Archives of Bone and Joint Surgery
Volume:8 Issue: 3, May 2020

An enormous technological improvement in Ultrasonography devices has occurred during last decade, providing excellent soft-tissue contrast and high spatial resolution images. Nowadays, musculoskeletal ultrasonography is going to be a stethoscope in the hand of orthopedic surgeons for the diagnosis of many musculoskeletal pathologies, as well as an accurate guide for therapeutic interventions. Therefore, it is wise for practicing orthopedic surgeons to learn musculoskeletal ultrasonography in collaboration with radiology colleagues as this would improve the patients' care .

Patellofemoral (PF) osteoarthritis (OA) is a somewhat predominant illness, affecting up to 24% of women and 11% ofmen over the age of 55 years who suffer from symptomatic knee OA. The purposes of this narrative overview are tosummarize the present situation of patellofemoral arthroplasty (PFA) in the treatment of solitary PF-OA, and to givean account of the clinical results of PFA for the management of solitary PF degenerative OA of the knee. A CochraneLibrary and PubMed (MEDLINE) examination related to the position of PFA in PF-OA was carried out. A number ofpublications have encountered that PFA is an efficacious treatment for solitary PF-OA. Additionally, a systematic reviewdescribed fairly good results of PFA survivorship and functional outcomes at short- and mid-run follow-up in the settingof solitary PF-OA. Success of PFA depends on accurate patient selection rather than prosthetic failure or wear. In manyreports, the main cause of PFA failure is advancement of tibiofemoral OA. In contemporary times, encouraging resultshave been accomplished by the association of PFA and unicompartmental knee arthroplasty (UKA). In conclusion,patients with solitary PF-OA with severe anterior knee pain may be candidates for PFA. The success of the surgicalprocedure and the long-run survivorship of PFA are related to a good surgical technique and observation to meticulousindications and contraindications in patient selection. Newer prostheses have also played a part to amelioratedoutcomes. PFA is an alternative for younger patients with solitary PF-OA.Level of evidence: III

Ever since its description, anterolateral ligament (ALL) of the knee joint remains as the hotspot of controversies.Though it has been described under various descriptions, the structure gained its limelight when it was christenedas anterolateral ligament by Claes in 2013. The main reason for the controversies around it is the lack of concreteevidences regarding its attachments, morphology, biomechanical aspects and radiological appearance. Similarly therole of ALL in pivot shift phenomenon also remains as a point of debate. The advocates of ALL suggest that becauseof its ability to modulate internal rotation and attachment to the lateral meniscus, ALL contributes to the pivot shiftphenomenon. Similarly, the orientation of ALL stands as the reason for varied documentation with respect to imagingtechniques. With the growing body of evidence, it is imperative to fix our stand regarding the structure because, iffound to be morphologically persistent, it can be used for concomitant anterolateral stabilization along with anteriorcruciate ligament reinforcement surgeries. The present review tries to systematically review the anatomy, variations inclassifications, descriptions, histology, radiology and biomechanical features of ALL. At the end of the review, we wouldlike to find the answer for the question: Is ALL a distinct ligamentous structure located at the anterolateral aspect of theknee? What is the contribution of it to the tibial internal rotation stability?Level of evidence: II

Of the pharmacological modalities for knee osteoarthritis (OA), intra-articular injections including ozone(O3) and hyaluronic acid (HA) are commonly used for reducing pain and improving function. In this systematic reviewand meta-analysis, we aimed to compare the effect of O3 versus HA in reducing pain and increasing function in patientswith knee OA.

After searching databases, we included 6 randomized controlled trials on patients with knee OA thatcompared the effects of intra-articular injection of ozone versus HA. The primary outcome was visual analogue scale(VAS) of pain. The secondary outcome was Western Ontario and McMaster Universities Arthritis Index (WOMAC)score.

There was a total of 237 patients in the HA group and 230 patients in the Ozone group. Of 6 studies, 4 werein English, 1 was in Persian, and 1 was in German language. The overall Standardized Mean Difference (SMD) for VASpain did not show a significant difference between the groups although it favored HA injection (1.27 [95%CI: (-0.12)-2.66]). Total WOMAC score showed a significant difference over the time favoring HA injection (4.5 [95%CI: 1.1-8]).However, no single time point showed any significant difference between groups.

