Archives of Bone and Joint Surgery
Volume:9 Issue: 3, May 2021

The Cochrane Library makes the outcomes of well-conducted controlled trials quickly accessible and is an essential resource for evidence-based medicine.

The purpose of this article is to review the data on the surgical treatment of knee osteoarthritis currently provided by the Cochrane database of systematic reviews (CDBSR).

The main results included the following: Joint lavage and arthroscopic debridement have no benefit for osteoarthritis; valgus high tibial osteotomy (HTO) reduces pain and improves knee function in patients with medial compartmental osteoarthritis of the knee; in primary total knee arthroplasty (TKA) cemented fixation of the tibial components demonstrated less displacement compared with cementless fixation (with and without hydroxyapatite) after a follow‐up of two years; however, the cemented fixation presented a greater risk of future aseptic loosening than cementless fixation; clinically irrelevant differences have been found between retention and sacrifice of the posterior cruciate ligament (PCL) in primary TKA; moderate‐ to low‐quality evidence suggests that mobile-bearing prostheses can have similar effects on various parameters compared with fixed-bearing prostheses in PCL-retaining TKA.

The CDBSR discourages joint lavage and arthroscopic debridement, demonstrates the utility of the valgus HTO in patients with medial compartmental osteoarthritis of the knee, and suggests that the various design types in primary TKA offer similar results.

The frequency of acute hematogenous infection (AHI) following total knee arthroplasty (TKA) is between 0.2% and0.5%. There is controversy over the results of patients treated for AHIs by surgical debridement, antibiotics, and implantretention (DAIR). This narrative review of the literature aims to establish of DAIR in late AHIs after TKA. The publishedsuccess rate (retention of the prosthesis) after DAIR is between 50% and 100%. The success rate is associatedwith a shorter duration of symptoms (5–14 days from the onset of symptoms). Factors associated with failure are anaccompanying infection and the diagnosis of rheumatoid arthritis before the TKA is performed. It is not recommendedto indicate a DAIR in patients with atrial fibrillation, chronic obstructive pulmonary disease, the presence of >15 cellsper high-powered field, preoperative C-reactive protein >500 mg/L or methicillin-resistant S. aureus. In such patients,a two-stage revision arthroplasty should be recommended. In conclusion, arthroscopic DAIR has a limited effect. It ismost efficacious in the very early stage of acute presentations of infected TKA. It can be useful in patients with extremefrailty as an adjunct to suppressive antibiotic therapy. If carried out, high volumes of fluid should be utilized. Theindications for an open DAIR are the following: duration of clinical signs and symptoms is less than 3 weeks; patientswith a well-fixed implant; no abscess or sinus tract; low-virulence bacteria; elderly patients with multiple comorbidities;and nonimmunocompromised patients. Open DAIR should not be advised in cases with chronic infection (>4 weekspostoperatively, insidious beginning of symptoms).Level of evidence: III

The medial collateral ligament (MCL) is a major stabilizer of the knee joint, providing support against rotatory andvalgus forces; moreover, it is the most common ligament injured during knee trauma. The MCL injury results in valgusinstability of the knee and makes the patient susceptible to degenerative knee osteoarthritis. Although it has beennearly a dogma to manage MCL injury nonoperatively, recent literature has suggested operative MCL managementas a suitable option for specific patient populations. The present review aimed to assess the current literature on themanagement of MCL injuries of the knee. In this regard, we go over the anatomy, physical examination, and MCLimaging.Level of evidence: IV

Acute compartment syndrome (ACS) is a devastating condition, further aggravated by delayed diagnosis.Since ACS is a clinical diagnosis, identification of risk factors for individual patients may help with earlier detection. Thisstudy aims to identify the risk factors associated with the development of ACS of the extremities.

We performed a systematic review and meta-analysis of studies with adult patients at risk for and withtraumatic ACS of the extremity. Non-traumatic, chronic exertional, vascular and abdominal compartment syndromewere excluded. Technical reports, biomechanical studies, abstracts, studies of non-human subjects, non-Englishstudies, and studies with less than five subjects were excluded. Meta-analysis was performed on a subset of studiesincluding a control group. We addressed cases of substantial heterogeneity among the studies with subgroup analysis,and whenever heterogeneity remained significant, we employed random effect meta-analysis for the data pooling. Thestudy protocol has been registered in PROSPERO (ID = CRD42019126603).

