Archives of Bone and Joint Surgery
Volume:9 Issue: 5, Sep 2021

Pseudoaneurysms in hemophilic patients are unusual. We must have a suspicion when the patient has sufferedan arterial trauma (following arthroscopy, total joint replacement and other surgical operations). Pseudoaneurysmsmay take place in any anatomical zone where there has been trauma. The diagnosis must be verified by duplexultrasonography (US), standard angiogram, computed tomography angiogram or magnetic resonance angiography.There are diverse alternatives for the management of arterial pseudoaneurysms. Small pseudoaneurysms can beresolved with conservative noninterventional management. It includes outside pressing, US probe pressing or USguidedthrombin injections. In larger pseudoaneurysms, endovascular methods, such as coil embolization, are nowpreferred. If the aforesaid methods are unsuccessful, standard surgical management with simple ligation or arterialreconstruction must be carried out. We must suspect a pseudoaneurysm when, following an arterial trauma, thereis severe bleeding that does not stop with appropriate management with intravenous injection of the insufficientcoagulation factor. The diagnosis has to be verified by imaging. Endovascular tmethods, such as coil embolization, arenow preferred by the majority of physicians. The diagnosis and managment of an arterial pseudoaneurysm must becarried promptly to avert adverse events.Level of evidence: III

Urinary catheters (UC) are used by some surgeons during total joint arthroplasty (TJA). This studyinvestigated the impact of intraoperative urinary catheters on postoperative urinary retention (POUR) following TJAcases. We conducted a retrospective comparative study across 11 medical centers on 9,580 TJA patients. Visitsto urgent care or the emergency department within 7 and 30 postoperative days were reviewed. Medical recordsover a 12-month period for all patients older than 18 years old were used to gather demographic and surgicaldata as well as the incidence of urinary tract infection (UTI). Chi-squared tests (RStudio) were used to determinestatistical significance against P-Values (P) < 0.05. 13 (0.14%) patients returned within 7 days for POUR. POUR was more common in males [10 (0.3%) vs.3 (0.1%) females, (P = 0.01)]. There was no difference in POUR when comparing total hip and knee arthroplastyprocedures [0.16% vs. 0.12%, (P = 0.60)]. Of all operations, 25% had intraoperative UC use. There was no differencein POUR between the UC and no UC groups [0.21 vs. 0.11%, (P = 0.26)]. However, there was an increase in UTIin UC vs. no UC use within 7 postoperative days [0.92 vs. 0.43%, (P = 0.005)] and 30 postoperative days [2.60 vs.1.50 %, (P < 0.001)]. In our study, there was no difference in POUR rates between the intraoperative UC vs. no UC groups.Therefore, the use of intraoperative UC may not decrease the rate of POUR following TJA procedures. Additionally,UTI risk was higher in the UC group which may be attributable to other factors, especially when comparing femalevs. male patients.Level of evidence: II

Platelet-rich plasma (PRP), an autologous source of growth factors, and hyaluronic acid (HA) are amongthe minimally invasive treatments for knee osteoarthritis (OA). This trial was designed to compare the effectiveness ofintra-articular injection of PRP with HA (as one of the standard treatments) on mild to moderate knee OA. In this phase I open-label clinical trial, 10 patients underwent intra-articular PRP injection and 10 othersreceived HA injection. At baseline (pre-injection) visit and 1, 3, 6, and 12 months post-injection, clinical assessmentswere performed using visual analogue scale (VAS) and Knee injury and Osteoarthritis Outcome Score (KOOS)questionnaire. Physical examinations of the knee, including crepitation and range of motion (ROM) were performed ateach visit. The follow-up responses were compared with the baseline visit. The PRP treatment was ascertained to be safe and caused no adverse effects. Significant improvementsin the majority of KOOS subscales and VAS were found throughout the entire 12-month follow-up, following the PRp injections. HA injection, however, caused only one month significant improvement in the majority of patient-reportedoutcomes. In the majority of visits, the extent of improvements in the scores of KOOS subscales, as well as the extentof reduction in VAS were significantly greater in PRP recipients, compared to HA recipients. The ROM in both groupsslightly increased after interventions. The frequency of coarse crepitation, which was detected in 100% of the patientsin both groups at the baseline visit, decreased significantly to fine crepitation at the first follow-up visit in 80% and 40%of the PRP and HA recipients, respectively. Intra-articular injection of PRP or HA alleviates symptoms and pain and improves functionality and physicalexaminations in patients with knee OA. However, PRP therapy produces greater and longer-lasting improvements inmost of the outcome parameters compared to HA.Level of evidence: II