This meta-analysis showed no significant difference between HA and ozone in reducing pain andimproving function in patients with knee OA, although the overall results favored HA over ozone. Since previous studieshave shown comparable results between HA and placebo, ozone seems to fall in the same category with more placeboeffect rather than a real disease-modifier.Level of evidence: I

Total knee arthroplasty (TKA) can cause excessive blood loss requiring allogenic transfusions.Tranexamic acid (TXA) has been increasingly used for lowering blood loss. The present study aimed to comparethe efficacy of intravenous (IV) and intra-articular (IA) administrations of TXA in TKA patients who receive aspirin aschemoprophylaxis and uses no drain post-operative.

In this prospective randomized clinical trial, 49 TKA patients were intravenously given 15 mg/kg dose ofTXA, and 49 patients intraarticularly received 15 mg/kg of TXA. Demographic information, pre-operative and postoperativehemoglobin values of the patients were used for assessing total perioperative blood loss by GOOD &NADLER formulae.

There was not any significant difference between the IV TXA and IA TXA groups concerning blood loss(P=0.102). However, the decrease in hemoglobin level at 48 hours post-operation compared to the preoperativelevel in the IV TXA group was significantly higher than that in the IA TXA group (-2.3 ±0.8 vs. -1.9 ±1.0 g/dL;P=0.038). No blood transfusion was needed, and the deep venous thrombosis and pulmonary embolization werenot observed in either of the groups (P>0.05).

Our study showed that during TKA, the IA TXA is equally safe and effective as its IV infusion concerningdecreased blood loss and adverse effects. The use of TXA during TKA is safe for patients who receive less potentchemoprophylaxis agents such as aspirin.Level of evidence: I

Blood loss during and immediately after total knee arthroplasty (TKA) is among the most challengingconcerns. It has been demonstrated that Tranexamic acid (TXA) can help to reduce perioperative blood loss. TXAcan be used as an oral, topical or intravenous injection. Many studies evaluated the effectiveness of each route ofadministration but few works on a comparison between them. The current study aimed to compare the effectivenessof intravenous injection versus topical use of TXA in reducing perioperative blood loss after primary total kneearthroplasty.

Eighty-five patients who were a candidate for total knee arthroplasty were randomized into two groups:one group received Intravenous injection of 15 mg/kg TXA, 10 min before tourniquet inflation while the other groupreceived 1 g diluted TXA during wound closure. The postoperative blood loss was estimated by measuring thewhole drain output and also hemoglobin (HB) drops. Both groups compared based on the need for allogenic bloodtransfusion and also thromboembolic events.

Patients who received topical TXA had a higher total drain output (P<0.0001) compared to intravenousinjection. The hemoglobin drop also was more in the topical group although it was marginally significant (P=0.05).

Intravenous injection of TXA is more effective in reducing postoperative blood loss after primary TKAcompared to topical administration.Level of evidence: I

plexus injury. Few studies report the rate of revision surgeries following free functional muscle transfers. We examinedthe reoperation rate and indication for reoperation after primary reconstruction of upper extremity function with a freegracilis transfer after brachial plexus injury.

From 2003-2016, we identified 25 patients who underwent a free functional gracilis muscle transfer forrestoration of upper extremity function. We reviewed their medical charts to record patient, injury, and treatmentcharacteristics. Indication for reoperation and reoperative procedure were also identified.

Fourteen out of 25 patients (56%) had a reoperation after FFGT. Four flaps were re-explored for vascularcompromise, but there were no flap failures. The majority of reoperations involved adjustment of tendon excursion(8/14) which demonstrated that tenolysis was the main procedure.

Despite promising results of free functional gracilis transfers, reoperation is relatively common and shouldbe discussed with the patient as a preoperative strategy. Early exploration of vascular compromise may decrease theflap failure. Poor tendon excursion is a common unpredicted consequence after FFMT and is the main indication forreoperation.Level of evidence: IV

Angioleiomyomas are rare tumors arising from vascular tissue that can occasionally present in the hand.Reports of angioleiomyomas in this location are highly limited. Here, we describe the presentation and outcomes of aseries of cases of angioleiomyomas.

A retrospective case review of five patients with angioleiomyomas arising in the hand was performed. Patientswere identified via International Classification of Diseases, Ninth and Tenth Revision (ICD-9 and ICD-10) diagnosiscodes and were reviewed through the electronic medical record for demographic information, tumor characteristics,management, and outcomes. A literature review was also conducted of angioleiomyomas.

