-release hydrogel, etc. The composition, preparation, and therapeutic effect of these hydrogels are briefly discussed and comprehensively evaluated. In the end, the future development of hydrogels in SCI repair is prospected to inspire more researchers to invest in this promising field.

Bowel and Bladder Dysfunction after SCI: A Comparison between India and Canada

Background

The inclusion of people living with spinal cord injury (SCI) in research has allowed for an informed understanding of priorities of recovery of which bowel dysfunction and bladder dysfunction have been continuously identified. Research has also demonstrated the global disparities in SCI outcomes particularly when comparing high- and low-income countries. Currently, there is a lack of direct comparison between countries when assessing SCI outcomes.

Objectives

This is an exploratory study to better understand bowel and bladder dysfunction amongst individuals with SCI in India and Canada.

Methods

Data from 33 participants were analyzed. Participants completed an online questionnaire assessing demographic information and the Neurogenic Bowel Dysfunction (NBD) score, Wexner score, Neurogenic Bladder Symptom Score (NBSS), and the Incontinence Quality of Life Instrument (I-QOL). Continuous data were compared using t tests. For not normally distributed data, the independent Mann-Whitney U test was used. Categorical variables were evaluated for association using Fisher's exact or chi-square test, depending on the sample size.

Results

Independent Mann-Whitney U test demonstrated that the Canadian participants had poorer bowel function with higher total NBD scores (p = .007) and less frequent bowel movements (p = .036), and they were more likely to experience uneasiness, headaches, and perspiration during bowel movements (p < .001). NBSS results indicated a small but significantly higher proportion of the Indian participants were unsatisfied or unhappy with their bladder function (p = .049). The distribution of Wexner and I-QOL scores were the same across countries.

Conclusion

Potential explanations for differences include lifestyle, management, financial resources, patient and caregiver education, and societal pressures, which are all heavily influenced by cultural, geographical, and economic circumstances.

Understanding the Structure-Function Relationship through 3D Imaging and Biomechanical Analysis: A Novel Methodological Approach Applied to Anterior Cruciate Ligaments

Understanding the microstructure of fibrous tissues, like ligaments, is crucial due to their nonlinear stress-strain behavior from unique fiber arrangements. This study introduces a new method to analyze the relationship between the microstructure and function of anterior cruciate ligaments (ACL). We tested the procedure on two ACL samples, one from a healthy individual and one from an osteoarthritis patient, using a custom tensioning device within a micro-CT scanner. The samples were stretched and scanned at various strain levels (namely 0%, 1%, 2%, 3%, 4%, 6%, 8%) to observe the effects of mechanical stress on the microstructure. The micro-CT images were processed to identify and map fibers, assessing their orientations and volume fractions. A probabilistic mathematical model was then proposed to relate the geometric and structural characteristics of the ACL to its mechanical properties, considering fiber orientation and thickness. Our feasibility test indicated differences in mechanical behavior, fiber orientation, and volume distribution between ligaments of different origins. These indicative results align with existing literature, validating the proposed methodology. However, further research is needed to confirm these preliminary observations. Overall, our comprehensive methodology shows promise for improving ACL diagnosis and treatment and for guiding the creation of tissue-engineered grafts that mimic the natural properties and microstructure of healthy tissue, thereby enhancing integration and performance in biomedical applications.

Protective effect of modified lange "second position" for developing avascular necrosis following closed reduction for developmental dysplasia of the hip

BACKGROUND

Developmental Dysplasia of the Hip (DDH) is a condition affecting hip joint development in children, presenting multiple manifestations. Immobilization methods to ensure hip concentricity, such as the human position and modified Lange position, vary in effectiveness and risks, especially avascular necrosis. The purpose of this study was to identify whether closed reduction (CR), with two different immobilization techniques, is effective in avoiding complications such as residual hip dysplasia (RHD), re-dislocation, and Avascular Necrosis (AVN).

METHODS

A total of 66 patients with DDH (84 hips) were treated with two different techniques of immobilization (groups A and B); the mean age at the time of reduction was 8 (6-13) months. The rates of RHD, Re-dislocation, and AVN were determined with a minimum follow-up of 48 months in both techniques.

