Good mid- to long-term outcomes after meniscus bucket-handle tear repair: A comparative analysis with and without anterior cruciate ligament reconstruction

Purpose

To evaluate mid- to long-term clinical outcomes after arthroscopic bucket-handle meniscal tear (BHMT) repair and to assess the impact of concurrent anterior cruciate ligament reconstruction (ACLR).

Methods

A comparative retrospective case series with blinded outcome assessment was conducted. All consecutive patients treated with arthroscopic BHMT repair with or without concurrent ACLR between 2001 and 2021 were eligible for inclusion. Fifty-five patients with an average follow-up of 7.3 ± 3.4 years were included in the analysis. Outcome measures comprised post-operative IKDC Subjective Knee Form, Lysholm Score, Tegner Activity Scale, KOOS, and visual analogue scale (VAS) for satisfaction. Additionally, failure and reoperation rates were assessed.

Results

The failure rate was 9%. Medial BHMT repair showed superior post-operative IKDC scores compared to lateral meniscus repair (p = 0.038). Concurrent ACLR did not demonstrate any impact on post-operative KOOS, IKDC, Tegner or patient satisfaction. The mean IKDC score at final follow-up across both groups was 80.4 ± 17.8. The mean Lysholm score was 86.9 ± 16.7. Mean KOOS scores were (i) symptoms: 83.6 ± 18.3, (ii) pain: 90.2 ± 14.4, (iii) activities of daily living: 93.6 ± 15.1, (iv) sports: 78.3 ± 26.0 and (v) quality of life: 70.5 ± 24.5. Mean patient satisfaction (VAS) was 7.9 ± 2.5. The mean Tegner score was 4.9 ± 1.9. A consistent positive correlation between the number of sutures used and post-operative outcome measures was observed but did not reach statistical significance for most items.

Conclusion

Arthroscopic BHMT repair achieved good clinical outcomes and an acceptable failure rate of 9% at a mean follow-up of 7 years, supporting the clinical value of meniscal repair, including large BHMTs. Concurrent ACLR showed no impact on clinical outcomes.

Level of Evidence

Level IV (retrospective case series).

Initial Heart Rate Predicts Functional Independence in Patients With Spinal Cord Injury Requiring Surgery: A Registry-Based Study in a Mature Trauma System Over the Past 10 Years

STUDY DESIGN

Retrospective Cohort Study.

OBJECTIVES

To determine the ability of early vital sign abnormalities to predict functional independence in patients with SCI that required surgery.

METHODS

A retrospective analysis of data extracted from the Pennsylvania Trauma Outcome Study database. Inclusion criteria were patients >18 years with a diagnosis of SCI who required urgent spine surgery in Pennsylvania from 1/1/2010-12/31/2020 and had complete records available.

RESULTS

A total of 644 patients met the inclusion criteria. The mean age was 47.1 ± 14.9 years old and the mean injury severity score (ISS) was 22.3 ± 12.7 with the SCI occurring in the cervical, thoracic, and lumbar spine in 61.8%, 19.6% and 18.0%, respectively. Multivariable logistic regression analyses for predictors of functional independence at discharge showed that higher HR at the scene (OR 1.016, 95% CI 1.006-1.027, P = .002) and lower ISS score (OR .894, 95% CI .870-.920, P < .001) were significant predictors of functional independence. Similarly, higher admission HR (OR 1.015, 95% CI 1.004-1.027, P = .008) and lower ISS score (OR .880, 95% CI 0.864-.914, P < .001) were significant predictors of functional independence. Peak Youden indices showed that patients with HR at scene >70 and admission HR ≥83 were more likely to achieve functional independence.

CONCLUSIONS

Early heart rate is a strong predictor of functional independence in patients with SCI. HR at scene >70 and admission HR ≥83 is associated with improved outcomes, suggesting lack of neurogenic shock.

Clubfoot: Congenital Talipes Equinovarus

Congenital talipes equinovarus (CTEV), also known as clubfoot, is a common musculoskeletal entity that affects one to two per 1000 live births worldwide. Imaging modalities including radiography, US, and MRI have emerged as valuable tools for the diagnosis, treatment, and monitoring of CTEV. The deformity is characterized by midfoot cavus, forefoot adductus, and hindfoot varus and equinus. The Ponseti method of manipulation and serial casting is the standard treatment of CTEV. Radiography shows the anatomy, position, and relationships of the different bones of the foot. US allows accurate assessment of cartilaginous and bony structures, in addition to its inherent advantages such as absence of ionizing radiation exposure. One of the indications for US is to monitor the response to Ponseti method treatment. MRI enables visualization of bones, cartilage, and soft tissues and allows multiplanar evaluation of deformities, providing a comprehensive imaging analysis of CTEV. An integrated approach that combines clinical examination and imaging findings is essential for effective management of CTEV. The authors provide a comprehensive overview of CTEV with a review of imaging modalities to help evaluate CTEV, focusing on radiography, US, and MRI. Using this article as a guide, radiologists involved in the assessment and treatment of CTEV can contribute to the management of the condition. ©RSNA, 2024 Supplemental material is available for this article.

Exploring the impact of osteoprotegerin on osteoclast and precursor fusion: Mechanisms and modulation by ATP

Osteoclast (OC) differentiation, vital for bone resorption, depends on osteoclast and precursor fusion. Osteoprotegerin (OPG) inhibits osteoclast differentiation. OPG's influence on fusion and mechanisms is unclear. Osteoclasts and precursors were treated with OPG alone or with ATP. OPG significantly reduced OC number, area and motility and ATP mitigated OPG's inhibition. However, OPG hardly affected the motility of precusors. OPG downregulated fusion-related molecules (CD44, CD47, DC-STAMP, ATP6V0D2) in osteoclasts, reducing only CD47 in precursors. OPG reduced Connexin43 phosphorylated forms (P1 and P2) in osteoclasts, affecting only P2 in precursors. OPG disrupted subcellular localization of CD44, CD47, DC-STAMP, ATP6V0D2, and Connexin43 in both cell types. Findings underscore OPG's multifaceted impact, inhibiting multinucleated osteoclast and mononuclear precursor fusion through distinct molecular mechanisms. Notably, ATP mitigates OPG's inhibitory effect, suggesting a potential regulatory role for the ATP signaling pathway. This study enhances understanding of intricate processes in osteoclast differentiation and fusion, offering insights into potential therapeutic targets for abnormal bone metabolism.

Innovations in the Treatment of Spinal Cerebrospinal Fluid Leaks

Spontaneous spinal cerebrospinal fluid (CSF) leaks are uncommon but can be neurologically debilitating. When initial treatments fail, definitive repair or closure of the leak is indicated. Depending upon the type of leak present, innovative strategies for their treatment have been developed. Among them are open surgical techniques using a transdural approach for the closure of ventral CSF leaks, minimally invasive tubular techniques for the reduction and repair of lateral meningeal diverticula, and endovascular embolization of CSF-venous fistulas. Illustrative cases demonstrating the indications for and implementation of these techniques are provided.

A Rehabilitation Algorithm After Lateral Ankle Sprains in Professional Football (Soccer): An Approach Based on Clinical Practice Guidelines

Lateral ankle sprain (LAS) is one of the most common types of injury in professional football (soccer) players with high risk of recurrence. The rehabilitation after LAS in professional football players is often still time-based and relies on anecdotal experience of clinicans. There is still a lack of utilization of criteria-based rehabilitation concepts after LAS in professional football. The aims of this clinical commentary are (1) to critically discuss the need for criteria-based rehabilitation concepts after LAS in professional football players, (2) to highlight the current lack of these approaches and (3) to present a novel clinical guideline-based rehabilitation algorithm. Short time-loss (15 days) and high recurrence rate (17%) raise the question of trivialization of LAS in professional football. Despite consequences for many stakeholders involved (players, teams, clubs, insurers), there is still a lack of of criteria-based, step-by-step approaches. The use of a criteria-based rehabilitation approach might reduce the high recurrence rate after LAS in professional football players and will lead, in turn, to increased long-term player availability. Practical experiences of he authors demonstrate the feasibility of such an approach. The effectiveness of this novel rehabilitation algorithm remains to be evaluated in future studies. Level of Evidence: 5.

Increased risk of fragility fractures in patients with primary biliary cholangitis

Large-scale studies on the risk of fragility fractures in patients with primary biliary cholangitis (PBC) are limited due to low incidence. We aimed to investigate whether PBC is associated with fragility fractures using real-world nationwide data. The Korean National Health Insurance Service claims data from 2007 to 2020 were analyzed in this population-based cohort study. Patients with PBC (n = 4951) were matched with controls (n = 19 793) using a 1:4 ratio based on age, sex, and follow-up duration. The primary outcome was fragility fracture, which comprised fractures of the vertebra, hip, distal radius, and proximal humerus. The incidence rates (IRs) and hazard ratios (HRs) were determined to assess the impact of PBC on fragility fractures. During the median follow-up period of 5.37 years, 524 patients in the PBC group had fragility fractures (IR, 18.59/1000 person-years [PYs]). After adjusting for covariates, PBC increased the risk of fragility fractures by 1.63-fold (95% confidence interval, 1.20-2.22; P = .002). The vertebra and hip were particularly susceptible to fracture in patients with PBC, with adjusted HRs of 1.77 and 2.23, respectively. In the subgroup analysis, the risk of fragility fracture was 2.53-fold higher in men and 1.59-fold higher in women with PBC than that in the respective matched control groups. Considering the morbidity and mortality related to fragility fractures, increasing awareness of fragility fracture risk and implementing appropriate preventive measures in patients with PBC are imperative.

Variable Return to Play and Sport Performance After Elbow Ulnar Collateral Ligament Reconstruction in Baseball Players: A Systematic Review

PURPOSE

To evaluate return to play (RTP) and return to same level of play (RTSP) rates as well as preoperative and postoperative in-game performance metrics in baseball pitchers who underwent ulnar collateral ligament reconstruction (UCLR). Secondarily, this review sought to assess outcomes based on primary versus revision UCLR as well as level of competition.

