Archives of Bone and Joint Surgery
Volume:5 Issue: 6, Nov 2017

In the field of orthopedic surgery, highly impact journals like Journal of Bone and Surgery (JBJS-Am) and Clinical orthopedics and Related Research (CORR) publishing the LOE for their manuscript. JBJS-Am started to publish the level of evidence (LOE) for all manuscript since 2013.
310 articles were reviewed. Country of origin for these, were twelve different countries including Iran. International articles consistently increased from 23 % of all published articles in 2013 to 47% in 2016. Overall one- third of articles came from USA and Europe in this period and at the last year, this proportion exceeds 41 %.
Publishing LOE and the study type helps the reader to imagine the estimated quality of the research presented before starting to read . The aim of this study was to determine the level of contribution of international researchers and also detect any possible progress in LOE of publications over the past four years in ABJS.

Many studies have reported the association of estrogen receptor α gene (ESRα) ESRα PvuII T>C, XbaI A>G and BtgI G>A polymorphisms with Knee osteoarthritis (KOA) risk, but the results remained controversial. In order to drive a more precise estimation, the present systematic review and meta-analysis was performed to investigate the association between ESRα polymorphisms and KOA susceptibility.
Eligible articles were identified by search of databases including PubMed, ISI Web of Knowledge and Google scholar up to March 1, 2017. Data were extracted by two independent authors and pooled odds ratio (OR) with 95% confidence interval (CI) was calculated.
A total of 22 case-control studies in eleven publications with 6,575 KOA cases and 7,459 controls were included in the meta-analysis. By pooling all the studies, either ESRα PvuII T>C and XbaI A>G polymorphisms was not associated with KOA risk in the overall population. However, ESRα BtgI G>A was significantly associated with KOA risk under all five genetic models. In the subgroup analysis by ethnicity, a significant association was observed between ESRα PvuII T>C polymorphism and KOA risk in Asians under heterozygote model. In addition, significant association was found between ESRα XbaI A>G polymorphism and KOA in Caucasians under allelic, homozygote, dominant and recessive models.
The present meta-analysis suggests that ESRα BtgI G>A rather than ESRα PvuII T>C and XbaI A>G polymorphisms is associated with an increased KOA risk in overall population. Moreover, we have found that ESRα PvuII T>C and XbaI A>G polymorphisms associated with KOA susceptibility by ethnicity backgrounds.

Osteoporosis has become a major medical problem as the aged population of the world rapidly grows. Osteoporosis predisposes patients to fracture, progressive spinal deformities, and stenosis, and is subject to be a major concern before performing spine surgery, especially with bone fusions and instrumentation. Osteoporosis has often been considered a contraindication for spinal surgery, while in some instances patients have undergone limited and inadequate procedures in order to avoid concomitant instrumentation. As the population ages and the expectations of older patients increase, the demand for surgical treatment in older patients with osteoporosis and spinal degenerative diseases becomes progressively more important. Nowadays, advances in surgical and anesthetic technology make it possible to operate successfully on elderly patients who no longer accept disabling physical conditions. This article discusses the biomechanics of the osteoporotic spine, the diagnosis and management of osteoporotic patients with spinal conditions, as well as the novel treatments, recommendations, surgical indications, strategies and instrumentation in patients with osteoporosis who need spine operations.

To study if patients that have a second radiograph 2 or more years after nonoperative treatment of an isolated radial head fracture have radiocapitellar osteoarthritis (RC OA).
We used the database of 3 academic hospitals in one health system from 1988 to 2013 to find patients with isolated radial head fractures (no associated ligament injury or fracture) that had a second elbow radiograph after more than 2 years from the initial injury. Of 887 patients with isolated radial head fractures, 54 (6%) had an accessible second radiograph for reasons of a second injury (57%), pain (30%), or follow-up visit (13%). Two orthopedic surgeons independently classified the radial head fractures on the initial radiographs using the Broberg and Morrey modified Mason classification, and assessed the development of RC OA on the final radiograph using a binary system (yes/no).
Four out of 54 (7.5%) patients had RC OA, one with isolated RC arthrosis that seemed related to capitellar cartilage injury, and 3 that presented with pain and had global OA (likely primary osteoarthritis).
With the caveat that some percentage of patients may have left our health system during the study period, about 1 in 887 patients (0.1%) returns with isolated radiocapitellar arthritis after an isolated radial head fracture, and this may relate to capitellar injury rather than attrition. Patients with isolated radial head fractures can consider post-traumatic radiocapitellar arthritis a negligible risk.