There were 19 studies with 48,887 patients investigating risk factors of traumatic ACS. Of these, therewere 1,716 patients with the diagnosis of traumatic ACS. Fourteen studies (46,300 controls and 1,358 ACS patients)qualified for meta-analysis. Male to female ratio was 5.5 with an average age of 36 years. Factors that were significantlyassociated with the development of ACS were: age 18-64 (OR: 1.34, 95% CI: 1.07-1.68), male (OR: 2.18, 95% CI:1.53-3.10), gunshot wound with fracture and vascular injury (OR: 12.5, 95% CI: 5.69-27.46), combined forefoot andmidfoot injury (OR: 3.3, 95% CI: 2.39-4.57), injury severity score (ISS) 0-9 (OR: 1.58, 95% CI: 1.27-1.97), OTA/AO typeC fractures (OR: 2.75, 95% CI: 1.04-7.28), vascular injury (OR: 9.05, 95% CI: 6.69-12.26), and high-energy trauma(OR: 3.10, 95% CI: 1.60-5.82). Factors such as tibia fracture and crush injury were reported but were not included inquantitative analysis, due to lack of control groups and/or only one study qualifying for meta-analysis.

This study reports on the current significant risk factors for developing traumatic ACS. The most commonrisk factors included age, sex, gunshot wound with a vascular injury, OTA/AO fracture type C and high-energy trauma.Level of evidence: II

Pilon fractures represent one of the most surgically challenging fractures in orthopaedics. Differenttechniques exist for their management, with open reduction and internal fixation (ORIF) and External fixation (Ex-Fix) the most widely used. Whilst there is a plethora of data regarding these strategies for Pilon fractures as a whole,very limited data exists solely on the management of open Pilon fractures. This study aimed to elucidate how surgicalmanagement options can influence postoperative complications, and if this can influence future management protocols.

We conducted a search in PubMed, EMBASE and CENTRAL for postoperative complications andfunctional outcomes in open pilon fractures in those treated with Ex-Fix vs ORIF (PROSPERO-CRD42020184213).The postoperative complications measured included non-union, mal-union, delayed union, bone grafting, amputation,osteoarthritis, deep infection and superficial infection. Functional outcomes in the form of the AOFAS score was alsomeasured where possible. We were able to carry out a meta-analysis for both deep infections and non-unions.

The search yielded 309 results and a total of 18 studies consisting of 484 patients were included. All fracturesincluded were open, and consisted of 64 Gustilo-Anderson Type I, 148 Type II, 103 Type IIIa, 90 Type IIIb and 9 TypeIIIc. 60 Type III fractures could not be further separated and 12 were ungraded. Both ORIF and Ex-Fix were found tohave statistically similar AOFAS scores (P=0.682). For all included studies, the Ex-Fix group had significantly higherrates of superficial infections (P=0.001), non-unions (P=0.001), osteoarthritis (P=0.001) and bone grafting (P=0.001).The meta-analysis found no significant difference in non-union (pooled OR=0.25, 95% CI: 0.03 to 2.24, P=0.44) or deep infection rates (pooled OR=1.35, 95% CI: 0.11 to 16.69, P=0.12) between the ORIF and Ex-fix groups.

Based on our study, while Ex-Fix and ORIF have similar functional outcomes, Ex-Fix appears to havea significantly higher risk of postoperative complications which must be considered by surgeons when choosingsurgical management options. Further research, ideally in a randomised control trial format, is required to definitivelydemonstrate ORIF superiority in the management of open pilon fractures.Level of evidence: I

Atypical femoral fractures are the femoral fractures located anywhere between the lesser trochanterand the supracondylar flare of the femur. Long-term bisphosphonates, as the most common preventive and treatmentmedications for osteoporosis, are thought to have an important role in these fractures. Most of the fractures should betreated surgically, and the complications are considerable.

