Towards the First Generation of Biomimetic Fixation for Resurfacing Arthroplasty Endoprostheses

This paper presents advances in designs of resurfacing arthroplasty endoprostheses that occurred through their historical generations. The critical characteristics of contemporary generation hip resurfacing arthroplasty endoprostheses are given and the failures resulting from the specific generation cemented and short stem fixation of the femoral component are reviewed. On the background of these failures, the critical need arises for an alternative approach to the fixation of components of resurfacing arthroplasty leading towards the first generation of biomimetic fixation for resurfacing arthroplasty endoprostheses. The state of the art of the completed bioengineering research on the first biomimetic fixation for resurfacing arthroplasty endoprostheses is presented. This new design type of completely cementless and stemless resurfacing arthroplasty endoprostheses of the hip joint (and other joints), where endoprosthesis components are embedded in the surrounding bone via the prototype biomimetic multi-spiked connecting scaffold (MSC-Scaffold), initiates the first at all generations of biomimetic endoprostheses of diarthrodial joints.

Radiofrequency Denervation of the Spine and the Sacroiliac Joint: A Systematic Review based on the Grades of Recommendations, Assesment, Development, and Evaluation Approach Resulting in a German National Guideline

STUDY DESIGN

Systematic review of the literature and subsequent meta-analysis for the development of a new guideline.

OBJECTIVES

This manuscript summarizes the recommendations from a new clinical guideline published by the German Spine Society. It covers the current evidence on recommendations regarding the indication, test blocks and use of radiofrequency denervation. The guidelines aim is to improve patient care and efficiency of the procedure.

METHODS

A multidisciplinary working group formulated recommendations based on the Grades of Recommendations, Assessment, Development, and Evaluation (GRADE) approach and the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument.

RESULTS

20 clinical questions were defined for guideline development, with 87.5% consensus achieved by committee members for one recommendation and 100% consensus for all other topics. Specific questions that were addressed included clinical history, examination and imaging, conservative treatment before injections, diagnostic blocks, the injected medications, the cut-off value in pain-reduction for a diagnostic block as well as the number of blocks, image guidance, the cannula trajectories, the lesion size, stimulation, repeat radiofrequency denervation, sedation, cessation or continuation of anticoagulants, the influence of metal hardware, and ways to mitigate complications.

CONCLUSION

Radiofrequency (RF) denervation of the spine and the SI joint may provide benefit to well-selected individuals. The recommendations of this guideline are based on very low to moderate quality of evidence as well as professional consensus. The guideline working groups recommend that research efforts in relation to all aspects of management of facet joint pain and SI joint pain should be intensified.

Periarticular blast wounds without fracture a prospective case series

BACKGROUND

During the wars in Afghanistan and Iraq most injuries to service members involved the musculoskeletal system. These wounds often occurred around joints, and in some cases result in traumatic arthrotomy-a diagnosis that is not always clear, especially when there is no concomitant articular fracture. The aim of the present study is to evaluate the diagnosis and treatment of peri-articular blast injuries without fracture.

METHODS

The study cohort included 12 consecutive patients (12 involved extremities) who sustained peri-articular blast wounds of the extremities without fractures. The diagnosis of penetrating articular injury was based on clinical examination, radiographic findings, or aspiration. A peri-articular wound was defined as any wound, or radio-opaque blast fragment, within 5 cm of a joint. The New Injury Severity Score (NISS) was calculated for each patient. Four patients had upper, and 8 patients had lower extremity injuries. Nine of 12 patients had joint capsular penetration and underwent joint irrigation and debridement.

RESULTS

Two patients had retained intra-articular metal fragments. One patient had soft tissue blast wounds within 5 cm of a joint but did not have joint capsule penetration. There were no significant differences (p = 0.23) between the distribution of wounds to upper versus lower extremities. However, there were a significantly greater number of blast injuries attributed to Improvised Explosive Devices (IEDs) than from other blast mechanisms (p = 0.01).

CONCLUSION

Extremity blast injuries in the vicinity of joints involving only soft tissues present a unique challenge in surgical management. A high index of suspicion should be maintained for joint capsular penetration so that intra-articular injuries may be appropriately treated.

Plate-Assisted Intramedullary Nailing of Distal Tibia Fractures

The combination of plate and intramedullary nailing has been established as the treatment of proximal tibial fractures. Nevertheless, at the distal end of the tibia, the application of the plate-assisted intramedullary nailing is rarely applied as a therapeutic technique. This technical note demonstrates the use of the reduction plating technique for nail insertion as the management of distal tibia fractures.

Management of Vancouver B3 Periprosthetic Femur Fracture Using a Modular Uncemented Long Femoral Stem Prosthesis With Cerclage Wiring Technique

Periprosthetic fractures (PPF) of the femur in connection with total hip arthroplasty are becoming common and also frequently challenging to repair. Such patients typically are frail, elderly, and have osteoporosis. Owing to a scarcity of research there are no clear strategies for its effective management. However, the Vancouver classification may help in facilitating treatment decisions. For fractures around a loose femoral prosthesis (types B2 and B3), revision using a modular uncemented long stem, with or without additional fracture fixation, has been known to provide a reliable outcome. It is prudent to treat osteoporosis for fracture healing and to prevent further fractures. In this case report, we share our experience with the use of an uncemented modular long femoral stem prosthesis with a cerclage wiring technique for the management of Vancouver type B3 PPF of the left femur in a 63-year-old male patient. Revision arthroplasty using a long stem prosthesis with a cerclage wiring technique can provide better fixation, stability, and functional outcomes for the patient.

Idiosyncratic bone responses to blood flow restriction exercise: new insights and future directions

Applying blood flow restriction (BFR) during low-load exercise induces beneficial adaptations of the myotendinous and neuromuscular systems. Despite the low mechanical tension, BFR exercise facilitates a localized hypoxic environment and increase in metabolic stress, widely regarded as the primary stimulus for tissue adaptations. First evidence indicates that low-load BFR exercise is effective in promoting an osteogenic response in bone, although this has previously been postulated to adapt primarily during high-impact weight-bearing exercise. Besides studies investigating the acute response of bone biomarkers following BFR exercise, first long-term trials demonstrate beneficial adaptations in bone in both healthy and clinical populations. Despite the increasing number of studies, the physiological mechanisms are largely unknown. Moreover, heterogeneity in methodological approaches such as biomarkers of bone metabolism measured, participant and study characteristics, and time course of measurement renders it difficult to formulate accurate conclusions. Furthermore, incongruity in the methods of BFR application (e.g., cuff pressure) limits the comparability of datasets and thus hinders generalizability of study findings. Appropriate use of biomarkers, effective BFR application, and befitting study design have the potential to progress knowledge on the acute and chronic response of bone to BFR exercise and contribute toward the development of a novel strategy to protect or enhance bone health. Therefore, the purpose of the present synthesis review is to 1) evaluate current mechanistic evidence; 2) discuss and offer explanations for similar and contrasting data findings; and 3) create a methodological framework for future mechanistic and applied research.

Multiscale Porous Poly (Ether-Ether-Ketone) Structures Manufactured by Powder Bed Fusion Process

The aim of the study is to create a multiscale highly porous poly (ether-ether-ketone) (PEEK) structure while maintaining mechanical performance; the distribution of pores being generated by the manufacturing process combined with a porogen leaching operation. Salt at 70 wt% concentration was used as a porogen in a dry blend with PEEK powder sintered in the powder bed fusion process. The printed porous PEEK structures were examined and evaluated by scanning electron microscopy, microcomputed tomography, and mechanical testing. The PEEK structures incorporating 70 wt% salt achieved 79-86% porosity, a compressive yield strength of 4.1 MPa, and a yield strain of ∼60%. Due to the salt leaching process, the PEEK porous frameworks were fabricated without the need to drastically reduce the process parameters (defined by the energy density [ED]), hence maintaining the structural integrity and good mechanical performance. The compression results highlighted that the performance is influenced by the printing orientation, level of the PEEK particle coalescence (controlled here by the ED), pore/cell wall thickness, and subsequently, the overall porosity framework. The porous printed PEEK structures could find potential uses in a wide range of applications from tissue engineering, filtration and separation to catalysts, drug release, and gas storage.

Developing an antibiogram for empiric antibiotic prescribing for adult non-spinal orthopaedic infections in a developing world setting

PURPOSE

Empiric antibiotic strategies in the treatment of fracture-related infections, chronic osteomyelitis, prosthetic joint infection, and septic arthritis should be based on local microbiological antibiograms. This study aims to describe the microbiology and review the antibiogram profiles of bacterial isolates from patients undergoing surgical treatment for non-spinal orthopaedic infections, to identify the most appropriate empiric antibiotic strategy.

METHODS

A retrospective review was performed of all cases of non-spinal orthopaedic infections treated surgically from 1 January 2018 to 31 December 2018. The National Health Laboratory Service microbiology database was used to identify all intra-operative microbiological specimens obtained from orthopaedic patients, and data were correlated with the orthopaedic surgical database. Cases were divided into fracture-related infections, chronic osteomyelitis, prosthetic joint infection, and septic arthritis. Antibiotic susceptibility data were used to predict the efficacy of different empiric antibiotic regimens.

RESULTS

A total of 107 cases were included in the study; 184 organisms were cultured. Overall, the most common organism cultured was Staphylococcus aureus (25%) followed by Acinetobacter baumannii (9%), Enterococcus faecalis (7%) and Enterobacter cloacae (5%). Across all categories the oral antibiotic combination with the highest effectiveness (81%) would have been a combination of co-trimoxazole, ciprofloxacin and amoxicillin. The most effective intravenous antibiotic combination would have been either piperacillin-tazobactam, amikacin and vancomycin or meropenem and vancomycin; 90% of tested isolates were susceptible to either of these combinations.

