Archives of Bone and Joint Surgery
Volume:10 Issue: 5, May 2022

A foundational knowledge of the anatomy and biomechanics of meniscal root tears is warranted for proper repair of meniscal root tears and for preventing some of their commonly described iatrogenic causes. Meniscal root tears are defined as either a radial tear occurring within one cm of the root attachment site of the meniscus or a complete bony or soft tissue avulsion of the root attachment altogether. Meniscal root tears disrupt the protective biomechanical function of the native meniscus. Biomechanical analyses of the current techniques for meniscal root repair highlight the importance of restoring menisci to their correct anatomic orientation, thereby restoring their biomechanical function. A comprehensive understanding of the clinical and radiographic presentations of these injuries is critical to preventing their underdiagnosis. The poor long-term outcomes associated with conservative treatment measures, namely, ipsilateral compartment osteoarthritis, warrants the surgical repair of meniscal root tears whenever possible. While excellent patient-reported outcomes exist for the various surgical repair techniques, adherence to stringent post-operative rehabilitation protocols is critical for patients to avoid damaging the integrity of a repaired root. This review will focus on current concepts pertaining to the anatomy, biomechanics, diagnosis, treatment, and postoperative rehabilitation for meniscal root tears.

The effect of biomechanical footwear on pain from knee osteoarthritis (OA) is still unclear and controversial. The purpose of this article is to review the literature with the aim of answering the following question: What is the impact of biomechanical footwear on pain from knee OA? A Cochrane Library and PubMed (MEDLINE) search related to the effect of biomechanical footwear on pain from knee OA was performed. Several authors have reported knee pain alleviation in people with knee OA using biomechanical footwear. However, many of them have also stated that further investigation was required to evaluate its long-run effectiveness and safety, as well as replication, prior to reaching conclusions about the clinical value of this treatment. The cost of biomechanical footwear treatment is around 5,000 US dollars. Considering the weak evidence currently available on the efficacy of biomechanical footwear and its high cost, we do not advise the routine use of that treatment until it can be unequivocally confirmed that it is truly effective for pain alleviation in patients with knee OA.Level of evidence: III

Primary total hip arthroplasty (THA) is becoming an increasingly popular and efficacious medical procedure. There have been a number of studies evaluating tantalum acetabular cups compared with the conventional titanium acetabular cups for use in total hip arthroplasties. We conducted a systematic review and summarize clinical studies comparing tantalum acetabular cups with the conventional titanium acetabular cups for use in primary total hip arthroplasties.

A literature search was performed to find all relevant clinical studies until March 2020, which then underwent a further selection criteria. The inclusion criteria was set as follows: Reporting on human patients undergoing primary total hip arthroplasty; Direct comparison between tantalum acetabular cups with conventional titanium acetabular cups for use in primary total hip arthroplasty; Radiological evaluation (cup migration, osteointegration); Clinical (functional scores, need for subsequent revision, patient-reported outcomes; Post-operative complications; Reporting findings in the English Language. After a thorough search a total of six studies were included in the review. The primary outcome measures were clinical outcomes, implant migration, change in bone mineral density and rate of revision and infection. 

Tantalum is superior to titanium with regards to fewer radiolucencies, 100% survivorship at 12 years postoperatively, improved long-term implant osteointegration and survivorship as well as decreasing osteolysis and mechanical loosening. There has been no significant difference in radioisometric analysis, bone mineral density or Harris Hip Score. Revision and infection rates were found to be significantly lower in tantalum group at 10 years from pooled data of national joint registry (England and Wales), while it was found to be higher in the same at 9 years from pooled data of Swedish and Australian registry although this is not statistically significant.

The use of tantalum should be reserved for cases of high risk of failure or mechanical loosening, where failure of a contralateral joint occurred. The use of Tantalum carries lower risk of failure and infection. Further studies with longer follow-up would be useful in drawing further conclusions. Level of evidence: II

As the prevalence of Total Knee Arthroplasty increases, there is still debate over the preferred method of treatment of supracondylar periprosthetic femoral fractures. The aim of this study was to compare two of the common methods of fixation: Locked Plating and Retrograde Intramedullary Nailing with respect to nonunion, delayed union and surgical revision rate.