METHODS

This review was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed/MEDLINE, Embase, Web of Science, and Cochrane Database of Systematic Reviews were queried to identify articles evaluating UCLR in baseball players between January 2002 and October 2022. Data included RTP, RTSP, and performance metrics including earned run average, innings pitched, walks and hits per inning pitched, batting average against, strikeouts per 9 innings, walks per 9 innings, percentage of fastballs thrown, and average fastball velocity. The Methodological Index for Non-randomized Studies criteria were used for quality assessment.

RESULTS

Analysis included 25 articles reporting on 2,100 elbows. After primary UCLR, RTP ranged from 336 to 615 days (57% to 100% achieved) and RTSP ranged from 330 to 513 days (61% to 95%). After revision UCLR, RTP ranged from 381 to 631 days (67% to 98%) and RTSP ranged from 518 to 575 days (42% to 78%). When stratifying primary UCLR outcomes by competitive level, RTP and RTSP ranged respectively from 417 to 615 days (75% to 100%) and 513 days (73% to 87%) for Major League Baseball only, 409 to 615 days (57% to 100%) and 470 to 513 days (61% to 95%) for Major League Baseball plus Minor League Baseball, and 336 to 516 days (73% to 85%) and 330 days (55% to 74%) for college plus high school. Heterogeneity was seen in postoperative sports performance metrics.

CONCLUSIONS

Although more than half of baseball players appear able to RTP after primary and revision UCLR, RTSP rates after revision UCLR were as low as 42% in the literature. Preoperative and postoperative performance metrics varied.

LEVEL OF EVIDENCE

Level IV, systematic review of Level II-IV studies.

Elective THA for Indications Other Than Osteoarthritis Is Associated With Increased Cost and Resource Use: A Medicare Database Study of 135,194 Claims

BACKGROUND

Under Medicare's fee-for-service and bundled payment models, the basic unit of hospital payment for inpatient hospitalizations is determined by the Medicare Severity Diagnosis Related Group (MS-DRG) coding system. Primary total joint arthroplasties (hip and knee) are coded under MS-DRG code 469 for hospitalizations with a major complication or comorbidity and MS-DRG code 470 for those without a major complication or comorbidity. However, these codes do not account for the indication for surgery, which may influence the cost of care.Questions/purposes We sought to (1) quantify the differences in hospital costs associated with six of the most common diagnostic indications for THA (osteoarthritis, rheumatoid arthritis, avascular necrosis, hip dysplasia, posttraumatic arthritis, and conversion arthroplasty), (2) assess the primary drivers of cost variation using comparisons of hospital charge data for the diagnostic indications of interest, and (3) analyze the median length of stay, discharge destination, and intensive care unit use associated with these indications.

METHODS

This study used the 2019 Medicare Provider Analysis and Review Limited Data Set. Patients undergoing primary elective THA were identified using MS-DRG codes and International Classification of Diseases, Tenth Revision, Procedure Coding System codes. Exclusion criteria included non-fee-for-service hospitalizations, nonelective procedures, patients with missing data, and THAs performed for indications other than the six indications of interest. A total of 713,535 primary THAs and TKAs were identified in the dataset. After exclusions were applied, a total of 135,194 elective THAs were available for analysis. Hospital costs were estimated using cost-to-charge ratios calculated by the Centers for Medicare and Medicaid Services. The primary benefit of using cost-to-charge ratios was that it allowed us to analyze a large national dataset and to mitigate the random cost variation resulting from unique hospitals' practices and patient populations. As an investigation into matters of health policy, we believe that assessing the surgical cost borne by the "average" hospital was most appropriate. To analyze estimated hospital costs, we performed a multivariable generalized linear model controlling for patient demographics (gender, age, and race), preoperative health status, and hospital characteristics (hospital setting [urban versus rural], geography, size, resident-to-bed ratio, and wage index). We assessed the principal drivers of cost variation by analyzing the median hospital charges arising from 30 different hospital revenue centers using descriptive statistics. Length of stay, intensive care use, and discharge to a nonhome location were analyzed using multivariable binomial logistic regression.

RESULTS

The cost of THA for avascular necrosis was 1.050 times (95% confidence interval 1.042 to 1.069; p < 0.001), or 5% greater than, the cost of THA for osteoarthritis; the cost of hip dysplasia was 1.132 times (95% CI 1.113 to 1.152; p < 0.001), or 13% greater; the cost of posttraumatic arthritis was 1.220 times (95% CI 1.193 to 1.246; p < 0.001), or 22% greater; and the cost of conversion arthroplasty was 1.403 times (95% CI 1.386 to 1.419; p < 0.001), or 40% greater. Importantly, none of these CIs overlap, indicating a discernable hierarchy of cost associated with these diagnostic indications for surgery. Rheumatoid arthritis was not associated with an increase in cost. Medical or surgical supplies and operating room charges represented the greatest increase in charges for each of the surgical indications examined, suggesting that increased use of medical and surgical supplies and operating room resources were the primary drivers of increased cost. All of the orthopaedic conditions we investigated demonstrated increased odds that a patient would experience a prolonged length of stay and be discharged to a nonhome location compared with patients undergoing THA for osteoarthritis. Avascular necrosis, posttraumatic arthritis, and conversion arthroplasty were also associated with increased intensive care unit use. Posttraumatic arthritis and conversion arthroplasty demonstrated the largest increase in resource use among all the orthopaedic conditions analyzed.

CONCLUSION

Compared with THA for osteoarthritis, THA for avascular necrosis, hip dysplasia, posttraumatic arthritis, and conversion arthroplasty is independently associated with stepwise increases in resource use. These cost increases are predominantly driven by greater requirements for medical and surgical supplies and operating room resources. Posttraumatic arthritis and conversion arthroplasty demonstrated substantially increased costs, which can result in financial losses in the setting of fixed prospective payments. These findings underscore the inability of MS-DRG coding to adequately reflect the wide range of surgical complexity and resource use of primary THAs. Hospitals performing a high volume of THAs for indications other than osteoarthritis should budget for an anticipated increase in costs, and orthopaedic surgeons should advocate for improved MS-DRG coding to appropriately reimburse hospitals for the financial and clinical risk of these surgeries.

LEVEL OF EVIDENCE

Level IV, economic and decision analysis.

Diagnostic accuracy of a novel ultrasound imaging index for knee osteoarthritis: Evaluation of sensitivity, specificity, and predictive values

PURPOSE

We aimed to develop and validate a new ultrasonography (US) index for the diagnosis of primary medial-type knee osteoarthritis (OA).

METHODS

In total, 156 patients (203 limbs) underwent standing knee radiography and the US for suspected knee OA. Total osteophyte height (TOH) and distance between bones (DBB) aided diagnosis. Logistic regression identified optimal cutoff values. Thresholds from logistic regression informed recipient operating characteristic curve (ROC) analysis, balancing sensitivity and specificity. These thresholds were then applied in the differential thermal analysis (DTA) to construct a 2 × 2 table.

RESULTS

The TOH-DBB index showed that a DBB of 5.6 mm or less was required to diagnose primary medial-type knee arthropathy. The results in the 2 × 2 table were 41 true-positive (TP), 10 false negative (FN), 22 true-negative (TN), and 7 false positive (FP). A DBB of 5.6 mm or less and TOH of 4.7 mm or more were necessary to diagnose severe deformity. The results in the 2 × 2 table were 10 TP, 4 FN, 23 TN, and 4 FP.

CONCLUSION

The TOH-DBB index was confirmed to capture changes in primary medial-type knee OA across various stages.

Cervical fracture dislocation without neurological abnormality: Rare case reports

INTRODUCTION AND IMPORTANCE

Traumatic lower cervical dislocation with spinal cord injury (SCI) can cause long-lasting dysfunction in many organ systems resulting in significant financial burden and functional disability. The patient may come with complete or incomplete neurological deficit. However, there is also possibility of no neurological deficit.

CASE PRESENTATION

This case reports presented two cases of a 68-year-old man and a 54-year-old man that came to the emergency department after a traffic accident and fell from a height. Surprisingly there was no neurological deficit found on both patients. The patient underwent emergency open reduction and posterior stabilization. Several months later, the neurological function was still excellent, and the pain was absent.

CLINICAL DISCUSSION

Traumatic cervical dislocation without neurological deficit is rare. Enlargement of the spinal canal is significant when the vertebral body and the shattered posterior arch separate, which may play a protective role on the spinal cord. The neurological deficit did not happen in the first case due to a widening spinal canal. Still, in the second case, the patient's neurological condition remained excellent despite no disruption on the posterior arch after cervical dislocation.

CONCLUSION

Neurological deficit may not occur in the cervical dislocation with disruption of the posterior arch due to the widening of the spinal canal. This injury should be treated properly to prevent other morbidities and even mortality. The posterior technique for stabilization gives various benefits, such as the safety and familiarity of the procedure and the high success rate.

Peroneus Longus Tendon Autografts have Better Graft Diameter, Less Morbidity, and Enhanced Muscle Recuperation than Hamstring Tendon in ACL Reconstruction

Background

Recently the peroneus longus tendon (PLT) gained popularity in anterior cruciate ligament (ACL) reconstruction and has been utilized with satisfactory outcomes. However, there are concerns regarding donor site morbidity. This study aims to compare the functional outcome of ACL reconstruction using hamstring (HT) and PLT autografts and evaluate the donor site morbidity.

Methods

Patients who underwent ACL reconstruction were allocated to two groups (HT and PLT). Graft diameter was measured intraoperatively. Knee functional outcome was evaluated with IKDC and Tegner-Lysholm scores preoperatively, and postoperatively after 3 months, 6 months, and 1 year. Donor site morbidities were assessed with thigh circumference measurements, subjective evaluation of sensory disturbances, and ankle scoring with AOFAS and FADI scores.

Results

At 1-year follow-up, the PLT group showed comparable IKDC (p = 0.925) and Tegner-Lysholm (p = 0.600) scores with those of the HT group. The mean graft diameter in the PLT group (7.93 ± 0.52 mm) was larger compared with the HT group (7.43 ± 0.50 mm) (p < 0.001). The incidence of thigh atrophy (HT-16.7%, PLT-10%) and sensory disturbances (HT-73.3%, PLT-10%) was greater in the HT group. There was no significant ankle donor site morbidity in the PLT group (AOFAS-98.67 ± 3.45, FADI-99.23 ± 1.69).

