Archives of Bone and Joint Surgery
Volume:9 Issue: 1, Jan 2021

The finite element method (FEM) is an engineering tool to assess the mechanical behavior of a structure under applied loads. This method was first applied for stress analysis of mechanical structures in the late 1950s. Later on, this new method got the application in biomedical engineering by analyzing the mechanical behavior of human femora. With the advent of faster computers, more advanced imaging modalities, and better FE software resulting in increased sophistication in 3D modeling, FE models have been greatly improved and the possibility of creating a FE model that can closely mimic the geometry and material properties of bones of an individual patient, so-called a patient-specific model, is accessible. The objective of this editorial is to try to elucidate the advancements in and applications of patient-specific finite element modeling and discuss whether such models can give promising results in predicting the outcome of orthopedic surgeries and enter clinical practice as a decision support system.

Achilles insertional tendinopathy (AIT) is inflammation and painful thickening of the Achilles tendon at its insertion on the posterior calcaneus. After a failed six month trial of non-operative management, the patient may elect to undergo operative management. Operative management involves a series of procedures including debridement of the diseased tendon, resection of the retrocalcaneal bursa, and excision of the calcaneal exostosis. Despite a variety of surgical techniques reported in the literature, there is no single gold standard. Previous studies has described complete detachment of the tendon at its insertion, partial detachment, as well as tendon sparing techniques, such as splitting of the tendon. Most studies show good to excellent results using these different techniques, however there are flaws with each. With there being no gold standard, management is most commonly based on individual surgeon preference. With over 30 years of experience, the senior author (JD) has felt that many of the reported techniques offer a variety of advantages and disadvantages with none being all encompassing. The senior author utilizes his own modification of an excisional debridement in which the most diseased central one-third portion of the Achilles tendon insertion is resected in an apex-superior triangle fashion. This is followed by a calcaneal exostectomy, FHL tendon transfer, and side to side repair of the tendon. The author believes this technique combines many of the best features of the wide variety of techniques that currently exist, while still minimizing complications.

Total knee replacement (TKR) is a growing attractive treatment for a degenerative knee disease. However, thereremain some certain devastating complications to be discussed with patients preoperatively, including limbamputation. This systematic review aimed to determine the rate of amputation following TKR. In this study, theliterature was searched up to 2019. The papers were included in which knee amputation was reported followingTKR. The primary search concluded the articles from EMBASE, SCOPUS, PubMed, Web of Science, MEDLINE,OvidSP, CINAHL, EBSCO, Web of Science™, and CENTRAL. After screening and excluding case reports, 40papers were included in the present study. The present review showed that amputation is a real end result ofknee replacements either in primary or revision knee arthroplasties, which needs to be discussed with patientsfor their decision-making. Prevalence of amputation in terms of failure or complications after TKR procedures wasestimated between 0.1-10% in different studies , with 5.1% amputation rate in infected TKR and 0.025% amputationrate in primary TKR as a result of infection in our review. Deep infection was the main cause of amputation.Vascular complications and fractures associated with bone loss and compartment syndrome were other reasonsfor amputation.Level of evidence: III

The distal radioulnar joint (DRUJ) prostheses have been available for many years and despite their superior outcomescompared to conventional DRUJ reconstructions in both short and long-term follow-ups, they have not become aspopular as common hip and knee prostheses.In the current review article, at the first step, we discussed the applied anatomy and biomechanics of the DRUJ, andsecondly, we classified DRUJ prostheses according to available literature, and reviewed different types of prostheseswith their outcomes. Finally we proposed simple guidelines to help the surgeon to choose the appropriate DRUJprosthesis.Level of evidence: IV

Consistent diagnosis of periprosthetic infection in total joint arthroplasty continues to elude the orthopedic surgeonbecause no gold standard test exists. Therefore clinicians must rely on a combination of tests to help aid the diagnosis.The expanding role of biomarkers has shown promising results to more accurately diagnose an infection when combinedwith clinical suspicion and bacterial culture testing. This paper reviews the diagnostic capabilities of the most currentserum and synovial biomarkers as well as next generation sequencing in the setting of periprosthetic joint infection.Future research and high-powered studies will be necessary to determine sensitivity and specificity of each biomarker.Level of evidence: III