RESULTS

The Chi-square analysis conducted across the study groups unveiled that patients in Group B demonstrated a protective effect against AVN compared to those in Group A (OR: 0.248, 95% CI: 0.072-0.847, p = 0.026). However, no statistically significant differences were found between the groups concerning RHD (p = 0.563) and re-dislocation (p = 0.909).

CONCLUSIONS

After the initial Human Position immobilization, the second cast with the modified Lange "second position" demonstrated a protective effect compared with maintaining the Human Position immobilization throughout the immobilization period, reducing the likelihood of AVN development in patients undergoing closed reduction for developmental dysplasia of the hip.

Fixation options for total knee arthroplasty: a comprehensive literature review

Total knee arthroplasty is a consistently successful, cost-efficient, and highly effective surgical procedure for treating severe knee osteoarthritis. The success and longevity of total knee arthroplasty depend significantly on the fixation method used to secure the prosthetic components. This comprehensive review examines the primary fixation methods (cemented, cementless, and hybrid fixation), analysing their biomechanics, clinical outcomes, advantages, and disadvantages, focusing on recent advances and trends in total knee arthroplasty fixation.

Exploring vertebral bone density changes in a trunk with adolescent idiopathic scoliosis: a mechanobiological modeling investigation of intact and unilaterally paralyzed muscles

This study aimed to elucidate the vertebral bone density variations associated with adolescent idiopathic scoliosis (AIS), specifically examining the impact of unilateral muscle paralysis using an integrated approach combining Frost's Mechanostat theory, a three-dimensional subject-specific finite element model and a musculoskeletal model of the L2 vertebra. The findings revealed a spectrum of bone density values ranging from 0.29 to 0.31 g/cm3, along with vertebral micro-strain levels spanning from 300 to 2200, consistent with existing literature. Furthermore, the ratio of maximum von Mises stress between the concave and convex side in the AIS model with intact muscles was approximately 1.08, which decreased by 4% due following unilateral paralysis of longissimus thoracis pars thoracic muscle. Overall, this investigation contributes to a deeper understanding of AIS biomechanics and lays the groundwork for future research endeavors aimed at optimizing clinical management approaches for individuals with this condition.

The effect of intra spinal administration of cerium oxide nanoparticles on central pain mechanism: An experimental study

This study investigated Cerium oxide nanoparticles (CeONPs) effect on central neuropathic pain (CNP). The compressive method of spinal cord injury (SCI) model was used for pain induction. Three groups were formed by a random allocation of 24 rats. In the treatment group, CeONPs were injected above and below the lesion site immediately after inducing SCI. pain symptoms were evaluated using acetone, Radian Heat, and Von Frey tests weekly for six weeks. Finally, we counted fibroblasts using H&E staining. We evaluated the expression of Cx43, GAD65 and HDAC2 proteins using the western blot method. The analysis of results was done by PRISM software. At the end of the study, we found that CeONPs reduced pain symptoms to levels similar to those observed in normal animals. CeONPs also increased the expression of GAD65 and Cx43 proteins but did not affect HDAC2 inhibition. CeONPs probably have a pain-relieving effect on chronic pain by potentially preserving GAD65 and Cx43 protein expression and hindering fibroblast infiltration.

Comparative effectiveness of denosumab vs alendronate among postmenopausal women with osteoporosis