Five patients were diagnosed with angioleiomyoma at our institution between 1992 and 2015. Patientspresented with a painful, slow-growing hand mass in all cases. The majority of patients were male and of middle-age.All of the patients were successfully treated with marginal excision and had full return to functional status withoutrecurrence.

Angioleiomyomas are rare tumors that can arise in the hand and should be included in the differentialdiagnosis of a patient presenting with a painful hand mass. They can be successfully treated with marginal excision.Level of evidence: IV

Surgery in the time of COVID-19 pandemic is a challenging issue while treatment of affected fracturepatients is inevitable. The present study summarizes the challenges that an orthopedic surgeon is confronting duringthe surgical treatment of fracture patients with concomitant COVID-19 infection.

Demographic and fracture related data of 13 fracture patients with concomitant COVID-19 infection whowere treated with surgery was collected from three trauma centers in Tehran and Kermanshah cities from 21, February2020 to April 3, 2020.

All patients were male with mean age of 38.6±19.5 years. Eight patients had high energy fracture and sevenpatients had multiple fractures and trauma. Wrist and hand were the common sites of fracture following hip and pelvis. Themean interval time period between the diagnosis of COVID-19 infection and surgery was 2.3±1.5 days. Before surgery, allpatients except one had been admitted to the corona dedicated wards, while two patients were admitted to the intensivecare unit (ICU). One of the ICU admitted patients died. All the 12 alive patients remained in home isolation after discharge.

Fracture surgery in COVID-19 patients has many challenges such as lack of medical resources, delayof surgery, medial staff fear, and patient isolation. However, a multidisciplinary approach using all potential hospitalresources would lead to successful operation and acceptable outcome.Level of evidence: III

Patient-Reported Outcomes Measurement Information System (PROMIS) scores can quantify symptomsand limitations after upper extremity surgery. Our objective was to determine how these scores compare amongstpatients with trapeziometacarpal osteoarthritis treated either nonoperatively or operatively. In this retrospective comparative study, we compared PROMIS scores (upper extremity function [UEF],pain interference, and depression) between 43 patients who underwent nonoperative treatment (nonsteroidal antiinflammatorydrugs/splinting/injections) and 33 patients who underwent trapeziectomy with ligament reconstructionand tendon interposition for trapeziometacarpal osteoarthritis (minimum 6-month recovery period) by 4 surgeons from2014–2018. PROMIS scores were compared across all patients by Eaton-Littler staging. We used linear regression toassess correlations between time-since-surgery and each PROMIS domain. Multivariable linear regression was usedto identify patient and disease factors independently associated with PROMIS scores. Surgery was not associated with better UEF (37 vs. 40, P=0.23), less pain interference (58 vs. 56, P=0.42),or fewer symptoms of depression (47 vs. 46, P=0.59). Similarly, no differences were observed across all patient byEaton-Littler stage for UEF (P=0.49), pain (P=0.48), or depression (P=0.90). For the operative group, greater timesince-surgery, or patient recovery period, correlated moderately with worse UEF (R=0.41) and increased pain (R=0.37). In small retrospective comparative cohorts, surgery was not associated with better UEF, pain, ordepression scores compared with nonoperative treatment for trapeziometacarpal osteoarthritis.Level of evidence: III

The effect of race and ethnicity on some kind of malignant bone tumors including Ewing sarcomahas been proven in different studies. In order to evaluate the latter, national cancer registries may help to increaseunderstanding about potential cancer causes, prevention and control strategies, and apply these findings to controlhealth problems among populations with similar characteristics.

A national population-based cancer registry study based on all patients affected by Ewing Sarcoma wasregistered in the Iran National Cancer Registry (INCR) between 2008 and 2015 was designed. Demographic data ofmicroscopically confirmed cases of bone Ewing sarcoma were registered. Patients with Ewing sarcoma were dividedin groups to describe the primary site of the tumor (including axial or appendicular bones) and analyzed. In order toanalyze the survival rate, randomized selection of the patient through the INCR data-base was performed.

A total of 678 cases of malignant Ewing sarcoma of the bone were identified through the INCR. The meanage of Ewing sarcoma in Iran was 21.53 years. Nearly half of patients were observed at the age group of 15-24. Thetotal crude incidence rate of Ewing sarcoma was 1.29 in 1 million. The mean 5 year survival rate was 47%. The Meansurvival rate for study population was 5.53.