The purpose of this study was to compare latissimus dorsi tendon transfer (LDTT) and arthroscopicsuperior capsular reconstruction (SCR) to determine if one is superior to the other regarding improvement in range ofmotion (ROM) or patient-reported outcomes (PROs). A multicenter, retrospective cohort study was conducted on 43 patients with an irreparable, posterosuperiorrotator cuff tear who underwent either LDTT or SCR. Preoperative and postoperative forward flexion and externalrotation, as well as PROs including ASES, VAS, and SSV, were assessed. Student t-test and chi-square statisticalanalyses were performed. 16 LDTT, at mean follow-up of 18 months, and 27 SCR, at mean follow-up 15 months, were studied. Mean activeforward flexion significantly improved from 85.2° to 137.6° in the SCR cohort (P=0.001). SCR patients demonstrated asignificantly greater increase in forward flexion as compared to LDTT patients (52.4° vs 14.1°, P=0.001). Mean activeexternal rotation amongst the LDTT group significantly improved from 41.7° to 61.5° (P=0.032). LDTT demonstratedsignificantly greater improvement in external rotation as compared to SCR (19.4° vs 0.8°, P=0.011). There were nosignificant differences in reported ASES, VAS, or SSV scores. This study demonstrates successful clinical and patient-reported outcomes with both LDTT and SCRfor irreparable, posterosuperior rotator cuff tears, with greater improvement in forward flexion with SCR and greaterimprovement in external rotation with LDTT.Level of evidence: III

Many fixation options (Open and arthroscopic) are described for Posterior Cruciate Ligament avulsion(PCL) fractures. In this retrospective series, we evaluated functional and radiographic outcomes following arthroscopicdual tunnel double sutures knot bump technique for acute PCL tibial end avulsion fractures. 23 patients with acute PCL avulsion fractures who were operated between 2009 and 2016 by Arthroscopicdual tunnel double sutures technique at a minimum of two years of follow-up were included in the study. Clinicaloutcomes were measured by Lysholm and International Knee Documentation Committee (IKDC) scores. Theradiographic assessment included union status of fracture, the grade of osteoarthritis, and knee laxity. The mean age of patients was 34.43 years (range, 18-54 years) with a mean follow up of 52.8 months(36-94 months). At the final follow-up, mean subjective IKDC and Lysholm scores were 82.71 (range, 65.5-100) and95.82 (range, 81-100), respectively. On the IKDC objective scale, ten patients (43.47%) were graded as A, 11 patients[47.82%] as grade B, and two patients as grade C [8.7%]. On kneeling stress view, knee laxity in 21 patients (91.3%)was graded 0, and the remaining two as grade I and II. The fracture had united in all cases by the end of 12 weeksexcept one which had non-union. 21 patients had no evidence of osteoarthritis at the final follow up. Arthroscopic dual tibial tunnel double suture knot bump technique for acute PCL avulsion fractures is asafe and reliable technique that restores the stability and function of the knee.Level of evidence: IV

As preferred treatment options for superior labral tears continue to evolve, this study aims to describethe recent longitudinal trends in the treatment of SLAP tears in a sub-specialized practice at a single institution. Wehypothesized that there was a trend toward biceps tenodesis over repair for Type II SLAP lesions. A retrospective review was performed using an institutional billing database to identify all patients with aSLAP tear who underwent surgical intervention between January 2002 and January 2016. Procedural codes associatedwith the surgery were analyzed to determine type of treatment each patient received. Of the 6,055 patients who underwent surgery for a SLAP tear during the study period, 39.1% (2,370)underwent labral repair, 15.4% (930) underwent tenodesis without repair, and 45.5% (2,755) underwent arthroscopywithout tenodesis or repair. Labral repair made up a significantly higher proportion of surgical interventions in 2002(82.2%) compared to in 2015 (21.8%; P<0.001). Surgeon experience did not impact trends. Over the study period,the mean age of patients receiving labral repair decreased from 40.4 years (range: 16.2 – 63.9) to 32.6 years (range:14.0 – 64.7; P<0.001). This study demonstrates that over the 14-year study period the rate of labral repairs for SLAP tears hasdecreased significantly and that these repairs have been directed towards a younger patient population.Level of evidence: III