Although clinical trials have shown that denosumab significantly increases bone mineral density at key skeletal sites more than oral bisphosphonates, evidence is lacking from head-to-head randomized trials evaluating fracture outcomes. This retrospective cohort study uses administrative claims data from Medicare fee-for service beneficiaries to evaluate the comparative effectiveness of denosumab vs alendronate in reducing fracture risk among women with PMO in the US. Women with PMO ≥ 66 yr of age with no prior history of osteoporosis treatment, who initiated denosumab (n = 89 115) or alendronate (n = 389 536) from 2012 to 2018, were followed from treatment initiation until the first of a specific fracture outcome, treatment discontinuation or switch, end of study (December 31, 2019), or other censoring criteria. A doubly robust inverse-probability of treatment and censoring weighted function was used to estimate the risk ratio associated with the use of denosumab compared with alendronate for hip, nonvertebral (NV; includes hip, humerus, pelvis, radius/ulna, other femur), non-hip nonvertebral (NHNV), hospitalized vertebral (HV), and major osteoporotic (MOP; consisting of NV and HV) fractures. Overall, denosumab reduced the risk of MOP by 39%, hip by 36%, NV by 43%, NHNV by 50%, and HV fractures by 30% compared with alendronate. Denosumab reduced the risk of MOP fractures by 9% at year 1, 12% at year 2, 18% at year 3, and 31% at year 5. An increase in the magnitude of fracture risk reduction with increasing duration of exposure was also observed for other NV fracture outcomes. In this cohort of almost half-a-million treatment-naive women with PMO, we observed clinically significant reductions in the risk of MOP, hip, NV, NHNV, and HV fractures for patients on denosumab compared with alendronate. Patients who remained on denosumab for longer periods of time experienced greater reductions in fracture risk.

Tracing the evolving dynamics and research hotspots of spinal cord injury and surgical decompression from 1975 to 2024: a bibliometric analysis

Background

Exploration of the benefits and timing of surgical decompression in spinal cord injury (SCI) has been a research hotspot. However, despite the higher volume and increasing emphasis on quality there remains no bibliometric view on SCI and surgical decompression. In this study, we aimed to perform bibliometric analysis to reveal the core countries, affiliations, journals, authors, and developmental trends in SCI and surgical decompression across the past 50 years.

Methods

Articles and reviews were retrieved from web of science core collection between 1975 and 2024. The bibliometrix package in R was used for data analysis and visualizing.

Results

A total of 8,688 documents were investigated, indicating an ascending trend in annual publications. The USA and China played as the leaders in scientific productivity. The University of Toronto led in institutional productions. Core authors, such as Michael G. Fehlings, showed high productivity, and occasional authors showed widespread interests. Core journals like Spine and Spinal Cord served as beacons in this field. The interaction of core authors and international collaboration accentuated the cross-disciplinary feature of the field. Prominent documents emphasized the clinical significance of early decompression in 24 h post SCI.

Conclusion

Based on comprehensive bibliometric analysis and literature review, we identified the hotspots and future directions of this field: (1) further investigation into the molecular and cellular mechanisms to provide pre-clinical evidence for biological effects of early surgical decompression in SCI animal models; (2) further evaluation and validation of the optimal time window of surgical decompression based on large cohort, considering the inherent heterogeneity of subpopulations in complicated immune responses post SCI; (3) further exploration on the benefits of early decompression on the neurological, functional, and clinical outcomes in acute SCI; (4) evaluation of the optimal surgical methods and related outcomes; (5) applications of artificial intelligence-based technologies in spinal surgical decompression.

Total knee arthroplasty following surgical treatment of tibial plateau fractures - A retrospective cohort study

BACKGROUND

Previous studies have shown the risk of post-traumatic osteoarthritis to be high following tibial plateau fracture surgery. Several investigations have examined the risk of total knee arthroplasty (TKA) following tibial plateau fracture treatment, but the risk of TKA in relation to the general population in Sweden has not previously been explored.

AIM

To determine the incidence of TKA following surgical treatment of tibial plateau fractures and compare it with that of an age-matched population in Sweden.

METHODS

A total of 349 tibial plateau fractures treated with open reduction internal fixation between 2002 and 2010 were identified from local hospital registers using diagnosis and surgical codes. The cohort was cross-matched with the Swedish Knee Arthroplasty Register to determine which patients had been treated with TKA within 10 years of fracture surgery. The incidence of primary TKA in the age-matched population in Sweden was obtained from the National Patient Register for comparison.

RESULTS

Mortality-adjusted prevalence of TKA at 10 years following fracture surgery was 6.7% (relative risk (RR) = 5.5) and peaked during the second postoperative year (RR=19.3). High age was independently associated with increased risk of TKA (P=0.004); no other examined patient factors were significantly associated with TKA.