Osteoporosis is a common condition among the elderly population, and is associated with an increased risk of fracture. One of the most common fragility fractures involve the distal radius, and are associated with risk of subsequent fragility fracture. Early treatment with bisphosphonates has been suggested to decrease the population hip fracture burden. However, there have been no prior economic evaluations of the routine treatment of distal radius fracture patients with bisphosphonates, or the implications on hip fracture rate reduction.
Age specific distal radius fracture incidence, age specific hip fracture rates after distal radius fracture with and without risendronate treatment, cost of risendronate treatment, risk of atypical femur fracture with bisphosphonate treatment, and cost of hip fracture treatment were obtained from the literature. A unique stochastic Markov chain decision tree model was constructed from derived estimates. The results were evaluated with comparative statistics, and a one-way threshold analysis performed to identify the break-even cost of bisphosphonate treatment.
Routine treatment of the current population of all women over the age of 65 suffering a distal radius fracture with bisphosphonates would avoid 94,888 lifetime hip fractures at the cost of 19,464 atypical femur fractures and $19,502,834,240, or on average $2,186,617,527 annually, which translates to costs of $205,534 per hip fracture avoided. The breakeven price point of annual bisphosphonate therapy after distal radius fracture for prevention of hip fractures would be approximately $70 for therapy annually.
Routine treatment of all women over 65 suffering distal radius fracture with bisphosphonates would result in a significant reduction in the overall hip fracture burden, however at a substantial cost of over a $2 billion dollars annually. To optimize efficiency of treatment either patients may be selectively treated, or the cost of annual bisphosphonate treatment should be reduced to cost-effective margins.

Conflicting studies link several conditions and risk factors to Dupuytren’s disease (DD). A questionnaire-based case-control study was set to investigate associated conditions and clinical features of DD in a sample of Italian patients. The main purpose was the identification of predicting factors for: DD development; involvement of multiple rays; involvement of both hands; development of radial DD; development of recurrences and extensions.
A self-administered questionnaire was used to investigate medical and drug histories, working and life habits, DD clinical features, familial history, recurrences and extensions. Binary logistic regression, Mann Whitney U-test and Fisher’s exact test were used for the statistical analysis.
A role in DD development was found for male sex, cigarette smoking, diabetes and heavy manual work. The development of aggressive DD has been linked to age, male sex, high alcohol intake, dyslipidemias and positive familial history.
Further studies might explain the dual relationship between ischemic heart disease and DD. According to our results, the questionnaire used for this study revealed to be an easy-handling instrument to analyze the conditions associated to DD. Nevertheless, its use in further and larger studies is needed to confirm our results as well as the role of the questionnaire itself as investigation tool for clinical studies.