A comprehensive database search via Pubmed was conducted, yielding 16 eligible studies. Six of those studies were comparative and were used in the meta-analysis section. All 16 studies were used in the pooled sample analysis section. The primary outcome analyzed was nonunion and delayed union rate while the secondary outcome was the surgical revision rate. Odds ratios (ORs) and corresponding 95% confidence intervals (CIs) were calculated by comparing incidences of nonunion and delayed union, and surgical revision rates among the studies.

The meta-analysis showed that there is no statistically significant difference among the two groups in terms of nonunion and delayed union rate (OR = 1.43, CI = 0.74, 2.74, P=0.28), but there is a significant difference in the surgical revision rate favoring locked plating over retrograde intramedullary nailing (OR = 2.71, CI = 1.42, 5.17, P=0.003). The pooled sample analysis showed that there is no significant difference in the nonunion and delayed union rates (P=0.210) or the surgical revision rates (P=0.038). 

Both locked plating and Retrograde Intramedullary Nailing are reliable options for treating supracondylar femoral fractures around Total Knee Arthroplasty. Locked plating demonstrated a trend towards decreased nonunion and delayed union rates and a significantly lower surgical revision rate in the meta-analysis. Level of evidence: IV

Developmental dysplasia of the hip (DDH) is a spectrum of diseases involving the femoroacetabular joint. Due to the controversies over the value of different strategies used for DDH screening, this systematic review and meta-analysis aimed to assess the diagnostic performance of standard physical examination maneuvers on the diagnosis of DDH, compared to the Graf ultrasonography (US) method.

PubMed, Web of Science, and SCOPUS databases were searched until the end of October 2020. Studies that (i) used the Ortolani test, Barlow test, or limited hip abduction (LHA) test to assess the risk of DDH in physical examination, (ii)used the Graf US method to examine DDH in sonography, and (iii) provided adequate data to extract the diagnostic performance were included. Pooled sensitivity and specificity were calculated for clinical examinations. 

A total of 25 studies (72,079 patients in total) were considered eligible to enter the present study. The pooled data of the Ortolani-Barlow test demonstrated a sensitivity of 36% (95% CI:0.25-0.48) and specificity of 98% (95% CI:0.93-0.99). Calculated pooled sensitivity and specificity for the limited hip abduction exam were obtained at 45% (95% CI:0.24-0.69) and 78% (95% CI:0.62-0.88) respectively. A separate analysis of the studies using both exams revealed a sensitivity of 57% (95% CI:0.30-0.82) and a specificity of 95% (95% CI:0.68-0.99).

Based on the results, the investigated clinical examinations have high specificity but low sensitivity to detect the DDH; therefore, they have limited application as a screening test. If obliged to rely on clinical examinations for screening, the combination of Ortolani-Barlow and LHA tests can provide more sensitivity than either of these tests performed independently. Level of evidence: III

In LE (Lateral Epicondylitis) otherwise known as Tennis Elbow, the Extensor Carpi Radialis Brevis (ECRB) tendon is most commonly involved. In the majority of studies, injections are performed with a lack of standardization. The Instant Tennis Elbow Cure (ITEC) device has been developed to perform reproducible and standardized perforations by multiple needles. The goal of this pilot study was to estimate the accuracy of this ITEC device by means of a cadaveric study and to assess the clinical safety of this procedure.  Ten cadaveric arms were injected using the ITEC device. The location and depth of the ECRB tendon was measured by ultrasound imaging. The accuracy of the infiltration was assessed by locating the injected dye through dissection and arthrotomy of the cadaveric elbow. A prospective clinical pilot study was conducted to assess the safety of the ITEC device in treating patients with chronic LE. An optional infiltration with an injection fluid was carried out?? Primary outcome measures were side effects and complications of the ITEC device occurring within a follow up period of 8 weeks after treatment. In all cadaveric elbows the injection fluid ( in this case an injection fluid) was located at the ECRB tendon. In one cadaver, a minimal amount of dye was found intra-articular and in 3 cadavers a small quantity was located in the surrounding tissue of the ECRB tendon. 122 patients with LE were treated with the ITEC device. No adverse effects or complications were reported at 8-week follow up.  Treatment of LE using the ITEC device appears accurate and safe. It may improve future research since it is reproducible and it can be performed in a standardized way. Level of evidence: IV