Conclusion

ACL reconstruction with PLT had comparable functional outcome with that of HT at 1 year. However, PLT demonstrated larger graft diameter, less donor site morbidity, and enhanced muscle recovery without significantly affecting the ankle function. PLT can be safely used as an acceptable alternative graft choice harvested from outside the knee for ACL reconstruction.

Multifocal Skeletal Tuberculosis - A Case Report

Introduction

Tuberculosis (TB) remains a pervasive infectious disease, and extrapulmonary manifestations account for a significant proportion of cases. Skeletal involvement is observed in about 10% of extrapulmonary TB instances. While spinal TB is relatively common, sacroiliac (SI) joint TB is a rare occurrence, particularly in immunocompetent individuals.

Case Report

This case report discusses an unusual presentation in a 19-year-old immunocompetent lady where the spine, acetabulum, and SI joint were concurrently affected. The patient, initially undergoing alternative medicine, exhibited severe pain, weight loss, and restricted mobility. Radiological evaluations, including X-rays and magnetic resonance imaging, revealed extensive vertebral and pelvic destruction with abscess formation. Surgical debridement and stabilization, alongside antitubercular treatment, led to significant improvement.

Conclusion

This case emphasizes the challenges in diagnosing multifocal skeletal TB, highlights the importance of early intervention, and underscores the impact of alternative medicine on treatment delays. A multidisciplinary approach involving histopathological and microbiological examinations is crucial for optimal management.

Magnetic targeting of lornoxicam/SPION bilosomes loaded in a thermosensitive in situ hydrogel system for the management of osteoarthritis: Optimization, in vitro, ex vivo, and in vivo studies in rat model via modulation of RANKL/OPG

Osteoarthritis is a bone and joint condition characterized pathologically by articular cartilage degenerative damage and can develop into a devastating and permanently disabling disorder. This investigation aimed to formulate the anti-inflammatory drug lornoxicam (LOR) into bile salt-enriched vesicles loaded in an in situ forming hydrogel as a potential local treatment of osteoarthritis. This was achieved by formulating LOR-loaded bilosomes that are also loaded with superparamagnetic iron oxide nanoparticles (SPIONs) for intra-muscular (IM) administration to improve joint targeting and localization by applying an external magnet to the joint. A 31.22 full factorial design was employed to develop the bilosomal dispersions and the optimized formula including SPION (LSB) was loaded into a thermosensitive hydrogel. Moreover, in vivo evaluation revealed that the IM administration of LSB combined with the application of an external magnet to the joint reversed carrageen-induced suppression in motor activity and osteoprotegerin by significantly reducing the elevations in mitogen-activated protein kinases, extracellular signal-regulated kinase, and receptor activator of nuclear factor kappa beta/osteoprotegerin expressions. In addition, the histopathological evaluation of knee joint tissues showed a remarkable improvement in the injured joint tissues. The results proved that the developed LSB could be a promising IM drug delivery system for osteoarthritis management.

Gluteal Tendinopathy Is Associated With Lower Patient-Reported Outcome Measures in Total Hip Arthroplasty With a Posterior Approach: A Prospective Cohort Study of 1,538 Patients

BACKGROUND

Gluteal tendinopathy (GT) is found in 20 to 25% of patients undergoing total hip arthroplasty (THA). Despite this, there is a scarcity of literature assessing the association between GT and THA outcomes. The aim of this study was to evaluate whether intraoperative diagnosis of GT negatively affected postoperative outcomes.

METHODS

Consecutive patients undergoing primary THA for osteoarthritis via a posterior approach over 5 years were recruited in a prospective study. Gluteal tendinopathy was assessed and graded at the time of surgery, but not repaired. A total of 1,538 (93%) completed the patient-reported outcome measures (PROMs) at 1 year after surgery and were included in the analysis. The PROMs included the Oxford Hip Score (OHS), Hip Disability and Osteoarthritis Outcome Score Joint Replacement (HOOS JR), and EuroQol 5-Dimension, and were collected preoperatively and one year after THA.

RESULTS

The gluteal tendons were graded as 4 distinct grades: normal (n = 1,023, 66%), tendinopathy but no tear (n = 337, 22%), partial thickness tear (n = 131, 9%), and full thickness tear (n = 47, 3%). The occurrence of GT was associated with age, body mass index, and sex. There was no significant difference in baseline OHS or HOOS JR scores according to GT grade. As GT grade increased, lower median 1-year OHS (P = .001) and HOOS JR (P = .016) were observed. This association was confirmed by linear regression analysis with 1-year OHS (B = 0.5, 95% CI = -0.9 to -0.1, P = .011) when controlled for age and sex.

CONCLUSIONS

Gluteal tendinopathy was commonly observed and was associated with inferior 1-year PROMs in patients undergoing THA via posterior approach. Increasing degree of tendinopathy was a negative prognostic factor for outcomes and patient satisfaction.

LEVEL OF EVIDENCE

Level 2 (High quality prospective cohort study).

In-silico study of the biomechanical effects of proximal-fibular osteotomy on knee joint contact pressure in varus-valgus misalignment

The aim of this work is to investigate in-silico the biomechanical effects of a proximal fibular osteotomy (PFO) on a knee joint with different varus/valgus deformities on the progression of knee osteoarthritis (KOA). A finite element analysis (FEA) of a human lower extremity consisting of the femoral, tibial and fibular bones and the cartilage connecting them was designed. The FEA was performed in a static standing primitive position to determine the contact pressure (CP) distribution and the location of the center of pressure (CoP). The analysis examined the relationship between these factors and the degree of deformation of the hip-knee angle in the baseline condition. The results suggested that PFO could be a simple and effective surgical treatment for patients with associated genu varum. This work also reported that a possible CP homogenization and a CoP correction can be achieved for medial varus deformities after PFO. However, it reduced its effectiveness for tibial origin valgus misalignment and worsened in cases of femoral valgus misalignment.

Association Between Diagnostic Delays and Spinal Involvement in Human Brucellosis: A Retrospective Case-Control Study

Background

Spinal involvement is a common but serious complication of human brucellosis. However, information on the risk factors associated with spinal involvement in individuals with brucellosis is limited.

Methods

This retrospective case-control study aimed to determine the potential risk factors associated with spinal complications in inpatients with brucellosis.

Results

During the study period, brucellosis was diagnosed in 377 patients, of whom 108 (28.64%) showed spinal involvement. Those with spinal involvement were significantly older than patients in the control group (mean age [standard deviation], 53.25 [10.48] vs 43.12 [13.84] years, respectively; P < .001). The diagnostic delays were significantly longer in patients with spinal involvement than in the control group (mean delay [standard deviation], 11.17 [13.55] vs 6.03 [8.02] weeks; P = .001). Age >40 years (odds ratio, 5.42 [95% confidence interval, 2.65-11.05]; P < .001) and diagnostic delay >4 weeks (2.94 [1.62-5.35]; P < .001) were independently associated with spinal involvement in brucellosis. The lumbar spine at the L3-5 level was the most affected (152 of 249 [61.04%]). Back pain (92 of 108 in case patients vs 21 of 108 in controls; P < .001) and splenomegaly (23 vs 42 of 108, respectively; P = .005) differed significantly between the 2 groups.

Conclusions

Age >40 years and diagnostic delay >4 weeks increased the risk of spinal involvement in brucellosis. Therefore, the time from symptom onset to diagnosis should be shortened, using effective measures to reduce spinal involvement risk.

Current Concepts in the Orthopaedic Management of Duchenne Muscular Dystrophy

Duchenne muscular dystrophy (DMD), a genetic condition marked by progressive muscle degeneration, presents notable orthopaedic challenges, especially scoliosis, which deteriorates patients' quality of life by affecting sitting balance and complicating cardiac and respiratory functions. Current orthopaedic management strategies emphasize early intervention with corticosteroids to delay disease progression and the use of surgical spinal fusion to address severe scoliosis, aiming to enhance sitting balance, alleviate discomfort, and potentially extend patient lifespan. Despite advancements, optimal management requires ongoing research to refine therapeutic approaches, ensuring improved outcomes for patients with DMD. This review synthesizes recent findings on surgical and nonsurgical interventions, underscoring the importance of a multidisciplinary approach tailored to the dynamic needs of patients with DMD.

No difference in stability among various knee flexion angles during fixation of anterolateral ligament reconstruction or lateral extra-articular tenodesis: A systematic review and meta-analysis of biomechanical studies

Purpose

The purpose of this study was to investigate the effect of anterolateral ligament reconstruction (ALLR) or lateral extra-articular tenodesis (LET) fixation at low versus high flexion angles during anterior cruciate ligament reconstruction (ACLR) on rotation or translational knee stability.

Methods

The inclusion criteria for this study were (1) cadaveric study, (2) cadaveric specimens underwent ACLR, (3) cadaveric specimen underwent ALLR or LET and (4) specimen preparation technique described the knee flexion angle at the time of ALLR or LET tensioning and fixation. A priori, 'low flexion' was defined as 0-30° and 'high flexion' was defined as 60-90° at graft fixation. Main outcomes of interest included internal rotation and anterior translation.

Results

Data from 92 cadaveric knees (from 9 studies) were extracted and included in the meta-analysis. The mean pooled value for internal rotation was 10.1° (95% confidence interval [CI], 5.7-14.5°) for the low flexion group and 11.5° (95% CI, 7.4-15.7°) for the high flexion group (n.s.). The mean pooled value for anterior translation was 4.3 mm (95% CI, 0.5-8.1 mm) for the low flexion group and 3.0 mm (95% CI, 1.1-5.0 mm) for the high flexion group (n.s.).

Conclusion

This meta-analysis of existing biomechanical research found that the rotational and translational stability of the knee were not significantly different between scenarios in which ALLR or LET fixation was performed at low knee flexion angles (0-30°) versus high knee flexion angles (60-90°).

Level of Evidence

Level IV.