CONCLUSION

The overall prevalence of TKA at 10 years following tibial plateau fracture surgery is low at 6.7%, however the risk is many times greater than that of the age-matched population in Sweden. The majority of patients require TKA within a few years of fracture treatment, hence post-traumatic osteoarthritis may arguably have not been the reason for TKA as this would have taken longer to develop.

Restoring initial steps by intermittent theta burst stimulation in complete spinal cord injury patient: a case report

INTRODUCTION

Spinal cord injury (SCI) causes damage to neurons and results in motor and sensory dysfunction. Intermittent theta burst stimulation (iTBS) has been used to induce neuronal and synaptic plasticity by applying a magnetic field in the brain. The plasticity induced in the cortex has an imperative role in the recovery of motor and sensory functioning. However, the effect of iTBS in complete SCI patients is still elusive.

CASE PRESENTATION

We report here the case of a 27-year-old female who sustained an L1 complete spinal cord injury (SCI) with an ASIA score of A. The patient lost all the sensory and motor functions below the level of injury. Intermittent theta burst stimulation (iTBS) was administered at 80% of the resting motor threshold over the M1 motor cortex, along with intensive rehabilitation training to promote sensorimotor function.

DISCUSSION

There was a partial recovery in functional, electrophysiological, and neurological parameters. The case report also demonstrates the safety and efficacy of iTBS in complete SCI patients. No adverse event has been observed in the patient during intervention sessions.

Operative Management of Pediatric Physeal Bar Development and Genu Valgum

Background

Pediatric orthopedic conditions present unique challenges due to ongoing skeletal growth and development. Managing these cases requires addressing both structural anomalies and functional deficits.

Care presentation

This case report discusses a 13-year-old male with recurrent left knee pain exacerbated by physical activity. The patient's history of a left knee infection at 1.5 years of age, possibly septic arthritis or osteomyelitis, underscores the long-term consequences of early pathology on skeletal growth and alignment. Imaging studies revealed a distal lateral femur physis bar and genu valgum, necessitating surgical intervention.

Management and Outcomes

The surgery involved medial distal femur hemiepiphysiodesis and lateral distal femur bar excision to correct anatomical deformities and restore optimal limb alignment and function. Postoperative rehabilitation, including targeted exercises to improve quadriceps strength, was crucial for functional recovery and reducing the risk of complications such as medial patellofemoral pain.

Conclusion

This case highlights the importance of a multidisciplinary approach in managing complex pediatric orthopedic cases.

Implementation of a Fracture Liaison Service in a tertiary hospital in Malaysia: a feasibility study

Fracture Liaison Service is a coordinator-based model effective in addressing the fragility fracture care gap. This study found that the service was feasible in Malaysia and could improve the delivery of secondary fracture prevention. Local adaptations and reactive responses addressed challenges, enhancing feasibility.

PURPOSE

To assess the feasibility of a Fracture Liaison Service in Malaysia and to benchmark our service against the International Osteoporosis Foundation Best Practice Framework.

METHODS

This feasibility study was conducted at a tertiary hospital in Malaysia from March 2021 to March 2022. Patients aged ≥ 50 years admitted with fragility fractures were recruited. Excluded were those with poor prognosis or transferred out from the hospital during admission. Patients were screened, assessed, and followed up at months 4 and 12 post-fracture presentations. Data was collected using Microsoft Excel and the REDCap database. The feasibility of the Fracture Liaison Service was evaluated using the typology of feasibility.

RESULTS

A total of 140 patients (female (93/140, 66.4%), median age 77 (IQR 72, 83), hip fractures (100/140, 65.8%)) were recruited into the Fracture Liaison Service. The recruitment rate was (140/215, 65.1%), as some patients were "missed" due to the COVID-19 pandemic. The completion rate was high (101/114, 88.6%). Among those indicated for antiosteoporosis medication, 82/100 (82%) were initiated on treatment. Various "Best Practice Standards," such as patient evaluation (140/140, 100%), fall prevention (130/140, 92.9%), and medication review standards (15/15, 100%) were high. Complicated referral pathways, inexperienced staff, lack of resources, and communication issues were some of the barriers identified while implementing the Fracture Liaison Service. Challenges were overcome by modifying the service workflow and coordinating with different departments.