CONCLUSION

Antibiogram profiles can serve to guide to empiric antibiotic choice in the management of different categories of non-spinal orthopaedic infections.

Additively Manufactured Zn-2Mg Alloy Porous Scaffolds with Customizable Biodegradable Performance and Enhanced Osteogenic Ability

The combination of bioactive Zn-2Mg alloy and additively manufactured porous scaffold is expected to achieve customizable biodegradable performance and enhanced bone regeneration. Herein, Zn-2Mg alloy scaffolds with different porosities, including 40% (G-40-2), 60% (G-60-2), and 80% (G-80-2), and different unit sizes, including 1.5 mm (G-60-1.5), 2 mm (G-60-2), and 2.5 mm (G-60-2.5), are manufactured by a triply periodic minimal surface design and a reliable laser powder bed fusion process. With the same unit size, compressive strength (CS) and elastic modulus (EM) of scaffolds substantially decrease with increasing porosities. With the same porosity, CS and EM just slightly decrease with increasing unit sizes. The weight loss after degradation increases with increasing porosities and decreasing unit sizes. In vivo tests indicate that Zn-2Mg alloy scaffolds exhibit satisfactory biocompatibility and osteogenic ability. The osteogenic ability of scaffolds is mainly determined by their physical and chemical characteristics. Scaffolds with lower porosities and smaller unit sizes show better osteogenesis due to their suitable pore size and larger surface area. The results indicate that the biodegradable performance of scaffolds can be accurately regulated on a large scale by structure design and the additively manufactured Zn-2Mg alloy scaffolds have improved osteogenic ability for treating bone defects.

Anterior Cruciate Ligament Reconstruction Plus Lateral Extra-articular Tenodesis Has a Similar Return-to-Sport Rate to Anterior Cruciate Ligament Reconstruction Alone but a Lower Failure Rate

PURPOSE

To determine whether the addition of lateral extra-articular tenodesis (LET) to anterior cruciate ligament reconstruction (ACLR) would improve return-to-sport (RTS) rates in young, active patients who play high-risk sports.

METHODS

This multicenter randomized controlled trial compared standard hamstring tendon ACLR with combined ACLR and LET using a strip of the iliotibial band (modified Lemaire technique). Patients aged 25 years or younger with an anterior cruciate ligament-deficient knee were included. Patients also had to meet 2 of the following criteria: (1) pivot-shift grade 2 or greater, (2) participation in a high-risk or pivoting sport, and (3) generalized ligamentous laxity. Time to return and level of RTS were determined via administration of a questionnaire at 24 months postoperatively.

RESULTS

We randomized 618 patients in this study, 553 of whom played high-risk sports preoperatively. The proportion of patients who did not RTS was similar between the ACLR (11%) and ACLR-LET (14%) groups; however, the graft rupture rate was significantly different (11.2% in ACLR group vs 4.1% in ACLR-LET group, P = .004). The most cited reason for no RTS was lack of confidence and/or fear of reinjury. A stable knee was associated with nearly 2 times greater odds of returning to a high-level high-risk sport postoperatively (odds ratio, 1.92; 95% confidence interval, 1.11-3.35; P = .02). There were no significant differences in patient-reported functional outcomes or hop test results between groups (P > .05). Patients who returned to high-risk sports had better hamstring symmetry than those who did not RTS (P = .001).

CONCLUSIONS

At 24 months postoperatively, patients who underwent ACLR plus LET had a similar RTS rate to those who underwent ACLR alone. Although the subgroup analysis did not show a statistically significant increase in RTS with the addition of LET, on returning, the addition of LET kept subjects playing longer by reducing graft failure rates.

LEVEL OF EVIDENCE

Level I, randomized controlled trial.

Usefulness of the Phalen Test and the Tinel Sign in the Prognosis and the Impact on Quality of Life of Patients with Carpal Tunnel Syndrome Undergoing Classical Open Carpal Tunnel Release

Objective:  To evaluate the usefulness of the Phalen test and the Tinel sign in the prognosis and the impact on quality of life in the clinical course of patients with carpal tunnel syndrome undergoing surgical treatment through the traditional open approach. Methods:  The present is a cohort study on prognosis. We included 115 patients with high probability of receiving a clinical diagnosis of carpal tunnel syndrome with indication for surgical treatment. All patients underwent the Phalen test and Tinel sign and answered the Boston Carpal Tunnel Questionnaire before and after the surgical treatment. Results:  The estimates for the probability of the time until remission of the Phalen test at 2, 4 and 16 weeks postoperatively were of 3.54% (95% confidence interval [95%CI]: 1.16%-8.17%), 0.88% (95%CI: 0.08%-4.38%) and 0.88% (95%CI: 0.08% to 4.38%) respectively, and, for the Tinel sign, they were of 12.39% (95%CI: 7.13%-19.18% ), 4.42% (95%CI : 1.65%-9.36%) and 2.65% (95%CI : 0.70%-6.94%) respectively. There was a reduction in the postoperative score on the Boston Carpal Tunnel Questionnaire of 1.8 points for symptom severity ( p  < 0.001) and of 1.6 points for functional status ( p  < 0.001). Conclusion:  Phalen test remission was earlier than that of the Tinel sign, but, when performed as of the second postoperative week, they were prognostic factors favorable to the clinical course, with improved quality of life.

Primary Versus Secondary Total Knee Arthroplasty for Tibial Plateau Fractures in Patients Aged 55 or Over-A Systematic Review and Meta-Analysis

BACKGROUND

Total knee arthroplasty allows immediate postoperative weight-bearing and is increasingly recognized as a suitable treatment option for older patients who have tibial plateau fractures (TPFs). This systematic review evaluated the clinical and functional outcomes associated with primary versus secondary TKA for the treatment of TPFs in patients aged ≥55 years.

METHODS

Various databases were searched from inception to December 2021. Studies investigating outcomes of primary TKA (pTKA) as the initial treatment for TPFs in patients of mean age ≥55 years or those investigating outcomes of secondary TKA (sTKA) following any other primary treatment for TPFs were included. Quality of included studies was assessed using a methodological scale. Of 767 potentially relevant studies, 12 studies comprising 341 patients were included: 121 patients underwent (pTKA) and 220 patients underwent sTKA. There were 3 high-quality studies. Patients in the sTKA cohort were significantly younger at the time of TKA compared with those undergoing pTKA (mean 61.3 versus 72.2 years, P < .001, 95% confidence interval (CI) 8.2 to 13.6).

RESULTS

Intraoperative and postoperative complication rates were lower with pTKA; in particular, sTKA was associated with a significantly increased rate of stiffness requiring reintervention and patella tendon rupture. Functional outcome was greater after pTKA, but this did not reach statistical significance (85.2 versus 79.9%, P = .359, 95% CI -16.7 to 6.1).

CONCLUSION

Primary TKA was associated with lower complication rates than secondary TKA after TPF. In appropriate cases of TPF in older adults, it may be preferable to proceed with TKA as primary treatment rather than delaying until after fracture union or malunion.

Radiographic Assessment of Bone Quality Using 4 Radiographic Indexes: Canal Diaphysis Ratio Is Superior

BACKGROUND

Osteoporosis increases the risk of periprosthetic fracture and loosening in hip arthroplasty. Many methods have been proposed to assess bone quality in X-rays, including both qualitative such as the Dorr classification and quantitative such as the Calcar-Canal Ratio (CCR) and Cortical-Thickness index/Canal-Bone ratio (CTI/CBR). The Canal-Diaphysis ratio (CDR) has been described as a predictor for hip fragility fractures; however, its relationship with bone mineral density (BMD) has not been described. The purpose of this study was to evaluate the correlation of the Dorr classification, CCR, CTI/CBR, and CDR with BMD of the proximal femur in patients without hip fracture.

METHODS

Forty-seven patients over 45 years of age who had less than 6 months between radiographs and dual-energy X-ray absorptiometry were evaluated. Measurements of CCR, CBR, CDR, and Dorr classification were performed in all radiographs by 2 independent observers.

RESULTS

The CDR had a high correlation (r = 0.74, P=<0.01) with BMD, whereas the CTI/CBR had a moderate correlation (r = 0.49, P=<0.01), and the CCR had no correlation with BMD (r = 0.06, P = .96). When evaluating the receiver operating characteristic curve, CDR showed the best performance (area under curve [AUC] = 0.75) followed by CBR (AUC = 0.73) and CCR (AUC = 0.61). The optimal cutoff value for the CDR was 0.49, with 100% sensitivity and 58% specificity. The inter- and intra-observer variability was good for all methods. No differences were found between Dorr classification of patients who had or did not have osteoporosis.

CONCLUSION

Of all the analyzed methods, the CDR was found to have the best correlation with BMD. This study proposes the use of CDR as a tool for assessing bone quality when deciding the implant fixation method in hip arthroplasty.

