Archives of Bone and Joint Surgery
Volume:2 Issue: 3, May 2014

Developmental dysplasia of the hip (DDH) or congenital hip dysplasia (CDH) is the most prevalent developmental childhood hip disorder. It includes a wide spectrum of hip abnormalities ranging from dysplasia to subluxation and complete dislocation of the hip joint. The natural history of neglected DDH in adults is highly variable. The mean age of onset of symptoms is 34.5 years for dysplastic DDH, 32.5 years for low dislocation, 31.2 years for high dislocation with a false acetabulum, and 46.4 years for high dislocation without a false acetabulum. Thorough understanding of the bony and soft tissue deformities induced by dysplasia is crucial for the success of total hip arthroplasty. It is important to evaluate the existing acetabular deformity three-dimensionally, and customize the correction in accordance with the quantity and location of ace tabular deficiencies. Acetabular reconstruction in patients with DDH is hallenging. Interpretation of published data is difficult and should be done with caution because most series include patients with different types of hip disease. In general, the complication rate associated with THA is higher in patients with hip dysplasia than it is in patients with osteoarthritis. Overall, clinical and functional outcomes following THA in patients hip dysplasia (DDH) differ from those treated for primary hip osteoarthritis, possibly due to the lower age and level of activity. Although function scores decline with age, the scores for pain and range of motion presented with a statistically significant improvement in the long-term.

The aim of this review article is to analyze the clinical effectiveness of total knee replacement (TKR) compared to unicompartmental knee replacement (UKR) in patients with medial unicompartmental osteoarthritis (MUO) in terms of survival rates, revision rates and postoperative complications. The search engine was MedLine. The keywords used were: medial knee osteoarthritis. Three thousand and ninety-six articles were found on 28 April 2014. Of those, only twenty-eight were selected and reviewed because they were strictly focused on the topic of this article. Compared with those who have TKR, patients who undergo UKR have higher revision rates and lower survival rates at 5, 10 and 15 years. The reported overall risk of postoperative complications for patients undergoing TKR is 11%, compared with 4.3% for patients undergoing UKR. In conclusion, UKR have higher revision rates and lower survival rates than TKR. There is, however, an increased risk of postoperative complications after TKR.

Tranexamic acid (TXA) has received extensive attention in management of blood loss in orthopedic surgeries. However, the ideal method of TXA administration is still controversial. This study aims to determine whether intraarticular injection of TXA reduces blood loss after total knee arthroplasty (TKA). Through a retrospective case-control study consecutive TKA patients receiving intraarticular TXA (Case group) were compared with similar patients undergoing TKA using traditional blood management strategy (Control group). Hemoglobin levels (Hb) before and after the surgery, need for transfusion, and reoperation due to massive blood loss were compared between the two groups. Fifty TXA patients were compared with 50 patients of the control group. There was no significant difference between the two groups in terms of age, gender, and preoperative Hb. Postoperative blood loss and transfusion rate were significantly reducedin TXA patients compared to the control group (P<0.05). Our study revealed that intraarticular administration of TXA reduces postoperative blood loss as well as need for blood transfusion in patients undergoing TKA.

New discoveries about the pathophysiology changed the concept that all forms of osteoarthritis are alike; this lead to the delineation of different phenotypes such as age, trauma or obese related forms. We aim to compare soluble mediator profiles in primary knee and posttraumatic wrist osteoarthritis. Based on the general faster progression rate of wrist osteoarthritis, we hypothesize a more inflammatory profile. We collected synovial fluid from 20 primary osteoarthritic knee and 20 posttraumatic osteoarthritic wrist joints. 17 mediators were measured by multiplex enzyme-linked immunosorbent assay: chemokine ligand 5, interferon-γ, leukemia inhibitory factor, oncostatin-M, osteoprotegerin, tumor necrosis factor-α, vascular endothelial growth factor, interleukin (IL)-1α, IL-1β, IL-1 receptor antagonist, IL-4, IL-6, IL-7, IL-8, IL-10, IL-13 and IL-17. Ten mediators were higher in posttraumatic osteoarthritic synovial fluid: tumor necrosis factor-α (TNFα), IL-1α, IL-1RA, IL-6, IL-10, IL-17, oncostatin-M, interferon-γ, chemokine ligand 5 and leukemia inhibitory factor(P<0.001). IL-1ß, IL-4, IL-7 were not detected, TNFα was not detected in knee osteoarthritic synovial fluid. IL-8, IL-13, osteoprotegerin and vascular endothelial growth factor levels did not differ between the synovial fluid types. In general wrist osteoarthritis seems characterized by a stronger inflammatory response than primary knee osteoarthritis. More pronounced inflammatory mediators might offer a paradigm for the faster progression of posttraumatic osteoarthritis. Increase of specific mediators could form a possible target for future mediator modulating therapy in wrist osteoarthritis.

Previous studies suggest total hip arthroplasty may have some benefits compared to hemi-arthroplasty for displaced intracapsular femoral neck fractures in patients more than 60 years of age. The primary research question of our study was whether in-hospital adverse events, post-operative length of stay (LOS) and mortality in patients 60 year of age or older differed between total hip and hemi-arthroplasty for femoral neck fracture. We obtained data on 82951 patients more than 60 years of age with an isolated femoral neck fracture treated with either hemi-arthroplasty or total hip arthroplasty in 2009 or 2010 from the National Hospital Discharge Survey (NHDS) database. The International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9, CM) was used to code diagnoses, comorbidities, complications, and procedures. Controlling for demographics and comorbidities, patients treated with hemi-arthroplasty had a 40% (95% CI 1.4-1.5) higher risk of adverse events compared to patients treated with a total hip arthroplasty. Length of stay and in-hospital mortality did not differ between these groups. The observed advantage for total hip arthroplasty might reflect greater infirmity in hemi-arthroplasty patients that was not accounted for by ICD-9 codes alone.

