Archives of Bone and Joint Surgery
Volume:12 Issue: 5, May 2024

This meta-analysis was conducted to study the hemostatic efficacy of bone wax in total joint arthroplasty (TJA) defined in this manuscript as total knee arthroplasty and total hip arthroplasty.

PubMed, Embase, Google Scholar (page 1-20), and Scopus were searched updated to November 2023. Only comparative studies were included. The clinical outcomes evaluated were the transfusion rate, total blood loss, and the loss of hemoglobin on day 1, 3, and 5 post-operatively.

Only 3 studies met the inclusion criteria and were included in this meta-analysis. Bone wax was associated with a reduced transfusion rate (p=0.01), reduced total blood loss (p=0.001), and a decrease in hemoglobin loss on day 1 (p<0.00001), day 3 (p<0.0001), and day 5 (p<0.00001) after the surgery.

Bone wax reduced the rate of transfusion, total blood loss, and hemoglobin loss after the surgery. This may induce a reduction the cost of correcting post-operative anemia as well as decrease hospital stay and improving functional outcomes in patients undergoing TJA. Better-conducted randomized controlled studies and cost-effectivity studies could strengthen these findings. Level of evidence: III

To compile the existing literature on bilateral anterior shoulder dislocation (BASD) and analyze patient demographics, mechanisms of injury, injury characteristics, management, and outcome .

This systematic review was conducted in accordance with Preferred Reporting Items for Systematic review and Meta-Analyses (PRISMA) guidelines. Online databases, including Ovid Medline 1946-, Embase.com 1947-, Scopus 1960-, Cochrane Central, and Clinicaltrials.gov were systematically queried. Studies eligible for inclusion were case reports or case-series, documenting BASD. Two reviewers independently screened and applied a set of a priori exclusion criteria to each returned study. Data were extracted, compiled, and synthesized from each reported case of BASD. Contingency tables/Chi-Square Analyses, T-tests, and univariate regression analyses were conducted to assess relationships between different variables.

Eighty-one studies (87 cases of BASD) were included. Patients were 41.1 (SD± 19.5) years old and most were male (n=63; 72.4%). Around a quarter of patients (28.7%) had a history of epilepsy/seizures or were being worked-up for such. Younger males were more likely to have BASD due to a seizure or electrocution (P<0.05). Close to a third of cases (n=27; 31.0%) were delayed in presentation. Those sustaining seizures or electrocutions were more likely to be delayed in presentation (P=0.013). Most events resulted in simple dislocations that were closed reduced successfully. BASD resulting from seizures or electrocutions were more likely to be fracturedislocations (P=0.018); and in younger patients with fracture-dislocations, closed reduction was more often to fail or not be attempted (P<0.05). Median follow-up was 6 months (IQR: 3 months – 12 months). Seven patients (10.6%) had complications and 4 (2.3%) demonstrated recurrent instability.

In young males presenting with BASD without known trauma, suspicion should be high for a convulsantevent. In patients with a known seizure disorder who present with chronic bilateral shoulder or arm pain, BASD should be considered and work-up should be expedited to avoid misdiagnosis. Level of evidence: V

The rate of re-revision total knee arthroplasty (TKA) ranges between 4% and 10%, depending on the cause of the procedure. Periprosthetic joint infection (PJI) and periprosthetic fracture are the main causes of re-revision TKA. The likelihood of implant survival of re-revision TKA diminishes with each subsequent revision, with PJI being the main cause of multiple revisions. Acute early asep tic revision TKA (within 90 days of surgery) involves a high risk of re-revision at 2 years and a high risk of subsequent PJI. The use of antibiotic-loaded cement is associated with lower risk of re-revision. Patients younger than 50 years experiencing aseptic revision TKA have a 1 in 3 risk of re-revision. Patients revised for instability or having prior TKA revisions have the highest risk of re -revision at 10 years. Patients younger than 55 years experiencing revision TKA have a 5 -year revision-free survival of 80%. Level of evidence: III

Supracondylar humerus fracture (SHF) is the most common fracture observed in children. The present study aimed to assess the characteristic parameters in one of the most extensive available pediatric SHF series referred to a tertiary hospital in Iran.