We searched Medline, CENTRAL, Embase, and DART on February 26, 2020. One author reviewed andretrieved citations from these four databases for irrelevant and duplicate studies, and two other authors independentlyextracted data from the studies and rated their quality.Patients with surgical treatment of bisphosphonate-related atypical femoral fracture, according to the American Societyfor Bone and Mineral Research definition, were included. Animal studies, case reports, studies with high-energy trauma,pathological fracture, or malignancy-related fractures were excluded.

In total, 316 patients (348 fractures) were included in this study. Mean age of patients was 70.47 years,and 97.5% of them were female. Duration of using bisphosphonates was 4.04 to 8.8 years, and Alendronate was themost common type. Moreover, 65.27% and 34.72% of the reported fractures were in diaphyseal and subtrochanteric,respectively. Moreover, the most common fixation type was intramedullary. Rate of complication was 17.52%, and themost frequent one was non-union, followed by implant failure. The main limitation of this research was that most of thestudies did not have a high level of evidence.

An increase in the rate of atypical femoral fracture with its challenging management makes it an importantissue to be noted by orthopedic surgeons. Based on the results of this study, subtrochanteric fractures might have morecomplications post-operatively and are suggested to be operated on by more experienced surgeons. It was also foundthat extra-medullary fixation increases the risk of complications. Future studies on union time, outcomes of differentsurgical methods, and teriparatide therapy may help shed more light on the surgical management of these fractures.Level of evidence: III

The present study aimed to perform a meta-analysis on the performance of Graf’s ultrasonographymethod in the detection of developmental dysplasia of the hip (DDH).

A query was conducted on electronic bibliographic databases until the end of October 2020. The inclusioncriteria entailed: 1. the use of Graf method in less than 12 weeks of age, 2. the use of follow-up as reference test, and 3.provision of crude data. Pooled diagnostic performance measures were calculated. Quality Assessment of DiagnosticAccuracy Studies-2 (QUADAS-2) checklist was utilized to assess the quality of the included studies. The hierarchicalsummary receiver-operating characteristic (HROC) curves were also drawn.

Six articles (including seven populations, 11,012 patients) were considered eligible. The pooled sensitivityand specificity were obtained at 93% (95% CI: 0.57-0.99) and 97% (95% CI:0.86-0.99), respectively (area under curve=0.99). The pooled positive and negative likelihood ratio, as well as diagnostic odds ratio, was reported as 28.4, 0.07,and 396, respectively.

As evidenced by the obtained results, Graf’s method is a useful ultrasonography technique with acceptableaccuracy for screening DDH in neonates. However, there are uncertainties about the best population and age forscreening. Furthermore, more attention should be paid to the proper training of this method to reduce the number ofoperator errors.Level of evidence: I

The object of this study was to examine return to golf and changes in golf performance after shoulderarthroplasty. Additionally, we set out to determine if there were differences in return to play and performance betweentotal shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RTSA). We also examined pain during the golfswing to determine if there is a change in pain level after surgery. Patients were identified using a Current Procedural Terminology code 23472 search for TSA. A 19-questiononline survey was sent out to each patient with questions detailing golfing performance and pain during the swing beforeand after surgery. Comparisons were made to determine differences in pain, performance and enjoyment between TSAand RTSA groups before and after surgery. A total of 586 patients who underwent shoulder arthroplasty were sent the online survey via email. Of thosepatients, 33 identified themselves as golfers and who responded to the survey, resulting in an overall response rate of5.6%. Twenty-three of 31 (74%) patients were able to return to golf following their procedure. Overall, the respondentswho reported pain associated with golfing activity had significantly decreased pain after undergoing either TSA orRTSA. The RTSA group had a significant drop in driving distance following the procedure and this was significantlylower than the postoperative driving distance in the TSA group, despite an insignificant preoperative difference. Overall, TSA offers a safe and effective means for reducing pain during the golf swing in patientssuffering from advanced shoulder osteoarthritis. While there were no significant changes in performance followingTSA, individuals undergoing RTSA can be counseled that they are at risk for lower driving distances due to alteredmechanics. Overall, patients were satisfied with their procedure and their ability to return to the golf course.Level of evidence: IV