With the rise in distal radius fracture (DRF) incidence and treatment through open reduction internal fixation, there are increasing concerns in the current medical cost containment climate. To help reduce costs, manufacturers are introducing sterile packed kits. The purpose of this study is to compare the costs of the single use kit (SK) against conventional reprocessed DRF surgical sets (RS). A four-year retrospective review at three surgical centers was performed to determine a company’s RS average sterilization and processing costs. RS instrumentation cost was estimated by straight-line depreciation from the original purchase price. RS implant costs were calculated from the list price. SK list cost was obtained from the same company. Incidence of surgical delays was estimated by a survey of 23 hand surgeons and cost of delays was obtained from surgical center reports. Sensitivity analysis on delay frequency was performed to assess a range of overall costs.  OR delays were estimated at one out of 100 cases, with an average cost of $11 per case. For RS, average instruments, implants, and sterilization costs per case was $47, $2882, and $39. The total RS cost of $2,978 and the SK was $1,667 with a difference of $1,313 per case. RS was found to cost $1,313 more per case than the SK in an ambulatory surgical setting and potentially more cost effective. Ultimately, pricing is highly variable at each center based on negotiated and contractual pricing.Level of evidence: IV

Arthroscopic ACL reconstruction using hamstring autograft is a quite a popular surgical procedure. But there is a conflict regarding the use of isolated semitendinosus graft or a combined hamstring graft. We did a comparative analysis of the functional outcome after ACL reconstruction performed with four strand semitendinosus graft and a combined hamstring graft over tightrope. Two groups of 30 patients each with similar demographic profiles, presenting with symptoms of instability after chronic ACL tear were included. A standard single bundle arthroscopic ACL reconstruction was performed by using four-strand semitendinosus graft in Group A and combined hamstring graft in Group B patients. Clinical and functional outcome analysis was done using quantitative anterior tibial translation measurement and Lysholm score.  The mean age of subjects in group A was 29 years and in Group B was 28 years. The semitendinosus graft length was insufficient in 13.33% cases in group A. The improvement in Lysholm score and the decrease in the tibial translation were comparable in both the groups at one year of follow-up. No added comorbidities were noted in additional removal of gracilis tendon in group B patients. Isolated semitendinosus four-strand autograft can be used for arthroscopic single bundle ACL reconstruction when adequate graft length is obtained. However, one should not be hesitant in additional removal of gracilis tendon when needed. In terms of functional outcome and patient satisfaction, both the graft configurations stand the same.Level of evidence: I

To evaluate the clinical and radiological outcomes of aseptic revision of total knee arthroplasty (TKA) using the Vanguard 360 Revision Knee System with the hybrid cementation technique.

Between January 2014 and October 2016, nineteen aseptic revision TKAs were carried out with the Vanguard 360 Revision Knee System (Zimmer-Biomet, Warsaw, IN, USA) performed by two different surgeons. The patients were evaluated clinically and radiographically at one, six, and twelve months after surgery and yearly thereafter. Functional outcomes were assessed according to the range of motion (ROM), knee society knee score (KSKS) and knee society function score (KSFS). Radiological evaluations were performed using the hip-knee-ankle angle (HKA), weight-bearing anteroposterior view, latero-lateral view, Rosenberg x-rays of the knee and skyline patellar x-rays. A triple-phase technetium bone scan was performed on all the patients complaining of knee pain after one year from surgery.

Clinical and radiological results including KSKS, KSFS, ROM and HKA angle improved after revision of TKA with a statistically significant difference (P<0.05). There were seven revisions of the CCK prosthesis due to persistent pain. 

Patients who underwent revision of TKA using the Vanguard 360 with the hybrid cementation technique had a failure rate of 36.8% at a mean time of 29 months due to aseptic loosening. Further studies are required to analyse the role of cementation in detail to prevent this complication.Level of evidence: IV

Megaprostheses are one of the preferred choices of reconstruction after tumor resection. Periprosthetic joint infections are one of the most serious complications of joint prostheses surgeries. In this study, our aim was to analyze the efficacy of silver-coated megaprostheses in reducing the risk of prosthesis-related infection. One hundred forty-two patients who had undergone implantation of a mega-endoprosthesis for nonneoplastic or post-neoplastic conditions were included in this retrospective study. The end-point of the survival analysis was the prosthesis failure due to infection.  Thirty-eight patients had undergone implantation of a silver-coated megaprosthesis and 104 patients a megaprosthesis without silver coating. The survival analysis showed an overall infection-free survival rate of 82.3% at five years and 61.9% at 10 years. Silver-coated prostheses had an HR of 0.72 (95% CI: 0.26-2.05; P=0.54). Implantation of a silver-coated mega-prosthesis in non-oncological patients did not significantly reduce the risk of prosthesis-related infection.Level of evidence: III