The treatment of distal clavicle fracture is always a challenge, as it is mostly unstable and has higher rate of delayed union, malunion, non-union and associated acromioclavicular arthritis. So the management of these fractures remains controversial. The purpose of this study is to evaluate the functional results of Type 2 distal end clavicle fractures treated with superior anterior locking plate.
From June 2011 to August 2015 a retrospective study of12 male patients (mean age of 41.3 years) 11 with unilateral and 1 with bilateral distal clavicle fractures treated with superior anterior locking plate was done. They were evaluated at regular intervals with mean follow up of 14 months(12-18 months).Those with minimum one year follow up were included in our study. All were evaluated for the functioning of the shoulder joint by both Oxford shoulder score and Quick DASH scores, rate of bone union, complications and earliest time for return to work.
All fractures union seen within 6-8 weeks (mean time: 7.1 weeks).All had good shoulder range of motion. The average oxford shoulder and Quick DASH score were 46.2 and 6.5.There were no major complications in our study viz. non-union, plate failure, secondary fracture. But one patient had superficial wound infection. All patients returned to work within 3 months of postoperative period.
Displaced distal clavicle fractures treated with superior anterior locking plates achieved excellent results in terms of bony union with rarely any complications and demonstrate promising results with this novel technique.

Mindfulness based interventions may be useful for patients with musculoskeletal conditions in orthopedic surgical practices as adjuncts to medical procedures or alternatives to pain medications. However, typical mindfulness programs are lengthy and impractical in busy surgical practices. We tested the feasibility, acceptability and preliminary effect of a brief, 60-second mindfulness video in reducing pain and negative emotions in patients presenting to an orthopedics surgical practice.
This was an open pilot study. Twenty participants completed the Numerical Rating Scale to assess pain intensity, the State Anxiety subscale of the State Trait Anxiety Scale to assess state anxiety, and emotional thermometers to assess distress, anxiety, anger and depression immediately prior to and following the mindfulness video exercise. At the end of the exercise patients also answered three questions assessing satisfaction with the mindfulness video.
Feasibility of the mindfulness video was high (100%). Usefulness, satisfaction and usability were also high. Participants showed improvements in state anxiety, pain intensity, distress, anxiety, depression and anger after watching the video. These changes were both statistically significant and clinically meaningful, when such information was available.
People with musculoskeletal pain seeking orthopedic care seem receptive and interested in brief mindfulness exercises that enhance comfort and calm.

Due to the known disadvantages of autologous bone grafting, tissue engineering approaches have become an attractive method for ridge augmentation in dentistry. To the best of our knowledge, this is the first study conducted to evaluate the potential therapeutic capacity of PRP-assisted hADSCs seeded on HA/TCP granules on regenerative healing response of canine alveolar surgical bone defects. This could offer a great advantage to alternative approaches of bone tissue healing-induced therapies at clinically chair-side procedures.
Cylindrical through-and-through defects were drilled in the mandibular plate of 5 mongrel dogs and filled randomly as following: I- autologous crushed mandibular bone, II- no filling material, III- HA/TCP granules in combination with PRP, and IV- PRP-enriched hADSCs seeded on HA/TCP granules. After the completion of an 8-week period of healing, radiographic, histological and histomorphometrical analysis of osteocyte number, newly-formed vessels and marrow spaces were used for evaluation and comparison of the mentioned groups. Furthermore, the buccal side of mandibular alveolar bone of every individual animal was drilled as normal control samples (n=5).
Our results revealed that hADSCs subcultured on HA/TCP granules in combination with PRP significantly promoted bone tissue regeneration as compared with those defects treated only with PRP and HA/TCP granules (P In conclusion, our results indicated that application of PRP-assisted hADSCs could induce bone tissue regeneration in canine alveolar bone defects and thus, present a helpful alternative in bone tissue regeneration.

It has been shown that the proper placement of ACL graft during the ACL reconstruction surgery significantly improves the clinical outcomes. This study investigated whether a change in the femoral tunnel position in both axial and coronal planes can significantly alter the postoperative functional and clinical outcomes of the patients.
This comparative, retrospective, single-center study was performed on 44 patients undergone single-bundle anterior cruciate ligament reconstruction (ACLR). Radiographic assessments were done to evaluate the tunnel position in coronal and axial planes. Patients were classified into 4 groups based on radiographic data. The time interval between surgery and last visit averaged 23.6 ± 2.2 months (18-30 mos.). Lysholm knee score and Cincinnati score were completed for all of the patients. Furthermore, the Lachman, anterior drawer and pivot-shift tests were performed.
Of the 44 patients included in the study, 9 patients (20.4%) were classified as the low-anterior group, 17(38.6%) were classified as the low-posterior group and 18(40.9%) were classified as the high-posterior group. None of the patients were included in high-anterior group. A greater mean Lysholm score (96±3) in low-posterior group was the only significant difference between the three groups (P Findings of the current study demonstrated that low-posterior placement of the ACL graft through the intercondylar notch, based on both antero-posterior (AP) and tunnel-view x-rays, is associated with better clinical outcomes in short-term compared to the routine tunnel placements.