To document the clinical presentation of glomus tumors of the hand and evaluate the outcome ofcomplete surgical excision in terms of relief of symptoms, any postoperative nail deformities and tumor recurrence overa period of one year. This descriptive case series spanned over a period of twelve years. All patients of either gender and all ageswho had histologically confirmed glomus tumors of the hands were included. All of them underwent surgical excisionunder local anesthesia. Out of 17 patients, majority (n=12; 70.58%) were females. The mean age was 41.17±13.7 years. Thedominant hand was involved in 11 (64.70%) patients. There were 14 patients (82.35%) with subungual tumors whereas3(17.64%) had volar pulp glomus tumors. The mean diagnostic delay was 18.88±9.3 months. The tumor size rangedfrom 2 mm to 1.1cm with a mean of 4.05±4.3mm. All the patients (n=17,100%) experienced complete symptomaticrelief within 2-4 weeks after surgical excision. There were no postoperative nail deformities. There was no recurrenceover a period of one year. Glomus tumors of the hands were more frequently found among women in their fourth and fifth decades.Dominant hand, index finger and distal phalanx represented the commonest affected anatomic locales. Majority of thetumors were subungual. Majority of the patients suffered over 12 months in distressful pain before being diagnosed.Complete surgical excision under local anesthesia provided rapid relief of the symptoms. Creation of awareness aboutthe tumor among doctors as well as public would help to ensure early presentation to plastic surgeon, prompt diagnosisand hence avoidance of the prolonged periods of agonizing misery.Level of evidence: III

Opioid usage has increased in recent years. The purpose of this study is to assess post-operativeopioid, sedative, and benzodiazepine usage in a Medicare population. Consecutive patients undergoing elbow, wrist, and hand surgery by hand surgeons at one academicoutpatient surgical center were prospectively enrolled. Patients were excluded if they were minors or if they underwentmore than one surgical procedure during the study period. There were 269 patients enrolled, and this group was dividedby insurance type into younger commercial insurance (CI) and older Medicare (MC) groups.The Pennsylvania Physician Drug Monitoring Program website was used to document all prescriptions of controlledsubstances filled six months prior to and after the surgical procedure. The mean age in the CI group was 45.8 years (range: 16-88) and 69.2 years (range: 43-91) in the MC group.Postoperatively, the CI patients filled significantly less opioid prescriptions than the MC group, 1.10 vs. 1.79. Patients inthe CI group were given an average of 0.3 benzodiazepine prescriptions before surgery and 0.2 after surgery. Patientsin the MC group were given 0.6 prescriptions before and 0.5 prescriptions of benzodiazepines after surgery. The CIgroup was given an average of 0.1 sedative/hypnotic prescriptions before surgery and 0.1 after surgery. The MC group was given 0.7 prescriptions before and 0.4 prescriptions of sedative/hypnotics after surgery.There were 0.17 prescriptions per patient in the CI group and 0.75 per patient in the MC group (P <.05). Twenty-twoof 208 (10.6%) of CI and 16/61 (26.2%) of MC patients filled a prescription between 3-8 months post-operatively. Prolonged use of opioid, benzodiazepine and sedative medications is common after upper extremitysurgical procedures. Older patients are also at risk, and may be even more likely than younger patients to use thesemedications post-operatively.Level of evidence: III