The purpose of this study was to compare the intra- and inter-observer reliability of CT and T2-weightedMRI for evaluation of the severity of glenoid wear, glenohumeral subluxation, and glenoid version. Sixty-one shoulders with primary osteoarthritis had CT and MRI scans before shoulder arthroplasty. Allslices were blinded and randomized before evaluation. Two fellowship-trained shoulder surgeons and three orthopaedicsurgery trainees reviewed the images to classify glenoid wear (Walch and Mayo classifications) and glenohumeralsubluxation (Mayo classification). Glenoid version was measured using Friedman’s technique. After a minimum twoweekinterval, the process was repeated. Intraobserver reliability was good for the CT group and fair-to-good for the MRI group for the Walch, Mayoglenoid, and Mayo subluxation classifications; interobserver reliability was poor for the CT and fair-to-poor for the MRIgroup. For the measurement of glenoid version, intraobserver reliability was good the CT and substantial for the MRIgroup; interobserver agreement was good for both groups. There were no significant differences in reliability betweenstaff surgeons and trainees for any of the classifications or measurements. CT and MRI appear similarly reliable for the classification of glenohumeral wear patterns. For themeasurement of glenoid version, MRI was slightly more reliable than CT within observers. Differences in traininglevel did not produce substantial differences in agreement, suggesting these systems can be applied by observers ofdifferent experience levels with similar reliability.Level of evidence: III

This study aims to determine the extent of utilization of health care resources in the geriatric fracturepopulation and to identify factors associated with burden on resources. This is a retrospective study of 1074 patients ≥65 years admitted to an orthopaedic service for a long bonefracture between July 2014 - June 2015. Outcomes were hospital length of stay (LOS), discharge disposition, andpost-acute care facility LOS. Secondarily, readmission rates and mortality were assessed. Multivariable regression wasperformed to identify factors associated with utilization. Prior to injury, 96% of patients lived at home and 50% ambulated independently. Median hospital LOS was5 days (IQR 3 – 7). 878 patients were discharged to a rehabilitation facility, with 45% being discharged <20 days.Ten percent of patients (n = 108) were re-admitted <90 days of their discharge. 924 patients were still alive oneyear after the injury. Higher Charlson Comorbidity Index (CCI) (P=0.048), male sex (P<0.001), pre-injury use of anambulatory device (P = 0.006), and undergoing surgical treatment (P<0.001) were associated with longer hospitalLOS. Older age (P<0.001), pre-injury ambulatory device (P=0.001), and surgery (P=0.012) were risk factors forrequiring discharge to another inpatient facility. Older age (P<0.001), pre-injury ambulatory aid (P<0.001), and preexistingimmobility (P<0.001) were independent risk factors for LOS >20 days in a rehabilitation facility. Dischargehome was not found to be associated with an increase in 1-year mortality after adjusting for age, CCI, sex, fracturelocation, and surgery (P=0.727). Shorter LOS in rehabilitation facilities (<20 days) was also not associated with anincrease in 1-year mortality (P=0.520). Elderly fracture patients utilize a significant amount of post-acute care resources and age, CCI, surgery,fracture location, pre-injury ambulatory status, and pre-injury living status were found to be associated with the use ofthese resources.Level of evidence: III

Regarding this, the present study aimed to assess the clinical outcome of anatomical arthroscopicposterior cruciate ligament (PCL) reconstruction using Achilles tendon allograft. This cross-sectional retrospective study was conducted on 24 patients undergoing anatomical arthroscopicPCL reconstruction using Achilles tendon allograft during 2008-2014. The patients were examined in terms of kneestability by clinical examinations and KT-2000 arthrometer, as well as regarding health and knee status, over a meanfollow-up of 36 months. In addition, the 36-Item Short-Form Health Survey (SF-36), International Knee DocumentationCommittee Subjective Knee Form (IKDC), Knee Injury and Osteoarthritis Outcome Score (KOOS), Kujala, and Lysholmwere adopted to collect data. The participants had a mean age of 30±8 years and a mean body mass index of 25±2 kg/m2. Based on theresults of the SSD-KT2000 arthrometer, 12.5%, 34.37%, 28.12%, and 25% of the patients had normal, nearly normal,abnormal, and severely abnormal laxity, respectively. In addition, the mean KOOS, Lysholm, IKDC, and Kujala scoreswere estimated at 73.92±15, 79.50±17, 58.20±10.47, and 80.06±16, respectively. The patients with concomitant partialmeniscectomy had a significantly lower IKDC score (P<0.01). Based on the findings, the use of Achilles tendon allograft in the surgical reconstruction of PCL would yieldexcellent results both subjectively and objectively. In addition, patient selection and surgeon’s choice and preferenceshould be considered in determining the treatment plan for the patients.Level of evidence: III

