Archives of Bone and Joint Surgery
Volume:10 Issue: 2, Feb 2022

There are several manners to take care of the hemophilic ankle in the initial phases of degeneration of the articularcartilage, in the event that hematologic prophylaxis is unsuccessful in accomplishing no bleeds. Some of these arenonoperative, with which management must start. These are Physical and Rehabilitation Medicine protocols and theutilization of orthoses (patellar tendon bearing). When these are unsuccessful, more aggressive types of treatmentcan be utilized, such as radiosynovectomy and some surgical operations (open or arthroscopic removal of anteriorosteophyte of the distal part of the tibia, arthroscopic ankle debridement). Nonetheless, in the late phases of degenerationof the articular cartilage (advanced arthropathy), the solely options are surgical: ankle fusion or total ankle arthroplasty.The review of the literature has shown that the percentage of consolidation is between 90% and 100%, and that thepercentage of postoperative infection is between 0% and 10%%. When the Ilizarov external fixator is utilized for anklefusion, the percentage of pin tract infection is around 14%. Ankle fusion is a secure surgical technique that melioratesarticular pain and improves the quality of life of hemophilic patients.Level of evidence: III

Though infection is a common and costly complication following fracture, there is a scarcity of literature focused on the additional cost of healthcare when a fracture becomes infected. This literature review compiles existing heterogenous data to evaluate the cost of infected fractures, yielding an estimate of a 1.2-fold to six-fold increase in healthcare costs associated with infection. The increases in cost were largely driven by an increased length of stay. Factors which affect this increase include the infectious agent, the depth of infection and the location of the fracture. In order to reduce healthcare costs, early soft tissue cover and prophylactic antibiotics are effective in that they reduce the infection rates. An alternative approach is to reduce the length of stay, the key driver of cost, for example by reducing the length of inpatient antibiotic therapy. Further cost-utility analyses which focus on the same aspects of the healthcare costs are required for a more accurate estimation of the cost. Level of evidence: IV

Modern advances in techniques and implants have allowed for a better operative fixation for distal femoral fractures. Both locked plating and retromedullary nail have allowed surgeons to stabilize these fractures with minimal soft tissue dissection and preserve blood supply. Although both the implants have been used extensively for such types of fractures, the superiority of one implant over the other is still doubtful. Therefore, we conducted this meta-analysis to compare locked plating and retrograde intramedullary nailing in distal femoral fractures. Based on prisma guidelines, electronic databases, including PubMed, Embase, Scopus, and Ovid Medline were searched using a well-defined search strategy. Outcome measures which were studied included blood loss, implant failure, infection, knee range of motion, malunion, non-union, pain, surgical duration and union time Surgical duration (95% CI 2.90 to 17.13, p <0.01) and blood loss (95% CI 69.60 to123.18, p <0.01) favoured plating group and the difference is significant. But while analysing parameters like implant failure, knee range of motion, non-union and union time, our analysis favoured nailing group, but the difference is not significant. Overall, both locked plating and retrograde intramedullary nailing are comparable with respect to union and complications in distal femur fractures, but we need further larger and high quality randomized studies to evaluate the difference. Level of evidence: Therapeutic-Level II

Refracture after both bone forearm fracture fixation may vary with or without plate removal. We testedthe null hypothesis that there is no difference in the rate of refracture in patients who have undergone open reductionand internal fixation of a diaphyseal forearm bone who have retained implants versus removed implants. We alsostudied factors associated with plate removal. We retrospectively identified 645 adult patients with a total of 925 primary fractures that underwent primaryplate fixation of an ulnar or radial shaft fracture between 2002 and 2015 at a single institutional system. Patients withnonunion, pathological fracture or infection were excluded. Independent factors associated with refracture and plateremoval were identified using multivariable analysis. Refractures occurred in 6.3% of the fractures that had forearm implant removal, compared to 2.1% of thefractures with retained plates. Refractures were independently associated with plate removal (OR: 3.7, 95% CI: 1.2-11.7, P=0.023) and was more frequent in the radius (OR: 2.4, 95% CI: 1.0-5.8, P=0.06). A refracture after implantremoval occurred within 3 months after removal. Ulnar plates were removed more often compared to radial plates (OR:2.6, 95% CI: 1.4-4.7, P=0.002) as were plates used for type A fractures compared to type C fractures (OR: 3.2, 95%CI: 1.1-9.2, P=0.032). The rate of refracture is higher after plate removal compared to patients who did not have plates removed.Although uncommon, refractures of the radius tend to be more common than a refracture of the ulna. If the implant issymptomatic on the ulnar side, it may be preferable to remove the ulnar implant and retain the radius implant ratherthan remove both plates when possible. Furthermore, limiting strenuous activity for three months after implant removalis a consideration.Level of evidence: III