The incidence of total shoulder arthroplasty (anatomic and reverse) is increasing as indications expand.The purpose of this study is to identify predictors of short-term complications and readmission following total shoulderarthroplasty for patients with glenohumeral osteoarthritis. The American College of Surgeons National Surgical Quality Improvement Program was used to identify12,982 patients who underwent total shoulder arthroplasty (anatomic or reverse) from 2011-2016. Demographic data,postoperative complications, and readmission within 30 days were analyzed. Multivariable logistic regression was usedto determine independent risk factors for complications and for readmission occurring within 30 days of surgery. The mean age of the cohort was 69.1 years, 56.1% were female. Mean American Society ofAnesthesiologists (ASA) classification score was 2.6. The postoperative complication rate was 5.6% and thereadmission rate was 2.8% within 30 days of surgery. Independent predictors for any complication includedpreoperative dependent functional status (OR 1.8, p <0.001), ASA class 3 (OR 3.6, P=0.021) and 4 (OR 8.5,p <0.001), age 70-79 (OR 1.4, P=0.019) age ≥ 80 years (OR 2.3, p <0.001, and female gender (OR 1.6, P=0.001).Independent predictors for readmission included congestive heart failure (OR 3.4, P=0.002) and ASA class 4(OR 14, P = 0.013). Independent functional status was associated with decreased odds of readmission (OR 0.4,p <0.001). Patients with age greater than 70 years, congestive heart failure, and ASA class 3 and 4 are at increasedrisk for postoperative complications and readmission. Preoperative risk stratification and medical optimization areimportant in these patients.Level of evidence: III

An understanding of patient and clinician opinions about remote video musculoskeletal consultationsmight help determine how to increase appeal and utilization. The purpose of this study was to evaluate perceptions ofremote video musculoskeletal consultations. Our research questions was what are patient and clinician facilitators andbarriers for the use of remote video consultations? Prior to the COVID-19 pandemic 27 English speaking adult patients seeking ambulatory care for amusculoskeletal problem, and 10 English-speaking musculoskeletal clinicians were interviewed using a guide.Interviews were audio-recorded, transcribed, and coded using applied thematic analysis. Patient and clinician incentives for remote video consultations included increased convenience, lower costs,less waiting time, and a better experience. Patient and clinician barriers to remote video consultations included concernsabout familiarity with technology, lack of personal interaction and physical examination, inability to perform procedures,difficulties with reimbursement (clinicians), as well as technical, logistical, and privacy issues. This qualitative study performed prior to the pandemic found that adoption of remote video consultation formusculoskeletal problems may improve with seamless, efficient, and effective care, at an affordable price, particularly ifthe human connection is similar to what occurs in person.Level of evidence: Not applicable

Shortened versions of validated PRO measures of coping strategies e.g. PSEQ-2, may facilitatescreening and monitoring of psychological conditions such as depression and anxiety. The primary researchquestion in this study assesses the sensitivity and specificity of a PSEQ-2 score of less than 10 for importantsymptoms of depression (a PHQ-2 score greater than 2), anxiety (GAD-2 score greater than 2), any impactfulprior episode of psychological trauma, and QuickDASH greater than 49. Secondarily we assess the associationsbetween self-efficacy and other demographic and psychological factors on the magnitude of limitations and painintensity. We performed a retrospective PRO evaluation in 926 adult patients attending upper extremity clinicbetween 1st January 2018 and 31st January 2019. Demographic factors were assessed using electronic medicalrecords and PRO data using an online platform. Patients included 556 (60%) women, 370 (40%) men (mean 51years + 14 (range, 19-88), mostly (n=584, 63%) with safety net insurance. A PSEQ-2 scoring threshold of less than 10 was 81% sensitive for a PHQ-2 score of 3 or greater, 84%sensitive for a GAD-2 score of 3 or greater, 84% sensitive for one or more important psychological traumas, and 82%sensitive for a QuickDASH of 50 or greater. PSEQ-2 less than 10 was independently associated with greater upperextremity limitations (β=11 [6.3 to 17, 95% Confidence interval [C.I], p <0.001) and pain intensity (β=0.92 (0.31 to 1.5,95% C.I) P=0.003) amongst other psychological and demographic factors. A PSEQ-2 score less than 10 might, along with verbal and non-verbal signs of distress, be a usefulway to introduce the use of more sensitive screening questionnaires about anxiety or depression, or open up the option of speaking directly to mental or social health professionals. Future studies are required to test thishypothesis. Level of evidence: III

