Archives of Bone and Joint Surgery
Volume:10 Issue: 7, Jul 2022

Orthobiologics are organic and synthetic materials that help in the cure of musculo-skeletal problems and are utilizedin Orthopaedic Surgery, both in and out of the surgical theater, to augment the possibilities of curing bone and softtissue lesions. Taking into account that their effect is frequently multifactorial and, in some occasions not entirely comprehended,together with the insufficient clinical information, orthobiologics should be scrupulously assessed againstother secure and clinically accepted options. The fundamental orthobiologics today ready for use in Orthopedic Surgeryare the following: osseous hollow fillers, extracellular matrix (ECM) substances, platelet-rich plasma (PRP), bonemorphogenetic protein-2 (BMP-2), bone marrow aspirate (BMA), bone marrow aspirate concentrate (BMAC), and mesenchymalstem cells (MSCs). It is predictable that in the time to come we will have more secure and more efficaciousorthobiologics. Meanwhile, it is paramount that orthopedic surgeons have appropriate information of contemporaryorthobiologics (biological adjuvants) so that they can utilize them correctly.Level of evidence: III

Most surgeons used, or are currently using telehealth during the SARS-CoV-2 (COVID-19) pandemic.We studied surgeon personal factors associated with relative use of telehealth during the worldwide height of thepandemic.Questions/ (1) Are there any personal factors/characteristics associated with use and utilization of telehealth?(2) What are surgeon’s perspectives/ opinions with regard to use of telehealth for five common upper extremityconditions in terms of future prospects and viability? Hand and upper extremity surgeons in the Science of Variation Group (SOVG) were invited to participate ina web-based survey. The first part of the survey focused on surgeon characteristics and work preferences. The secondpart focused on care strategies during the pandemic and utilization of telehealth. The final part of the survey addressedthe care of five common upper extremity conditions during the pandemic. Ninety percent of surgeons used telehealth during the first few months of the pandemic, but only 20% ofvisits were virtual. A greater percentage of telehealth visits compared to office visits was independently associated witha policy of only seeing people with emergencies in person (RC: 0.64; CI 95%: 0.21 to 1.1; P<0.01). Surgeons foundit difficult to reproduce most parts of the physical examination on video, but relatively easy to make a diagnosis, withboth ratings associated with less belief that the physical exam is essential. Comfort in offering surgery by video visitwas associated with having young children, preference for remote meetings, and less belief that the physical exam isessential. Utilization of, and comfort with, telehealth is related to personal factors and preferences, acceptance ofa more limited physical examination in particular. Utilization of early adopters and training to increase comfort with theprobabilistic aspects of medicine could facilitate incorporation of telehealth into standard practice.Level of evidence: N/a

Orthopaedic surgeons rely on visual and tactile cues to guide performance in the operatingroom (OR). However, there is very little data on how sound changes during orthopaedic procedures andhow surgeons incorporate audio feedback to guide performance. This study attempts to define meaningfulchanges in sound during vital aspects of total hip arthroplasty (THA) within the spectrum of human hearing. 84 audio recordings were obtained during primary elective THA procedures during sawing of thefemoral neck, reaming of the acetabulum, acetabular cup impaction, polyethylene liner impaction, femoralbroaching, planning of the femoral calcar and press-fit of a porous-coated stem in 14 patients. We graphedchanges in frequency intensity across the human spectrum of hearing and sampled frequencies showingdifferences over time for statistically meaningful changes. Sawing of the femoral neck, polyethylene impaction, and stem insertion showed significanttemporal increases in overall sound intensity. Calcar planing showed a significant decrease in soundintensity. Moreover, spectrographic analysis showed that, for each of the critical tasks in THA, there werecharacteristic frequencies that showed maximal changes in loudness. These changes were above the 1 dBchange in intensity required for detection by the human ear. Our results clearly demonstrate reproducible sound changes during total hip arthroplasty thatare detectable by the human ear. Surgeons can incorporate sound as a valuable source of feedback whileperforming total hip arthroplasty to guide optimal performance in the OR. These findings can be extrapolatedto other orthopaedic procedures that produce characteristic changes in sound. Moreover, it emphasizes theimportance of limiting ambient noise in the OR that might make sound changes hard to distinguish.Level of evidence: IV