Multiple surgical techniques for fixation of Neer type IIB distal clavicle fractures have been described without consensus on optimal treatment. The purpose of this study is to compare functional and radiographic results with surgical management of Neer type IIB distal clavicle fractures at a single institution. Sixty-three patients with acute Neer type IIB fractures treated operatively were evaluated. Patients with a minimum of two year follow up were included. Functional scores included American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), Simple Shoulder Test (SST), and Likert patient satisfaction (1 to 5). Radiographs were assessed for osseous union and coracoclavicular (CC) distance. Thirty-eight patients met inclusion with a mean follow-up of 5.3 years. Patients were divided into five groups based on fixation technique: suture-only CC fixation (n=6), CC screw fixation only (n=3), open reduction internal fixation (ORIF) without CC fixation (n=8), hook plate fixation (n=4), and ORIF with suture CC reconstruction (n=17). Outcome scores for the entire cohort were 91.8 for ASES, 90.2 for SANE, and 10.8 for STT. Patients with hook plates had significantly lower SANE score (p=0.016), but no other significant differences in functional, satisfaction, or radiographic outcomes were found between groups. Sixteen patients (42.1%) required reoperation. Treatment of Neer type IIB fractures via suture- only fixation, plate-only fixation, or a combination of both demonstrated satisfactory mid to long term outcomes. While implant removal was more common in the CC screw and ORIF groups, no fixation technique proved functionally superior. Level of evidence: IV

osteotomy around the knee is one of the most common corrective surgeries for lower limb deformities. The exact relationship between the effects of these surgeries on the ankle joint is unclear.This study aimed to investigate the effect of HTO on the subtalar joint in patients with genu varum. In the case series study33 patients including 27.2% men and 72.7% womenwith an average age of 41.9, with genu varum who underwent corrective surgery of open wedge high tibial osteotomy were studied. the heel alignment angle was determined before and after surgery in 10-months follow-up based on Saltzman view in conventional radiography. The data were then compared. Average genu varum correction angle was 11.9±1.3°. Heel alignment degree was 5.9±1.3° before HTO surgery, and after the surgery,in final follow-up,it was to 3.4±1.2° valgus, this value was statisticallysignificant(p=0.04). Moreover, there was a significant statistical relationship between average correction of Varus deformity and heel alignment anglechanges (P=0.02, r=0.3). Correcting Varus knee deformity can be effectiveon heel alignment angle in patients undergoing HTO surgery with genu varum. The angle of the subtalar valgus decreases as a result. Level of evidence: III

To evaluate intra and intersession reliability of the Center of Pressure (COP) parameters in AnteriorCruciate Ligament Reconstructed (ACLR) athletes with and without ankle vibration using a dual-task paradigm.

Postural sway of 14 ACLR individuals was assessed during a single-leg stance on a force platform. COPparameters were assessed with manipulating sensory inputs via vision and ankle vibration under single and dual-taskconditions. The outcome variables included COP displacement in medial-lateral (ML) and anterior-posterior (AP) range,mean velocity (mV), and area. During dual-task conditions, the auditory Stroop Task was applied. Intraclass correlationcoefficient (ICC) values and standard error of measurement (SEM) were assessed for relative and absolute reliability.

The COP measures had moderate to very high intrasession reliability (ICC range: 0.51-0.93) for conditionswith vibration and cognitive task, with the highest ICCs for mV and the lowest for area, regardless of eyes being openor closed. The intersession reliability was moderate to high for mV (ICC range: 0.60-0.82) and little to very high (ICCrange: 0.21-0.97) for the range of ML and AP, as well as an area in conditions with vibration and cognitive task.