CONCLUSION

The Fracture Liaison Service was found to be feasible in Malaysia. It demonstrated promise in improving bone health management; however, several changes were needed to adapt the service to suit our environment.

Imaging evaluation of hip capsule disorders: a comprehensive review

The hip capsule and capsular ligaments play crucial roles in providing hip stability and mobility. Their role in hip pathologies is being increasingly recognized, underscoring the need for thorough imaging evaluation, which is better performed through MRI-arthrography. Various diseases affect the hip capsule directly or indirectly. Improper mechanical loading, as seen in conditions such as femoroacetabular impingement or chondrolabral pathology, can induce capsule thickening, whereas thinning and laxity of the capsule are characteristics of microinstability. Inflammatory conditions, including adhesive capsulitis of the hip, crystal deposition disease, polymyalgia rheumatica, and infections, also lead to capsular changes. Traumatic events, particularly posterior hip dislocations, cause capsule ligament disruption and may lead to hip macroinstability. Friction syndromes can lead to capsular edema due to impingement of the adjacent capsule. Hip arthroscopy can result in various postoperative findings ranging from fibrotic adhesions to focal or extensive capsule discontinuation. Although the significance of hip capsule thickness and morphology in the pathogenesis of hip diseases remains unclear, radiologists must recognize capsule alterations on imaging evaluation. These insights can aid clinicians in accurately diagnosing and effectively managing patients with hip conditions.

Update on Perioperative Medication Management for the Hand Surgeon: A Focus on Diabetes, Weight Loss, Rheumatologic, and Antithrombotic Medications

Diabetes mellitus and obesity are growing health concerns. New pharmacologic interventions have recently begun to play a more notable role in the treatment pathway of these separate but related conditions. In particular, glucagon-like peptide-1 receptor agonists, such as semaglutides (Ozempic, Wegovy) and tirzepatide (Mounjaro), and sodium glucose co-transporter 2 inhibitors, such as dapagliflozin (Farxiga) and empagliflozin (Jardiance), have emerged as treatment options. Multiple clinical trials have demonstrated their efficacy in regulating metabolism, improving glycemic control, and managing long-term weight reduction. However, glucagon-like peptide-1 receptor agonists have also been associated with gastrointestinal side effects, including delayed gastric emptying as well as regurgitation and aspiration during general anesthesia or deep sedation, and sodium glucose co-transporter 2 inhibitors have been associated with severe diabetic ketoacidosis. Therefore, discontinuation of these medications before surgery is imperative. Given the popularity of these medications among the general public, it is essential for hand surgeons, to understand how to appropriately manage them perioperatively. The objective of this article was to review these new diabetes mellitus and weight loss medications, including their mechanisms of action, indications for use, and perioperative management guidelines. Additionally, we will take this opportunity to review perioperative guidelines for other common medications relevant to patients undergoing procedures involving the hand and upper extremity such as antithrombotic medications and rheumatoid arthritis-related immunosuppressive medications. Finally, we will describe how the electronic medical record system can be used to optimize perioperative medication management in this population.

TREATMENT OF PEDIATRIC FEMUR FRACTURES WITH FLEXIBLE STAINLESS STEEL INTRAMEDULLARY NAIL

OBJECTIVES

To identify the characteristics of patients and femur fractures treated with a stainless steel intramedullary nail (ESIN) in children under 15 years of age. Know the results of using the ESIN of related steel in the service.

METHODS

Retrospective study with review of hospital records and organization of data in spreadsheets.

RESULT

24 cases were identified, 17 male cases and 7 female cases. A minimum age of 4 years and a maximum of 11 years were observed (average of 7 years). The 3 most common trauma mechanisms were being run over (n:8, 33%) and falling from a height (n:8, 3%). The most common location of the fractures was in the mid-diaphyseal region (n: 20, 88%), only one case presented a bilateral femur fracture. The most common associated trauma was traumatic brain injury. The observation period observed several months between 2 and 5. With regard to complications, 3 cases were observed (12.5%) being bursitis, vicious construction and loss of reduction.

CONCLUSION

Steel HIF shows similar good results. As the study includes the retrospective profile, the absence of a group and the small sample size. Level of Evidence IV, Case series.