There is a growing interest in engaging patients in research priorities and project design. This studycompared topics patients and surgeons would like to address in upper extremity musculoskeletal research. We invited patients on social media-based support groups for specific musculoskeletal illnesses andmembers of the Science Of Variation Group to indicate the three most important research topics by disease. Wealso measured agreement that patients should participate in research on a five-point Likert scale. We categorizedresearch priorities into the following categories: treatment, cause and natural history, recovery, diagnostic process,and economic impact. Bivariate analysis was used to detect differences between surgeons and patient responses.Multivariable regression models sought factors associated with agreement whether patients should participate inresearch. Sixty-two surgeons and 350 patients completed the survey, who had one of the following musculoskeletalillnesses: Dupuytren contracture, adhesive capsulitis, Kienböck disease, complex regional pain syndrome, rotator cufftendinopathy, carpal- or cubital tunnel syndrome, and rheumatoid arthritis. Both patients and surgeons were most interested in research into treatment options. There were fewdifferences in the number of responses per category between surgeons and patients. Patients and surgeons with feweryears of practice agree most with involving patients in research. Patients and surgeons prioritize research about treatment. Surgeons were more interested in naturalhistory of disease and surgical techniques, while patients were more interested in alleviation of pain.Level of evidence: I

Medical students and residents rely increasingly on web-based education. Online videos provide uniqueopportunities to share knowledge. The objective of this study was to investigate the accuracy and quality of instructionalvideos on the physical examination of the elbow and identify factors influencing educational usefulness. On October 7, 2018, a search on YouTube, VuMedi, Orthobullets, and G9MD was performed. Videos wererated for accuracy and quality by two independent authors using a modified version of a validated scoring system forthe nervous and cardiopulmonary system. Inter-rater reliability was analysed. The 126 included videos were uploaded between June 2007 and February 2018. Twenty-three videos wereindicated as useful for educational purposes. Accuracy, quality and overall scores were significantly higher for videosfrom specialized platforms (VuMedi, Orthobullets, G6MD) compared to YouTube. Video accuracy and quality variedwidely and were not correlated. Number of days online, views, and likes showed no or weak correlation with accuracyand quality. For the overall score, our assessment tool showed excellent inter-rater reliability. There is considerable variation in accuracy and quality of currently available online videos on the physicalexamination of the elbow. We identified 23 educationally useful videos and provided an assessment method for thequality of educational videos. In educational settings, this method may help students to assess video reliability and aideducators in the development of high-quality instructional online content.Level of evidence: III

Acrometastases are rare and account for approximately 0.1% of metastases. The most common primarycancer site is the lung, followed by colorectal and genitourinary system.

We searched PubMed (www. pubmed.com), Google scholar (www.scholar.google.com), Science Direct (http://www.sciencedirect.com), and Springer (http://link.springer.com) databases, using a combination of controlled vocabularyand text word terms and reviewed the last 10 years literature in order to describe demographic trends, anatomicaldistribution, the most common primary sources of malignancy, and survival rates in the reports of foot metastases.

In conclusion 38 cases were included in this review analysis. Lung and genitourinary system were the mostfrequent primary sites.

Forefoot was involved in 71% of all metastases to foot either alone or in combination with other areas ofthe foot. Calcaneus was involved in about 23% of patients either alone or in combination with other foot bones.Level of evidence: IV

To evaluate the relative and absolute reliability of reaction time measuring methods during differentconditions in participants with and without patellofemoral pain syndrome (PFPS).

30 patients with PFPS and 30 healthy controls were recruited in the present study. The upper extremityreaction time, upper extremity error rate, involved and non-involved lower extremity braking reaction times, and involvedand non-involved knee extension reaction times were measured. Each condition was repeated three times, 2 sessionswith a 5-7 days interval. The intra-session reliability was evaluated in three-trial (A), second- and third-trial (B) modes.In addition, the inter-session reliability was evaluated in mode A, mode B, and best score (C) mode.

The result of inter-session reliability of mode A showed that all measurements except upper extremity reactiontime in PFPS group showed high to very high relative reliability (ICC: 0.74-0.94). In mode B, all measurements exceptnon-involved knee extension reaction time in PFPS group showed high to very high relative reliability (ICC: 0.71-0.93).In mode C, all measurements showed high to very high relative reliability (ICC: 0.70-0.94) except upper extremity errorrate and non-involved knee extension reaction time in PFPS group. The result of intra-session reliability showed thatall measurements had high to very high relative reliability (ICC: 0.78-0.94) in mode A. In mode B, all measurementsshowed high to very high relative reliability (0.78-0.94).