Anterior Cruciate Ligament Reconstruction: Fixation Techniques

Anterior cruciate ligament reconstruction (ACLR) is among the most common procedures performed by orthopaedic sports medicine surgeons and has inherent challenges due to the complex anatomy and biomechanical properties required to reproduce the function and stability of the native ACL. Awareness of the anatomic and biomechanical factors, including graft selection and tunnel placement, along with graft tensioning and fixation techniques, is vital in achieving a successful clinical outcome. Common techniques for ACLR graft fixation include intratunnel fixation with interference screws, suspensory fixation, or hybrid fixation strategies, along with several supplemental fixation techniques. Interference screw fixation may decrease graft-tunnel motion, tunnel widening, and graft creep and may be performed with metallic, PEEK (polyether ether ketone), or bioabsorbable screws. Suspensory fixation techniques primarily include suture-buttons, anchors, staples, and screws/washers. Suspensory fixation allows adequate biomechanical strength, although some techniques have been linked to increased graft-tunnel motion and potential tunnel widening. Supplemental fixation techniques may be performed in the setting of concerns for adequacy of primary fixation and includes the use of suture anchors, staples, and screw/washer devices. Regardless of the implant chosen for fixation, secure fixation is paramount to avoid displacement of the graft and allow for integration into the bone tunnel and facilitates early postoperative rehabilitation. It is important for orthopaedic sports medicine surgeons performing primary and revision ACLR to be familiar with multiple fixation techniques.

Does combined anterior cruciate ligament and anterolateral ligament reconstruction improve return to sport?

PURPOSE

Only 50-65% of patients return to their previous sporting level after ACL rupture. The literature reports a reduced rate of graft rupture when an anterolateral ligament reconstruction (ALLR) is associated with ACL reconstruction. ACL reconstruction combined with ALL allows a higher return to sport at pre-injury level than isolated reconstruction in patients playing pivot-contact sports.

METHODS

A retrospective, single-centre study between 2012 and 2020 comparing reconstruction by hamstring tendon technique, isolated ACLR vs ACL with ALLR. An isokinetic test was performed at 6 months post-operatively and patients were re-contacted at a minimum 2-year follow-up to assess their level and delay to return to sport, graft rupture rate and functional evaluation.

RESULTS

83 patients were included, 42 in ACLR group and 41 in ACL + ALLR group. Four patients were lost to follow-up and 79 patients were analysed. No significant difference was found on the level of return to sport (28.2% vs. 42.5%; p = 0.18), return to competition (43% vs. 60%; p = 0.18), delay to sports return, isokinetic assessment, functional scores, but a significant difference was found on graft rupture rate in favour of ALLR (12.8% vs. 0%; p = 0.02).

CONCLUSION

In our study, the addition of an ALL to ACL reconstruction did not improve pre-injury sports recovery or return to competition.

STUDY DESIGN

Cohort study, level of evidence 4.

Knee Flexion Angle of Fixation During Anterolateral Ligament Reconstruction or Lateral Extra-articular Tenodesis: A Systematic Review and Meta-analysis of Lateral Extra-articular Reinforcement Techniques Performed in Conjunction With ACL Reconstruction

Background

Anterolateral ligament reconstruction (ALLR) or lateral extra-articular tenodesis (LET) is being used more frequently in conjunction with anterior cruciate ligament reconstruction (ACLR). However, the knee flexion angle at which fixation of ALLR or LET is performed during the procedure is quite variable based on existing technique descriptions.

Purpose/Hypothesis

The purpose of this study was to identify whether flexion angle at the time of ALLR/LET fixation affected postoperative outcomes in a clinical population. It was hypothesized that ALLR/LET fixation at low versus high flexion angles would lead to no statistically significant differences in patient-reported outcome measures and graft failure rates.

Study Design

Systematic review; Level of evidence, 4.

Methods

The PubMed, Embase, and Cochrane Library databases were searched according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to identify published clinical studies of ACLR with ALLR/LET in which the knee flexion angle at the time of ALLR/LET was reported. A priori, low flexion was defined as 0° to 30°, and high flexion was defined as 60° to 90°. Studies were excluded if the flexion angle was between 31° and 59° because these angles constituted neither low nor high flexion angles and including them in an analysis of high versus low flexion angle at fixation would have biased the study results toward the null. The overall risk of bias was assessed using the Newcastle-Ottawa Scale. The pooled results of the studies were analyzed using the International Knee Documentation Committee (IKDC), Lysholm, and Tegner scores, along with reported graft failure rates.

Results

A total of 32 clinical studies (5230 patients) met inclusion criteria: 22 studies (1999 patients) in the low-flexion group and 10 studies (3231 patients) in the high-flexion group. The median Newcastle-Ottawa Scale score was 6. Comparisons of patients with a low flexion angle versus a high flexion angle demonstrated no differences in the IKDC (P = .84), Lysholm (P = .67), or Tegner (P = .44) scores or in graft failure (3.4% vs 4.1%, respectively; P = .69).

Conclusion

The results of this review indicated that ACLR performed in conjunction with ALLR/LET provides good to excellent patient-reported outcomes and low graft failure rates when ALLR/LET fixation is performed in either low or high knee flexion.

Pediatric Forearm Malunions

The aim of this article is to review the evaluation and management of pediatric forearm malunions. Acceptable parameters for nonoperative management of pediatric forearm fractures are reviewed, followed by clinical and imaging workups of malunions and decision-making points for treatment. The landscape of available technology for planning and execution of corrective osteotomy is discussed. Several cases of pediatric forearm malunion are presented, along with surgical and functional outcomes. Recommendations are given regarding the authors' preferred approach for management of pediatric forearm malunions.

Clinical outcome of iterative meniscal suture after ACL reconstruction at a minimum of 2 years' follow-up

INTRODUCTION

Failure rates in meniscal suture associated to ACL reconstruction range from 10 to 26.9%, often leading to meniscectomy. In young patients, the wish to conserve the meniscus may lead to iterative suture, if the lesion allows. There are no data available for clinical results of repeat meniscal suture at the same site as the primary lesion in a stabilized knee. The immediate socioeconomic cost, compared to meniscectomy, needs to be taken into account, and benefit needs to be demonstrated. The main aim of the present study was to assess the rate of secondary meniscectomy after iterative meniscal suture in stabilized knees. The study hypothesis was that failure rates are higher in iterative isolated meniscal suture after ligament reconstruction than in primary repair.

MATERIAL AND METHODS

This single-center retrospective study analyzed patients receiving iterative meniscal suture on stable knee, between 2009 and 2019, with a minimum 26 months' follow-up. Twenty-three patients were analyzed: 15 male, 8 female; mean age at iterative suture, 28.1±7.9 years (range, 14-49 years); mean BMI, 24.2±2.9kg/m2 (range, 19-31). Mean time to recurrence was 38.9±25.1 months (range, 6-93 months). Initial ACL graft used the patellar ligament in 69.6% of cases (n=16) and the hamstrings in 30.4% (n=7). Mean differential laximetry before iterative suture was 1.7±0.3mm (range, 1.2-2.3mm). Iterative suture was in the medial meniscus in 69.6% of cases (16/23) and in the lateral meniscus in 30.4% (7/23). Risk factors for failure, defined by requirement for meniscectomy, were assessed. Functional results were assessed on Knee injury and Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee (IKDC) score and Tegner score.

RESULTS

The failure rate was 48% (11/23), incorporating all lesions together. Bucket-handle tear was most frequently associated with failure (91%; p<0.01). There was significant improvement after iterative suture in subjective IKDC score (51.6±15.2 vs. 81.3±15.6; p<0.001) and KOOS scores: symptoms and stiffness, 66.6±13.7 vs. 91.1±7.53 (p<0.001); pain, 79.2±12.7 vs. 93.4±7.4 (p<0.01); function, 91.3±11.2 vs. 97.9±4.44 (p<0.001); quality of life, 38.1±23.2 vs. 62.3±30.1 (p<0.001).

CONCLUSION

The failure rate for iterative meniscal suture on stabilized knee was 48%. Bucket-handle tear was a major risk factor for failure (91%). Despite these high failure rates, functional results systematically improved.

LEVEL OF EVIDENCE

IV.

Intraoperative Assessment of Stability in Total Hip Arthroplasty: A Novel Method Utilizing Implant Collinearity

Background

Hip dislocation remains a leading cause of revision following total hip arthroplasty, and intraoperative assessment of acetabular positioning can be difficult to perform. There are multiple clinical tests, as well as computer and robotic techniques, that aim to reduce dislocation rates after hip arthroplasty. These approaches aim to optimize the relationship between acetabular and femoral component positioning. It is hypothesized in this study that implant collinearity assessment intraoperatively can help determine appropriate acetabular component position. More specifically, implant collinearity, when achieved with a specific leg position, can reliably predict appropriate acetabular positioning.

Methods

A single-surgeon, single-centered study with 55 patients was undertaken between August 2017 and March 2020. Using preoperative imaging and computer simulation, data points were taken for 3 different acetabular configurations and comparing using 2 femoral positions. The angle differences from the collinear position (0 degrees) were compared between groups.

Results

A total of 55 patients' imaging was analyzed using 3 acetabular configurations and 2 femoral positions. The test leg position (30-degree flexion/30-degree internal rotation/10-degree adduction) was closer to collinearity than the control position (30-degree flexion/30-degree internal rotation/0-degree adduction) in all 3 acetabular configurations by a mean of 8 degrees (P < .001), 7 degrees (P < .001), and 4 degrees (P < .001), respectively.

Conclusions

The use of a 10-degree adducted position more reliably recreates implant collinearity when determining acetabular positioning during total hip arthroplasty. This intraoperative test adds another data point to assist the surgeon in achieving safe component positioning.

Comparing the mechanical characteristics between leg lengthening using only an Ilizarov external fixator and leg lengthening over a nail using an external fixator manufactured in Vietnam

PURPOSE

The mechanical characteristics of leg lengthening over a nail (LON) using an external fixator are not well known; specifically, the number of rings and K-wires required for this method has not been determined. This study aimed to compare the mechanical characteristics of leg LON using the simplest configuration for a domestic frame and those of leg lengthening using the Ilizarov frame alone.