The crude incidence rate of Ewing sarcoma in Iran is relatively lower with respect to other registries. Themajority of patients are in 15-25 years group and shows affection by Ewing sarcoma in an older age. Socioeconomicfactors had direct influence on survival rate.Level of evidence: IV

Acquiring knowledge about anatomic and geometric quantities of bones is among the most vitalparameters in orthopedic surgery that has a significant effect on the treatment of various disorders and subsequentoutcomes. The aim of this study was to obtain anthropometric information for distal femur in order to compare withsimilar dimensions of prosthesis used in total knee arthroplasty (TKA) surgery and to design more suitable and optimalcomponents. Morphological data of distal femur were measured in 132 knees (81 males and 51 females) using magneticresonance imaging (MRI). The data included anterior-posterior (AP) length, medial-lateral (ML) width, medial AP (MAP),lateral AP (LAP), MAP to LAP distance in the anterior distal femur namely anterior medial lateral (AML) width, medialand lateral condyle width, and intercondylar notch. The aspect ratio (ML/AP) was also calculated and the results werecompared with similar dimensions of currently used knee implants. Our data showed that men are significantly larger in all dimensions than women. In the distal femur withsimilar AP lengths in both sexes, women had a smaller ML width than men (P<0.001). Comparison between the distalfemur and studied prostheses showed no high correlation and similarity between the femoral component and femoralcondyle prostheses in the resected surface of the bone. The results of this study can provide the data needed to design prostheses suitable for the Iranianpopulation.Level of evidence: III

An oscillating bone saw is rarely used to perform laminectomy. The purpose of this study was to describea relatively quick and harmless technique for multilevel laminectomy in patients with lumbar spinal stenosis (LSS) usingan oscillating bone saw to find out how this instrument affects the time of surgery and rate of complications. This prospective study was conducted on 45 patients with LSS who required multilevel laminectomy. Thebones were cut using an oscillating sagittal saw equipped with a fine 1-cm blade. Posterolateral fusion was performed ifany evidence of spinal instability occurred, or the correction of deformity was addressed. The time spent for laminectomyfrom initial cutting to the whole bone removal (T1) and the duration of laminectomy (i.e., from initiation to the end ofdecompression; T2) were recorded for the corresponding level. The volume of harvested autograft was also measured,and any dural injuries were reported. Posterolateral fusion was performed on 32 (71.1%) patients. The mean T1 and T2 per level were estimated at70.5±5.4 and 157.5±12.1 sec, respectively. In addition, the mean volume of harvested autograft per level was obtainedas 3.5±1.2 cc. No durotomy was observed during laminectomy using an oscillating bone saw. However, a dural tearoccurred in one patient when a Kerisson punch was utilized for ligamentum flavum removal and foraminotomy. Based on the findings, it can be concluded that laminectomy by means of the oscillating bone saw is asafe procedure that provides a sufficient volume of harvested autograft for fusion. This technique could also induce aremarkable reduction in the time of surgery.Level of evidence: IV

The maintenance of deformity in the ankle and hindfoot after correction of knee deformity following kneearthroplasty may cause abnormal tension in the knee and patient dissatisfaction. The aim of this study was to determinethe effect of knee arthroplasty on the hindfoot alignment in patients with severe genu varum and valgum. A total of 84 patients with primary osteoarthritis, were enrolled in the study. The knee deformity was measuredusing a long leg film before surgery. The long axial radiographic view of hindfoot was taken in the standing position forall patients, before and six months after surgery. Comparisons were made on changes in the hindfoot angles measuredbefore and after surgery. A total of 84 patients with mean age of 62.28 ± 7.77 years, 77 (92%) and seven patients (eight percent)had knee varus and valgus deformity, respectively. In the knee varus group, the mean preoperative hindfoot anglewas + 5.32 ± 6.12 ° (valgus) which was changed to - 0.25 ± 4.91 ° (varus) in the postoperative phase. In the kneevalgus group, the mean pre and postoperative hindfoot angles were - 7.71 ± 7.06° (varus) and - 2.14 ± 5.92 ° (varus),respectively. The mean preoperative hindfoot angle in severe and very severe varus knee groups were + 5.45 ± 3.30and + 5.28 ± 6.86 °, respectively. These angles were changed to + 0.21± 5.17 and -1.60 ± 3.89° six months aftersurgery, respectively. The mean preoperative hindfoot angle in severe and very severe valgus knee deformity groupswere - 7.00 ± 4.69 and -8.66 ± 10.69 °, respectively. These angles were changed to - 2.00 ± 5.71 and - 2.33 ± 7.50°after surgery, respectively. There was no significant difference between patients with severe and very severe deformityin terms of pre and post-operative hindfoot angle. The hindfoot alignment is significantly corrected after knee arthroplasty. The severity of knee deformitydoes not correlate with the severity of the hindfoot deformity before and after surgery.Level of evidence: I