Hand and wrist disorders are common during pregnancy. Most of these problems develop during the third trimesterwhen hormonal changes, fluid retention, and weight gain are maximum. This review study aimed to discusspregnancy-related hand and wrist problems, and provide an overview of their pathology, clinical presentations, clinicalexaminations, and treatment options. Pregnancy-related carpal tunnel syndrome and De Quervain disease are amongthe most encountered disorders; however, neuralgic amyotrophy, pyogenic granuloma in hand, ligamentous laxity ofthe joints, arthralgia, and exacerbation of hand and wrist arthritis are among other reported disorders during pregnancy.Pregnancy-related hand and wrist problems may remain undertreated and reduce pregnant females’ quality of life. Nonsurgicaltreatments are usually effective for pregnancy-related hand and wrist problems. In general, pregnancy-relatedhand and wrist problems have a good prognosis and usually resolve after childbirth.Level of evidence: IV

The treatment options for posterior instability associated with epilepsy includes grafts, osteotomies, arthrodesis andarthroplasty. The technique of reverse arthroscopic remplissage was described in 2006 as a method of filling the anteriorhumeral bone defect, associated with tenodesis of the subscapularis tendon. This case report presents the results of thereverse remplissage technique in relation to a patient who suffered a bilateral posterior glenohumeral dislocation with areverse Hill-Sachs lesion.Level of evidence: IV

Pigmented villonodular synovitis (PVNS) is a locally destructive benign lesion usually affecting the synovial tissue ofweight-bearing joints. Herein we reported a 20-year-old male patient who was an army staff with a foot lesion which waspainful in army boots. In the beginning, the lesion was considered a ganglion cyst. Further investigations revealed corticalerosion of cuboid bone on the radiograph. Pigmented villonodular synovitis was considered as a probable diagnosisafter observation of low signal lesion around the calcaneocuboid joint on both T1 and T2 images of Magnetic ResonanceImaging. The treatment included excision of the lesion and synovectomy of the calcaneocuboid joint. The diagnosis wasconfirmed with histological studies. At more than one year follow-up, the patient was completely asymptomatic, and therewas no evidence of recurrence. This study aimed to raise the awareness of clinicians about the diagnosis of this rare softtissue neoplasm which might be misdiagnosed as a ganglion or synovial cysts in the hindfoot zone.Level of evidence: V

Atraumatic posterior thigh compartment syndrome is a rare but serious condition. We document a case of atraumaticposterior thigh compartment syndrome that presented as an acute sciatic nerve palsy and required emergent fasciotomy.Based on this case, one should keep in mind the diagnosis of posterior thigh compartment syndrome when encounteringa patient presenting with an acute sciatic nerve palsy.Level of evidence: V

Erratum to: The Effect of Ozone (O3) versus Hyaluronic Acid on Pain and Function in Patients with Knee Osteoarthritis: A Systematic Review and Meta-Analysis In the article entitled “The Effect of Ozone (O3) versus Hyaluronic Acid on Pain and Function in Patients with Knee Osteoarthritis: A Systematic Review and Meta-Analysis”(1), which was published in Volume 8, Issue 3 of the Archives of Bone and Joint Surgery, an incorrect data was reported in Table 2 mistakenly. In the last column of Table 2, the reported complication of the trial performed by Invernizzi et al in 2017 (2) was not correct. It should be noted that only two self-limiting adverse events including local pain and swelling was reported in this trial. References: 1. Javadi Hedayatabad J, Kachooei AR, Taher Chaharjouy N, Vaziri N, Mehrad-Majd H, Emadzadeh M, et al. The Effect of Ozone (O(3)) versus Hyaluronic Acid on Pain and Function in Patients with Knee Osteoarthritis: A Systematic Review and Meta-Analysis. Arch Bone Jt Surg. 2020 May;8(3):343-354. doi: 10.22038/abjs.2020.46925.2292. 2. Invernizzi M, Stango D, Carda S, Grana E, Picelli A, Smania N, et al. Safety of Intra-Articular Oxygen-Ozone Therapy Compared to Intra-Articular Sodium Hyaluronate in Knee Osteoarthritis: A Randomized Single Blind Pilot Study. Int J Phys Med Rehabil 2017, 5:1DOI: 10.4172/2329-9096.1000385