The medical profiles of the SHF patients who were referred to our tertiary hospital between January 2017 and January 2022 were retrospectively reviewed. The inclusion criteria entailed age < 14 years and a radiographically confirmed diagnosis of SHF. The collected data included age, gender, side of injury, mechanism of injury, season of the injury, concurrent complications, type of fracture, and treatment.

A total of 1,309 patients with a mean age of 7.7±2.7 years were included in this study. The incidence of SHF was 1.8-fold higher in males, while the mean age of incidence was significantly lower in female patients (7.2 vs. 8 years; P<0.001). Falling was the most frequent mechanism of injury (97%). Gartland type I was the most prevalent type of injury (n=482; 36.8%). Moreover, the majority of fractures were extension-type (n=1,249; 95.4%). Most patients were managed conservatively (n=785; 60%). Concurrent fractures as well as neuralgic, vascular, and muscular complications were present in 3%, 1.45%, 1.22%, and 0.5% of patients, respectively.

As evidenced by the results of this study, SHF is prevalent among the Iranian pediatric population. Therefore, greater awareness is required regarding the high incidence of this fracture in this population and its adequate management with respect to concurrent complications, particularly neurovascular compromise. Level of evidence: IV

Knee osteoarthritis is common among older individuals, necessitating Total Knee Arthroplasty (TKA) for end-stage cases. The aging population has increased TKA demand, leading to a rise in revision surgeries. Genu recurvatum, a rare complication, often req uires surgical intervention, with late-onset cases linked to neuromuscular conditions. This case series focuses on the infrequent occurrence of late-onset genu recurvatum resulting from spinal stenosis in patients without other predisposing conditions.

A retrospective case series of 10 patients (11 knees) referred between February 2016 and August 2020 due to late recurvatum instability. Exclusion criteria encompassed neuromuscular diseases other than spinal stenosis, prosthetic joint infection, and pre-existing recurvatum deformity. Data, including demographics, medical history, imaging findings, and surgical details, were collected retrospectively. Patient performance was assessed using the Knee Society Score (KSS) at specified postoperative intervals.Results The study cohort, exhibiting hyperextension ranging from 11 to 30 degrees, underwent successful revision surgery using rotating hinge knee (RHK) implants after failed conservative measures. Follow-up assessments at 6, 18, and 24 months showed no recurrence of genu recurvatum.

Late-onset genu recurvatum poses a challenge, necessitating surgical intervention. Identifying predisposing factors is crucial, with spinal stenosis emerging as a rare cause. The use of posterior stabilized (PS) implants in primary surgery aligns with higher revision rates, possibly linked to PCL removal. Limited literature explores the spinal-genu recurvatum relationship. A stepwise screening protocol is proposed for high-risk patients, emphasizing history, physical examination, and imaging. Strategic considerations include lower constraining, a tighter extension gap, and potential use of Hinge implants. Level of evidence: V

Pre-operative assessment is routinely performed for all hip fractures, and include a thorough clinical examination and multiple pre-operative tests. While abnormalities are often detected in many tests, they have varied effect on mortality. The purpose of the study was to assess the prevalence and impact of these abnormal tests and comorbidities. This was a prospective study of 283 consecutive hip fracture patients aged above 50 years admitted in a major trauma hospital from February 2019 to December 2019. The prevalence of abnormalities in the following tests were assessed: chest x-ray, electrocardiogram, complete blood count, serum electrolytes, renal function test, prothrombin time/international normalized ratio, and serum bilirubin. Also, presence of comorbidities were recorded. Mortality within 90 days of admission was assessed. 91.5% (N= 259/283) of the patients had at least one abnormal investigation. The most common abnormal investigation was anemia (70.3%, N= 199/283), followed by deranged sodium (36.4%, N= 103/283). 17.7% (N= 50/283) of the patients had at least one new comorbidity diagnosed after admission. The most common newly diagnosed comorbidity was hypertension (10.6%, N= 30/283). Anemia (p=0.044), deranged sodium (p=0.002), raised urea (p=0.018), raised creatinine (p=0.002), renal disease (p=0.015), neurological diseases (p=0.024), and charlson comorbidity index (p=0.004) were associated with increased mortality in multivariate analysis. Pre-operative hemoglobin, sodium, urea, and creatinine were the most important tests influencing mortality, and derangements of these should therefore be carefully evaluated and managed. Hip fracture care pathways should focus on correction of these abnormalities. Level of evidence: II

