Archives of Bone and Joint Surgery
Volume:11 Issue: 11, Nov 2023

Radiofrequency (RF) is a minimally invasive procedure for interrupting or modifying nociceptive pathways to manage musculoskeletal neuropathic and nociplastic pain. RF has been used to manage cervical and lumbar facet joint syndromes. The benefits of RF are the following: it is safer than surgery; it doesn´t need general anesthesia, by that means diminishing the complications; it causes pain alleviation for a minimum of 3-4 months; it can be repeated if needed; it improves joint function; and it minimises the necessity for oral pain treatment. RF must not be used in pregnant women; unstable joints, uncontrolled diabetes mellitus; and presence of an implanted defibrillator. Even though complications from RF are rare, possible adverse events are infection, hemorrhage, numbness or dysesthesia, greater pain in the procedure area, and deafferentation impact. Even though there is a peril of injuring non-targeted neural tissue and other tissues, this can be lessened by carrying out the procedure with the help of fluoroscopy, ultrasonography or computed tomography. RF seems to be a helpful procedure for relieving chronic pain syndromes; despite this, definite proof of the procedure’s effectiveness is still needed. RF is an encouraging procedure for treating chronic spinal pain, especially when other procedures are pointless or not feasible.Level of evidence: III

There is debate about when to start exercises in the nonoperative treatment of a proximal humerus fracture. This randomized trial compared immediate and one-month delayed shoulder exercises in the nonoperative treatment of fractures of the proximal humerus. Twenty-six patients with a fracture of the proximal humerus who chose nonoperative treatment were randomized to start pendulum exercises within a few days and 24 were randomized to delayed exercises and started with active self-assisted stretching 1 month after fracture. Three and six months after the injury, patients completed the Disabilities of the Arm Shoulder and Hand questionnaire to measure capability, a measure of pain intensity, and had motion measurements. There was no significant difference in forward flexion (primary outcome) six months after injury between patients that started motion exercises immediately compared to 1 month after injury (p = 0.85). There was no difference in any motion measurement, pain intensity, upper extremity specific disability (DASH score) three or six months after injury. Delaying exercises for a month does not affect recovery from nonoperative treatment of a fracture of the proximal humerus. People can choose whether to start exercises immediately or wait until they feel comfortable.Level of evidence: II

The primary purpose of this study was to compare the rates of nonunion among different osteotomy designs (company brand) and the rates of nonunion between oblique and transverse osteotomies. We secondarily aimed to assess the differences in reoperation and hardware removal rates after ulnar shortening osteotomy (USO).
A retrospective cohort study of patients undergoing ulnar shortening osteotomy between 2015 and 2022 in our institute amongst 17 providers resulted in 92 consecutive patients. We included skeletally mature patients who underwent USO for the ulnar impingement abutment diagnosis. Demographic information was collected, including age, gender, race/ethnicity, BMI, and medical comorbidities. Six brand-specific devices were used and compared to the conventional plate fixation. Nonunion was determined based on the final available radiograph with a minimum follow-up of four months.
Of the 92 patients, 83 (90%) had a bone union. There is a remarkable difference in union among implant brands, although statistical analysis was not performed due to the small number of patients in each group. Transverse osteotomy was significantly related to a higher nonunion rate. Out of nine patients with resultant nonunion (10%), three healed after revision surgery (3.2%), two were lost to follow-up (2.2%), and four remained asymptomatic despite radiographic nonunion (4.6%). Plate removal was performed in four patients (4.3%), all of whom were in the union group.
Patients should be informed about the nonunion rate with possible subsequent secondary surgery. Using procedure-specific devices may have mitigated the risk of nonunion.
Level of evidence: III

Headless screw fixation used to treat metacarpal neck and metacarpal shaft fractures is gaining popularity. The aim of the study is to determine the proportion of the metacarpal head articular surface that is compromised during retrograde insertion of headless screws. Metacarpal screw fixation through a metacarpal head starting point was performed using fluoroscopic guidance on 14 metacarpals. Headless compression screws, with a tail diameter of 3.6mm, were used. The specimens were subsequently skeletonized and digitized using a 3-dimensional surface scanner. The articular surface defects created by the screws were then determined using computer software. Screw position in the dorsal aspect of the metacarpal head was expressed as a percentage of the total volar-to-dorsal distance. The 14 metacarpals studied consisted of 2 index, 4 long, 4 ring and 4 small metacarpals, taken from 4 hands. The average total metacarpal head surface area was 284.6 mm2 (range, 151.0-462.2 mm2); the average screw footprint in the metacarpal head was 13.3 mm2 (range, 10.3-17.4 mm2), which compromised a mean of 5.0% (3.0-7.8%) of the total cartilaginous metacarpal head surface area. In the sagittal plane, screw placement was found to lie in the dorsal 37.4% of the metacarpal head (range, 20.7-58.6%). The proportion of the articular surface area injured with retrograde insertion of headless compression screws into the metacarpal head is 5.0%. Screw placement is generally in the dorsal 37% of the metacarpal head.Level of evidence: V