Effects of body mass index on mortality in elderly patients with hip fractures

Hip fractures remain a substantial health concern, particularly among elderly individuals with osteoporosis, leading to high global mortality rates. This study aimed to analyze the association between body mass index (BMI) and postoperative mortality in patients who underwent surgery for hip fractures. A total of 680 patients treated at a single institution between January 2018 and December 2022 were included. Factors such as age, BMI, sex, Charlson Comorbidity Index (CCI), preoperative hemoglobin levels, American Society of Anesthesiologists score, anesthesia method, duration of surgery, and time from injury to surgery were assessed. Underweight status, male sex, higher CCI, and general anesthesia were significantly associated with 1-year and in-hospital mortality. Notably, underweight individuals exhibited a higher risk of mortality than normal-weight individuals, and female patients had lower mortality rates. This study underscores the importance of considering BMI, along with other demographic and clinical factors, in predicting postoperative mortality among patients with hip fractures, aiding the development of tailored management strategies to improve outcomes and reduce complications in this vulnerable patient population.

Nonphysician Evaluators and Recording-Based Tools in Surgical Skill Assessment: A Feasibility Study

OBJECTIVES

To investigate the feasibility of nonmedically trained evaluators and image- and video-based tools in the assessment of surgical skills in a key orthopedic procedure.

DESIGN

Orthopedic surgeons at varying skill levels were evaluated by their ability to repair a cadaveric bi-malleolar ankle fracture. Nonphysician viewers and expert orthopedic surgeons independently scored video recordings and fluoroscopy images of the procedure through Global Rating Scales (GRS) and procedure-specific checklist tools. Statistical analysis was used to determine if the evaluators and assessment tools were able to differentiate skill level.

SETTING

An academic tertiary care hospital.

PARTICIPANTS

The surgical procedure was completed by 3 orthopedic residents, 3 orthopedic trauma fellows, and 4 orthopedic trauma attending surgeons. The procedure was independently evaluated by 2 orthopedic surgeons and 2 nonphysicians.

RESULTS

Operating participants were stratified by ≤ or >10 bimalleolar ankle fracture cases performed alone (inexperienced, n = 5 vs experienced, n = 5). Expert surgeon viewers could effectively stratify skill group through the GRS for video and fluoroscopy analysis (p < 0.05), and the video procedure-specific checklist (p < 0.05), but not the fluoroscopy procedure-specific checklist. Nonphysician viewers generally recognized skill groupings, although with less separation than surgeon viewers. These evaluators performed the best when aided by video and fluoroscopy procedure-specific checklists. Meanwhile, breakdowns of each tool into critical zones for improvement and evaluator-independent metrics such as case experience, self-reported confidence, and surgical time also indicated some skill differentiation.

CONCLUSIONS

The feasibility of using video recordings and fluoroscopic imaging based surgical skills assessment tools in orthopedic trauma was demonstrated. The tools highlighted in this study are applicable to both cadaver laboratory settings and live surgeries. The degree of training that is required by the evaluators and the utility of measuring surgical times of specific tasks should be the subject of future studies.

Orthopedic Surgery Volume Trends During the COVID-19 Pandemic and Postvaccination Era: Implications for Healthcare Planning

BACKGROUND

The Coronavirus Disease 2019 (COVID-19) pandemic decreased surgical volumes, but prior studies have not investigated recovery through 2022, or analyzed specific procedures or cases of urgency within orthopedic surgery. The aims of this study were to (1) quantify the declines in orthopedic surgery volume during and after the pandemic peak, (2) characterize surgical volume recovery during the postvaccination period, and (3) characterize recovery in the 1-year postvaccine release period.

METHODS

We conducted a retrospective cohort study of 27,476 orthopedic surgeries from January 2019 to December 2022 at one urban academic quaternary referral center. We reported trends over the following periods: baseline pre-COVID-19 period (1/6/2019 to 1/4/2020), COVID-19 peak (3/15/2020 to 5/16/2020), post-COVID-19 peak (5/17/2020 to 1/2/2021), postvaccine release (1/3/2021 to 1/1/2022), and 1-year postvaccine release (1/2/2022 to 12/30/2022). Comparisons were performed with 2 sample t-tests.