The mV is the most reliable COP parameter for assessing postural control under ankle vibration and dualtaskconditions for both operated and non-operated sides. During closed-eye conditions, the application of vibrationaffected the intersession reliability with decreased ICCs on the operated side and increased ICCs on the non-operatedside.Level of evidence: III

Ankle fractures represent one of the most common orthopedic injuries in the lower extremity. Weightbearingand rehabilitation protocols after surgical treatment of ankle fracture have recently evolved from traditionalmethods to full weight-bearing protocols. However, more evidence is needed on unprotected immediate weight-bearingalong with a standardized rehabilitation program. The purpose of this study was to evaluate effects of unprotectedimmediate weight-bearing as tolerated and an eight-week prescheduled supervised rehabilitation program on the midtermclinical and functional outcomes of surgically treated ankle fractures, and to compare functional results with theunaffected side. Eighty patients (24F and 56M) who underwent rigid fixation of bimalleolar ankle fractures were included(mean age 41.57±13.22 years). Preoperative radiographs and computed tomography scans were used to evaluateand classify the fractures. The fractures were classified using Lauge-Hansen classification system. Ankle ROMs, PainDisability Index (PDI), American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scores, and Short Form-36 scores were evaluated. Patients were allowed unprotected weight-bearing on the immediate postoperative periodand a standardized supervised prescheduled rehabilitation program was undertaken following surgery. The mean follow-up period was 30.32±6.91 months. Based on Lauge-Hansen classification, supinationexternalrotation injuries were found in 32(40%) patients, supination adduction injuries in 14(17.4%) patients, pronationexternalrotation injuries in 28(35%) patients, and pronation-abduction fractures in 6(7.6%) patients. The solid unionwas achieved in all patients at the final follow-up. The mean PDI score was 12.78±14.78, and the AOFAS score was80.93±17.24. Although patients’ health-related quality of life was at a good level, the injured-side ankle ROM was lowerthan the healthy side (P≤ 0.05). Satisfactory clinical and functional outcome can be achieved at mid-term with unprotected weight-bearingas tolerated and pre-scheduled supervised eight-week rehabilitation program following rigid internal fixation of anklefractures. However, this protocol is not studied in patients with associated comorbidities.Level of evidence: III

Patellar tumors are rare but certainly must be considered in the differential diagnosis in patients with knee pain. Diagnosis can be challenging as often patellar neoplasms are confused with benign conditions and their clinical presentation is usually not specific. We performed an institutional and a literature review to determine what are the most common tumors affecting the patella and what is the best management.

This is a case series from our institution including all patients with benign, malignant, and metastatic patellar neoplasms. Charts were reviewed for patient demographics, clinical presentation, pathology characteristics, radiographic classification, and oncologic and functional outcomes.

Twenty-four patients were identified; twelve patients had benign lesions, 10 metastatic and 2 primary malignant tumors. Chondroblastoma and Giant Cell Tumor were the most common tumors. Management of benign lesions with intralesional curettage and packing with bone graft or cement demonstrated excellent results with no local recurrence. In terms of malignant tumors, the spectrum of treatment is variable; it could range from medical management alone or in combination with surgical procedures to total patellectomy with reconstruction of the extensor mechanism.

Patellar tumors should be part of the differential in patients with chronic knee pain that does not respond to initial conservative interventions. Recurrence rate with intralesional curettage and bone grafting or cement packing is very low and therefore should be the treatment of choice for benign intraosseous neoplasms. Resection with negative margins in malignant neoplasms or bone metastasis decreases local recurrence but only in the former group there is a potential impact in survival. Level of evidence: IV