Combining an Anterolateral Complex Procedure With Anterior Cruciate Ligament Reconstruction Reduces the Graft Reinjury Rate and Improves Clinical Outcomes: A Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND

Anterior cruciate ligament (ACL) reconstruction (ACLR) is a well-established surgical procedure, but it may not always restore complete rotational knee stability. Interest is increasing in anterolateral complex (ALC) procedures, lateral extra-articular tenodesis (LET) and anterolateral ligament reconstruction (ALLR), in association with ACLR to overcome this problem. The better ALC procedure, LET or ALLR, remains controversial to date.

PURPOSE

To analyze the patient-reported outcome measures and ACL reinjury rate after ACLR with an ALC procedure compared with after isolated ACLR, as well as to analyze the clinical results and graft failure rate of the LET group versus the ALLR group.

STUDY DESIGN

Systematic review and meta-analysis; Level of evidence, 2.

METHODS

A PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flowchart was used to conduct a comprehensive search of 5 databases: Scopus, MEDLINE, Embase, PubMed, and the Cochrane Database of Systematic Reviews. Only randomized controlled trials were included. Eligible articles were classified according to the levels of evidence of the Oxford Centre for Evidence-Based Medicine. A methodological quality assessment of randomized controlled trials was performed using the Risk of Bias 2 tool. The present systematic review and meta-analysis was registered on PROSPERO.

RESULTS

A total of 14 clinical trials were included in the final analysis, with 1830 patients. Isolated ACLR or a combined procedure with LET or ALLR was performed, with several characteristics described, including the surgical technique, additional torn knee structures and their management, graft failure, complications, clinical outcomes, clinical and instrumental examinations to assess knee stability, and postoperative protocols. Regarding clinical outcomes, pivot-shift tests and reduced graft failure, a significant difference was found in the superiority of the combined ACLR associated with the ALC procedure compared with an isolated ACLR (P < .05). No statistically significant difference was found between the 2 ALC procedures.

CONCLUSION

This systematic review and meta-analysis reported on the importance of combined ACLR and ALC procedures in patients with a high-grade rotational laxity, as both procedures, LET or ALLR, without superiority of one over the other, are associated with improved pivot-shift tests, patient-reported outcome measures, and reduced graft failure rates.

Hounsfield Unit values on the subchondral bone are related to clinical outcomes in bone marrow stimulation for osteochondral lesions of the talus

BACKGROUND

Poor clinical outcomes in bone marrow stimulation (BMS) for the osteochondral lesion of the talus (OLT) are caused by subchondral bone deterioration. It is reported that microfracture induces endochondral ossification in the subchondral bone, which may affect the subchondral bone condition after BMS. This study analyzed osteosclerotic patterns of the bed in OLTs on computed tomography (CT) images and the relationship between the subchondral bone condition and clinical outcomes of BMS.

METHODS

Sixty-nine ankles in 61 patients with OLT were included. Hounsfield unit (HU) on the bed of OLTs was measured on CT images and the pattern of osteosclerosis or absorption in the bed was analyzed. In these patients, 25 ankles in 24 patients underwent BMS. They were divided into 2 groups according to the presence of bone marrow edema (BME) one year after surgery, and clinical outcomes were compared.

RESULTS

HUs in the anterior region were significantly higher than those of other areas. In patients with BMS, the JSSF scale for BME positive group (88.0 ± 7.7 points) was significantly lower than that for BME negative group (95.0 ± 6.1 points) (p < 0.05) at the final follow-up. On preoperative CT images, HU values of the central region in the BME-positive group were significantly lower than those in the BME-negative group (p < 0.05).

CONCLUSION

Osteosclerotic changes in the anterior part of the bed were frequently observed, and BMS for the area with low HU values decreased clinical outcomes. BMS should be performed with attention to subchondral bone condition to obtain good clinical outcomes.

LEVEL OF EVIDENCE

4, case series.

Performance Comparison of Augmented Reality Versus Ultrasound Guidance for Puncture: A Phantom Study

PURPOSE

Augmented reality (AR) is an innovative approach that could assist percutaneous procedures; by directly seeing "through" a phantom, targeting a lesion might be more intuitive than using ultrasound (US). The objective of this study was to compare the performance of experienced interventional radiologists and operators untrained in soft tissue lesion puncture using AR guidance and standard US guidance.

MATERIAL AND METHODS

Three trained interventional radiologists with 5-10 years of experience and three untrained operators performed punctures of five targets in an abdominal phantom, with US guidance and AR guidance. Correct targeting, accuracy (defined as the Euclidean distance between the tip and the center of the target), planning time, and puncture time were documented.

RESULTS

Accuracy was higher for the trained group than the untrained group using US guidance (1 mm versus 4 mm, p = 0.001), but not when using AR guidance (4 mm vs. 4 mm, p = 0.76). All operators combined, no significant difference was found concerning accuracy between US and AR guidance (2 mm vs. 4 mm, p = 0.09), but planning time and puncture time were significantly shorter using AR (respectively, 15.1 s vs. 74 s, p < 0.001; 16.1 s vs. 59 s; p < 0.001).

CONCLUSION

Untrained and trained operators obtained comparable accuracy in percutaneous punctures when using AR guidance whereas US performance was better in the experienced group. All operators together, accuracy was similar between US and AR guidance, but shorter planning time, puncture time were found for AR guidance.

Arthroscopic Capsular Release Versus Manipulation under Anesthesia for Refractory Frozen Shoulder: A Systematic Review with Meta-Analysis

OBJECTIVE

Frozen shoulder (FS) is a painful and debilitating condition affecting the shoulder joint. When patients fail to improve after conservative treatments, operative treatments including arthroscopic capsular release (ACR) and manipulation under anesthesia (MUA) are recommended. However, the comparison between these two interventions remains controversial. This study aimed to compare the efficacy and safety of ACR and MUA for refractory FS.

METHODS

A systematic review and meta-analysis was conducted following the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) guidelines. PubMed, EMBASE, Cochrane Library, and Web of Science were searched for eligible studies until December 10, 2023. Meta-analyses were conducted using Manager V.5.3.3. Pooled effect sizes were expressed as the weighted mean difference (WMD) or odds ratio (OR) with 95% confidence intervals (CIs).

RESULTS

A total of eight comparative studies with 768 patients were included. Compared with MUA, ACR had statistically better Δ VAS (WMD, -0.44; 95% CI, -0.71 to -0.18; I2 = 6%; p = 0.001) at over 12-month follow-up, which did not reach the minimal clinically important difference (MCID). Other outcomes regarding pain relief, function, and range of motion (ROM) improvements were not statistically different between the two groups at different follow-up timepoints. Compared with the MUA group, the ACR group had a significantly higher rate of severe complications (OR, 4.14; 95% CI, 1.01 to 16.94; I2 = 0%; p = 0.05), but comparable rates of mild complications and additional intervention.

CONCLUSIONS

In treating refractory FS, ACR demonstrated comparable pain relief, functional and ROM improvements, rates of mild complications and additional intervention but a higher risk of severe complications to MUA during short-term follow-up periods. Notably, ACR exhibited statistically superior improvement in the long-term pain relief compared to the MUA group, although it did not reach the MCID.

Clinical Effects of Tourniquet Use for Nontraumatic Major Lower Limb Amputation: A Two-Center Retrospective Cohort Study

BACKGROUND

To investigate the effect of tourniquet use on outcomes after major lower limb amputation (MLLA) due to peripheral arterial disease or complications from diabetes mellitus.

METHODS

In this 2-center retrospective observational study, vascular patients who underwent MLLA between January 1, 2016 and December 31, 2020 at 2 UK hospitals were identified using operating theater databases. Hospital databases were used to access medical records, operation notes, and laboratory reports. The use of a tourniquet in each MLLA was noted. The primary outcome was postoperative hemoglobin (Hb) drop (g/L). Secondary outcomes were units of allogeneic blood transfused perioperatively, 90-day revision rates, 90-day wound breakdown rates, surgical site infection (SSI) rates (at 30 days), and 90-day mortality. A follow-up index (a measure of follow-up completeness) was calculated for all 30-day and 90-day outcomes.

RESULTS

Four hundred seventy two patients underwent MLLA, of which 124 had a tourniquet applied. The median postoperative Hb drop was significantly lower in the tourniquet group compared to the nontourniquet group (13 [interquartile range 5-22] g/L vs. 20 [interquartile range 11-28] g/L; P ≤ 0.001). Thirty three point one percent (41) of tourniquet patients received a blood transfusion perioperatively, compared to 35.6% (124) of nontourniquet patients (P = 0.82). Sixteen percent (76) of patients required surgical revision within 90 days, with no significant difference between the tourniquet and nontourniquet group (20.2% tourniquet vs. 14.7% no tourniquet; P = 0.15). SSI rates (12.0% tourniquet vs. 10.6% no tourniquet, P = 0.66) and 90-day mortality (6.5% tourniquet vs. 10.1% no tourniquet; P = 0.23) were similar. Multivariable regression demonstrated that tourniquet use was independently associated with a reduced hemoglobin drop (β = -4.671, 95% confidence interval -7.51 to -1.83, P ≤ 0.001) but was not associated with wound breakdown, revision surgery, or SSI. Hypertension, SSI, and below-knee amputation using the skew flap technique were all significant predictors of revision surgery. All follow-up indices were ≥ 0.97.

CONCLUSIONS

Tourniquet use in MLLA was associated with a significantly lower fall in postoperative Hb without evidence of harm in terms of SSI, wound breakdown/revision rates, or mortality.

Study on the efficacy of brace therapy for developmental dysplasia of the hip with Graf IIc and greater severity

To assess changes in the α and β angle with brace treatment in DDH classified as Type Graf IIc, D, III, and IV; to study the α angle threshold that can predict the treatment effect; to analyze the effective rate in different groups. A retrospective study was conducted on children from 2013 to 2018 with Graf type IIc and greater diagnosed with ultrasound (US). Brace therapy was applied to 356 patients, with 423 affected hips (Graf IIc: 202 hips; Graf D: 17 hips; Graf III: 118 hips; and Graf IV: 86 hips). For follow-up efficacy analyses using US, X-ray and clinical examination, based on the success of early treatment of the brace, the outcomes were divided into 'effective' and 'noneffective' groups. The statistical results showed that the α angle increased ( P  < 0.05) and the β angle decreased ( P  < 0.05). When α≥43°, the accuracy of success with early treatment was 95.95%. The overall effective rate of bracing treatment was 74.70%. Children with α ≥ 43° are recommended to receive brace therapy as soon as possible and demonstrate the best effects. The effective rate varies across different Graf types and the age at treatment initiation. Brace therapy is more effective for Graf IIc and D hips compared to Graf III and IV.