Acetabular aseptic loosening due to bone defect in total hip arthroplasty revisions is a great challengeand several solutions have been proposed, but a broadly accepted consensus in the literature has not been reachedyet. The aim of this study is to compare the clinical and radiographic results of acetabular bone defects treatment withbiological-only graft or with a mixture of bone graft substitute and biological graft. 33 patients had revision hip arthroplasty using impaction grafting with biological-only graft (21 patients,Group A) or a 1/3 mixture of allograft and tricalcium phosphate bone graft substitute (12 patients, Group B). Patientswere reassessed at a minimum of one year after surgery with new x-rays and the Harris Hip Score (HHS). Survivorship of bone graft was 86% in Group A and 100% in Group B at a mean follow-up of 35 months. Nostatistical difference between the two groups was found in terms of implants survivorship (P=0.28), clinical (P=0.08) orradiographic (P=0.27) outcomes. In our experience the use of tricalcium phosphate bone graft substitutes in combination with allo andautograft provides good outcomes, low risk of failure and great clinical and radiographic results. Further investigationson larger samples are needed to impact clinical practice.Level of evidence: III

Failed open reduction internal fixation (ORIF) of peri-articular fractures due to deep infection is associatedwith decreased functional outcomes and increased mortality rates. Two-stage revision total joint arthroplasty (TJA) isoften needed as a salvage procedure. The aim of this study was to evaluate the outcome of two-stage revision totalhip and knee arthroplasty as a salvage procedure for the treatment of deep infection of peri-articular fracture fixation. Using propensity score-matching, a total of 120 patients was evaluated: 1) 40 consecutive patients weretreated with planned salvage two-stage revision for the treatment of deep peri-articular infection, and 2) a controlgroup of 80 patients who underwent two-stage revision for periprosthetic joint infection (PJI) after non-IF TJA. Aninfection occurred after a fracture of the acetabulum (27.5%), femoral neck (22.5%), intertrochanteric femur (15.0%),subtrochanteric femur (5.0%), femoral shaft (7.5%), distal femur (5.0%), and tibia (15.0%). At an average follow up of 4.5 years (range, 1.0-25.8), the overall failure rate was 42.5% for the IF groupcompared to 21.3% for the non-ORIF group (P=0.03). There was a significantly higher reinfection rate for the IF groupcompared to the non-IF group (35.0% vs. 11.3%, p=0.005). Tissue cultures for the IF patients demonstrated significantlyhigher polymicrobial growth (30.0% vs. 11.3%, P=0.01) and methicillin-resistant Staphylococcus aureus (20.0% vs.7.5%, P=0.04). Salvage two-stage revision arthroplasty for infected IF of peri-articular fractures was associated withpoor outcome. The overall post-operative complications after salvage two-stage revision for infected IF of peri-articularfractures was high with 35% reinfection rates associated with the presence of mixed and resistant pathogens.Level of evidence: III

High cost of eight-plate makes it unavailable in many countries; therefore, developing an alternativedevice for temporary hemiepiphysiodesis of knee deformities in pediatrics is valuable. In this study, we compared theoutcome of the eight-plate with the reconstruction-plate in this setting. In this retrospective study, 109 skeletally immature patients (212 physes) who underwent temporaryhemiepiphysiodesis to correct idiopathic genu valgum were included. The eight-plate and reconstruction-plate wereused in 45 patients (90 physes) and 62 patients (122 physes), respectively. Outcome measures were the valgus angle,medial proximal tibial angle (MPTA), the lateral distal femoral angle (LDFA), the joint-line convergence angle (JLCA),and lower limb mechanical axis (LLMA). The baseline characteristics of the patients were comparable between the two plate groups. The meanfollow-up of the patients was 32.9 ± 15.1 months. The mean MPTA change was 2.7 ± 3.7º in the eight-plate groupand 2.1 ± 3.4º in the reconstruction-plate group (P=0.2). The mean LDFA improvement was 8 ± 3.7º in the eight-plategroup and 7.9 ± 3.5º in the reconstruction-plate group (P=0.61). The mean valgus correction was 10.7 ± 4.4º in theeight-plate group and 10.4 ± 4.6º in the reconstruction-plate group (P=0.74). Moreover, the mean change of JLCA was0.7 ± 1.3º in the eight-plate group and 0.8 ± 1.3º in the reconstruction-plate group (P=0.58). The postoperative LLMAwas comparable between the two study groups as well. In total, five postoperative complications were recorded inthis series, which included one case of screw loosening in each group, two cases of overcorrection, and one screwbreakage in the reconstruction-plate group. The radiologic results and complications of the reconstruction-plate are comparable with the eight-plate.Therefore, it can be safely and efficiently used in hemiepiphysiodesis to correct idiopathic genu valgum.Level of evidence: III