The epidemiology of traumatic dislocations and ligamentous/tendinous injuries is poorly understood. In this study, we aimed to evaluate the prevalence and distribution of various dislocations and ligamentous/tendinous injuries in a tertiary orthopedic hospital in Iran.
Musculoskeletal injuries in an academic tertiary health care center in Tehran February 2005 to October 2010 were recorded. The demographic details of patients with pure dislocations and ligamentous/tendinous injuries were extracted and the type and site of injuries were classified according to their specific age/gender groups.
Among 18,890 admitted patients, 628 (3.3%) were diagnosed with dislocations and 2.081 (11%) with ligamentous/tendinous injuries. The total male/female ratio was 4.2:1 in patients with dislocations and 1.7:1 in patients with ligamentous/tendinous injuries. Shoulder was the most prevalent site of dislocation (50.6%), followed by fingers (10.1%), toes (7.6%), hip (7.3%), and elbow (6.5%). Ankle was the most common site of ligamentous/tendinous injury (53.5%), followed by midfoot (12.3%), knee (8.3%), hand (7%), and shoulder (5%). The mean ages of the patients in dislocations and ligamentous/tendinous injuries were 35.0±18.2 and 31.3±15.1, respectively. There was no seasonal variation.
Shoulder dislocation and ankle ligamentous injury are the most frequent injuries especially in younger population and have different distribution patterns in specific age and sex groups. Epidemiologic studies can help develop and evaluate the injury prevention strategies, resource allocation, and training priorities.

Posterior tibial slope (PTS) is an important factor in the knee joint biomechanics and one of the bone features, which leads to knee joint stability. Posterior tibial slope affects flexion gap, knee joint stability and posterior femoral rollback that are related to wide range of knee motion. During high tibial osteotomy and total knee arthroplasty (TKA) surgery, proper retaining the mechanical and anatomical axis is important. The aim of this study was to evaluate the value of posterior tibial slope in medial and lateral compartments of tibial plateau and to assess the relationship among the slope with age, gender and other variables of tibial plateau surface.
This descriptive study was conducted on 132 healthy knees (80 males and 52 females) with a mean age of 38.26±11.45 (20-60 years) at a medical center in Mashhad, Iran. All patients required to MRI admitted for knee pain with uncertain clinical history and physical examination that were reported healthy at knee examination were enrolled in the study.
The mean posterior tibial slope was 7.78±2.48 degrees in the medial compartment and 6.85±2.24 degrees in lateral compartment. No significant correlation was found between age and gender with posterior tibial slope (P≥0.05), but there was significant relationship among PTS with mediolateral width, plateau area and medial plateau.
Comparison of different studies revealed that the PTS value in our study is different from other communities, which genetic and racial factors can be involved in these differences. The results of our study are useful to PTS reconstruction in surgeries.

Although the developmental dysplasia of the hip (DDH) is well known to pediatric orthopedists, its etiology has still remained unknown and despite dedication of a vast majority of research, the results are still inadequate and confusing. The exact incidence of DDH and its relationship with known risk factors in Iran is still unknown. Here we represent the results of one year study on the incidence and related conditions of DDH.
Sonography was performed on the hip joints of 1073 full term healthy newborns at Imam Khomeini Hospital from March 2013 to March 2014. The results were classified according to Graf’s classification. Pathologic hips were cross checked by the known risk factors for DDH.
A significant correlation was found between DDH and breech presentation (P=0.000), torticollis (P=0.004), metatarsus adductus (P=0.024).
The incidence of DDH is significantly high in the studied group of neonates, suggesting reevaluation of current approach to DDH. The screening protocols need to be improved with the help of trained pediatricians and other health professions.