Extra-spinal osseous hydatid disease is reported in a small number of case series. In the present study, we report our experience with extra-spinal hydatid disease of the bone in a series of nine patients. In this retrospective study, the patients who were diagnosed with an extra-spinal osseous hydatid disease were included. All patients were treated surgically. Preoperative anthelmintic drugs were employed for the cysts that were diagnosed before the operation. Postoperative chemotherapy was performed for all patients. The study population included nine patients, including seven males and two females, with a mean age of 45.2±7.9 years and an average follow-up of 4.1±2.7 years. Non-specific pain was the most common symptom at presentation. Pelvic bones were the most frequent site of involvement. Serologic tests were false negative in seven patients. The disease was diagnosed preoperatively in five patients, and all of them were located in flat bones. The cysts were treated by radical excision in four patients, extended curettage in four patients, and amputation in one patient. The recurrence of the lesion was recorded in two patients who were treated by intralesional curettage. One case of suppuration was the only postoperative complication of this series. Osseous hydatid disease is a serious disease with challenging diagnosis, difficult treatment, and significant morbidity. Preoperative diagnosis is generally easier in flat bones. Radical resection is the optimal treatment of this disease, while non-radical resection is associated with a higher risk of recurrence.  Level of evidence: II

The incidence of gunshot injuries is growing, and civilian orthopedics should be more aware of the treatment and consequences of these injuries. This study aimed to describe the characteristic features and complications of gunshot injuries to long-bones. A total of 50 patients who presented with an open gunshot fracture of the tibia, humerus, and femur in the emergency room of our hospital were included in this study. Primary irrigation and debridement, as well as prophylactic antibiotics, were administered in the emergency room. The treatment was performed either conservatively (n=4) or surgically (n=46). The external fixator, nailing, or plating was used for surgical fixation.  The mean age and follow-up duration of the patients were 32.3±9.9 years and 13.1±5.6 months, respectively. The most common injured long bone was the femur (32 of 50). Regarding the Gustilo grade, IIIa, IIIb, and IIIc were observed in 37, 7, and 5 patients, respectively. The Masquelet technique was used for 7 (14%) patients, and 12 (24%) cases had skin flaps. Furthermore, the vascular injury was present in 5 (10%) patients, and Malunion of the fracture site was observed in 5 (10%) cases. Nonunion of the fractured bone occurred in 13 (26%) patients that was significantly associated with the presence of vascular injuries (P=0.02). Postoperative infection occurred in 9 (18%) patients and was significantly associated with the presence of skin flap (P=0.014).  Gunshot injuries of long bones are associated with a high incidence of post-treatment complications, such as infection and nonunion, and therefore, more intensive care should be taken to avoid these complications.Level of evidence: III

De Quervain’s disease (DQD) is tenosynovitis of the first dorsal compartment (DC1) of the wrist between the osteofibrous tunnel and the tendons involving the APL and EPB sheaths at the radial styloid. Surgical intervention is indicated when pain does not resolve despite 3 to 6 months of conservative management. Release of the first dorsal compartment is an effective treatment of DQD. In addition to surgical release, we performed pulley reconstruction using a new technique in the present series of 20 patients which has not been previously described with a followup of over 1 year. All patients showed a consistent improvement in VAS score at over one year followup with resolution of Finkelstein, Eichoff and WHAT test. Only one temporary neuropraxia was encountered due to stretching/scar entrapment of superficial branch of radial nerve. Our innovative technique of pulley reconstruction is not only easy to understand and perform but has shown consistent result in the 20 cases operated with this technique with a follow up of at least 1 year. The technique has the distinct advantage of having a quick learning curve and gives reliable, lasting results without complications or recurrence. Level of evidence: IV

Lunotriquetral (LT) ligament tear, usually in combination with an adjacent carpal ligament injury, can result in complete LT dissociation and VISI (Volarflexed Intercalated Segment Instability). Operative techniques for the management of instability are highly variable with many described in literature, although there is little evidence to demonstrate the superiority of one definitive therapeutic technique of repair and reconstruction. In this paper, we discuss our proposed technique for performing LT ligament repair using an augmented internal brace, which addresses triquetral extension and lunate flexion. The internal brace construct also provides biomechanical superiority as it includes the augmentation of the ligament and capsule repair. We use figures and references from our case example to demonstrate this technique.Level of evidence: V