Archives of Bone and Joint Surgery
Volume:10 Issue: 12, Dec 2022

Robotic-assisted total knee arthroplasty (RA-TKA) improves the accuracy of component alignment compared with patient-specific instruments (PSI) and conventional TKA (C-TKA), although clinically there is no difference between them in terms of postoperative outcomes. RA-TKA still has significant limitations that advise against its widespread use, such as high installation costs, additional radiation exposure, a steep learning curve, the small number of implant designs that are compatible with robotic technology, the lack of long-term results and the large heterogeneity of available systems.

Shoulder imbalance (SI) is among the most rated manifestations of adolescent idiopathic scoliosis (AIS)pointed to by patients and spine surgeons. It serves as a criterion to assess the outcome of scoliosis surgery and isalso a cause of dissatisfaction for the patients postoperatively. Despite the availability of multiple studies on this issue,a comprehensive survey of the risk factors and preventive measures has yet to be elucidated. The present study aimedto highlight the most recent approach to the evaluation and management of SI, as well as medical counseling about theexpectations and limitations of the surgery.

A systematic literature review using electric databases was conducted, including PubMed, Embase, theCochrane Library, and Google Scholar, with a well-defined search strategy on SI definition, risk factors, and preventiveand surgical recommendations.

A total of 69 articles were identified; SI > 2 cm was the most used cut-off, and its risk factors included the mainthoracic Cobb angle > 80˚, preoperative level shoulder, high left shoulder, and higher Risser grade. The most statedstrategies to preclude SI were the sufficient correction of the proximal thoracic curve, and moderate correction of themain thoracic and lumbar curve (LC).

Shoulder imbalance should be prevented not only for appearance or satisfaction but also for possiblecomplications such as distal adding-on, new LC progression, or trunk shift postoperatively in AIS patients.Level of evidence: V

Metacarpal and phalangeal fractures remain among the most frequently encountered orthopedic injuries, accountingfor 10% of all fractures. For operative fractures, there is an array of treatment options with percutaneous kirschner wirestabilization and screw and plate fixation strategies predominating. Recently, a new fixation method was introduced,intramedullary (IM) fixation with headless screws, which has advantages of a percutaneous technique and buriedhardware. The purpose of this review is to highlight the indications and surgical techniques of IM screw fixation ofmetacarpal and phalangeal fractures. Although more research is needed, IM fixation represents a potentially reliablealternative to Kirschner-wire and plate fixation.Level of evidence: V

The goal of this study was to determine if there is an association between glenohumeral synovitis andearly post-operative pain after arthroscopic rotator cuff repair. Fifty patients with symptomatic rotator cuff tears were prospectively enrolled prior to RCR. Baseline ASESscore, VAS Pain score, forward elevation, and external rotation were recorded. Intra-operatively, synovitis was gradedon a scale of zero to six as based on a previously validated scoring system. VAS Pain scores were obtained frompatients post-operatively on days one through 14, week 6, and 3 months. Average intra-operative synovitis score was 2.4 ± 1.6. No significant correlation was found between synovitisscore and pre-operative forward elevation (P=0.171), external rotation (P=0.126), VAS Pain (P=0.623), or ASES(P=0.187) scores. No significant correlation was found between synovitis score and post-operative VAS Pain level atany time point. There was a moderate correlation between both pre-operative VAS Pain and ASES scores and postoperativeVAS Pain in the first post-operative week. Workers’ compensation patients had worse pain at 3 months postoperativelycompared to non-workers compensation patients (P=0.038). This study reveals that macroscopically assessed glenohumeral synovitis does not have any significantcorrelation with pre-operative or post-operative pain in patients undergoing arthroscopic rotator cuff repair; althoughhigher pre-operative pain levels, worse pre-operative ASES scores, and workers compensation status do influencepost-operative pain levels in arthroscopic rotator cuff repair.Level of evidence: III

Post-operative urinary retention (POUR) and dysfunction are recognized complications followingorthopaedic surgery. Recent literature has focused on urinary retention and its associated complications following hipand knee reconstruction and lower extremity surgery. There is a paucity of literature focusing on POUR and shouldersurgery. The purpose of this study is to describe the rates of urinary dysfunction in patients undergoing shoulder surgeryas well as the associated risk factors. This was a single institution, prospective cohort study. Eligibility criteria included patients older than 50years of age undergoing open or arthroscopic shoulder surgery. The primary outcome was the American UrologicalAssociation (AUA) symptom score (7 questions total scored 0-5, total 35 points max) administered before and aftersurgery. Higher scores reflect worse urinary dysfunction. Intra-operative data such as type of surgery, type of anesthesia,use of anticholinergics, peripheral nerve block, length of case, and amount of intravenous fluids were collected. Of 194 patients, the mean age was 61.4 years (Standard Deviation (S.D.) = 13.0)) and the average BMI was29.2 (S.D. = 5.6). The sample was 35.6% female. Overall, 46.4% reported worse AUA scores post-operatively within thefirst 3 to 5 days, including 4.1% of which were clinically defined as “moderately worse” (>5 point worse) or “much worse”(>11 points worse). Worse preoperative AUA scores correlated with worse postop AUA score on linear regressionanalysis (r=0.883, P<0.0001). Males with a history of BPH showed a statistically significant positive association withworsening urinary dysfunction postoperatively (P=0.039). Four patients (2.1%) required postoperative catheterization.A significantly higher percentage of patients with preoperative AUA scores of ≥11 experienced worsening of urinaryfunction post-operatively (P=0.04). Worsening of urinary function following shoulder surgery is common. The AUA score may be used toidentify at-risk patients and to track changes in urinary function post-operatively. Men with a diagnosis of BPH are atparticularly high risk. Further investigation is needed to elucidate the impact of urinary dysfunction on patient outcomes,satisfaction, and cost as well as the role of prophylactic medications.Level of evidence: II