Orthopaedic trauma surgeons believe that nutritional status is important. The primary aim of this studywas to prospectively investigate the prevalence and progression of malnourishment in orthopaedic trauma patients anddetermine when and what labs should be ordered. The secondary aim was to determine if malnourished patients hadincreased complications. Prospective cohort study of orthopaedic trauma patients at a Level I trauma center. Assessment of nutritionalstatus over the hospital course was performed using the Rainey MacDonald nutritional index (RMNI) and nutritionallaboratory markers on admission, day 3, day 7, and 6 weeks post-op. 98 patients were enrolled and included. On admission, 60%, 41%, and 38% of patients were malnourishedbased on albumin, prealbumin, and RMNI values, respectively, with 31% in severe acute-phase response (APR)as determined by CRP. By day 3, a significant increase in the percent of malnourished patients was noted basedon the laboratory markers, 85%, 90%, and 80%, respectively, with 70% in severe APR. On day 7, values stabilizedat 74%, 89%, 69%, with 56% in severe APR. At six weeks, malnourishment persisted in 13%, 19%, and 12%of patients, with 4% in severe APR. Older patients demonstrated a greater depression of nutritional markersthroughout the hospital stay. The prevalence of malnourishment, based on serum nutritional markers, in the presence of acuteorthopaedic injury is substantial, and it continues to rise during the acute hospital stay. Recommend obtaining prealbuminor albumin levels on hospital day 3 to assess nutritional status.Level of evidence: II

Bone disease-related fractures constitute a heavy burden on the healthcare systems and economy.Vitamin D is an important regulator of bone health and its deficiency is a global problem. This study aimed to evaluatethe effect of the 1,500 IU nano-encapsulated vitamin D used for fortifying low-fat dairy products (milk and yogurt) onbone health parameters.

This parallel totally blinded, randomized controlled trial was part of the Ultraviolet Intake by NutritionalApproach study and conducted on 306 individuals with abdominal obesity. Individuals were randomly assigned tofour groups, including fortified low-fat milk (1,500 IU nano-encapsulated vitamin D3 per 200 g/d), non-fortified low-fatmilk, fortified low-fat yogurt (1,500 IU nano-encapsulated vitamin D3 per 150 g/d), and non-fortified low-fat yogurt,for 10 weeks between January and March 2019. Bone mineral density (BMD) and trabecular bone score (TBS) weremeasured at the baseline and end of the trial. Trabecular bone score and BMD were defined as primary and secondaryoutcomes.

There were no significant differences in TBS and BMD between the intervention and control groups at theend of the trial (P>0.05).

This trial demonstrated no significant effect of nano-encapsulated vitamin D fortified milk and yogurt onBMD and TBS. There remains a need for longer-term trials regarding bone health outcomes to establish optimal dosesof fortification.Level of evidence: I