The anterior cruciate ligament (ACL) reconstruction surgery improves mechanical stability; however, functional stability remains impaired. Balance exercises can help improve functional stability. The effect of cognitive dual-task balance exercises has not been studied in people with ACL reconstruction surgery; therefore, this study aimed to compare the effect of cognitive dual -task and single-task balance exercises on the static balance indices in these individuals. This study was a randomized clinical trial. After a period of conventional physiotherapy and applying inclusion criteria, 28 patients with ACL reconstruction surgery were randomly divided into two groups of cognitive dual-task and single-task balance exercises. Each group received the relevant exercises for four weeks, three times a week, with each session lasting 20 min. Center of pressure variables, including mean displacement in anteriorposterior and medial-lateral directions, total path length, mean velocity of displacement, root mean square of displacement and velocity, and the elliptical area, were measured using the FDM pressure platform before and after the interventions as the primary outcomes. Knee Injury and Osteoarthritis Outcome Score (KOOS) scale was completed by the participants before and after the interventions. The measured static balance variables and KOOS subscales had significant differences before and after intervention in both groups (P<0.05); however, no statistically significant difference was observed in these variables between the two groups. There was no significant correlation between KOOS subscales and measured static balance variables. Both cognitive dual-task and single-task balance exercises improved the indicators related to static balance and the level of functional disability of the knee. However, cognitive dual-task balance exercises had no superiority over single-task balance exercises in ACL-reconstructed individuals. Level of evidence: II

Total hip arthroplasty (THA) is the mainstay therapy for patients with terminal hemophilic arthropathyof the hip. However, the largest case series published between 2017 and 2023 in the literature on THA in patients with hemophilia have found a higher 1-year infection rate (8.1% versus 3.4%) in hemophilia patients than in the general population, a higher rate of in-hospital bleeding complications (38.7% versus 16.1%), a higher length of stay (6 days versus 3 days) and a higher 30 -day readmission rate (22.6% versus 4.1%). Finally, a lower 5-year survival rate has also been observed in hemophilia patients than in the general population (91.9% versus 95.3%). In the last decade there have been dramatically positive improvements in implant designs and hematological treatment, and therefore it does not seem that THA in hemophilia is so far from that in osteoarthritic patients. Level of evidence: III

Here we present a novel adaptation of the previously described fibula pro -tibial fixation in a case requiring salvage fixation of a bimalleolar ankle fracture in an osteoporotic patient. Unstable osteoporotic ankle fractures are a challenging injury to manage and typically occur in a frail and comorbid subgroup of patients. Various techniques have been described in the evolution of managing these injuries, e.g. hindfoot nailing and anatomical locking plates, however in this uniquely challenging case a novel strategy was required to mitigate bone loss in the distal fibular fracture fragment. There is some evidence to suggest fibular protibial fixation offers a lower complication profile to its alternatives. The novel use of distal fibula pro-tibial screws offers a new alternative to hindfoot nailing of bimalleolar ankle fracture in osteoporotic bone with compromised distal fibular fragment bone purchase. Further research is required to investigate the compatibility of this technique with early weightbearing. Level of evidence: IV

We greatly appreciate the comments on our recent technical note. However we continue to support the effectiveness of our hamstrings harvest technique, cause of no differences in terms of premature amputations of the graft were observed and the other technique proposed does not eliminate the risk of damage to the infrapatellar branch of the saphenous nerve.