Pedicle screw fixation devices are the predominant stabilization systems adopted for a wide variety ofspinal defects. Accordingly, both pedicle screw design and bone quality are known as the main parameters affecting thefixation strength as measured by the pull-out force and insertion torque. The pull-out test method, which is recommendedby the standards of the American Society for Testing and Materials (ASTM), is destructive. A non-destructive test methodwas proposed to evaluate the mechanical stability of the pedicle screw using modal analysis. Natural frequency (ωn)extracted from the modal analysis was then correlated with peak pull-out force (PPF) and peak insertion torque (PIT). Cylindrical pedicle screws with a conical core were inserted into two different polyurethane (PU) foams withdensities of 0.16 and 0.32 g/cm3. The PIT and PPF were measured according to the well-established ASTM-F543standard at three different insertion depths of 10, 20, and 30 mm. Modal analysis was carried out through recordingtime response of an accelerometer attached to the head of the screw impacted by a shock hammer. The effect of theinsertion depth and foam density on the insertion torque, natural frequency, and pull-out force were quantified. The maximum values of ωn, PIT, and PPT were obtained at 2,186 Hz, 123.75 N.cm, and 981.50 N, respectively,when the screw was inserted into the high-density foam at the depth of 30 mm. The minimum values were estimatedat 332 Hz, 16 N.cm, and 127 N, respectively, within the low-density PU at the depth of 10 mm. The higher value of ωnwas originated from higher bone screw stability and thus more fixation strength. According to the regression analysisoutcomes, the natural frequency (ωn) was linearly dependent on the PIT (ωn=14 PIT) and also on the PPF (ωn=1.7PPF). Coefficients of variation as the results of the modal analysis were significantly less than those in conventionalmethods (i.e. pull-out and insertion torque). The modal analysis was found to be a reliable, repeatable, and non-destructive method, which could beconsidered a prospective alternative to the destructive pull-out test that is limited to the in-vitro application only. Themodal analysis could be applied to assess the stability of implantable screws, such as orthopedic and spinal screws.Level of evidence: V

The Identification Pain questionnaire (IDPQ) is one of the recommended tools by the Neuropathic Pain Special Interest Group of the International Association for the Study of Pain for neuropathic pain screening. This study aimed to translate, cross-culturally adapt, and validate the Persian version of the IDPQ. First, the IDPQ was translated based on the recommended guidelines. Afterward, the internal consistency (Cronbach’s alpha coefficient), test-retest reliability (intraclass correlation coefficient), construct validity (compared to the Douleur Neuropathique 4 [DN4] questionnaire), and discriminant validity (Receiver operating curve analysis) of the IDPQ-P were evaluated. A total of 90 patients with neuropathic (n=50) and nociceptive pain (n=40) were enrolled in the study. In the next 72 h after the initial assessment, 30 patients (15 with neuropathic and 15 with nociceptive pain) completed the IDPQ-P. No modifications were needed in the process of translation and cultural adaptation. Cronbach’s alpha coefficient was obtained at 0.47 for all patients, indicating poor internal consistency. The intraclass correlation coefficient was estimated at 0.97, showing excellent test-retest reliability. A high correlation was found between the DN4 questionnaire and IDPQ-P (0.74), showing acceptable construct validity. The area under the curve was 0.94 (95% CI: 0.88-0.99) and 0.92 (95% CI: 0.85-0.99) when the physician’s diagnosis and the DN4 cut-off value were used as the reference standard, respectively. The optimal cut-off value of ≥ 2 demonstrated the highest sensitivity (98%) and specificity (79%). The IDPQ-P can be used in the clinical setting as an accurate and quick screening tool to diagnose patients with neuropathic pain. Sufficient test-retest reliability, construct validity, discriminant validity, and high diagnostic accuracy were found for the IDPQ-P. Level of evidence: I

Post-operative rehabilitation for patients with flexor tendon injuries is necessary for a full recovery. Thisrandomized controlled trial study investigates the effectiveness of a text message-based rehabilitation program (i.e.,TextRehab) on the improvement rate of hand rehabilitation in patients with flexor tendon injuries after repair. This study is designed as a randomized, three-month, single-center, two-arm, parallel controlled trial. A totalof 40 patients will be randomly classified as either the control or intervention group. Both groups receive usual care;however, the intervention group is also asked to perform the designed rehabilitation activities through the TextRehabprogram. The activity instructions are sent to patients step by step at least once a day. Self-reported outcomes will beassessed at 6 and 12 weeks after discharge and include self-reported Patient Rated Wrist Evaluation, self-reportedQuick-Disability of Arm, Shoulder, and Hand, and Visual Analogue Scale. Moreover, the reports of the physicianregarding the grip strength and Total Active Motion will be assessed at week 12. The development of the message scheduling system and its contents is completed. This trial has the code ofethics in research (removed due to blinding issues). Study results are expected to be available in mid-2021. The TextRehab program is developed to provide advice, motivation, information, and care for patientswith hand flexor tendon injuries after repair. This trial provides evidence of the effectiveness of sending text messageson persuading patients to perform home-based rehabilitation activities.Level of evidence: Not applicable