There are still some debates regarding the best treatment of Giant Cell Tumor (GCT) of the sacrum. Since GCT of this location is rare, therapeutic strategies are mainly based on the treatment of GCT in other anatomic locations. The objective of this study was to evaluate the oncologic and clinical results of surgical management of sacral GCT with and without local adjuvant therapy. Medical records of 19 patients diagnosed with GCT of the sacrum, were retrospectively reviewed. Sixteen patients were treated by intralesional curettage and three patients with marginal resection. Musculoskeletal tumor society (MSTS) score was used for the evaluation of functional outcome. Prolonged pain was the most common complication after treatment. Mean Pre and post-operative pain based on visual analogue scale (VAS) was 6.1 ± 1.99 and 3.05 ± 1.64, respectively. Postoperative neurologic deficit appeared in six patients. In addition, infection occurred in five patients. One case of spinopelvic instability was also observed after surgery. At average follow up of 158.5 ± 95.9 months (25 to 316 months), recurrence was seen in eight (42.7%) out of seventeen patients treated by intralesional curettage. The size of the tumor significantly correlated with the tumor recurrence (r=0.654, P=0.001). Mean MSTS score was 74.7 ± 16.78. Those patients, in whom sacral nerve roots remained intact before and after surgery, had better functional outcome. Preservation of sacral nerve roots is associated with better functional outcome and less pain. Although an acceptable surgical outcome was observed in our cohort, the problem of local recurrence still warrants further investigations for better local control of the tumor.

Hand and wrist radiographic indexes such as radial inclination, ulnar variance, carpal height ratio, and radial tilt play an important role in the diagnosis and management of medical disorders, so they should be modified regarding the population and race difference. This study aims to compare the normal radiologic wrist indexes in Mashhad population with other existing databases and define some of the factors that may influence the normal radiographic indexes. A total of 100 healthy participants were enrolled in this prospective cross-sectional study. After performing PA and lateral wrist radiographs, all radiological indexes including the wrist height; 1st and 3rd metacarpal length; ulnar variance; radial tilt and radial inclination; radiolunate, capitolunate, and scapholunate angle; capitate and scaphoid length; lunate and wrist width; and lunate diameter were measured. Significant differences were found between the two genders in the 1st and 3rd metacarpal length (P

The patient was a 61-year-old female with massive rotator cuff tear who had no history of smoking, COPD, asthma, or other pulmonary diseases. Four hours following shoulder arthroscopy, the patient developed progressive dyspnea, which was diagnosed as pneumothorax with subcutaneous emphysema extending to the neck and face. Chest tube was inserted promptly. The patient was discharged with a good condition after 7 days. Follow up of the patient for the next 3 months was uneventful.

Locking plate fixation is increasingly used for first metatarsophalangeal joint (MTP-I) arthrodesis. Still there is few comparable clinical data regarding this procedure.
We retrospectively evaluated 60 patients who received an arthrodesis of the MTP-I between January 2008 and June 2010. With 20 patients each we performed a locking plate fixation with lag screw, arthrodesis with crossed-screwsor with a nonlocking plate with lag screw.
There were four non-unions in crossed-screws patients and one nonunion in non-locked plate group. All the patients in locking plate group achieved union. 90% of the patients were completely or mildly satisfied in locking plate group, whereas this rate was 80% for patients in both crossed screws and non-locking plate groups.
Use of dorsal plating for arthrodesis of MTP1 joint either locking or non-locking were associated with high union rate and acceptable and comparable functional outcome. Although nonunion rate was high using two crossed screws but functional outcome was not significantly different compare to dorsal plating.