Major surgical approaches for volar plating of the distal radius include the standard flexor carpi radialis (FCR) approach, the extended FCR (eFCR) approach, and the extended FCR approach combined with radial-sided carpal tunnel release (eFCR+CTR). The purpose of this study was to determine which of these three surgical approaches offers the greatest exposure and visualization of the distal radius.
Sequential dissections were performed on each of 30 fresh frozen below elbow cadaveric samples in order to simulate the three surgical approaches for distal radius volar plating, starting with the standard FCR approach, advancing to eFCR, and finishing with eFCR+CTR. Prior to the initial dissection of each cadaveric sample, radiographs were taken in order to calculate the total area of the distal radius. Then, following each sequential dissection, photographs were taken of each specimen and analyzed with an image measuring software in order to obtain the area of distal radius exposed. The percentage of total distal radius exposure was then calculated for each of the three surgical approaches.
The eFCR+CTR approach offered the greatest average distal radius exposure at 87% of total distal radius visualized. The eFCR approach provided the next greatest exposure with an average of 73% visualized, followed by the standard FCR approach with an average of 61% visualized.
The extended FCR approach with radial-sided carpal tunnel release is both safe and efficacious for osteosynthesis of distal radius fractures in the setting of concomitant carpal tunnel syndrome. This study demonstrates that an additional advantage of this approach includes improved surgical exposure and visualization of the distal radius. This surgical approach is a valuable addition to any upper extremity surgeon’s armamentarium and should be considered when treating difficult distal radius fractures.
Level of evidence: V

Internal rotation (IR) remains unpredictable following reverse total shoulder arthroplasty (rTSA). This study aimed to determine if increasing IR limits range of motion in other planes, and to determine pre- and intra-operative factors associated with post-operative IR.
A retrospective analysis of a single surgeon’s primary rTSA with a single implant was undertaken, excluding patients with acute fracture or infection. A lesser tuberosity osteotomy (LTO) or subscapularis peel tenotomy was performed and repaired at the surgeon’s discretion. One hundred sixty rTSA were included; 142 (88.8%) had documented IR both pre-operatively and at one-year follow-up. Variables were collected to determine their effect on IR at the 1-year follow-up point. A multivariate logistic regression was used to determine independent predictors of sufficient IR.
Average age was 69.8 (range: 55-86) years and 55% (88/160) were female. Preoperatively, 20.4% of patients (29/142) had sufficient IR. This improved to 32.4% (46/142) one year following surgery, p<0.001). Factors associated with sufficient post-operative IR were female sex (p=0.05), decreasing body mass index (p=0.04), pre-operative IR (p=0.01), preoperative external rotation (ER) in adduction (p<0.001), radiographic evidence of LTO healing (p=0.02), increased one-year postoperative forward elevation (p<0.001), and increased one-year postoperative ER (p<0.001). Increased postoperative IR did not adversely affect forward elevation or ER. On multivariate analysis, higher preoperative IR and one-year postoperative forward elevation were independently associated with sufficient one-year postoperative IR.
IR following rTSA continues to be modest and unpredictable. Independent predictors of sufficient post-operative internal rotation were higher preoperative IR and one-year postoperative forward elevation. In a Grammont-style rTSA system, humeral version, glenosphere lateralization, and glenosphere size do not appear to impact IR. Importantly, achieving sufficient IR does not come at the expense of other planes of motion.
Level of evidence: III

Total knee arthroplasty (TKA) serves as an effective surgical treatment method for advanced osteoarthritis (OA). Nonetheless, it is associated with postoperative pain that can influence patients’ functional outcome. This study aimed to compare the analgesic effect of subperiosteal and periarticular injection methods of a special local anesthetic in patients who underwent TKA. This double-blind prospective clinical study was conducted on patients with advanced knee OA who underwent TKA. Patients were randomly divided into two groups, with a local anesthetic (21 ml) administered either in periarticular (P group) or subperiosteal (S group) forms prior to wound closure. The local anesthetic consisted of lidocaine 2% (15 cc), dexmedetomidine (1 cc), and marcaine 0.5% (5 cc). A study-blinded orthopedic resident recorded postoperative pain levels using a 10-point visual analogue score (VAS) (0 indicating no pain, 10 indicating worst pain) at 6, 12, 24, and 48 hours after surgery. A total of 40 patients (P and S group; n=20 each), consisting of 10 males (mean age=67.4 years old), were included in this study. The intensity of pain in the S group was significantly lower than in the P group 24 hours after surgery (mean VAS scores in the P group: 4±1 vs. the S group: 3.3±0.7, P=0.024). Furthermore, VAS scores at 6, 12, and 48 hours post-surgery were lower in the S group compared to the P group; however, the difference was not statistically significant (P>0.05). Our study indicated that subperiosteal injection of lidocaine, dexmedetomidine, and marcaine is more effective than periarticular injection, providing effective postoperative pain management after TKA.Level of evidence: II