Carpal tunnel syndrome (CTS) is characterized by complications such as pain, paresthesia, andnumbness in the fingers. There are some surgical therapies for the management of severe carpal tunnel, but differencesexist between the treatments available for creating the opposition. The current study was conducted to compare theeffect of modified Camitz and BRAND techniques on thumb opposition in patients with severe CTS.

A total of 40 patients with severe CTS who were candidates for opponensplasty were enrolled in this clinicaltrial study at Alzahra and Kashani hospitals, Isfahan, Iran, from 2014 to 2018. The patients were divided into two groupsof modified Camitz and BRAND. Quick DASH-9 and Kapandji scores as well as pulp and side pinch and pronationangle were assessed before and after the surgeries.

Quick DASH-9 score, Kapandji score, pulp and side pinch and pronation angle significantly improved postoperatively(P=0.0XXX, P=0.0XXX, P=0.0XXX, P=0.0XXX, and P=0.0XXX, respectively). But, no significant differenceswere seen in the mentioned variables between both groups pre and post-operative (P>0.05, for all the studied variables).No postsurgical complications were seen in any of the groups.

The findings of the present study demonstrated that, both Modified Camitz and BRAND techniquesare effective and safe techniques, yielding high improvements, but no serious complications. Both techniques can beconsidered for treatment of patients with severe CTS.Level of evidence: II

Although some surgical techniques have been described for the operative treatment of unstableOsteochondritis dissecans (OCD) of the knee, outcomes are variable and are not satisfying totally. The aim of thepresent study is to evaluate the outcomes of autogenous osteochondral grafting for OCD of the knee.

In a case series study, from June 2014 to July 2015, 16 patients with stage II-IV OCD (International CartilageRepair Society (ICRS)) of the femoral condyle were investigated. Surgical intervention considered in cases of stage III(4 cases) and IV (2 cases) and in stage II (10 cases) ones that were nonresponsive to conservative treatment. At theinitial and final visits, the IKDC, Lysholm score and Tegner activity scale were evaluated.

The mean preoperative IKDC score (53.4) increased significantly following surgery (84.3) (P<0.001).Based on the IKDC grading system, before the operation, the knee status was graded as nearly normal, abnormal,and severely abnormal in 4, 10, and 2 patients, respectively. At final post-surgical follow up, 15 normal and 1abnormal knee were documented (P<0.001). The mean Lysholm score increased from 44.3 per operatively to 86.3(P<0.001).Tegner activity score improved from 2.8±1 pre operatively to 5.6 ±2 (P<0.001).

Surgical treatment of unstable OCD using autogenous osteochondral graft shows successful outcomes.In addition to reliable fixation, it can enhance healing and convert an uncontained lesion to contained one appropriatefor autogenous osteochondral grafting with healthy cartilage.Level of evidence: IV

Meniscus tear is a common finding in patients with anterior cruciate ligament (ACL) injury and may affectthe natural history of the injury and the outcomes of treatment. In the current study, the characteristics of meniscus tearsin patients who underwent arthroscopic ACL reconstruction were investigated.

The hospital records of 1022 patients were reviewed. The measured variables included the presence ofmeniscus tear, ramp and root injury, the zone of injury based on the Cooper classification, and the type of tear. The ACLtears with delay more than 3 months for ACLR were recorded as chronic injuries.

The incidence of meniscus tear was 44.4%; among whom, bucket-handle injury was the most common type(30.4%) and the ramp lesion was found in 20.5%. The meniscus was repaired in 56.6%. The incidence of medialmeniscus injury was significantly higher in chronic ACL tears and vice versa (P<0.001). The incidence of ramp lesion(9.1% Vs 20.5%) and root tear (1.3% Vs 2.9%) were significantly higher in the chronic and acute tears, respectively(P<0.001).