Although infections following arthroscopic surgery of cruciate ligament and meniscus are uncommon,they have potentially serious consequences for the graft and articular cartilage. This study aimed to investigatethe efficacy of correct sampling and appropriate media, especially resin-containing media, for the detection ofinfections in patients receiving antibiotics under suspicion of joint infection after arthroscopic anterior cruciateligament (ACL) and meniscal surgery. In such cases, proper sampling and the use of suitable culture media thatcause the neutralization of antibiotics are very effective in isolating microorganisms from the patient samples andpositive cultures. In total, 10 patients who had received antibiotics with suspected knee infection after arthroscopic ACLand meniscal surgery were identified after referral to surgeons during a period of 10 months and investigated in thisstudy. The sample collection, culture on various media (i.e., resin-containing culture media), microbiological tests,and antibiotic susceptibility tests were performed in this study. The amplification of the mecA gene using PCR assaywas accomplished for methicillin-resistant staphylococcus strains. This study was conducted on 10 patients who underwent arthroscopic procedures and had receivedantibiotics. Overall, joint fluid and tissue culture were positive in 60% of the patients. The resin-containing mediarevealed a trend toward increased detection of bacteria. Coagulase-negative staphylococcus strains were the mostfrequently isolated bacteria in arthroscopic ACL surgery infections. Out of five methicillin-resistant staphylococcusstrains, four strains were found that were resistant to cefoxitin and positive-mecA designated as methicillin-resistantstrains. Except for one case, the rest of the staphylococcal strains were resistant to methicillin but susceptible tovancomycin. Despite uncommon and low percentage of infections after arthroscopic ACL and meniscal surgery,the results of our study showed that correct sampling, appropriate cultures, especially aerobic and anaerobic resincontainingmedia, and microbiological testing remained useful and valuable for diagnosing bacterial infections.Level of evidence: II

The healthcare system is plagued finding the balance between opioid use and abuse. Orthopaedicsurgeons are expected to curtail the number of opioids prescribed in order to lower opioid abuse. We sought toprospectively evaluate opioid consumption following a wide range of sports orthopaedic surgical procedures todetermine utilization patterns. All patients receiving procedures within a one-year period were consented and then called daily for oneweek followed by weekly for up to two months or until the patients no longer were taking their opioid medication. Westudied the number of opioids patient’s took postoperatively and also collected information in regards to the patientand the surgical procedure. Included were 223 patients with a mean age of 32.9 years (range, 11 to 82). Surgeons prescribed amean total of 59.5 pills, and patients reported consuming a mean total of 20.9 pills, resulting in a utilization rateof 40%. 94.4% of patients received no education on how to properly dispose of unused opioids. The mean SANEscore was 53.9. The mean Pain Catastrophizing Scale score was 15.1. The mean Opioid Risk Tool was 3.3. Theprocedures were broken down into: 47.5% ligamentous knee repair, 18.4% shoulder arthroscopy/other shoulder,7.6% meniscus, 7.6% shoulder arthroplasty, 5.4% distal biceps, 4.0% lower leg (ankle/foot/tibia) and 4.0% shoulderORIF. Over-prescribing opioids after sports orthopaedic surgeries is widespread. In this study, we foundthat patients are being prescribed 2.48 times greater opioid medications than needed following sports orthopaedicsurgical procedures. We recommend surgeons take care when prescribing postoperative pain control and considercustomizing their opioid prescriptions on the basis of prior opioid usage, anatomic location and procedure type.We also recommend educating the patients on proper disposal of excess opioids and consider involving painmanagement for patients likely to require prolonged opioid usag e. Level of evidence: II