The study aimed at discovering the existing differences in lower limb joints' kinematics, and EMG signals of 4 particular muscles of the ankle joint during gait, between normal subjects and patients with bilateral triple arthrodesis.
In this research, a 3D motion analysis system was used and joints’ angles were calculated using a MATLAB code, and based on the data collected from markers movements, for patients with bilateral triple arthrodesis and normal subjects. Moreover, the EMG signals of ankle muscles in each subject, and the graphs of mean plus and minus standard deviation of lower limb joint angles and muscles’ EMG were calculated by MATLAB.
In all patients, an initial ankle eversion and valgus deformity were observed in their knee joints. In addition, for all patients, the maximum knee extension was less than that of the average value of the normal subjects. Furthermore, the results of the electromyography showed that, in all patients, delay occurred in gastrocnemius and soleus muscles in maximum contraction in their EMG signals. Besides, during the early stance phase of gait cycles, the mean value of EMG of peroneus brevis muscle for patients was more than that of normal subjects.
Atrophy of four ankle muscles including (soleus, lateral gastrocnemius, tibialis anterior and peroneus brevis), also limitation of joints movement were observed in patients, compared to normal subjects. Based on the results of this work, in order to reduce further musculoskeletal disorders in patients who underwent bilateral triple arthrodesis surgery, there is a serious need to use physiotherapy after the surgery.
Level of evidence: IV

Periprosthetic femoral fracture is the third most frequent complication after total hip replacement (THR). It is mainly caused by low-energy trauma in the elderly. Open periprosthetic fractures are significantly rarer and are caused by high-energy trauma. Here we present a case of a 73-year-old man who sustained an open (Gustilo II) left periprosthetic femoral fracture with an unstable femoral component (Vancouver B2). After an early stabilization with a temporary external fixator, a single-stage revision using a tapered long femoral stem was performed. At the last follow-up (3.2 years), the patient was satisfied and walked without pain and aids, and the Harris Hip Score was 83.5. No signs of infection or osteolysis were present in the last radiographs.
Level of evidence: V

The lateral talar dome osteochondral fracture has been described as shallow or wafer-shaped and is more likely to have an associated flake fracture than medial injuries. Displacement into the extracurricular space, however, is a rare occurrence. We present a case of ankle trauma with persistent pain and edema. A CT scan revealed a displaced osteochondral fracture of the lateral dome of the talus and an avulsion fracture of the tip of the medial malleolus. After appropriate dissection and exposure, the fragment was found below the skin, outside the ankle joint capsule. The fragment was fixed to the neck of the talus, and the deltoid ligament and anterior inferior tibiofibular ligament were repaired. After a one-year follow-up, full recovery was achieved without pain, stiffness, or osteonecrosis of the displaced fragment. Although the extra-articular displacement of lateral talar dome osteochondral fractures is rare, it should be considered when assessing ankle trauma.Level of evidence: IV

Orthopedic Specialty hospitals (OSHs) provide a larger surgical volume, while improving operative time and length of stay of patients, compared with general hospitals. It has been shown that adverse outcomes are less common in OSHs rather than in general hospitals. The main tips for designing OSHs extracted from the eight selected GB`s guidelines include Indoor environment quality (IEQ) items, ergonomic designing, site selection and surrounding land, climate-responsive designing, access to public transportation, ease of access for patients with ambulation disabilities, well-designed and efficient layout, adjustable features, patient flow optimization, dedicated imaging and X-ray areas, well-designed examination rooms, rehabilitation spaces, supportive flooring, lighting, patient-friendly amenities, Infection control measures, uneven surfaces, elevators, casting rooms, operating rooms and telemedicine. By prioritizing site selection to energy efficiency, water conservation, indoor environmental quality and healing outdoor spaces, OSHs can minimize their ecological footprint, create healing environments, and promote the well-being of patients, staff, and visitors.

We read with interest the article titled "Prophylactic Fibrinogen Reduces Excessive Bleeding in Total Hip Arthroplasty Surgery: A Randomized Double-blinded Placebo-controlled Trial" authored by Alireza Shakeri et al. with great interest. We commend the authors for their efforts to demonstrate the hemostatic effect of fibrinogen in total hip arthroplasty. However, we are concerned about the lack of clear criteria for postoperative blood transfusion in patients undergoing total hip arthroplasty, a crucial aspect that significantly influences the methodology of this study.