The braking time seems more reliable than other reaction time tasks. In addition, the results showedthat mode A is more reliable than other modes. The newly designed package is a reliable tool to measure the kneeextension reaction time in patients with knee musculoskeletal disorders.Level of evidence: II

The prevalence of wide-awake hand surgery using local anesthesia has increased substantially. The fullinfluence of perioperative factors, namely operating room temperature, on patient comfort during these procedures ispresently underreported. One hundred and fifty-eight patients undergoing wide-awake hand surgery using local anesthesia wereprospectively enrolled. Surveys with visual analog scale (VAS) were administered after surgery to assess overallpatient comfort (OPC) and patient comfort with temperature (TPC). Operating room temperature at the initiation of theprocedure, surgery type, duration of surgery, tourniquet use and local anesthetic use were all recorded and their impacton patient comfort analyzed. The VAS used ranged from 1 (least comfortable) to 5 (most comfortable). Across all patients, the mean OPC was 4.7 (Range: 2 – 5, SD=0.6) and the mean TPC score was 4.7 (Range2 – 5, SD=0.6). There were weakly negative correlations between room temperature and VAS score for OPC (rs =-0.2,P=.038) and TPC (rs=-0.2, P=.051). The mean OPC score was lower with tourniquet use [4.6 (SD=0.7) versus 4.9(SD=0.4), P=.002]. Patient comfort during surgery using local anesthesia is not substantially affected by operating roomtemperature. Tourniquet use negatively impacts patient-reported comfort. Continued studies into the optimization ofpatient comfort during wide-awake hand surgery are warranted.Level of evidence: IV

There is still some debate regarding the most proper anesthetic technique in minor hand surgeries. Wehypothesized that both the WALANT and forearm tourniquet Bier block methods provide effective anesthesia in minorhand surgeries without significant difference. A total of 85 patients consented to participate in this study and were randomized into WALANT and singletourniquet forearm Bier block groups. In WALANT group, patients received adrenaline-contained lidocaine withouttourniquet while lidocaine was administered accordingly after applying a forearm tourniquet in Bier group. Due todifference in intervention methods, the study was non-blinded. Need for additional analgesia during surgery, visualanalogue scale (VAS) for pain intensity during operation and an hour later, amount of bleeding and active handmovements were evaluated and recorded. The need for analgesia and severity of pain (VAS) during surgery and one hour later were significantly lessin WALANT group, whereas the amount of bleeding was less in Bier block group. The ability to move hand and fingersduring the operation was the same in both groups. Both WALANT and single cuff forearm tourniquet Bier block are effective methods in minor hand surgeries,however, forearm Bier block provides less analgesia and pain control with a drier field than WALANT method.Level of evidence: I

3D printing is an evolving technology which has a potential application in the treatment pediatric forearm fractures. Verylittle has been published with regard to 3D casting in children. We present two cases in which upper extremity fractures inpediatric patients were treated by wearing a custom made 3D printed cast. At latest follow-up at least one year post-injury,the clinical outcomes were excellent.Orthopaedic surgeons may benefit from familiarizing themselves with the potential of 3D printing technology and utilizingits current applications, as well as devising future applications, in clinical practice.Level of evidence: IV

We congratulate the authors for their publication on “Surgical Practice in the Shadow of COVID-19 Outbreak” (1). COVID-19 pandemic have forced the surgeons to continually evolve their clinical practices.Authors have rightly pointed out that by wearing full Personal Protection Equipments (PPE) could interfere with personal communication. To anticipate these problems, we find that a team briefing, before the start of a case regarding the planning of surgical procedure, is of great help and must be used. Additionally, the surgical plan can be sketched out on the OT wall over a blackboard. The author's view of ‘open surgery is superior to minimally invasive procedures is debatable and needs to be proved by future comparative studies. We believe that during the peri pandemic times, operative treatments requiring minimal invasion and shorter surgical times should be preferred.We are not convinced that the trainees should be entirely set aside from the clinical services during COVID-19 outbreak. We have used their services effectively in the emergency departments and in COVID-19-related wards. Trainees are a good force for health care activity everywhere. The continuity of surgeries and seeing patients in the emergency department will maintain a level of practical education in these trainees.

We read the recently published article [1] in your journal with great interest. This study has compared the efficacy of isolated buttress plate fixation with the combination of intra-wall/ lag screw and buttress plate in the surgical management of posterior wall acetabular fractures. The authors have highlighted the advantage of avoiding inadvertent intraarticular screw penetration and have also shown comparable outcomes with the use of isolated buttress plate. As the reader, we would like to put forward some concerns based on the study analysis.