This study aims to determine the effect of resilience, as measured by the Brief Resilience Scale(BRS), and perceived self-efficacy of knee function, as measured by the Single Assessment Numeric Evaluation(SANE) score on return to sport outcomes following ACL Reconstruction (ACLR) surgery. Seventy-one patients undergoing ACLR surgery were followed up for a minimum of one year. At sixmonthspost-op, ACLR patients completed the BRS and the SANE score. Patients were stratified into low, normal,and high resilience groups, and outcome scores were calculated. The median return to sports participation, in months post-operatively, for the low, normal, and highresiliency groups were 7.1, 7.3, and 7.2 months, respectively (P=0.78). A multiple logistic regression analysisrevealed that the SANE score was a significant predictor of return to sport at nine months when adjusted for age,sex, and BRS score (P=0.01). Patients that returned to sport by nine months demonstrated a mean SANE scoreof 92.7, compared to a mean of 85.7 (P=0.08). In patients who had returned to sport, neither the BRS resiliencegroup nor the SANE score were significant predictors of the retu rned level of competition status (P=0.06; P=0.18). The SANE score may serve as a significant predictor of return to sport when adjusted for age, sex,and BRS score. Resilience, as measured by the BRS, was not significantly associated with return to sport, but mayhave utility in specific patient populations.Level of evidence: IV

Proprioceptive training in the aquatic environment is more beneficial owing to water properties. Theprimary goal of the present study was to investigate the effectiveness of the incorporation of innovative aquaticproprioceptive training into conventional accelerated land-based rehabilitation protocol in knee function and jointposition sense in male athletes after anterior cruciate ligamen t reconstruction (ACLR). A total of 38 athlete male athletes with ACLR were randomly assigned to two rehabilitation groups. Theconventional therapy group (CT) (n=19) received conventional rehabilitation for 6 weeks, while the hydrotherapygroup (HT) (n=19) received the same conventional rehabilitation, in addition to 12 sessions of innovative aquaticproprioceptive training. The outcomes included the joint position sense (JPS) errors, visual analog scale (VAS), andinternational knee documentation committee (IKDC). Repeated measures analysis of variance (ANOVA) was usedto compare the means between the two groups. Cohen’s d from an independent t-test was used to calculate theeffect sizes for all variables after the intervention for both gr oups. Base on the results, there were a significant difference in absolute errors (AE) (FAE=56.231, p <0.001)and variable errors (VE) (FVE=60.245, p <0.001) between the two groups. No significant differences were detectedin constant error (CE), VAS, and IKDC between the two groups (P>0.05). Both groups displayed a significantdifference in terms of AE, VE, VAS, and IKDC after the intervention (p <0.05). Percent changes after the interventionfor AE(69.19%), VE (68.20%), CE (65.20%), VAS37.50%, and IKDC (38.61%) were greater in the HT group,compared to the CT group. As evidenced by the obtained results, innovative aquatic proprioceptive training incorporate into theconventional rehabilitation accelerated protocol offers the improvement of proprioception efficiency for individualswith ACL reconstruction. Therefore, it could be useful to clinicians when designing rehabilitation protocol to ensurethe optimal engagement of proprioception.Level of evidence: I