Total hip arthroplasty outcomes in Ehlers-Danlos patients: data from the Statewide Planning and Research Cooperative System

INTRODUCTION

Ehlers-Danlos syndromes (EDS) are genetic connective tissue disorders affecting multiple organ systems that frequently result in connective tissue hyperlaxity and early osteoarthritis. Short- and long-term outcomes after primary total hip arthroplasty (THA) in this patient population remain poorly characterised. The primary purpose of this study is to compare postoperative outcomes and survivorship after primary THA in patients with and without EDS.

METHODS

The New York Statewide Planning and Research Cooperative System (SPARCS) database was queried for all patients undergoing primary elective THA between September 2009 and December 2020. Patients with EDS were identified using ICD9 and ICD10 diagnosis codes. Given the relatively low incidence of EDS in this patient population, the cohort was propensity-matched 1:10 to patients without diagnosis of EDS based on demographics characteristics and medical comorbidities as measured by the Elixhauser Comorbidity Index.

RESULTS

A total of 66 THA patients with and 660 without EDS were included in each group after 1:10 propensity-matching. There were no significant differences in baseline characteristics or THA indications. Early postoperative outcomes such as length of hospital stay and discharge disposition were similar. Emergency Room visits and inpatient readmission rates at 3 months postoperatively did not significantly differ between groups. Patients with EDS had a higher overall revision rate compared to those without (15.0% vs. 3.2%, p < 0.001). Revision free survival after primary THA in patients with EDS was significantly lower than those without EDS at 9-year follow-up. Cox proportional hazard regression demonstrated EDS patients had 7-times higher risk of revision (hazard ratio [HR] 7.43; 95% CI, 3.46-16.00; p < 0.001). Lastly, revision due to instability insignificantly trended higher in the EDS cohort (HR 2.29; 95% CI, 0.95-5.49; p = 0.063).

CONCLUSIONS

EDS patients undergoing primary THA have increased rate of all cause revision and demonstrate decreased revision free survival compared to non-EDS THA patients.

Changes in standing stability when wearing different colored glasses cannot be determined by participants' subjective preference - A crossover randomized single-blinded pilot study

BACKGROUND

The use of individually preferred colored glasses has gained popularity with the expectation that it may improve balance control and sports performance, however, the results of previous studies remain inconclusive.

AIM OF THE STUDY

In the present pilot study, we aimed to determine the association between participants' subjective preference and standing balance performance when wearing five different colored glasses.

METHODS

Thirteen participants stood on one or two legs on a pair of synchronized force platforms for 30 seconds with 60 seconds rest between the five-five randomized stance trials, while wearing red, blue, yellow, green, or transparent colored glasses. In addition to 7 CoP-related variables, we analyzed five features of EMG data from three lower limb muscles on both legs.

RESULTS

No significant effect of colored glasses was found. Some CoP (velocity: χ²(4, 13) = 10.086; p = 0.039; Kendall's W = 0.194, root mean square [RMS]: χ²(4, 13) = 12.278; p = 0.015; Kendall's W = 0.236) and EMG-related (RMS of biceps femoris: χ²(4, 13) = 13.006; p = 0.011; Kendall's W = 0.250) variables showed differences between the colored glass conditions during dominant-leg stance, however, participants failed to consecutively determine these differences in standing stability.

CONCLUSIONS

Overall, our results may suggest that lens color preference, irrespective of the color itself, may influence dominant leg standing balance most probably due to psychological factors, however, only subjective determination have no potential to determine the color of the glasses that would support the individual's standing balance the most.

Prevalence, Characteristics, and Trends in Retracted Spine Literature: 2000-2023

BACKGROUND

Retraction of scientific publications is an important check on scientific misconduct and serves to maintain the integrity of the scientific literature. The present study aims to examine the prevalence, trends, and characteristics of retracted spine literature across basic science and clinical spine literature.

METHODS

Multiple databases were queried for retracted papers relating to spine or spine surgery, between January 2000 and May 2023. Of 112,668 publications initially identified, 125 were ultimately included in the present study following screening by 2 independent reviewers. Journal of origin, reasons for retraction, date of publication, date of retraction, impact factor of journal, countries of research origin, and study design were collected for each included publication.

RESULTS

Clinical studies were the most frequent type of retracted publication (n = 70). The most common reason for retraction was fraud (n = 58), followed by plagiarism (n = 22), and peer review process manipulation (n = 16). Impact factors ranged from 0.3 to 11.1 with a median of 3.75. Average months from publication to retraction across all studies was 37.5 months. The higher the journal impact factor, the longer the amount of time between publication and retraction (P = 0.01). China (n = 63) was the country of origin of more than half of all retracted spine publications.

CONCLUSIONS

The rate of retractions has been increasing over the past 23 years, and clinical studies have been the most frequently retracted publication type. Clinicians treating disorders of the spine should be aware of these trends when relying on the clinical literature to inform their practice.

The Multiplicative Effects of Individual Risk Factors in the Development of Osteonecrosis of the Femoral Head

BACKGROUND

While individual risk factors, including chronic corticosteroid use, alcohol abuse, and smoking, are implicated in osteonecrosis of the femoral head (ONFH), the degree to which multiple risk factors increase risk is unknown. This study aimed to: (1) identify the demographic characteristics of patients who have ONFH; (2) quantify the effects of individual risk factors on ONFH development; (3) quantify the effects of combined risk factors on ONFH development; and (4) determine the prognostic implications of combined risk factors on ONFH development.

METHODS

This was a retrospective cohort study. A national insurance database was used to study a population of 2,612,383 adult patients who had a 10-year follow-up period. There were 10,233 patients identified who had a diagnosis of ONFH. We identified patients who had chronic corticosteroid use, tobacco use, and/or alcohol abuse and assessed the risk of developing ONFH over a 10-year period. Patients who had individual and multiple risk factors were grouped for comparison, and Chi-square analyses were performed.

RESULTS

Higher proportions of patients who had each individual risk factor developed ONFH compared to proportions of patients who did not have risk factors. Patients who had combined risk factors were at greater risk of developing ONFH compared to patients who had no risk factors and those who had single risk factors. Combined risk factors demonstrated multiplicative effects on the development of ONFH: tobacco-alcohol risk ratio (RR) 5.25, corticosteroid-alcohol RR 10.20, tobacco-corticosteroid RR 8.69, and corticosteroid-tobacco-alcohol RR 12.54. Patients who had combined risk factors developed ONFH at younger ages than those who had single risk factors. Kaplan-Meier curve analyses demonstrated worse 10-year hip survival in the setting of combined risk factors.

CONCLUSIONS

Combined risk factors have a multiplicative effect on the risk of developing of atraumatic ONFH. Orthopaedic surgeons may care for at-risk individuals through modulation of risk factors.

LEVEL OF EVIDENCE

Retrospective Cohort Study, Level III.

ACL Reconstruction Using Quadrupled Semitendinosus Versus Double-Stranded Semitendinosus and Gracilis Autograft: 2-Year Results From a Prospective Randomized Controlled Study

BACKGROUND

A disadvantage of using hamstring tendon autograft consisting of the semitendinosus and gracilis tendons for anterior cruciate ligament reconstruction is pain from tendon harvesting and persistent hamstring weakness. In the tendon-sparing all-inside technique, a quadrupled semitendinosus graft and adjustable-loop cortical fixation are suggested to give less postoperative flexion deficits while displaying overall similar clinical results to the traditional hamstring technique. However, there are a limited number of high-quality studies comparing these techniques with inconsistent results.

PURPOSE

To investigate differences between the all-inside (quadrupled semitendinosus) and traditional hamstring (double-stranded semitendinosus and gracilis) technique regarding (1) self-reported function, (2) hamstring strength, and (3) knee laxity.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

A total of 98 patients were randomized to either the all-inside or the traditional hamstring technique. Perioperatively, duration of surgery and graft size were obtained. The International Knee Documentation Committee 2000 Subjective Knee Form score, Knee injury and Osteoarthritis Outcome Score, Tegner Activity Scale score, knee laxity (KT-1000 arthrometer side-to-side difference and pivot shift), range of motion, isokinetic knee strength, and hop test score were collected preoperatively and 2 years postoperatively. Return-to-sport readiness was evaluated 9 months postoperatively.

RESULTS

A total of 89 patients completed 2-year follow-up, 45 patients with the all-inside technique and 44 patients with the traditional hamstring technique. There were no significant differences between groups in any of the outcome measures 2 years after surgery, but there was a tendency in the all-inside group toward having increased anterior translation (mean, 3.6 mm vs 2.7 mm), a higher number of revision surgeries (5 patients vs 2 patients), and more patients having +1 and +2 pivot-shift values (29 vs 18 patients) when compared with the traditional group.

CONCLUSION

The all-inside technique yields equivalent results to the traditional hamstring technique 2 years after surgery and should be considered a reliable technique to use for ACL reconstruction. Sparing the gracilis tendon does not lead to less persistent hamstring weakness. Long-term follow-up is needed to further determine whether the tendency of increased anterior translation seen at 2 years postoperatively will lead to a higher risk of graft failure.

Comparative Outcomes and Failure Rates of Total Femur Replacement in Oncologic and Nononcologic Indications: A Systematic Review and Meta-analysis

BACKGROUND

Total femur replacement (TFR) has become increasingly significant as a salvage procedure for both oncologic reconstruction and complex nononcologic conditions such as revision arthroplasty. Despite its effectiveness in limb salvage, TFR is associated with high complication and failure rates, which vary depending on the underlying indication.