To investigate the reliability of orthopedic hand surgeons to evaluate radiographic healing in initial andfollow-up radiographs of the conservatively treated metacarpal shaft and neck fractures. The rationale for this studywas to reduce the rate of unnecessary, routine radiographs when treating metacarpal fractures. Forty sets of digital x-rays, twenty at the initial visit and twenty at the 4-week follow-up, were randomlyselected and reviewed. Three hand surgeons evaluated the x-rays for (1) fracture location, (2) radiograph timing,(3) healing status, (4) percentage healed, (5) angulation, and (6) confidence in healing status. Observers reviewedstudies in random order and evaluated the same set of radiographs one month after the initial review. Intra- andinterobserver agreements were analyzed using Fleiss’ kappa (κ) for all parameters and all possible observerpairings. Interobserver and intraobserver reliability was highest when evaluating fracture location and lowest whenassessing the percentage healed. The interobserver reliability was fair for radiograph timing and healing status andfair-to-moderate for angulation. The intraobserver reliability was moderate for radiograph timing and healing status andmoderate-to-substantial for angulation. Observers correctly differentiated initial vs. follow-up images 62% of the timeand reported to feel somewhat certain in their evaluation of healing status. When evaluating initial and 4-week follow-up radiographs, hand surgeons were somewhat confidentin their assessment of healing but had less than substantial intra- and interobserver reliability following radiographicevaluation. Due to their poor reproducibility, routine radiographs may be unnecessary when evaluating conservativelytreated metacarpal fractures. Further studies and guidelines that identify clear indications for the use of routine imagingin metacarpal fracture care are warranted.Level of evidence: II

In recent years, the increasing popularity of cycling for commuting and leisure has led to acorresponding increase in bicycle-related injuries. However, there is a lack of extensive analysis of bicycle-relatedinjuries to the upper limb in the literature. A retrospective review of all patients with conventional bicycle-related injuries of the upper limb wasperformed. Data on demographics, mechanisms of injury, region of injury, fracture type, management type, andlength of hospital stay were extracted and analyzed. A total of 177 of 733(24%) patients with bicycle-related upper limb injuries were identified. The most commonmechanism of injury was a collision with another vehicle (60%). Frequently affected regions were the shoulder(48%), hand (19%), and wrist (19%). Eighty-eight (50%) patients sustained bony injuries, while the remainder (50%)had isolated soft tissue injuries. Fifty-three (30%) patients required a mean of 3.9 days of hospitalization, whereas13 (25%) patients required high dependency or intensive care unit treatment. Surgical interventions were requiredin 47 (27%) patients. Bicycle-related injuries to the upper limb are common and result in significant morbidity. The mostcommon regions affected are the shoulder, wrist, and hand. Most of the injuries were caused by collisions with othervehicles. A third of affected patients required hospitalization, and a quar ter required surgical intervention.Level of evidence: III

This study aimed to determine whether combined intravenous (IV) and intraarticular (IA) Tranexamicacid (TXA) reduces blood loss and the requirement of blood transfusion, compared to IA use alone in the middle easternpatients undergoing primary cemented unilateral Total knee arthroplasty (TKA). The present study is a double-blind randomized controlled trial (RTC) comparing the efficacy of IA aloneto combined IA and IV routes of TXA administration in patients undergoing primary cemented TKA using a tourniquetperformed by two senior surgeons. There were 21 patients in the IA alone and 29 in the combined group. The primaryoutcome measure was a blood transfusion requirement, hemoglobin drop, and the total estimated blood loss on daythree postoperative period. The secondary outcomes were complications, including thromboembolic events, woundcomplications, periprosthetic infection, patient-reported outcomes (PROs) of pain visual analog scale (VAS), WesternOntario and McMaster Universities Osteoarthritis Index (WOMAC), and EuroQol 5-dimension (EQ-5D), as well as therange of motion (ROM), at one-year follow-up. None of the patients in either comparison group required blood transfusion in the perioperative period. Thedrop in hemoglobin levels (2.1±1.0 vs. 2.2±1.1, P=0.84) and the total estimated blood loss (884±489 vs. 877±324,P=0.96) on the third postoperative day in the IA alone group showed no statistically significant difference comparedto that in the combined group. Moreover, there were no complications noted in patients of either group. At one-yearfollow-up, there was no significant difference between the two comparison groups regarding the mean PROs of painVAS, WOMAC, and EQ-5D, as well as ROM. According to the obtained results, this RCT in the middle eastern patient population found no additionalbenefit of TXA administration through combined IV and IA route over the IA alone in reducing the requirement of bloodtransfusion and the total blood loss. Further similar studies with larger sample sizes are needed to ascertain the idealroute of TXA administration in patients undergoing primary TKA.Level of evidence: I