The aim of our study is to report the clinical and radiological outcomes of a series of prospectivelyenrolled patients who have had double-row transosseous equivalent rotator cuff repairs, where all-suture anchorswere used as medial-row anchors, with a minimum follow-up of 1 year. Twenty-two consecutive patients underwent arthroscopic transosseous equivalent double-row rotatorcuff repair using all-suture anchors as medial-row anchors. Oxford Shoulder Score, Constant Score and VisualAnalogue Scale pain score, together with shoulder range of motion, were used preoperatively and at 3 months, 6months and final follow-up. Radiological evaluation was performed with magnetic resonance imaging at one-yearpost surgery to assess the structural integrity of the repair and the rate of cyst formation in greater tuberosity. The patient mean age was 61 years (range 46-75). Minimum follow-up was 1 year, and the mean finalfollow-up was 15 months (range 12-24). Healing failure in our patients was less than 5% (1/22 patients). There weresignificant improvements in shoulder function outcome scores at final follow-up. The Constant and Oxford scoreswere 78 and 44 at final follow-up respectively. There were similar magnitudes of improvement in range of motion(combined abduction and rotation), pain score and supraspinatus strength at final follow up. The improvementsin outcome scores were already statistically significant at 3 months (p <.001). Using Kim’s classification for cystformation on T2-weighted MRI images, we observed no fluid or minimal fluid collection in 85% of the patients (17/22patients). There were no correlations between the grade of bone changes and the clinical outcomes. It is safe to use all-suture anchors as medial-row anchors when performing double-row anchortransosseous equivalent rotator cuff repairs. The purported advantages of all-suture anchors may outweigh theirperceived disadvantages in rotator cuff repair surgery.Level of evidence: IV

This study aimed to evaluate the efficacy of hemi-epiphysiodesis using a new device (X-plate) for thecorrection of genu valgum.

In total, 22 children with a total of 34 pathologic knee valgus deformities underwent the procedure andwere followed up 25.3 months on average.

The mean time to clinical correction of genu valgum was 10.9±2.2 months. Furthermore, the meanpreoperative anatomic Lateral Distal Femoral Angle (aLDFA) and mechanical Tibia Femoral angle (mTFA) wereobtained at 75.1±3.8 and 6±2.8 degrees, respectively. When clinical correction of the deformity was achieved, themean of aLDFA and mTFA corrections were determined at 8.9±5.3 and 6.5±3.2 degrees, respectively. The meanspeed of aLDFA and mTFA corrections were estimated at 0.8±0.45 and 0.6±0.3 degrees per month, respectively.The postoperative aLDFA and mTFA were measured at 84±4.2 and -0.8±2.9 on average. With a mean of 25.3±14.5months at final follow-up, there were 6 (17.6%) mild valgus knees, 26 (75.5%) normal alignment knees, and only 2(5.9%) mild varus knee within an acceptable clinical limit.

Hemi-epiphysiodesis using X-plate at the distal physis of the femur is an effective and safe method forthe treatment of valgus knee deformity in children.Level of evidence: IV

Modern glenoid cementing techniques for anatomic total shoulder arthroplasty has improved theability to achieve a stable cement mantle, but the efficacy of adjunctive agents in glenoid preparation is unclear. Thepurpose of this study is to compare the early radiolucency rate s of glenoids prepared with and without thrombin. We identified patients between January 2017 and February 2019 undergoing primary anatomic TSA usingtwo glenoid types. Group A glenoids had a cemented central peg without peripheral peg cementation, and Group B glenoids had cemented peripheral pegs without central peg cementation. The first postoperative radiographwas assessed for radiolucent lines. All patients had the same glenoid preparation except some had the addition ofthrombin as a preparation agent. We identified 83 Group A glenoids with and 63 without thrombin glenoid preparation, and109 Group Bglenoids with and 48 without thrombin preparation. All Group A glenoids had no radiolucent lines and 5 (3%) Group B glenoids had radiolucent lines. Use of thrombin showed no difference in early radiolucencies (p=1.00) in eitherGroup. The addition of thrombin as a preparation agent had no effect on early glenoid radiolucent lines inanatomic TSA, and its routine use should be reconsidered.Level of evidence: III

Relatively low incidence has led to an under-rating of fibula tumors. This study aimed to evaluatefibula tumors as a whole and to give detailed information based on histological types according to the anatomiclocation of the tumors in the fibula. Evaluation was made of all the primary bone tumors of the fibula recorded in our bone tumor registry andinstitute of pathology from 2007 to 2018. Of these, 62 cases were identified. Analysis included assessment of age,gender, tumor localization, the presenting symptoms, the duration of symptoms, and treatment methods. There were 48 (77.4%%) benign and 14 (22.6%) malignant tumors. The most commonly found benigntumors were non-ossifying fibroma (12/48; 25%) and aneurysmal bone cyst (12/48; 25%), and the malignant tumorswere chondrosarcoma (3/14; 21.4%) and chondroblastic osteosarcoma (3/14; 21.4%). The most common locationfor both benign and malignant tumors (58.3%, 71.4%) are the proximal fibula, followed by the distal fibula (27.1%,28.6%) and the diaphysis (14.6%, 0%). Six (9.7%) patients prese nted with pathological fibula fractures. Fibular tumors are rarely encountered in clinical practice but are mostly benign, with malignancydetermined in approximately a quarter of patients. However, as most benign tumors are asymptomatic, and thereforeremain undetected, the actual proportion of malignant tumors wi ll be much lower.Level of evidence: IV