METHODS

The mechanical characteristics of cow tibial samples for lengthening over an intramedullary nail in combination with a domestic external fixator (LON samples) and for lengthening with the Ilizarov frame (Ilizarov samples) were evaluated by assessing axial compression, bending load, and torsional load. The research indices were compression stiffness, bending stiffness, torsion stiffness, yield axial load, ultimate axial load, yield bending load, and ultimate bending load.

RESULTS

No statistically significant differences were observed in the compression stiffness, ultimate axial load, bending stiffness, and ultimate, yield bending forces between the Ilizarov samples and LON samples. The compressive stiffness, yield axial load, and ultimate axial load of the LON samples were 98 ± 1.31 N/mm, 915 ± 23.89 N, and 1032 ± 29.86 N, respectively. The anterior-posterior bending stiffness and lateral bending stiffness of the LON samples were 122.48 ± 2.92 N/mm and 116.34 ± 3.95 N/mm, respectively. The yield anterior-posterior bending and ultimate anterior-posterior bending forces of the LON samples were 616.4 ± 3.64 N and 753.2 ± 3.49 N, respectively. The yield lateral bending and ultimate lateral bending forces of the LON samples were 624.6 ± 4.04 N and 759.0 ± 3.39 N, respectively. The axial torsional stiffness of the LON samples was 1.73 ± 0.05 N m/°, which was significantly lower than that of the Ilizarov samples (2.63 ± 0.03 N m/°).

CONCLUSION

No statistically significant differences were observed in the mechanical fixation characteristics of axial compression and bending between the Ilizarov samples and LON samples. However, the axial torsional stiffness of the Ilizarov samples was statistically greater than that of the LON samples. We recommend using the simplest configuration for domestic frames in combination with LON for limb lengthening. Partial weight-bearing is permitted in the distraction stage.

LEVEL OF EVIDENCE

Case-control study.

Effect of individualized narrative nursing mode on recovery of elderly patients with fracture complicated with cerebrovascular accident

Fractures often occur in elderly patients. Osteoporosis caused by massive loss of calcium ions in the bones of elderly patients can easily lead to femoral fractures after suffering a low- and medium-energy injury. With the gradual entry of the aging society in China, the incidence of senile fracture is also gradually increasing. However, there is no report on the application of personalized narrative nursing to the mental health, cognitive function, and limb function recovery of elderly patients with fracture complicated with cerebrovascular accident, in order to enhance the cognitive level of elderly patients with fracture complicated with cerebrovascular accident. This study was specially conducted with a positive attitude toward the disease and improving the life quality. During July 2018 to July 2021, 80 elderly patients with fracture complicated with cerebrovascular accident cured were selected in our hospital. The patients were arbitrarily classified into an assigned control group (n = 40) and a study group (n = 40). The former received routine nursing, and the latter received personalized narrative nursing mode. The nursing satisfaction, functional independence scale (FIM), self-rating anxiety scale (SAS), self-rating depression scale (SDS), cognitive function, fracture healing time, length of hospital stays, and hospitalization expenses were compared. The study group had a satisfaction rate of 100.00%, while the control group had 87.50%. The nursing satisfaction of the study group was higher (P < .05). After 3 months of nursing, the FIM scores augmented. The FIM scores of upper and lower limbs in the study group were remarkably higher (P < .05). A decrease in SAS and SDS scores was observed. The SAS and SDS scores of the study group were lower (P < .05). Three months after discharge, the cognitive function score augmented. At 3 months after discharge, the study group had a higher cognitive function score (P < .05). The fracture healing time, length of stay, and cost of hospitalization in the study group were lower (P < .05). Personalized narrative nursing model can successfully enhance the mental health and cognitive function of elderly patients with fracture complicated with cerebrovascular accident, enhance the recovery of limb function, promote patients' nursing satisfaction, and alleviate the economic burden.

Prevalence of radiographic findings in chronic osteomyelitis

BACKGROUND

Simple radiography in conjunction with pertinent medical history and a comprehensive physical examination is typically adequate for diagnosing chronic osteomyelitis (CO). However, radiographic manifestations of CO lack specificity; therefore, the concordance among specialists in this regard has not been systematically assessed. This study aimed to compare and evaluate the proficiency of orthopedic surgeons and radiologists in identifying radiographic indicators present in simple radiographs for diagnosing CO.

METHODS

This cross-sectional study was a correlational investigation utilizing plain radiographs obtained from a cohort of 60 patients diagnosed with CO. Comprehensive assessments of the demographic and clinical characteristics, comorbidities, and microbiological parameters were conducted. Additional variables included the anatomical location of the CO, existence of fistulas, disease duration, and presence of pseudoarthrosis. This study meticulously documented the presence or absence of six specific findings: bone destruction, which incorporates erosion and radiolucencies around implants; bone sclerosis; cortical thinning concomitant with erosion; cortical thickening; sequestrum formation; and soft-tissue swelling.

RESULTS

Most patients were men (75%), with a mean age of 45.1 years. Hematogenous etiology of CO represented 23%. Bone sclerosis (71.3%) and cortical thickening (67.7%) were the most common radiographic findings, followed by soft-tissue swelling (51.3%), sequestration (47.3%), bone destruction (33.3%), and cortical erosion (30.3%). The mean agreement was 74.2%, showing a marked disagreement rate of 25.8% among all radiographic findings. The presence or absence of soft tissue edema, a prominent radiographic finding that was more important than the other findings, showed the greatest disagreement.

CONCLUSIONS

Radiographic findings in CO were universally observed in all patients, demonstrating a high degree of concordance among specialists, with the exception of soft tissue swelling.

Augmented reality-based surgical navigation of pelvic screw placement: an ex-vivo experimental feasibility study

BACKGROUND

Minimally invasive surgical treatment of pelvic trauma requires a significant level of surgical training and technical expertise. Novel imaging and navigation technologies have always driven surgical technique, and with head-mounted displays being commercially available nowadays, the assessment of such Augmented Reality (AR) devices in a specific surgical setting is appropriate.

METHODS

In this ex-vivo feasibility study, an AR-based surgical navigation system was assessed in a specific clinical scenario with standard pelvic and acetabular screw pathways. The system has the following components: an optical-see-through Head Mounted Display, a specifically designed modular AR software, and surgical tool tracking using pose estimation with synthetic square markers.

RESULTS

The success rate for entry point navigation was 93.8%, the overall translational deviation of drill pathways was 3.99 ± 1.77 mm, and the overall rotational deviation of drill pathways was 4.3 ± 1.8°. There was no relevant theoretic screw perforation, as shown by 88.7% Grade 0-1 and 100% Grade 0-2 rating in our pelvic screw perforation score. Regarding screw length, 103 ± 8% of the planned pathway length could be realized successfully.

CONCLUSION

The novel innovative system assessed in this experimental study provided proof-of-concept for the feasibility of percutaneous screw placement in the pelvis and, thus, could easily be adapted to a specific clinical scenario. The system showed comparable performance with other computer-aided solutions while providing specific advantages such as true 3D vision without intraoperative radiation; however, it needs further improvement and must still undergo regulatory body approval. Future endeavors include intraoperative registration and optimized tool tracking.

Effects of Self-Myofascial Release on Athletes' Physical Performance: A Systematic Review

Therapists and strength and conditioning specialists use self-myofascial release (SMR) as an intervention tool through foam rollers or massage rollers for soft tissue massage, with the purpose of improving mobility in the muscular fascia. Moreover, the use of SMR by professional and amateur athletes during warm-ups, cool downs, and workouts can have significant effects on their physical performance attributes, such as range of motion (ROM) and strength. The purpose of this study was to analyse the literature pertaining to these types of interventions and their effects found in different physical performance attributes for athletes. A systematic search was carried out using the following databases: PUBMED, ISI Web of Science, ScienceDirect, and Cochrane, including articles up to September 2023. A total of 25 articles with 517 athletes were studied in depth. SMR seems to have acute positive effects on flexibility and range of motion, without affecting muscle performance during maximal strength and power actions, but favouring recovery perception and decreasing delayed-onset muscle soreness. Some positive effects on agility and very short-range high-speed actions were identified, as well. In conclusion, although there is little evidence of its method of application due to the heterogeneity in that regard, according to our findings, SMR could be used as an intervention to improve athletes' perceptual recovery parameters, in addition to flexibility and range of motion, without negatively affecting muscle performance.

The effects of lower limb ischaemic preconditioning: a systematic review

Ischaemic preconditioning (IPC) involves the use of repeated occlusions and reperfusions of the peripheral muscle blood supply at a limb. This systematic literature review examines the typical responses in response to the method of application during an IPC applied at the lower limb. This review focuses on the physiological responses for VO2max, haemoglobin, metabolic and genetic responses to various IPC interventions. The literature search was performed using four databases and assessed using the PRISMA search strategy and COSMIN to assess the quality of the articles. Seventeen articles were included in the review, with a total of 237 participants. While there is variation in the method of application, the average occlusion pressure was 222 ± 34 mmHg, ranging from 170 to 300 mmHg typically for 3 or 4 occlusion cycles. The distribution of this pressure is influenced by cuff width, although 8 studies failed to report cuff width. The majority of studies applies IPC at the proximal thigh with 16/17 studies applying an occlusion below this location. The results highlighted the disparities and conflicting findings in response to various IPC methods. While there is some agreement in certain aspects of the IPC manoeuvre such as the location of the occlusion during lower limb IPC, there is a lack of consensus in the optimal protocol to elicit the desired responses. This offers the opportunity for future research to refine the protocols, associated responses, and mechanisms responsible for these changes during the application of IPC.