METHODS

This systematic review and meta-analysis adhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A comprehensive search of MEDLINE, EMBASE, Web of Science, and Cumulative Index to Nursing and Allied Health Literature databases was conducted, focusing on studies that reported outcomes of TFR in oncologic and nononcologic cases. Primary outcomes included failure mode and rates according to the Henderson classification, functional outcomes scores, and mobility status. Data were analyzed using random-effects models and generalized linear mixed models.

RESULTS

A total of 35 studies involving 1,002 patients were included. The majority of TFRs were performed for oncologic reasons (63.7%). The mean Musculoskeletal Tumor Society (MSTS) score was 66%, with a limb salvage rate of 89%. The meta-analysis revealed a combined failure rate of 34%. For type 4 failures (infection), nononcologic patients exhibited a significantly higher rate at 18% (95% confidence interval [CI], 12%-26%, I2 = 46%, p < 0.01) compared with 8% in oncologic patients (95% CI, 6%-12%, I2 = 0%). Regarding combined types 1 to 4 failures, oncologic patients had a rate of 20% (95% CI, 25%-52%, I2 = 60%), whereas nononcologic patients faced a higher rate of 37% (95% CI, 12%-26%, I2 = 63%) (p < 0.05), indicating a significant difference. There were no significant differences in the MSTS score. In addition, there were no notable differences when comparing failure modes 1, 2, and 3 independently. Mobility analysis showed that approximately 70% of patients required walking aids after surgery.

CONCLUSION

TFR offers a valuable limb salvage option in both oncologic and nononcologic scenarios, despite its high failure rates. Although functional outcomes were similar between groups, the higher failure rate in nononcologic cases and the poor overall quality of evidence warrant further comprehensive assessments into predictors of outcomes to optimize results.

LEVEL OF EVIDENCE

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

Os trigonum: a discussion of its role in posterior ankle impingement syndrome and a meta-analysis of its prevalence

PURPOSE

the os trigonum is a supernumerary bone that may lead to posterior ankle impingement syndrome. The present study aims to assess the prevalence of this bone.

METHODS

A meta-analysis regarding the presence of the os trigonum was performed. For this, the MEDLINE and SciElo databases were searched using "os trigonum" as the keyword. Only original articles, theses, books, dissertations, and monographs were included. Papers with a sample size of < 50 individuals were excluded. The data extracted from the articles were: the total sample size, the prevalence of the trigonum, the method of analysis, the region of the sample, and data regarding sex and side (left or right). Statistical analysis was performed using MedCalc Statistical Software version 14.8.1 (MedCalc Software bvba, Ostend, Belgium). The heterogeneity between the studies was assessed using the I² estimation and the Cochran Q test. For all analyses, a random effect was used and a value of p < 0.05 was considered significant.

RESULTS

249 papers were found, while 18 were included in the meta-analysis. A total of 17,626 ankles were included. The pooled prevalence of the os trigonum was 10.3% (95% CI 7-14.1%) in the present study. There was no significant difference regarding sex or side, while studies conducted in imaging exams showed a higher prevalence in comparison to cadaveric studies.

CONCLUSION

Our results suggest that the os trigonum is relatively common. Knowledge of the prevalence of the os trigonum may help surgeons and clinicians diagnose posterior ankle impingement syndrome.

Management of Suspected Peripheral Vascular Injuries in Orthopedic Trauma

OBJECTIVE

In orthopedic trauma, identification of extremity trauma combined with vascular injury is challenging. Missed diagnosis may result in amputation or even death. The purpose of this study was to investigate whether physical examination combined with handheld vascular ultrasound Doppler examination could be an effective method of screening for peripheral vascular injury and to explore the characteristics of vascular injuries in orthopedic trauma patients.

METHODS

Retrospective analysis of patients in the emergency department of orthopedic trauma in our hospital from January 2022 to October 2023. Physical examination combined with handheld vascular ultrasound Doppler examination was used as a screening method for suspected vascular injuries. Patients with suspected vascular injury would undergo further angiography and receive multidisciplinary treatment. Angiography was used as the gold standard for diagnosing vascular injuries. Patient demographics, mechanism of injury, location and type of injury, angiographic results, surgical notes, and early treatment outcome data were recorded.

RESULTS

A total of 55 cases (58 limb injuries) with suspected vascular injury were ultimately included. Angiography revealed that 53 cases (55 limbs, positive rate 94.8%) were considered to have confirmed vascular injuries. Forty-three were male (81.1%) and 10 were female (18.9%), with mean age 44.1 ± 16.6 years. The main mechanism of injury was traffic accident (30, 56.7%). Most common site of vascular injuries was knee joint (30/55, 54.5%), and popliteal artery (23, 47.9%) was the most commonly injured blood vessel. After multidisciplinary collaborative treatment, overall patient mortality was 3.8% (2/53), and limb survival rate among surviving patients was 81.1% (43/53) in our study.

CONCLUSION

In orthopedic trauma, "Hard signs" and "soft signs" combined with handheld vascular ultrasound Doppler examination were effective ways to screen for suspected vascular injuries. Most limbs had associated fractures or dislocations at the site of vascular injury. Collaboration of vascular surgery, microsurgery and orthopedic trauma may help improve patients' prognosis.

Isoflurane pretreatment protects against myocardial ischemia/reperfusion injury via mediating lncRNA CASC15/miR-542-3p axis

The protective effect of isoflurane on cardiomyocyte ischemia/reperfusion injury (I/RI) was explored in hypoxia and reoxygenation (H/R) induced cardiomyocyte injury model. In terms of mechanism, the participation of long non-coding RNA CASC15/microR-542-3p axis was further discussed. H9c2 cells received H/R treatment to mimic myocardial I/RI. RT-qPCR was performed to quantify mRNA levels. Cell viability and apoptosis were evaluated after isoflurane pretreatment and cell transfection. ELISA was performed to measure the concentrations of inflammatory/oxidative stress-related cytokines (TNF-α, IL-6, MDA, SOD). The target relationship between CASC12 and miR-542-3p was determined via dual-luciferase reporter assay. Isoflurane pretreatment alleviated H/R-induced cell viability suppression and cell apoptosis promotion, which was accompanied by CASC15 downregulation. CASC15 overexpression abolished the influence of isoflurane on cardiomyocytes' viability and apoptosis. H/R-induced excessive release of TNF-α and IL-6 was hold down by isoflurane, which was re-activated after CASC15 overexpression. The concentration changes of both MDA and SOD by isoflurane were reversed by CASC15 overexpression. CASC15 functioned as miR-542-3p sponger, and miR-542-3p overexpression attenuated the effect of isoflurane and CASC15 on H/R-induced cardiac I/RI. Isoflurane pretreatment was beneficial for the alleviation of cardiac I/RI by inhibiting oxidative stress and myocardial inflammatory response. CASC15/miR-542-3p axis was required for isoflurane to exhibit its protective activity against cardiac I/RI.

Sexual dysfunction in male patients treated with methorexate for arthritis: Analysis of the IIEF5 questionnaire and hormonal status

OBJECTIVE

The aim of this study is to evaluate the impact of methotrexate (MTX) on erectile function in male patients through the International Index of Erectile Function (IIEF5) questionnaire and hormonal dosage.

METHODS

Male patients affected by inflammatory arthritis (rheumatoid arthritis [RA] or psoriatic arthritis [PsA]) with good disease control and treated with chronic MTX were enrolled. Age-matched patients affected by chronic arthritis not treated with MTX were enrolled as controls. Each patient had a complete sexual hormone evaluation. IIEF5 questionnaire was administered to each patient.

RESULTS

One hundred and nine patients were included, 77 in the MTX group and 32 as controls. The median weekly MTX dose was 10mg (IQR 7.5) with a median MTX duration therapy of 8 years (IQR 17). The total IIEF5 score was lower in patients MTX exposed compared to the control group without a significant result. The total IIEF5 score of patients treated with MTX≥5 years was statistically significantly lower when compared to those non-MTX exposed patients (17 [IQR 15] versus 20 [IQR 7.7]; P=0.04) and compared to those treated for<5 years (17 [IQR 15] versus 20 [IQR 7]; P=0.01). A negative correlation was identified between the total IIEF5 score and MTX time exposure (r=-0.20 CI [-0.38 to -0.04]; P=0.039). MTX exposure was still associated with a lower IIEF5 score when adjusted for age (β Estimate=-2.63; CI [-5.13 to -0.13]; P=0.039). Hormonal dosage was similar in both groups for all hormones evaluated.

CONCLUSION

MTX exposure was associated with a lower IIEF5 score in male patients adjusted for age. The preliminary results need to be confirmed in larger prospective studies.

Relationship to the superficial radial nerve and anatomic variations of the first extensor compartment in Thai population: a basis for successful de Quervain tenosynovitis treatment

Knowledge of the superficial radial nerve (SRN) relationship and anatomic variations of the first extensor compartment (1st EC) will contribute to a better outcome of de Quervain tenosynovitis treatment. We dissected 87 embalmed cadaveric wrists to determine the relationship of the SRN, the 1st EC length, distance from the proximal and distal 1st EC borders to radial styloid process (RSP), abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendon slip numbers, and the presence of septum. Our results revealed SRN crossing over the 1st EC in 59.5%. The lateral branch of the superficial radial nerve to the 1st EC midline in most cases (61.9%) except for one specimen, where lateral antebrachial cutaneous nerve was the closest. Distances from proximal and distal 1st EC borders to the RSP were 19.7±4.1 mm and 7.6±1.8 mm, respectively. Extensor retinaculum (ER) width over 1st EC (1st EC length) was 14.8±3.2 mm. Complete and incomplete septa were found in 17.2%, and 42.5%, respectively. The most frequent APL tendon slip number in the compartment was two in overall 47 specimens (54.0%). Almost all compartments (85 specimens; 97.7%) contained one EPB tendon slip. We detected bilateral EPB absence in one cadaver. Moreover, we recorded a tendon slip from extensor pollicis longus traveling into 1st EC bilaterally in one cadaver and observed the EPB muscle belly extension into 1st EC in 9 wrists. Awareness of 1st EC anatomic variations would be essential for successful surgical and nonsurgical outcomes.