Peripheral compartment hip arthroscopy has gained popularity over central compartment hip arthroscopyas peripheral compartment arthroscopy does not cause perineal post compression, prolonged lower extremity tractionand thus complications such as acetabular labrum and articular cartilage injuries. The study, in essence, aims toemphasize that peripheral hip arthroscopy (OPHA) alone is sufficient without an additional surgical method in thetreatment of femoroacetabular impingement syndrome (FAI). A total of 35 patients, being 21 female and 14 male, among a group of patients who were suffering fromFAI syndrome and applied to private hip conservatory centers and has undergone hip arthroscopy at a later stageby a senior surgeon (I.T.) were selected from the medical-based software of the hospital. Patients with intra-articularpathology as a result of magnetic resonance imaging (MRI) were excluded from the study. The group had a meanage of 40.6, youngest being 17 and oldest 69, while the mean observation period was 26.6 months, varying betweenshortest 6 months and longest 63. In order to assess the patient satisfaction as well as clinical outcomes, Postel Merled’Aubigné (PMA) score was used. When patient satisfaction was evaluated, overall decrease in pain was found and when gait characteristicswere evaluated together with movement, an increase in overall satisfaction was found (P<0.05). Secondary arthroscopicprocedures was not required in any of the patients included in this study. A group of three patients only needed someadditional surgical interventions like stem cell therapy, hip arthroplasty and pelvic osteotomy. OPHA can provide adequate treatment in selected FAI patients as it allows us to avoid critical complicationssuch as damage to the cartilage, avascular necrosis, complications caused by traction and prolonged operation timesseen in central compartment arthroscopy.Level of evidence: III

The impact of periarticular corticosteroid injection for pain control after total joint arthroplasty (TJA) iscontroversial. The present study aimed to investigate this controversy in patients undergoing total hip arthroplasty(THA) and total knee arthroplasty (TKA).

A total of 42 THA and 42 TKA patients were included in this study. The patients of each group were randomlyallocated into group A (cocktail+Depo-Medrol) and group B (cocktail alone). The outcome measures were a VisualAnalog Scale (VAS) for pain at five different time points for both THA and TKA, as well as the knee range of motion(ROM) and straight leg raise (SLR) for the TKA group only. Patients were followed for three months to observe infection,wound complications, and any venous thromboembolic event.

In the THA group, the preoperative VAS, 12, 24, 48, and 72h postoperative VAS were not statistically differentbetween groups A and B (P=0.49, P=0.5, P=0.96, P=0.15, and P=0.11, respectively). In the TKA group, the preoperativeVAS, 12, 24 48h, and 72h postoperative VAS were not statistically different between groups A and B (P=1.0, P=0.47,P=0.82, P=0.92, P=0.5, respectively). The mean scores of knee range of motion and ability to perform SLR were notsignificantly different between TKA patients in the steroid and non-steroid groups (P=0.18 and P=0.58, respectively).The only observed complication was one surgical site infection in the non-steroid group of the TKA.

The obtained results did not support the benefit of including a steroid (Depo-Medrol) in the periarticularinjection cocktail for pain control after the THA and TKA.Level of evidence: II

Intramedullary screw fixation provides a less-invasive means of surgically managing metacarpal fractures. While thereare advantages to using this technique compared to CRPP and ORIF, disadvantages of intramedullary screw fixationinclude loss of reduction intraoperatively due to sagittal and coronal plane translation. The blocking screw techniquehas been previously described as a solution for this problem in intramedullary fixation of long bone fractures. Wedescribe the blocking screw technique as applied to aid intramedullary screw fixation of metacarpals.Level of evidence: V

We report a primary synovial osteochondromatosis in a 6-year-old male with a 1-year history of shoulder pain andstiffness. The patient underwent surgical treatment, resulting in significant improvement in range of motion andfunctional status. Primary synovial osteochondromatosis of the shoulder is a rare benign condition that can result inshoulder pain, stiffness, and locking. MRI helps identify these lesions within the affected joint. Removal of loose bodiesoften alleviates symptoms and allows for improved range of motion with satisfactory results.Level of evidence: IV