A, Kis L, Király K, Varga S, Marcsik A, Schütz O, Török T, Hunt DR, Tihanyi B. White plague among the "forgotten people" from the Barbaricum of the Carpathian Basin-Cases with tuberculosis from the Sarmatian-period (3rd-4th centuries CE) archaeological site of Hódmezővásárhely-Kenyere-ér, Bereczki-tanya (Hungary)

Tuberculosis (TB) is a bacterial infection that is well-known in the palaeopathological record because it can affect the skeleton and consequently leaves readily identifiable macroscopic alterations. Palaeopathological case studies provide invaluable information about the spatio-temporal distribution of TB in the past. This is true for those archaeological periods and geographical regions from when and where no or very few TB cases have been published until now-as in the Sarmatian period (1st-5th centuries CE) in the Barbaricum of the Carpathian Basin. The aim of our paper is to discuss five newly discovered TB cases (HK199, HK201, HK225, HK253, and HK309) from the Sarmatian-period archaeological site of Hódmezővásárhely-Kenyere-ér, Bereczki-tanya (Csongrád-Csanád county, Hungary). Detailed macromorphological evaluation of the skeletons focused on the detection of bony changes likely associated with different forms of TB. In all five cases, the presence of endocranial alterations (especially TB-specific granular impressions) suggests that these individuals suffered from TB meningitis. Furthermore, the skeletal lesions observed in the spine and both hip joints of HK225 indicate that this juvenile also had multifocal osteoarticular TB. Thanks to the discovery of HK199, HK201, HK225, HK253, and HK309, the number of TB cases known from the Sarmatian-period Carpathian Basin doubled, implying that the disease was likely more frequent in the Barbaricum than previously thought. Without the application of granular impressions, the diagnosis of TB could not have been established in these five cases. Thus, the identification of TB in these individuals highlights the importance of diagnostics development, especially the refinement of diagnostic criteria. Based on the above, the systematic macromorphological (re-)evaluation of osteoarchaeological series from the Sarmatian-period Carpathian Basin would be advantageous to provide a more accurate picture of how TB may have impacted the ancestral human communities of the Barbaricum.

Mindful attention is inversely associated with pain via mediation by psychological distress in orthopedic patients

BACKGROUND

Orthopedic patients report pain as their main symptom complaint. Subjective pain experience is correlated with self-reported psychological state, such as distress.

PURPOSE

This study tests whether scores from a measure of mindful attention are associated with subjective pain levels and whether psychological distress scores function as a mediation path.

METHODS

During routine visits to a single orthopedic clinic in East Los Angeles, California, 525 patients were recruited to participate in the study. Participants reported on measures of pain (Universal Pain Assessment Tool [UPAT]), mindful attention (Five-Facet Mindfulness Questionnaire [FFMQ]), and psychological distress (Depression, Anxiety, Stress Scale [DASS]). We used Pearson correlations to examine relationships between FFMQ and UPAT scores and mediation analyses to test indirect effects of DASS scores as a mediation path.

RESULTS

The average age of the sample was 54 years (range 18-98 years), 61% were male, and 64% were non-Hispanic White individuals. The locations of injury were the shoulder (72%), elbow (21%), and clavicle or wrist (7%). Ninety-one percent reported mild or greater pain in the prior 2 weeks (mean = 4.2 ± 2.5, range 0-10), and 49% reported mild or more severe distress symptoms (DASS: 13.0 ± 11.5). FFMQ scores inversely predicted UPAT scores (β = -0.22, P < .01), mediated through DASS scores. DASS subscale scores for depression (β = -0.10, P = .02) and stress (β = -0.08, P = .04) but not anxiety (β = -0.03, P = .33) produced significant indirect effects. FFMQ acting-with-awareness and non-judging subscales had the largest effect on depression and stress DASS subscale scores.

CONCLUSIONS

We find statistical support to suggest that distress-particularly depressed mood and stress-mediates the association between mindful attention and pain intensity among orthopedic patients. A disposition of mindful attention might counter distress ailments that exacerbate subjective pain, and this has possible implications for mindfulness training interventions offered to orthopedic patients.

Blood flow restriction training for an individual with relapsing-remitting multiple sclerosis: a case report

BACKGROUND AND PURPOSE

Individuals with Multiple Sclerosis (MS) often present with weakness, poor balance, and increased fatigue that affects physical function. Blood flow restriction training (BFRt) is a popular treatment method to improve strength in orthopedic patients. However, research is limited on the use of BFRt for individuals with MS. This case report describes the effects of BFRt for an individual with relapsing-remitting MS (RRMS).

CASE DESCRIPTION

A 30-year-old female with RRMS presented to physical therapy (PT) with weakness and balance difficulty. Initial PT interventions were ineffective at improving balance and strength to achieve specific functional standing and balance goals. BFRt was introduced at reevaluation and performed 2×/week for 8 weeks. Activities-specific Balance Confidence Scale, Modified Fatigue Impact Scale, Berg Balance, strength, and 10-meter walk were assessed at 4 and 8 weeks.

OUTCOMES

Measures of strength and balance improved with the addition of BFRt and no adverse events occurred. The addition of BFRt resulted in a meaningful improvement in the individual's ability to achieve her standing and balance goals.

DISCUSSION

This case report describes the successful application of BFRt to improve function in an individual with RRMS. Further research is warranted for the use of BFRt for individuals with MS.

Rehabilitation Techniques for Adults Undergoing External Fixation Treatment for Lower Limb Reconstruction: A Systematic Review

Introduction

External fixation devices are commonly used in orthopaedic surgery to manage a range of pathologies. In this patient population, there is currently no consensus on optimal rehabilitation techniques. There exists a large variation in practice, with a limited understanding of how these affect treatment outcomes.

Methods

Following Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, a systematic review was conducted of Allied and Complementary Medicine Database (AMED), Cumulative Index to Nursing and Allied Health Literature (CINAHL), MEDLINE, PEDro, and COCHRANE databases, grey literature sources and forward and backward searching of included articles. Studies were selected following rigorous screening with predefined inclusion criteria. Data quality was assessed using validated appraisal tools. Articles were synthesised by rehabilitation type and descriptive analysis was subsequently performed.

Results

From 1,156 articles identified, 18 were eligible for inclusion. The overall quality was low, with clinical commentaries and case studies being the most common study type. Studies were synthesised by rehabilitation type, the most common themes being gait re-education, strengthening, therapy-assisted, active exercises and weight-bearing exercises.

Conclusion

There is a lack of high-quality evidence to support meaningful recommendations and guide rehabilitation practices for this patient cohort. Further research for patients being treated in external fixation, especially related to the potential effects of physical rehabilitation on bone healing, return of strength, mobility and independent function is likely to have transferability within wider orthopaedic populations.

Clinical significance

This systematic review is unable to provide clinical recommendations due to the poor quality of the available literature. However, it is hoped this paper will provide a foundation for further research to improve rehabilitation for patients being treated with external fixation.

How to cite this article

Pawson JR, Church D, Fletcher J, et al. Rehabilitation Techniques for Adults Undergoing External Fixation Treatment for Lower Limb Reconstruction: A Systematic Review. Strategies Trauma Limb Reconstr 2024;19(1):45-55.

Comparative Evaluation of the Aesthetic Outcomes of Octyl-2-Cyanoacrylate Skin Adhesive and Ethilon Suture in Maxillofacial Surgery - A Randomised Clinical Study

Introduction

Wound closure methods have evolved, attributed to the armamentarium including the synthetic sutures, staples, surgical adhesive tapes and, most recently, the cyanoacrylate tissue adhesives. Cyanoacrylates have shown promising results in terms of aesthetic outcomes in other fields of surgery. The aim of this study is to compare the aesthetic value of Dermabond over Ethilon suture when used in case of facial surgical incisions. The purpose of this study was to demonstrate the efficacy of Dermabond for wound closure in the head-and-neck region.

Materials and Methods

This study involved 20 subjects undergoing maxillofacial surgery. In 10 subjects, skin closure was done with conventional suturing (Ethilon) and other 10 subjects with tissue glue (2-octyl cyanoacrylate). Observations regarding skin closure time and scar assessment were made, and their results were compared.

Results

The mean time for closure in the Dermabond group was 217.2 ± 42.0 s and for Ethilon suture group was 383.3 ± 140.2 s. Dermabond was significantly better than Ethilon sutures at both 1 month and 3 months with P = 0.001 and P < 0.001, respectively. For Dermabond, the average score improved from 8.2 ± 2.5 at 1 month to 6.1 ± 1.6 at the 3rd month. The improvement was statistically significant (P = 0.001) for Ethilon sutures; the average score improved from 12.0 ± 1.2 at 1 month to 10.2 ± 2.0 at 3rd month. The improvement was statistically significant (P = 0.038).

Discussion

Adhesive glue appears to be superior to conventional suturing in clean elective surgeries. It is a safe and effective method of skin closure with less operative time and better cosmesis of the scar.

Nicotine Dependence and Rates of Postoperative Complications in Achilles Tendon Repair

BACKGROUND

Nicotine is a modifiable risk factor that is well demonstrated to cause deleterious effects on tendon healing and overall health. Individuals that have a dependence on nicotine may be at an elevated risk for numerous postoperative complications when compared to nondependent patients. The purpose of this study is to evaluate the complications postoperatively between nicotine- and non-nicotine-dependent Achilles tendon repairs.