Delay more than 3 months in ACLR was associated with the increased incidence of meniscal injury,specially the medial meniscus, and ramp lesion. It seems that early ACLR may be more helpful for the patients.Level of evidence: IV

Conservative management is generally the primary treatment for intramuscular hemangimas. However,many patients will require surgery later in their life, after suffering a long period of pain. We aimed to evaluate theoncologic and functional outcomes of surgery as the initial treatment of single-muscle hemangiomas. Medical profiles of 17 patients with hemangiomas of vastus medialis for whom surgery was selected asthe initial treatment were reviewed. The indication for surgery was a bothersome pain. Postoperative muscle strengthwas assessed with manual muscle testing (range 0-5). The postoperative pain was measured by a visual analog scale(VAS) for pain (range 0-10). Lyshölm-Tegner knee scoring scale was used for the evaluation of knee function. The mean age of the patients was 25.9±8.6 years. Surgery was performed as wide resection in 13 cases andas marginal resection in 4 cases. At a mean follow-up of 55.76±30 months, two local recurrences (11.8%) were observed.At the last evaluation session, muscle strength grade was 5/5 in 13 patients and 4/5 in four patients. Postoperativepain was noticed in four patients (VAS=1). Knee function was excellent in 13 patients and good in four patients. Bothof the local recurrences occurred in marginally resected lesions. Three out of four cases with reduced muscle strength,postoperative pain, and reduced function were also treated with marginal resection. If a wide surgical margin is achievable without compromising the limb function, surgical resection couldbe considered as the primary choice of treatment for single-muscle hemangiomas.Level of evidence: IV

The purpose of this study was to identify the effects of eight weeks of conventional and suspension corestability exercises by use of the designed device on characteristic of intervertebral discs in low back pain. A total of 27 men with chronic low back (CLB) pain due to lumbar disc herniation in L4-L5 and L5-S1 regionswere enrolled in this quasi-experimental study. After assessing the pain intensity using a visual analog scale (VAS) anddetermining the disc herniation index using MRI, each group of patients were asked to perform either conventionalor suspension exercises for eight weeks, each week consisting of three training sessions. The pain intensity wasassessed at the end of the first, second, third, fourth and eighth weeks and the disc hernia index was determined againat the end of the eight weeks of exercises. The results indicated significant changes in the intensity of pain in both groups through the period of eightweeks of exercise with a remarkable pain relief. In relation to the structural characteristics of the intervertebral disc, dataanalysis did not reveal any significant change between the pre- and post-test. Considering the beneficial effects of the stability exercises and specially suspension stability exerciseswith respect to pain alleviation and reduced use of sedatives and anti-inflammatory drugs, this method can be helpfulat early stages of treatment for chronic pains.Level of evidence: I

Primary synovial sarcoma of mediastinum is very rare among soft tissue sarcomas. Only a few cases have been reportedin the literatures. The best treatment is still unclear, but, surgical resection is the main therapy. In this article we reporta case of a 20*20 cm (2000gr) primary giant mediastinal synovial sarcoma in a 42 year-old man. We performed radicalexcision of the tumor and the metastasis.Level of evidence: V

Article Highlights: 1) This article provides a full anticoagulant reference for the practicing orthopaedic surgeon which can be used in any clinical scenario, whether urgent or elective surgical intervention is required 2) A comprehensive list of anticoagulant reversal agents and drugs with short half-lives (for bridging) are described with the intention to provide the data needed to safely manage a patient peri-operatively during urgent orthopaedic surgical care (i.e. fracture or infection) 3) Half-life and method of excretion for all drugs are included with the intention to accurately guide decisions regarding the appropriate timing of scheduling elective orthopaedic surgical care with regards to anticoagulant metabolism and effect 4) The practicing orthopaedic surgeon using this guide should always consider medical co-management of these complex patients as their medical co-morbidities may not be amenable to anticoagulant reversal or peri-operative cessation of therapy, even for a short period 5) The data contained in this article stands to serve as a foundation upon which institution-specific guidelines regarding the peri-operative management of orthopedic patients on long-term anticoagulation can be developed

Proximal fibular osteotomy is a surgical procedure that has evoked significant interest and controversy in the recent past. Vaishya et al have made a significant effort in compiling the available evidence on the topic. However, we would like to make some significant suggestions and additions to the findings in their manuscript.

The causes of malalignment in total knee arthroplasty can be categorized into three different groups; 1) Errors in bone cuts 2) Errors in implant fixations, and 3) The method of setting down the cutting guides (1). We would like to announce that more several distal femoral valgus cut errors may occur during total knee replacement.