RESULTS

Pre-COVID-19 surgical volume fell by 72% at the COVID-19 peak, especially impacting elective procedures (P < .001) and both hip and knee joint arthroplasty (P < .001) procedures. Nonurgent (P = .024) and urgent or emergency (P = .002) cases also significantly decreased. Postpeak recovery before the vaccine saw volumes rise to 92% of baseline, which further rose to 96% and 94% in 2021 and 2022, respectively. While elective procedures surpassed the baseline in 2022, nonurgent and urgent or emergency surgeries remained low.

CONCLUSIONS

The COVID-19 pandemic substantially reduced orthopedic surgical volumes, which have still not fully recovered through 2022, particularly nonelective procedures. The differential recovery within an orthopedic surgery program may result in increased morbidity and can serve to inform department-level operational recovery.

High Area Deprivation Index is Associated With Not Achieving the Patient-acceptable Symptom State After TKA

BACKGROUND

The Area Deprivation Index (ADI) approximates a patient's relative socioeconomic deprivation. The ADI has been associated with increased healthcare use after TKA, but it is unknown whether there is an association with patient-reported outcome measures (PROMs). Given that a high proportion of patients are dissatisfied with their results after TKA, and the large number of these procedures performed, knowledge of factors associated with PROMs may indicate opportunities to provide support to patients who might benefit from it.

QUESTIONS/PURPOSES

(1) Is the ADI associated with achieving the minimum clinically important difference (MCID) for the Knee Injury and Osteoarthritis Outcome Score (KOOS) for pain, Joint Replacement (JR), and Physical Function (PS) short forms after TKA? (2) Is the ADI associated with achieving the patient-acceptable symptom state (PASS) thresholds for the KOOS pain, JR, and PS short forms?

METHODS

This was a retrospective study of data drawn from a longitudinally maintained database. Between January 2016 and July 2021, a total of 12,239 patients underwent unilateral TKA at a tertiary healthcare center. Of these, 92% (11,213) had available baseline PROM data and were potentially eligible. An additional 21% (2400) of patients were lost before the minimum study follow-up of 1 year or had incomplete data, leaving 79% (8813) for analysis here. The MCID is the smallest change in an outcome score that a patient is likely to perceive as a clinically important improvement, and the PASS refers to the threshold beyond which patients consider their symptoms acceptable and consistent with adequate functioning and well-being. MCIDs were calculated using a distribution-based method. Multivariable logistic regression models were created to investigate the association of ADI with 1-year PROMs while controlling for patient demographic variables. ADI was stratified into quintiles based on their distribution in our sample. Achievement of MCID and PASS thresholds was determined by the improvement between preoperative and 1-year PROMs.

RESULTS

After controlling for patient demographic factors, ADI was not associated with an inability to achieve the MCID for the KOOS pain, KOOS PS, or KOOS JR. A higher ADI was independently associated with an increased risk of inability to achieve the PASS for KOOS pain (for example, the odds ratio of those in the ADI category of 83 to 100 compared with those in the 1 to 32 category was 1.34 [95% confidence interval 1.13 to 1.58]) and KOOS JR (for example, the OR of those in the ADI category of 83 to 100 compared with those in the 1 the 32 category was 1.29 [95% CI 1.10 to 1.53]), but not KOOS PS (for example, the OR of those in the ADI category of 83 to 100 compared with those in the 1 the 32 category was 1.09 [95% CI 0.92 to 1.29]).

CONCLUSION

Our findings suggest that social and economic factors are associated with patients' perceptions of their overall pain and function after TKA, but such factors are not associated with patients' perceptions of their improvement in symptoms. Patients from areas with higher deprivation may be an at-risk population and could benefit from targeted interventions to improve their perception of their healthcare experience, such as through referrals to nonemergent medical transportation and supporting applications to local care coordination services before proceeding with TKA. Future research should investigate the mechanisms underlying why socioeconomic disadvantage is associated with inability to achieve the PASS, but not the MCID, after TKA.

LEVEL OF EVIDENCE

Level III, therapeutic study.