METHODS

The global health network database, TriNetX, was used to access and analyze deidentified patient information. Two cohorts were identified for the purposes of this study. Cohort A was defined as patients who had an Achilles tendon repair (Current Procedural Terminology [CPT]: 27650 or CPT: 27654) and had a dependence to nicotine (International Classification of Diseases, Tenth Revision, code: F17). Cohort B was defined as patients who had an Achilles tendon repair but did not have a dependence to nicotine. Data were gathered from health care organizations from August 21, 2000, to August 21, 2023. All postoperative complications were analyzed between 1 and 90 days after the Achilles tendon repair.

RESULTS

A total of 2117 nicotine-dependent patients were matched with 18 102 non-nicotine-dependent patients. After propensity matching for age at event, ethnicity, race, sex, and type 2 diabetes mellitus, nicotine-dependent patients who underwent Achilles tendon repair experienced higher associated risk for numerous postoperative complications. When compared to nondependent patients, nicotine-dependent patients had increased risk for wound disruption (risk ratio [RR] 1.55, 95% CI 1.11-2.16) and infection following a procedure (RR 1.64, 95% CI 1.09-2.47) within 90 days post Achilles tendon repair.

CONCLUSION

In this database study using propensity matching, nicotine-dependent patients who underwent Achilles tendon repair were correlated with an increased associated risk for wound disruption and infection after a procedure than their non-nicotine-dependent counterpart.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Role of Lateral Extra-articular Tenodesis in Restraining Internal Tibial Rotation: In Vitro Biomechanical Assessment of Lateral Tissue Engagement

BACKGROUND

The way in which force increases in the anterolateral tissues and the lateral extra-articular tenodesis (LET) tissue to resist internal rotation (IR) of the tibia after anterior cruciate ligament (ACL) reconstruction in isolation and after LET augmentation, respectively, is not well understood.

PURPOSE

(1) To compare in a cadaveric model how force increases (ie, engages) in the anterolateral tissues with IR of the tibia after isolated ACL reconstruction and in the LET tissue after augmentation of the ACL reconstruction with LET and (2) to determine whether IR of the tibia is related to engagement of the LET tissue.

STUDY DESIGN

Controlled laboratory study.

METHODS

IR moments were applied to 9 human cadaveric knees at 0°, 30°, 60°, and 90° of flexion using a robotic manipulator. Each knee was tested in 2 states: (1) after isolated ACL reconstruction with intact anterolateral tissues and (2) after LET was performed using a modified Lemaire technique with the LET tissue fixed at 60° of flexion under 44 N of tension. Resultant forces carried by the anterolateral tissues and the LET tissue were determined via superposition. The way force increased in these tissues was characterized via parameters of tissue engagement, namely in situ slack, in situ stiffness, and tissue force at peak applied IR moment, and then compared (α < .05). IR was related to parameters of engagement of the LET tissue via simple linear regression (α < .05).

RESULTS

The LET tissue exhibited less in situ slack than the anterolateral tissues at 30°, 60°, and 90° of flexion (P≤ .04) and greater in situ stiffness at 30° and 90° of flexion (P≤ .043). The LET tissue carried greater force at the peak applied IR moment at 0° and 30° of flexion (P≤ .01). IR was related to the in situ slack of the LET tissue (R2≥ 0.88; P≤ .0003).

CONCLUSION

LET increased restraint to IR of the tibia compared with the anterolateral tissue, particularly at 30°, 60°, and 90° of flexion. IR of the tibia was positively associated with in situ slack of the LET tissue.

CLINICAL RELEVANCE

Fixing the LET at 60° of flexion still provided IR restraint in the more functionally relevant flexion angle of 30°. Surgeons should pay close attention to the angle of internal and/or external tibial rotation when fixing the LET tissue intraoperatively because this surgical parameter is related to in situ slack of the LET tissue and, therefore, the amount of IR of the tibia.

The Need for Persistence in the Diagnosis of Mycobacterium Tuberculosis Mono-arthritis: A Unique Case Presentation

Although tuberculosis (TB) is considered to be a common disease confined to undeveloped or developing countries, it may also appear in countries that accept great migrant influx from endemic areas. In terms of the skeletal system, it can be involved in 1-6% of tuberculosis patients while the knee joint is the third most frequently affected site after spine and hip. Given that systemic symptoms are present in only one-third of patients with skeletal tuberculosis and secondary septic arthritis, TB is often indolent and diagnosis can hence be missed or delayed. As a result, a high index of suspicion is imperative. Here, we aim to report a case of mono-arthritis caused by Mycobacterium tuberculosis in a native 77-year-old man who was suffering from low-grade knee pain for six months and despite multiple presentations to the Accident and Emergency department, diagnosis had not been established.

Pain, function and quality of life are impaired in adults undergoing periacetabular osteotomy (PAO) for hip dysplasia: a systematic review and meta-analysis

BACKGROUND

Hip dysplasia is a common condition in active adults with hip pain that can lead to joint degeneration. Periacetabular osteotomy (PAO) is a common surgical treatment for hip dysplasia. The effect of this surgery on pain, function and quality of life (QOL) has not been systematically analysed.

PURPOSE

In adults with hip dysplasia: (1) evaluate differences in pain, function and QOL in those undergoing PAO and healthy controls; (2) evaluate pre- to post-PAO changes in pain, function and QOL; (3) evaluate differences in pain, function and QOL in those with mild versus severe dysplasia, undergoing PAO; and (4) evaluate differences in pain, function and QOL in those having primary PAO versus those with previous hip arthroscopy.

METHODS

A comprehensive, reproducible search strategy was performed on 5 different databases. We included studies that assessed pain, function and QOL in adults undergoing PAO for hip dysplasia, using hip-specific patient reported outcomes measures.

RESULTS

From 5017 titles and abstracts screened, 62 studies were included. Meta-analysis showed PAO patients had worse outcomes pre- and post-PAO compared to healthy participants. Specifically, pain (standardised mean difference [SMD] 95% confidence interval [CI]): -4.05; -4.78 to -3.32), function (-2.81; -3.89 to -1.74), and QOL (-4.10; -4.43 to -3.77) were significantly poorer preoperatively.Meta-analysis found patients experienced improvements following PAO. Pain improved from pre-surgery to 1-year (standardised paired difference [SPD] 1.35; 95% CI, 1.02-1.67) and 2 years postoperatively (1.35; 1.16-1.54). For function, the activities of daily living scores at 1 year (1.22; 1.09-1.35) and 2 years (1.06; 0.9-1.22) and QOL at 1 year (1.36; 1.22-1.5) and 2 years (1.3; 1.1-1.5) all improved. No difference was found between patients undergoing PAO with mild versus severe dysplasia.

CONCLUSIONS

Before undergoing PAO surgery, adults with hip dysplasia have worse levels of pain, function and QOL compared to healthy participants. These levels improve following PAO, but do not reach the same level as their healthy participants.

REGISTRATION

PROSPERO (CRD42020144748).

Radial head replacement with the 3D-printed patient-specific titanium prosthesis: Preliminary results of a multi-centric prospective study

PURPOSE

To report preliminary clinical results and safety of 3D-printed patient-specific titanium radial head (RH) prosthesis in treatment of the irreparable RH fractures.

MATERIAL AND METHODS

This multi-centric prospective study included 10 patients (6 men and four women, mean age 41 years (range, 25-64 years)). Three cases were classified as Mason type III and 7 cases as type IV. Patients were assessed preoperatively, intraoperatively, and at 1, 6, 12, 24, 36, and 48 weeks postoperatively. Range of motion (ROM), visual analog scale (VAS) score, Disabilities of the Arm, Shoulder and Hand (DASH) score, Mayo Elbow Performance Score (MEPS), radiology imaging, and laboratory blood and urine testing were evaluated.

RESULTS

The prostheses were implanted utilizing cemented stems in 5 patients and cementless stems in 5 patients. Intraoperatively, well congruency of a prosthesis with capitellum and radial notch of ulna was observed in all cases. All patients had improvement of ROM, VAS score, DASH score, and MEPS during the postoperative follow-ups. At the final follow-up, mean elbow extension was 6.5° (range, 0°-30°), flexion 145° (range, 125°-150°), supination 79° (range, 70°-80°), and pronation 73.5° (range, 45°-80°). Mean VAS score was 0.3 (range, 0-3), DASH score was 12.35 (range, 1.7-23.3), and MEPS was 99.5 (range, 95-100). Postoperative radiographs demonstrated heterotopic ossification in 2 cases, periprosthetic radiolucency in 2 cases, and proximal radial neck resorption in 2 cases. No one had the evidence of capitellar erosion, implant failure, malpositioning, overstuffing, or symptomatic stem loosening. There was no significant alteration of laboratory results or adverse events related to the 3D-printed prosthesis implantation.

CONCLUSION

The preliminary results demonstrated that implantation of the 3D-printed patient-specific titanium RH prosthesis is safe and may be a potential treatment option for irreparable RH fracture.

Safety and efficacy of blood flow restriction exercise in individuals with neurological disorders: A systematic review

OBJECTIVES

This systematic review evaluated the safety and efficacy of blood flow restriction exercise (BFRE) on skeletal muscle size, strength, and functional performance in individuals with neurological disorders (ND).

METHODS

A literature search was performed in PubMed, CINAHL, and Embase. Two researchers independently assessed eligibility and performed data extraction and quality assessments.

ELIGIBILITY CRITERIA

Study populations with ND, BFRE as intervention modality, outcome measures related to safety or efficacy.