The neglected patella fracture leading to non-union of the fracture in long term. Non-union patella is therare entity with incidence of 2.4-12.5%. The fractured proximal fragment of the patella is retracted proximally leading tofracture gap of various centimetres. Various surgical modalities are described to manage such fracture morphologies. Ten neglected patella fracture morphology were included in the study. Five patients with transverse fracturewas treated with ORIF with TBW. Two patients with communited fracture was treated with ORIF with TBW (K wires) andcerclage wire. Three patients with inferior pole patella was managed by open reduction and Krachow suture using fibrewire. The results were assessed in terms of time of union, knee range of motion, extension lag, quadriceps power, fracturegap, Knee society score, Kujala knee score and any complications. Follow-up with radiographs was done at 2, 4, 6 and12 months. All patients presented with a mean duration of 9.3 months (7-13months) after the trauma with mean gap betweenthe fracture fragments of 5.2cm (3.8-6.6cm) in maximum flexion and 2.6cm (2.0- 3.0cm) in full passive extension. Themean duration of the radiological union was 5months (3-6months). The average range of motion achieved at the end of12 months ranges from 10o to 110o. The quadriceps power in all patients were 4+ or 5 at 6 and 12months. The meanKnee Society Score was 75 (Range 72-82) and mean Kujala knee score was 73 (Range 70- 82) at the end of 12 months. We conclude that in cases of non-union patella ORIF using TBW has the best result. V-Y plasty is rarelyrequired for fracture reduction. The need for bone grafting can be assessed on case to case basis. Partial/total patellectomyshould be avoided and Krackow suture technique is helpful in management of inferior pole patella fractures.Level of evidence: IV

Open fractures can have devastating consequences, including chronic infections and amputations, leaving patientswith life-changing disabilities. Prompt and appropriate treatment can spare patients the sequelae of open fracturesand the long-term economic burden these injuries often inflict. The British Orthopaedic Association Standards forTrauma and Orthopaedics (BOAST-4) guideline outlines the acute management of patients with open fracturesand is often considered the gold standard for open fracture management in the UK. In an era of evidence-basedmedicine, clinicians are continually mindful of the science behind current guidelines and practices. This article aimsto critique the evidence underpinning the BOAST-4 guidelines and suggest improvements based on contemporaryliterature. Antibiotic delivery in the prehospital setting, the type and duration of antimicrobial therapy, timing for theconversion from external to internal fixation, and the differentiation between adult and paediatric open fractureswere among the many pertinent topics critiqued, and evidence-based improvements suggested.Level of evidence: V

Reconstruction of large bone defects in skeletally immature patients remains a surgical challenge.We report the long-term clinical outcomes of a novel surgical technique for lower limb reconstruction using the tibiaas a strut autograft following resection of primary malignant bone tumors in skeletally immature patients. We retrospectively reviewed the medical records of six patients diagnosed with lower limb primary bonesarcoma. All patients underwent tumor resection and reconstruction using tibial strut autograft. The radiological andclinical outcomes including complications at the recipient and donor sites were assessed. The mean age at presentation was ten years (range 6-15 years). Two cases had osteosarcoma andfour had Ewing sarcoma. The mean length of the resected tumor and tibial autografts were 20.83 and 19.33 cmrespectively. Union at both ends was achieved in five grafts while one graft achieved union only at the distal end.The mean time for union of the proximal and distal junctions was 4 and 8.8 months respectively. The mean follow-up period was 8.4 years (range 14 months–20 years). One patient developed a foot drop, and three patients underwentsubsequent joint arthrodesis (2 knees and 1 ankle). The mean musculoskeletal tumor society functional score was80.8%. Two patients had clinically significant leg-length discrepancy that needs further lengthening procedure.Four patients survived with no evidence of disease and two patients died due to their primary oncologic disease. Alldonor sites regenerated, with the earliest signs of new bone formation at (2-4) weeks post-operatively. Reconstruction using non-vascularized tibia strut autograft after resection of primary malignant lowerlimb bone tumors can be a viable alternative method for reconstructing large bone defects in the immature skeleton.Level of evidence: IV