An overview of the current diagnostic approach to Periprosthetic Joint Infections

The diagnosis of periprosthetic joint infections (PJI) presents a formidable challenge to orthopaedic surgeons due to its complex and diverse manifestations. Accurate diagnosis is of utmost importance, as even mild pain following joint replacement surgery may indicate PJI in the absence of a definitive gold standard diagnostic test. Numerous diagnostic modalities have been suggested in the literature, and international societies have continually updated diagnostic criteria for this debilitating complication. This review article aims to comprehensively examine the latest evidence-based approaches for diagnosing PJI. Through a thorough analysis of current literature, we explore promising diagnostic strategies that have demonstrated effectiveness in identifying PJI. These strategies encompass the utilization of laboratory markers, such as erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), alongside imaging techniques such as magnetic resonance imaging (MRI) and leukocyte scintigraphy. Additionally, we highlight the importance of synovial fluid analysis, including the potential role of alpha-defensin as a biomarker, and examine evolving international diagnostic criteria to standardize and improve diagnostic accuracy.

Incidence of Subclinical Deep Vein Thrombosis after Total Hip and Knee Arthroplasty Is Not Correlated with Number of Tranexamic Acid Doses

Background: Recent studies increasingly highlight the efficacy of tranexamic acid administration in total hip arthroplasty (THA) and total knee arthroplasty (TKA). However, the optimal dosage of tranexamic acid is still controversial. Methods: The current study analyzes the efficiency of tranexamic acid dosage and the number of administrations in THA and TKA. The objective of this study is to compare the incidence of deep vein thrombosis (DVT) based on the number of dosages. We divided the patients into two groups; one group received a single dosage, and the other group received two dosages. Doppler ultrasound examinations were conducted on the lower limbs of all patients at both six and thirty days postoperatively. The second objective is to compare the decrease in hemoglobin (Hb) in the two groups. Results: The results show that there is no difference in DVT incidence between the patients with different TXA numbers of dosages. There is no statistically significant decrease in Hb between the two groups at day one and day five postoperatively. Day one shows a statistically higher average in the two-dose group, approximately 0.06 g/dL, and day five shows a slightly elevated average in the single-dose group, approximately 0.06 g/dL. Blood transfusion requirements show no significant differences in the groups; one patient in the single-dose tranexamic acid group needed transfusion at day five postoperatively, while two patients in each group required immediate postoperative transfusion. Conclusion: There was no increase in the incidence of deep vein thrombosis among patients receiving two dosages of tranexamic acid.

Regional Anesthesia is Associated with Improved Mortality and Morbidity in Patients with Congestive Heart Failure Undergoing Lower Extremity Amputation

BACKGROUND

While existing literature reports variable results of general anesthesia (GA) and regional anesthesia (RA) in patients undergoing lower extremity amputation (LEA), the effect of RA on patients with congestive heart failure (CHF) has not been explored. This study aims to assess whether the choice of anesthesia plays a role in influencing outcomes within this vulnerable population.

METHODS

Using the American College of Surgeons National Surgical Quality Improvement Program files between 2005 and 2022, all patients receiving LEA were identified, and the subset of patients with CHF was included. Patient characteristics and 30-day outcomes were compared using χ2 or Fischer's exact test as appropriate for categorical variables and the independent t-test or Mann-Whitney U test as appropriate for continuous variables. The association between anesthesia modality and post-operative outcomes was studied using multivariable logistic regression analysis.

RESULTS

A total of 5,831 patients (4,779 undergoing GA, 1,052 undergoing RA) with a diagnosis of CHF undergoing LEA were identified. On multivariable logistic regression analysis, RA was associated with lower mortality (adjusted odds ratio [aOR] 0.79, 95% CI 0.65-0.97), pneumonia (aOR 0.76, 95% CI 0.58-0.99), septic shock (aOR 0.64, 95% CI 0.47-0.88), post-operative blood transfusion (aOR 0.82, 95% CI 0.70-0.97), and 30-day readmission (aOR 0.79, 95% CI 0.64-0.97).

CONCLUSIONS

This study demonstrates that RA for LEA in patients with CHF is associated with decreased morbidity and mortality compared to GA. While furthermore research is needed to confirm this association, RA should be at least considered in CHF patients undergoing LEA when feasible.

Primary Creep Characterization in Porcine Lumbar Spine Subject to Repeated Loading

Low back pain (LBP) is a common medical condition worldwide, though the etiology of injuries causing most LBP is unknown. Flexion and repeated compression increase lumbar injury risk, yet the complex viscoelastic behavior of the lumbar spine has not been characterized under this loading scheme. Characterizing the non-injurious primary creep behavior in the lumbar spine is necessary for understanding the biomechanical response preceding injury. Fifteen porcine lumbar spinal units were loaded in repeated flexion-compression with peak compressive stresses ranging from 1.41 to 4.68 MPa. Applied loading simulated real loading exposures experienced by high-speed watercraft occupants. The strain response in the primary creep region was modeled for all tests using a generalized Kelvin-Voigt model. A quasilinear viscoelastic (QLV) approach was used to separate time-dependent (creep) and stress-dependent (elastic) responses. Optimizations between the models and experimental data determined creep time constants, creep coefficients, and elastic constants associated with this tissue under repeated flexion-compression loading. Average R2 for all fifteen models was 0.997. Creep time constants optimized across all fifteen models were 24 s and 580 s and contributed to 20 ± 3% and 30 ± 3% of the overall strain response, respectively. The non-transient behavior contributed to 50 ± 0% of the overall response. Elastic behavior for this porcine population had an average standard deviation of 24.5% strain across the applied stress range. The presented primary creep characterization provides the response precursor to injurious behavior in the lumbar spine. Results from this study can further inform lumbar injury prediction and kinematic models.

Medical-informed machine learning: integrating prior knowledge into medical decision systems

BACKGROUND

Clinical medicine offers a promising arena for applying Machine Learning (ML) models. However, despite numerous studies employing ML in medical data analysis, only a fraction have impacted clinical care. This article underscores the importance of utilising ML in medical data analysis, recognising that ML alone may not adequately capture the full complexity of clinical data, thereby advocating for the integration of medical domain knowledge in ML.

METHODS

The study conducts a comprehensive review of prior efforts in integrating medical knowledge into ML and maps these integration strategies onto the phases of the ML pipeline, encompassing data pre-processing, feature engineering, model training, and output evaluation. The study further explores the significance and impact of such integration through a case study on diabetes prediction. Here, clinical knowledge, encompassing rules, causal networks, intervals, and formulas, is integrated at each stage of the ML pipeline, resulting in a spectrum of integrated models.

RESULTS

The findings highlight the benefits of integration in terms of accuracy, interpretability, data efficiency, and adherence to clinical guidelines. In several cases, integrated models outperformed purely data-driven approaches, underscoring the potential for domain knowledge to enhance ML models through improved generalisation. In other cases, the integration was instrumental in enhancing model interpretability and ensuring conformity with established clinical guidelines. Notably, knowledge integration also proved effective in maintaining performance under limited data scenarios.

CONCLUSIONS

By illustrating various integration strategies through a clinical case study, this work provides guidance to inspire and facilitate future integration efforts. Furthermore, the study identifies the need to refine domain knowledge representation and fine-tune its contribution to the ML model as the two main challenges to integration and aims to stimulate further research in this direction.

Femoral Head Fractures: Evaluation, Management, and Outcomes

Fractures of the femoral head typically occur after high-energy trauma. Radiographs and cross-sectional imaging are used to appropriately classify and identify associated injuries or morphologic characteristics that may influence management. Identification of the radiographic and clinical hallmarks of an irreducible variant is critical to optimizing the patient's outcome. Nonsurgical treatment can be used in the setting of small, infrafoveal femoral head fractures without hip instability. When surgical treatment is indicated, an anterior (Smith-Petersen), posterior (Kocher-Langenbeck), or surgical hip dislocation approach may be used depending on injury details and surgeon preference. The purpose of this review was to summarize current evidence on femoral head fractures regarding indications, variant patterns, surgical approaches, and outcomes.

Mapping global research trends: Nutrition associations with nonalcoholic fatty liver disease - a Scopus bibliometric analysis

BACKGROUND

Several bibliometric analyses have been carried out to identify research hotspots and trends in nonalcoholic fatty liver disease (NAFLD) research. Nonetheless, there are still significant knowledge gaps that must be filled to advance our understanding of and ability to treat NAFLD.

AIM

To evaluate, through bibliometric and visual analysis, the current status of related research, related research frontiers, and the developmental trends in the field of diet and NAFLD.

METHODS

We retrieved publications about diet and NAFLD published between 1987 and 2022 from Scopus. Next, we used VOSviewer 1.6.20 to perform bibliometric analysis and visualization.

RESULTS

We found a total of 1905 studies, including 1637 (85.93%) original articles and 195 (10.24%) reviews, focused on the examination of NAFLD and its correlation with diet that were published between 1987 and 2022. Among the remaining five types of documents, 38 were letters, notes, editorials, meeting minutes, or brief surveys, representing 1.99% of the total documents. The countries with the most publications on this topic were China (n = 539; 28.29%), followed by the United States (n = 379; 19.90%), Japan (n = 133; 6.98%), and South Korea (n = 127; 6.6%). According to the citation analysis, the retrieved papers were cited an average of 32.3 times and had an h-index of 106, with 61014 total citations. The two main clusters on the map included those related to: (1) Inflammation and oxidative stress; and (2) Dietary interventions for NAFLD.

CONCLUSION

This was the first study to use data taken from Scopus to visualize network mapping in a novel bibliometric analysis of studies focused on diet and NAFLD. After 2017, the two domains that received the most attention were "dietary interventions for NAFL"' and "'inflammation and oxidative stress implicated in NAFLD and its correlation with diet." We believe that this study provides important information for academics, dietitians, and doctors, and that additional research on dietary interventions and NAFLD is warranted.

Efficacy of lumbar and abdominal muscle rehabilitation training on degree of osteoporosis, pain and anxiety in elderly patients with osteoporotic vertebral compression fracture after PKP and compliance analysis

Purpose

To explore the rehabilitation effect and compliance of lumbar and abdominal muscle rehabilitation training in patients with osteoporotic vertebral compression fracture (OVCF) after percutaneous balloon vertebroplasty (PKP).