RESULTS

Out of 443 studies identified, 16 were deemed eligible for review. Three studies examined the efficacy and safety of BFRE, one study focused on efficacy results, and 12 studies investigated safety. Disease populations included spinal cord injury (SCI), inclusion body myositis (sIBM), multiple sclerosis (MS), Parkinson's disease (PD), and stroke. A moderate-to-high risk of bias was presented in the quality assessment. Five studies reported safety concerns, including acutely elevated pain and rating of perceived exertion levels, severe fatigue, muscle soreness, and cases of autonomic dysreflexia. Two RCTs reported a significant between-group difference in physical function outcomes, and two RCTs reported neuromuscular adaptations.

CONCLUSION

BFRE seems to be a potentially safe and effective training modality in individuals with ND. However, the results should be interpreted cautiously due to limited quality and number of studies, small sample sizes, and a general lack of heterogeneity within and between the examined patient cohorts.

Combined Anteversion Threshold to Avoid Anterior Dislocation in Primary Total Hip Arthroplasty Performed Through the Direct Anterior Approach

BACKGROUND

Component malposition in total hip arthroplasty (THA) can lead to dislocation, early implant failure, and revision surgery. As the surgical approach might affect the targeted combined anteversion (CA) of THA components, the present study aimed to evaluate the optimal CA threshold to avoid anterior dislocation in primary THA performed through a direct anterior approach (DAA).

METHODS

A total of 1,176 THAs in 1,147 consecutive patients (men: 593, women: 554) who had an average age of 63 years (range, 24 to 91) and a mean body mass index of 29 (range, 15 to 48) were identified. Medical records were reviewed for dislocation, whereas postoperative radiographs were assessed to measure the acetabular inclination and CA using a previously validated radiographic method.

RESULTS

An anterior dislocation occurred in 19 patients at an average of 40 days postoperatively. The average CA in patients who did and did not have a dislocation was 66 ± 8° and 45 ± 11°, respectively (P < .001). In 5 of 19 of the patients, a THA was performed for secondary osteoarthritis and 17 of 19 had a 28-mm femoral head. A CA ≥ 60° yielded a sensitivity of 93% and specificity of 90% for predicting an anterior dislocation in the present cohort. A CA ≥ 60° was associated with a significantly higher risk of anterior dislocation (odds ratio = 75.6; P < .001) compared to patients who had a CA<60 points.

CONCLUSION

The optimal CA to avoid anterior dislocations in THA performed through the DAA should be less than 60°.

LEVEL OF EVIDENCE

Cross-sectional study, Level III.

A prospective randomized controlled study of hamstring and bone-free quadriceps tendons autografts in arthroscopic ACL reconstruction

INTRODUCTION

Anterior cruciate ligament (ACL) reconstruction is one of the most common surgical procedures worldwide. However, the ideal graft source is still debatable. This study compared hamstring (HT) and bone-free quadriceps (QT) tendon autografts in terms of muscle strength and patient-reported outcomes.

METHODS

Between June 2018 and December 2019, 46 patients were enrolled in the study and randomly assigned to one of two groups for the ACL reconstruction surgery-the HT autograft group or the QT autograft group. An experienced examiner performed preoperative and postoperative examinations. The HUMAC NORM isokinetic machine (Computer Sports Medicine International-CSMI, 2004) was used to assess flexor and extensor thigh muscle strength. Both groups received the same surgical technique and fixation method. All patients were examined after three, six, nine, and 12 months. The final evaluations were performed at the 24-month follow-up. Patients' scores on the International Knee Documentation Committee (IKDC) evaluation form and the Lysholm Knee Scoring Scale were used to evaluate patient-reported outcomes. The two groups were also compared in terms of postoperative complications and activity levels.

RESULTS

The difference between preoperative and postoperative knee flexor peak torques (FPT) was lower in the QT group than in the HT group. The average difference between preoperative and postoperative knee extensor peak torque (EPT) was higher in the QT group than in the HT group. As a result, the HT group had a lower postoperative H/Q ratio (flexor strength normalized to body mass divided by extensor strength normalized to body mass) than the QT group (p < 0.001). The mean IKDC scores for the HT and QT groups were 90.13 ± 6.99 and 87.12 ± 6.61, respectively. The scores of the two groups postoperatively were close, and both groups showed significant improvement. The average graft size in the QT group was significantly greater than that in the HT group. Saphenous nerve palsy was the most common complication in the HT group (22%). Thigh hematomas were observed in two patients in the QT group and required urgent intervention (12%).

CONCLUSION

After ACL reconstruction, we found a significant decrease in strength at the donor sites in both techniques, with similar patient-reported measures and stability outcomes. The H/Q strength ratio was higher in the QT group postoperatively, which may have a protective effect on the reconstructed ligament. Level of Evidence I It is a randomized controlled trial.

Acute effects of static balance exercise combined with different levels of blood flow restriction on motor performance fatigue as well as physiological and perceptual responses in young healthy males and females

PURPOSE

This study investigated the acute effects of a static balance exercise combined with different blood flow restriction (BFR) pressures on motor performance fatigue development and recovery as well as physiological and perceptual responses during exercise in males and females.

METHODS

Twenty-four recreational active males (n = 13) and females (n = 11) performed static balance exercise on a BOSU ball (3 sets of 60 s with 30 s rest in-between) on three separate (> 3 days) laboratory visits with three different BFR pressures (80% arterial occlusion pressure [AOP], 40%AOP, 30 mmHg [SHAM]) in random order. During exercise, activity of various leg muscles, vastus lateralis muscle oxygenation, and ratings of effort and pain perception were recorded. Maximal squat jump height was measured before, immediately after, 1, 2, 4, and 8 min after exercise to quantify motor performance fatigue development and recovery.

RESULTS

Quadriceps muscle activity as well as ratings of effort and pain were highest, while muscle oxygenation was lowest in the 80%AOP compared to the 40%AOP and SHAM condition, with no differences in postural sway between conditions. Squat jump height declined after exercise with the highest reduction in the 80%AOP (- 16.4 ± 5.2%) followed by the 40%AOP (- 9.1 ± 3.2%), and SHAM condition (- 5.4 ± 3.3%). Motor performance fatigue was not different after 1 min and 2 min of recovery in 40% AOP and 80% AOP compared to SHAM, respectively.

CONCLUSION

Static balance exercise combined with a high BFR pressure induced the largest changes in physiological and perceptual responses, without affecting balance performance. Although motor performance fatigue was increased by BFR, it may not lead to long-term impairments in maximal performance.

Physician reported outcomes of hip arthroscopy without a perineal post: an international survey

Although the current literature reports an acceptable rate of complications with the use of a perineal post in hip arthroscopy, they are still possible and preventable. The purpose of this study was to survey International Society for Hip Arthroscopy (ISHA) members on their use of postless distraction in hip arthroscopy. A 19-question survey was emailed to hip preservation surgeons that are members of ISHA. The questions examined surgeons' location, experience, utilization of a perineal post or postless distraction and any complications they may have encountered. In all, 145 respondents completed the survey. Regarding complications encountered when using a perineal post, the most frequent responses were temporary nerve damage (115, 80.6%), temporary genitourinary complications (39, 27%), temporary genital skin injury (35, 24%) and permanent nerve injury (12, 8%). Regarding the postless technique, of the 60 respondents who noted they have utilized postless distraction, 9 (15%) reported complications, with 7 (12%) reporting temporary nerve damage being the most common and 0 reporting cases of permanent nerve injury. These were statistically significantly less than those reported with a perineal post. Ninety-seven percent reported that after utilizing postless distraction, their patients were recovering better than or the same as when using a perineal post. This survey had excellent international participation by experienced hip arthroscopists. There were a statistically significantly decreased number of complications reported by the surgeons utilizing postless distraction. This survey highlights that postless distraction is being done successfully with lower reported complications and excellent patient recovery.

Correction of Coronal Deformity and Intercompartmental Imbalance through Bone Resection

This review discusses the correction of coronal deformity and intercompartmental imbalance through bone resection in total knee arthroplasty (TKA). To achieve functional knee balance, coronal, rotational, and sagittal alignment are critical to successful patient outcomes. Though variations in coronal alignment are debated as a correlate to positive results, advancements in utilizing implant position, alignment, and soft tissue balance to improve patient outcomes and function are an evolving discussion. This study draws upon existing literature, clinical studies, and surgical techniques related to TKA, including advancements in navigation and robotics. The study highlights the importance of individualized alignment strategies for varus and valgus knees. While mechanical neutral alignment has shown excellent long-term data, reevaluating the anatomic recreation of the patient's joint line obliquity is now being studied extensively. Sensor data and navigation systems contribute to improved outcomes and patient satisfaction. The evolution of navigation and robotics has led surgeons to achieve their target angles consistently and accurately; now, the discussion is around the most effective alignment targets. The classification of various phenotypes assists in the proposed starting points for implant position, but soft tissue tension is required in the input data to achieve global balance and stable motion. Each approach's advantages and limitations are considered. In conclusion, achieving optimal coronal alignment, joint line obliquity, and soft tissue balance is crucial for successful TKA outcomes. Personalized alignment philosophies, supported by three-dimensional data and sensor technology, are evolving to minimize critical errors and enhance functional results. Robotic assistance and future advancements in artificial intelligence and machine learning hold promise for further improving TKA outcomes in the quest for soft tissue stabilization.