Orthopedic surgeons are sometimes hesitant to assess and address psychosocial factors.Surgeon-specific modifiable factors may contribute to surgeon attitudes and beliefs regarding the mental andsocial aspects of illness. A better understanding of these factors could help inform interventions to supportsurgeons and improve patient outcomes. We aimed to investigate whether orthopedic surgeons’ self-reportedcompassion, perceived stress, and experiential avoidance are independently associated with various surgeonattitudes and beliefs regarding psychosocial aspects of health. This is a cross-sectional study of 165 members of the Science of Variation Group (SOVG).Surgeons completed measures of compassion, stress, experiential avoidance, and demographics. Theyanswered questions addressing attitudes and beliefs regarding psychosocial aspects of care, which werecondensed to the following 6 dimensions through factor analysis: (1) confidence, (2) perceived resourceavailability, (3) blame towards patients, (4) fear of offending patients, (5) professional role resistance, and(6) fear of negative patient reactions. We performed 6 multivariable hierarchical regression analyses todetermine whether self-reported compassion, perceived stress, and experiential avoidance were associatedwith aspects of surgeons’ attitudes and beliefs regarding psychosocial care. After accounting for the influence of relevant covariates, experiential avoidance explained 2.9-6.6% of the variance (P-values .002 to .031) in all aspects of surgeon attitudes and beliefs regardingpsychosocial care, except for perceived resource availability. Perceived stress and compassion towardothers were not associated with any outcome variable. Targeting orthopedic surgeons’ tendency to avoid discomfort (i.e., experiential avoidance) viasupportive/educational programs may decrease barriers and increase their abilities to address psychosocialfactors, resulting in improved patient outcomes.Level of evidence: III

This study aimed to estimate the within-day and between-day reliabilities of sonoelastography to measurethe strain ratios of lumbopelvic muscles, including multifidus (MF), piriformis (P), quadratus lumborum (QL), and gluteusmedius (GM), in a resting position by the sonoelastography device in both patients with unilateral discogenic lumbarpain and healthy individuals. Failthe treatment of deep infection of peri-articular fracture fixation. First of all, the participants (n=25) were enrolled in this study, including patients (n=15) and healthy subjects(n=10). In the first session, an examiner estimated the strain ratio of lumbopelvic muscle three times by sonoelastography.The last session was held at a one-week interval. The collected data were analyzed using an intraclass correlationcoefficient (ICC) and a standard error of measurement. The ICC calculated for MF, P, QL, and GM measurements indicated good to excellent reliabilities in bothhealthy and patient groups for within- and between-intra-examiner reliabilities, which were obtained at 0.94-0.91 and0.86-0.86, 0.87-0.89 and 0.82-0.82, 0.88-0.86 and 0.86-0.86, 0.88-0.84 and 0.84-0.84, respectively. Furthermore, thestandard errors of intra-examiner reliability for MF, P, QL, and GM strain ratio measurements in both healthy andsubject groups were estimated at the ranges of 0.52-0.51 and 0.64-0.65, 0.60-0.62 and 0.77-0.78, 0.23-0.25 and 0.25-0.25, 0.25-026 and 0.30-0.35, respectively. The results revealed that sonoelastography seemed to be a reliable instrument to measure MF, P, QL,and GM muscle strain ratios in healthy subjects and patients with unilateral lumbar radicular pain. However, furtherstudies are recommended to support the findings of the present study in other patients.Level of evidence: III

Hypothermia increases bleeding during surgery, risk of ischemic heart disease and postoperative woundinfection. Intravenous amino acid increases cell synthesis and produces heat. Our goal was evaluating of the effect ofamino acid on intraoperative hypothermia under spinal anesthesia. This is a randomized, double-blinded clinical trial that 36 adults undergoing Hip Arthroplasty were randomlyassigned into two groups of 18 each. One group received Amino Acids solution (Aminoven 10%) 500ml (240ml/h)throughout spinal anesthesia, and control group received saline solution. We measured core body temperature, MAPand HR each 10 minutes, and also postoperative shivering, blood loss, operation time, postoperative BUN and Cr werecompared in two groups. Throughout surgery, the reduction in core temperature was more in the control group than the amino acidsgroup (statistically not clinically). The decrease in core temperature was significantly larger in the controls (0.96°C± 0.7°C) than in the amino acid patients (0.94°C ± 0.4°C), (P value= 0.02). Postoperative shivering was 73% in thecontrols regarding 11% in the amino acids patients. Overall, there were no significant statistical differences betweenother variables that we measured in two groups of patients. Amino acids infusion during spinal anesthesia exerted a thermogenic effect. Our findings showedhypothermia was less in the aminoacid group, and also postoperative shivering was more in the control group.Level of evidence: I