Methods

A total 177 elderly patients with OVCF were divided into rehabilitation group (n = 104) and control group (n = 73) according to whether they received psoas and abdominal muscle rehabilitation training for 3 months after PKP. The differences of general data, orthopaedic rehabilitation, prognosis and bone metabolism were compared between the two groups. All the patients were divided into compliance group (68 cases) and non-compliance group (36 cases) according to compliance. Orthopaedic rehabilitation indicators, prognostic indicators of PKP, and bone metabolism-related parameters were collected for analysis of Chi-square test and Logistic regression. ROC curve was used to analyze the predictive value of bone metabolism related indicators in the compliance of lumbar and abdominal muscle rehabilitation training.

Results

There was no significant difference in the general data between the rehabilitation training group and the control group (All p > 0.05). Compared with the control group, the Berg balance scale score was significantly increased, while the Visual Analogue Scale (VAS) score, Oswestry Disability Index (ODI) score and the proportion of new fractures were significantly decreased in the rehabilitation training group (All p < 0.05). Compared with the control group, the bone mineral density (BMD) T value, osteocalcin (OCN) and 25-hydroxyvitamin D (25 (OH) D) levels were significantly increased and the levels of type I N-propeptide (P1NP) and β-isomerized C-terminal telopeptides (β-CTX) were significantly decreased in the rehabilitation training group compared with the control group (All p < 0.05). Chi-square test and Logistic regression analysis showed that age > 75 years, severe anxiety, severe pain and postoperative complications were significantly associated with the compliance of psoas and abdominal muscle rehabilitation training in patients with OVCF after PKP. ROC curve analysis showed that BMD T value, OCN, P1NP, β-CTX, or 25-OH-D levels predicted the AUC of rehabilitation training compliance in patients with OVCF after PKP were 0.821, 0.835, 0.736, 0.715, and 0.748, respectively.

Conclusion

Rehabilitation training of lumbar and abdominal muscles can significantly improve the efficacy of PKP, reduce the degree of osteoporosis and improve the prognosis of patients with OVCF. Age, anxiety, pain and postoperative complications were independent risk factors affecting the compliance of psoas and abdominal rehabilitation training in patients with OVCF after PKP.

β2-adrenoceptors kick osteoarthritis - Time to rethink prevention and therapy

Although, during the past decades, substantial advances emerged in identifying major local and systemic factors contributing to initiation and progression of osteoarthritis (OA), some neuroendocrine mechanisms are still not understood or even neglected when thinking about novel therapeutic options. One of which is the sympathetic nervous system that exhibits various OA-promoting effects in different tissues of the joint. Interestingly, the β2-adrenoceptor (AR) mediates the majority of these effects as demonstrated by several in vitro, in vivo as well as in clinical studies. This review article does not only summarize studies of the past two decades demonstrating that the β2-AR plays an OA-promoting role in different tissues of the joint but also aims to encourage the reader to think about next-level research to discover novel and innovative preventive and/or therapeutic strategies targeting the β2-AR in OA.

Symptom response and episodic disability of long COVID in people with spinal cord injury: A case-control study

BACKGROUND

Spinal cord injury (SCI) is a consequence of significant disability and health issues globally, and long COVID represents the symptoms of neuro-musculoskeletal, cardiovascular and respiratory complications.

PURPOSE

This study aimed to identify the symptom responses and disease burden of long COVID in individuals with spinal cord injury.

METHODS

This case-control study was conducted on patients with SCI residing at a specialised rehabilitation centre in Bangladesh. Forty patients with SCI with and without long COVID symptoms (LCS) were enrolled in this study at a 1:1 ratio according to WHO criteria.

RESULT

Twelve LCS were observed in patients with SCI, including fatigue, musculoskeletal pain, memory loss, headache, respiratory problems, anxiety, depression, insomnia, problem in ADL problem in work, palpitation, and weakness. The predictors of developing long COVID include increasing age (p<0.002), increasing BMI (p<0.03), and longer duration of spinal cord injury (p<0.004). A significant difference (p<0.01) in overall years of healthy life lost due to disability (YLD) for non-long COVID cases was 2.04±0.596 compared to long COVID (LC) cases 1.22±2.09 was observed.

CONCLUSION

Bangladeshi patients of SCI presented 12 long COVID symptoms and have a significant disease burden compared to non long COVID cases.

Revision Surgery for Shoulder Infection after Arthroscopic Rotator Cuff Repair: Functional Outcomes and Eradication Rate-A Systematic Review

The outcomes after arthroscopic rotator cuff repair (RCR) have been reported to be successful. The incidence of deep infections (defined as an infection involving any part of the anatomy other than the skin and subcutaneous tissue) after surgery ranges between 0.03% and 3.4%. This systematic review aims to investigate the outcomes of revision surgery for infection following arthroscopic RCR. Clinical outcomes and eradication rates among patients treated with different surgical and antibiotic therapies are analyzed. A total of five studies were eligible for systematic review. A total of 146 patients were treated and evaluated, of whom 71 (48%) and 75 (52%) underwent arthroscopic and open surgery to manage the infection, respectively. The most common causative bacterium was Cutibacterium acnes (50.4%). Two studies reported the pre-and postoperative ASES score and Constant-Murley score (CMS), and a statistically significant improvement was found after surgery (p < 0.001 for both). Eradication was observed in a total of 138 patients (94.5%); no difference was found between arthroscopic and open revision surgery (92.8% and 96%, respectively, p = 0.90). The frequency-weighted mean duration of the intravenous antibiotic therapy was 6.6 ± 5.4 days, while the overall mean duration of antibiotic therapy, considering intravenous and oral administration, was 43.5 ± 40 days. Patients with infection following arthroscopic RCR undergoing revision surgery experienced a high rate of eradication. A significant improvement in shoulder functionality and less residual pain can be expected.

Clinical efficacy of Osteoking in knee osteoarthritis therapy: a prospective, multicenter, non-randomized controlled study in China

Background

Osteoking has been extensively used for the treatment of knee osteoarthritis (KOA). However, it is lack of high-quality evidence on the clinical efficacy of Osteoking against KOA and the comparison with that of nonsteroidal anti-inflammatory drugs (NSAIDs).

Aims

To evaluate the efficacy and safety of Osteoking in treating KOA.

Methods

In the current study, a total of 501 subjects were recruited from 20 medical centers, and were divided into the Osteoking treatment group (n = 428) and the NSAIDs treatment group (n = 73). The Propensity Score Matching method was used to balance baseline data of different groups. Then, the therapeutic effects of Osteoking and NSAIDs against KOA were evaluated using VAS score, WOMAC score, EQ-5D-3L and EQ-VAS, while the safety of the two treatment were both assessed based on dry mouth, dizziness, diarrhea, etc.

Results

After 8 weeks of treatment, the Osteoking group was compared with the NSAIDs group, the VAS score [2.00 (1.00, 3.00) vs. 3.00 (2.00, 4.00)], WOMAC pain score [10.00 (8.00, 13.00) vs. 11.00 (8.00, 16.00) ], WOMAC physical function score [32.00 (23.00, 39.00) vs. 39.07 ± 16.45], WOMAC total score [44.00 (31.00, 55.00) vs. 53.31 ± 22.47) ], EQ-5D-3L score [0.91 (0.73, 0.91) vs. 0.73 (0.63, 0.83) ] and EQ-VAS score [80.00 (79.00, 90.00) vs. 80.00 (70.00, 84.00) ] were improved by the treatment of Osteoking for 8 weeks more effectively than that by the treatment of NSAIDs. After 8 weeks of treatment with Osteoking, the VAS scores of KOA patients with the treatment of Osteoking for 8 weeks were reduced from 6.00 (5.00, 7.00) to 2.00 (1.00, 3.00) (p < 0.05), which was better than those with the treatment of NSAIDs starting from 2 weeks during this clinical observation. Importantly, further subgroup analysis revealed that the treatment of Osteoking was more suitable for alleviating various clinical symptoms of KOA patients over 65 years old, with female, KL II-III grade and VAS 4-7 scores, while the clinical efficacy of NSAIDs was better in KOA patients under 65 years old and with VAS 8-10 scores. Of note, there were no differences in adverse events and adverse reactions between the treatment groups of the two drugs.

Conclusion

Osteoking may exert a satisfying efficacy in relieving joint pain and improving life quality of KOA patients without any adverse reactions, especially for patients with KL II-III grades and VAS 4-7 scores.

Clinical Trial Registration

https://www.chictr.org.cn/showproj.html?proj=55387, Identifier ChiCTR2000034475.

Subtalar arthroereisis with metallic implant is a safe and effective treatment for pediatric patients with symptomatic flexible flatfeet. A 10-year clinical and radiographic follow-up

BACKGROUND

Subtalar arthroereisis (SA) is an increasingly applied minimally invasive approach for flexible flat foot (FFF) not responsive to conservative treatment. This study aimed at evaluating the long-term clinical and radiographic outcomes of SA in pediatric patients with symptomatic FFF.

METHODS

Thirty-seven patients (11.9 ± 1.6yy) underwent SA (74 feet), with outcomes assessed after a mean 10-year follow-up. Pain, quality of life, foot functionality, and alignment were evaluated using validated tools and radiographic parameters, calculated on weightbearing x-rays pre- and post-operatively.

RESULTS

Clinical outcomes reached excellent postoperative results (FFI: 9.1, AOFAS: 94.5) with a low 0.9 NRS pain (p < 0.01) and a 92 % satisfaction. All radiographic parameters improved significantly towards normal values: CP 17.5 ± 3.9, MA 4.3 ± 5.8, TCA 42.8 ± 6.2, TNCA 21.1 ± 8.5, TNU% 26.6 ± 8.4 (all p < 0.01).

CONCLUSIONS

SA with a metallic endosinotarsal device provided significant long-term clinical and radiographic improvements, with low complication rates and high patient satisfaction, supporting its efficacy as a treatment option for pediatric symptomatic FFF.

LEVEL OF EVIDENCE

IV.