Distal Femoral Osteotomy for the Management of Coronal Deformity Following Total Knee Arthroplasty: A Report of 2 Cases

CASE

We present 2 cases demonstrating the management of coronal malalignment with an existing total knee arthroplasty using opening wedge distal femur osteotomy. The mechanical axis was corrected, and the primary total knee implants were maintained. Patients resumed full activity 3 to 4 months after surgery.

CONCLUSION

In certain cases, opening wedge distal femoral osteotomy is an option to correct coronal malalignment with an existing total knee arthroplasty without revising the implant.

Physiotherapy Intervention Focusing on Proprioceptive Retraining for Tibial Pseudoarthrosis Patients Operated With Ilizarov External Fixator: A Case Report

Pseudoarthrosis of the tibia is an uncommon condition that occurs due to non-union of bone and typically requires surgery. It may cause fractures that develop spontaneously or after minor trauma. Physiotherapy is an excellent treatment for this uncommon condition. The tibia of the affected limb becomes malformed and bends backwards. This case report outlines the interdisciplinary programme adopted to successfully manage a 23-year-old female patient with right-sided tibial pseudoarthrosis. Following the implantation of Ilizarov's external fixator to correct the deformity, the patient was referred to the physiotherapy department for post-operative management. After the implementation of a tailor-made physiotherapy protocol focusing on proprioceptive retraining, significant improvements were seen in her joint proprioception, muscular strength and range of motion.

Isolated Extensor Hallucis Longus Compartment Syndrome: A Case Report

We present the case of an isolated extensor hallucis longus compartment syndrome following a diaphyseal fibular fracture. Our subject underwent syndesmotic fixation and experienced ongoing pain post-procedure. This was associated with an isolated loss of power in extension of the hallux. A diagnosis of an isolated extensor hallucis longus compartment syndrome followed. Our case highlights the vulnerability of this muscle belly to ischemia and reiterates the value of complete clinical examination in the postoperative patient.

Does the type of medial plate fixation matter for supplemental fixation of distal femur fractures manage with a lateral pre-contoured locked plate? A Biomechanical study

INTRODUCTION

Fixation of distal femur fractures with a lateral pre-contoured locking plate provides stable fixation and is the standard treatment in most cases, allowing early range of motion with a high rate of union. However, in situations, the stability achieved with the lateral plate alone may be insufficient, predisposing to fixation failure. The objective of the study was to compare, in synthetic bone models, the biomechanical behaviour of the fixation with a distal femur lateral pre-contoured locking plate solely and associated with a 3.5 mm proximal humeral locking plate applied upside down or a 4.5 mm helical locking compression plate on the medial side.

MATERIAL AND METHODS

A total of 15 solid synthetic left femur samples were used. A metaphysical defect at the level of the medial cortex was simulated. The samples were randomly distributed into three groups equally. All groups received a 4.5/5.0 mm single lateral 9-hole distal femur lateral pre-contoured locking plate. Group 1 had no supplementary plate. Group 2 received a supplementary 6-hole 3.5 mm proximal humeral locking plate and Group 3 received a supplementary 4.5/5.0 mm helical 14-hole narrow locking compression plate.

RESULTS

Both supplementary plate types used in groups 2 and 3 contributed to increase the apparent stiffness of the construct, but pairwise comparison showed statically significant difference only between group 1 and 3. No significant difference was observed between groups 2 and 3.

CONCLUSION

Both supplementary plates might be considered for improving the fixation in distal femur fracture in selected cases.

Management of Patellar Tendinopathy

Patellar tendinopathy is a common pathology typically seen in athletes involved in repetitive explosive jumping and running activities. Also known as jumpers' knee, it is commonly seen in high-level basketball players. Typically, athletes continue to play with symptoms, which can be aggravated and progress to partial patellar tendon tears. When partial patellar tendon tears occur, prolonged recovery and decreased performance is commonly seen. The pathology and treatment can be frustrating for both the athlete and medical provider. Patellar tendinopathy typically does not involve inflammation but rather microinjury to the tendon fibers, which leads to mucoid degeneration, necrosis, and loss of transitional fibrocartilage. When partial tendon tears do occur, the typical location is posteromedially adjacent to the patella. Treatment involves a stepwise approach starting with nonoperative means, including activity modification, nonsteroidal anti-inflammatories, and physical therapy focused on eccentrics. Extracorporeal shock wave treatments and injections with platelet-rich plasma or bone marrow aspirate concentrate should be considered, with evolving literature to support their use. Ultrasound percutaneous tendon scrapping with a needle supplemented with the aforementioned injections is an emerging treatment option that the authors have found to be helpful, although further studies are required. Surgical intervention is considered after failure of nonoperative treatments, and typically occurs in tears greater than 50% of the tendon thickness and in tendons with increased thickness (>8.8 mm). Open or arthroscopic debridement can be considered, with no studies showing superior outcomes with either technique; however, no high-quality comparison studies exist. The authors prefer an open technique where, much like a bone-patellar tendon-bone harvest, the unhealthy proximal tendon and bone are excised with then closure of the healthy tendon with absorbable sutures. Suture anchor repair may also be used when necessary. In a recent systematic review, surgical management of patellar tendinopathy has been shown to result in improved patient-reported outcomes with return to sport at high levels.1 Treatment for the difficult and sometimes frustrating pathology of patellar tendinopathy continues to evolve, with biologic and less-invasive ultrasound-based treatments showing promise, and surgical intervention providing reliable outcomes.

Retrograde intramedullary nailing of the femur: identifying the true anatomic axis for the ideal start point

PURPOSE

Retrograde femoral intramedullary nailing (IMN) is commonly used to treat distal femur fractures. There is variability in the literature regarding the ideal starting point for retrograde femoral IMN in the coronal plane. The objective of this study was to identify the ideal starting point, based on radiographs, relative to the intercondylar notch in the placement of a retrograde femoral IMN.

METHODS

A consecutive series of 48 patients with anteroposterior long-leg radiographs prior to elective knee arthroplasty from 2017 to 2021 were used to determine the femoral anatomic axis. The anatomic center of the isthmus was identified and marked. Another point 3 cm distal from the isthmus was marked in the center of the femoral canal. A line was drawn connecting the points and extended longitudinally through the distal femur. The distance from the center of the intercondylar notch to the point where the anatomic axis of the femur intersected the distal femur was measured.

RESULTS

On radiographic review, the distance from the intercondylar notch to where the femoral anatomic axis intersects the distal femur was normally distributed with an average distance of 4.1 mm (SD, 1.7 mm) medial to the intercondylar notch.

CONCLUSION

The ideal start point, based on radiographs, for retrograde femoral intramedullary nailing is approximately 4.1 mm medial to the intercondylar notch. Medialization of the starting point for retrograde intramedullary nailing in the coronal plane aligns with the anatomic axis. These results support the integration of templating into preoperative planning prior to retrograde IMN of the femur, with the knowledge that, on average, the ideal start point will be slightly medial. Further investigation via anatomic studies is required to determine whether a medial start point is safe and efficacious in patients with distal femur fractures treated with retrograde IMNs.

Does Computer Navigation or Robotic Assistance Affect the Risk of Periprosthetic Joint Infection in Primary Total Knee Arthroplasty? A Propensity Score-Matched Cohort Analysis

BACKGROUND

The use of technology during total knee arthroplasty (TKA) has been associated with more accurate component position and less blood loss. Yet to date, the risk of developing prosthetic joint infection (PJI) associated with computer navigation (CN) or robotic assistance (RA) has not been thoroughly evaluated. This study used propensity score-matching (PSM) in a large cohort of primary TKA patients to compare the rate of PJI following conventional TKA (TKA) versus CN-TKA and RA-TKA.

METHODS

We retrospectively reviewed 13,015 knees in 11,727 patients who underwent primary TKA at a single institution from 2018 to 2021. The cohort was stratified into TKA, CN-TKA, and RA-TKA groups. 1:1 PSM was applied to 11,834 patients. Propensity score-matching was performed using logistic regression accounting for age, sex, body mass index, Charlson Comorbidity Index (CCI) score, CCI components, and smoking status. Univariate and multivariable analyses were performed to evaluate differences in surgical time and PJI rate.

RESULTS

Significantly longer median operating times were noted in the RA-TKA group (14 minutes) compared to TKA (P < .001). The PJI rates among matched cohorts were similar among RA-TKA (0.3%), CN-TKA (0.3%), and conventional TKA (0.5%). Multivariable logistic regressions demonstrated that the use of robotic assistance (odds ratio (OR) = 0.5, P = .423) or computer navigation (OR = 0.61, P = .128) was not associated with increased risk of PJI when compared to conventional TKA.

CONCLUSIONS

Use of computer navigation and robotic assistance during primary TKA are associated with longer surgical times, but no difference in PJI frequency within 90 days of surgery.

Implant Surface Technologies to Promote Spinal Fusion: A Narrative Review

The technology surrounding spinal fusion surgery has continuously evolved in tandem with advancements made in bioengineering. Over the past several decades, developments in biomechanics, surgical techniques, and materials science have expanded innovation in the spinal implant industry. This narrative review explores the current state of implant surface technologies utilized in spinal fusion surgery. This review covers various types of implant surface materials, focusing on interbody spacers composed of modified titanium, polyetheretherketone, hydroxyapatite, and other materials, as well as pedicle screw surface modifications. Advantages and disadvantages of the different surface materials are discussed, including their biocompatibility, mechanical properties, and radiographic visibility. In addition, this review examines the role of surface modifications in enhancing osseointegration and reducing implant-related complications and, hopefully, improving patient outcomes. The findings suggest that while each material has its potential advantages, further research is needed to determine the optimal surface properties for enhancing spinal fusion outcomes.