This randomized clinical trial was carried out to document the clinical presentation of isolated highradial nerve palsy (high RNP) and compare the outcome of triple tendon transfers. The study included patients of all genders and ages who presented with isolated high RNP. Half of themwere randomly assigned to the flexor carpi radialis set (FCR-set) of tendon transfers (group A) and a half to theflexor carpi ulnaris (FCU-set) of tendon transfers (group B). Out of 44 patients, 38 were males, and 6 were females. The age ranged from 7 years to 55 years.26(59.09%) patients had primary RNP in association with fractures of the humerus. The postoperative meandisability of arm, shoulder, and hand score (Quick DASH-11 score) for the patients in the FCR-set of transfers was34.54%% versus 41.81% for the FCU-set of transfers. 11 patients (25%) developed radial deviation deformity. RNP was predominantly found among males of the young age group, and the majority of the casesresulted from preventable causes. The triple tendon transfers among patients of the two groups robustly restoredthe lost extension of the wrist and digits in a matching way. The patients also subjectively reported remarkableimprovement in terms of the favorable Quick-DASH-11 scores. Radial deviation deformity occurred among half ofthe patients who underwent the FCU set of tendon transfers.Level of evidence: II

Healing of large segmental bone defects can be challenging for orthopedic surgeons. This research wasconducted to provide further insight into the effects of BMP7 in combination with autograft and platelet fibrin glue (PFG)on bone regeneration by Masquelet technique (MT). Twenty five domestic male rabbits, more than 6 months old, weighing 2.00±0.25 kg were randomly dividedinto five equal groups as follows: MT-blank cavity (without any biological or synthetic materials) (1), blank cavity (2), MTautograft(3), MT-autograft-BMP7 (4), and MT-BMP7-PFG (5). A 20 mm segmental defect was made in radial bone inboth forelimbs. The Masquelet technique was done in all groups except group 2. The study was evaluated by radiology,biomechanics, histopathology and scanning electron microscopy. The results showed that Masquelet technique enhanced the healing process, as, the structural and functionalcriteria of the injured bone showed significantly improved bone healing (p <0.05). Treatment by PFG-BMP7, Autograft-BMP7, and autograft demonstrated beneficial effects on bone healing. However, Autograft-BMP7 was more effectivethan autograft in healing of the radial defect in rabbits. Our findings introduce the osteogenic materials in combination with Masquelet technique as an alternativefor reconstruction of the big diaphyseal defects in the long bones in animal models. Our findings may be useful forclinical application in future.Level of evidence: V

We report a mass without neurologic findings and moderate pain in a 33-year-old male’s wrist at the 3rd zone of theulnar nerve due to schwannoma that was excised successfully, and the patient was free of symptoms. We furtherdiscuss the prevalence and management of this lesion. Level of evidence: V

Schwannomas are the most common nerve sheath tumors which are usually solitary enucleated lesions. Multipleschwannomas are a rare circumstance which may occur with or without other manifestations of neurofibromatosis.In this study, we report the case of a 45-year-old man presenting with pain and swelling in the thigh and popliteal spacewithout any manifestation of neurofibromatosis or neurologic problems. Surgery was performed and revealed fourseparated tumors in the sciatic nerve which was characteristic of schwannoma and confirmed by pathologic findings.Although multiple schwannomas are frequently associated with neurofibromatosis, the current case demonstrateda patient with multiple schwannomas without any manifestation o f neurofibromatosis.Level of evidence: IV