We aimed to report outcomes of total hip arthroplasty (THA) in very young patients under the year of 30. Thirty patients (45 hips) with various indications for THA were retrospectively reviewed radiologically and clinically and analyzed regarding survival, reasons of failure, factors associated with outcomes and postoperative complications. Within a mean follow-up time of 116 months the 10-year survival rate was 90.3%. All hips were revised due to aseptic loosening. No association was found among the tested parameters with increased revision rates.Three complications associated with the THA were recorded and managed conservatively. All patients had statistically significant improved clinical scores compared to the pre-operative period, despite the underlying disorder that compromised the condition in the majority of the patients. Our study showed excellent long term outcomes of THA in patients younger than 30 years of age, comparable with those in older patients.

Patients undergoing cemented hip hemiarthroplasty may develop bone cement implantation syndrome (BCIS) which is a leading cause of intraoperative complications. The purpose of this study was to evaluate cardiovascular changes during cemented hip hemiarthroplasty in elderly patients. Cemented hip hemiarthroplasty was performed on 72 patients with femoral neck fracture. All patients were catheterized with a radial artery catheter to assess mean arterial pressure (MAP) and arterial blood gas (ABG) in these time points: just before cementation, just after cementation (0th), 5 min (5th) and 10 min (10th) after cementation, and at the end of surgery (END). Also, systolic and diastolic blood pressure (SBP & DBP), heart rate and any arrhythmia or cardiac arrest was evaluated. Seventy-two patients (33 females, 39 males; mean age: 66.8±7 years) were evaluated. All parameters changed during cementation with a significant drop in MAP, SBP, and DBP immediately after cementation and pH and base excess decreased significantly (P<0.001) with no changes in O2 saturation. Mean heart rate rose until the 5th and then decreased dramatically with no bradycardia presentation. During cementation, 12 patients showed arrhythmia, but no cardiac-arrest was observed. Under strict observation of a anesthesiology care team, hemiarthroplasty can be a safe method for femoral neck fracture in elderly osteoporotic patients without severe cardiopulmonary compromise.

Hip fracture Management in supine position on a fracture table with biplane fluoroscopic views has some difficulties which leads to prolongation of surgery and increasing x- rays’ dosage. The purpose of this study was to report the results and complications of hip fracture management in lateral position on a conventional operating table with just anteroposterior fluoroscopic view. 40 hip fractures (31 trochanteric and 9 femoral neck fractures) were operated in lateral position between Feb 2006 and Oct 2012. Age, gender, fracture classification, operation time, intra-operation blood loss, reduction quality, and complications were extracted from patients’ medical records. The mean follow-up time was 30.78±22.73 months (range 4-83). The mean operation time was 76.50 ± 16.88 min (range 50 – 120 min).The mean intra-operative blood loss was 628.75 ± 275.00 ml (range 250-1300ml). Anatomic and acceptable reduction was observed in 95%of cases. The most important complications were malunion (one case in trochanteric group), avascular necrosis of oral head and nonunion (each one case in femoral neck group). It sounds that reduction and fixation of hip fractures in lateral position with fluoroscopy in just anteroposterior view for small rural hospitals may be executable and probably safe.

Due to difficulty in obtaining anatomical reduction, management of the unstable intertrochanteric fractures in elderly osteoporotic patients is challenging. The purpose of this study is to compare the results of hip arthroplasty (total, hemi, or bipolar) with DHS in the elderly patients with unstable intertrochanteric fractures. We prospectively studied and followed-up 80 old patients with complex unstable intertrochanteric fracture from January 2007 to December 2010. Depending on the time of the patients’ admission, we alternatively treated them by DHS and arthroplasty, and placed them in Groups A and B, respectively. We followed them up radiologically and also clinically by Harris Hip Score for more than 24 months. Statistical analysis was performed using SPSS version 11.5 for Windows. The mean length of follow-up and age were 34.3±4.1 months (ranged; 24-59) and the 75.2±5.2 years (ranged; 58-96), respectively. Comparing Group A with B, demographic data, mean blood loss, duration of operation, time to walking and duration of hospital stay had no significant difference but overall device related complications were significantly higher in Group A. Functional scores were also higher in Group B, but this difference was not significant statistically. In both groups, the patients with Type A3 compared with Type A2, had more duration of surgery and blood loss. Arthroplasty is an alternative treatment in elderly patients with unstable intertrochanteric fractures and can provide good and satisfactory clinical outcomes associated with low complication and mortality rates.

Conventional treatments after complicated injuries of the distal radioulnar joint (DRUJ) such as Darrach and Kapandji-Sauvé procedures have many drawbacks, which may eventually lead to a painful unstable distal ulna. The development of DRUJ prosthesis has significantly evolved over the past years. In this study, we assessed the outcome results of patients after DRUJ implant arthroplasty using the Aptis (Scheker) prosthesis. We identified 13 patients with 14 prosthesis during the past 10 years. Patients underwent DRUJ arthroplasty due to persistent symptoms of instability, chronic pain, and stiffness. Records and follow-up visits were reviewed to find the final post-operative symptoms, pain, range of motion, and grip strength with a mean follow-up of 12 months (range: 2-25 months). Also, patients were contacted prospectively by phone in order to minister the disabilities of the armshoulder and hand (DASH), patient rated wrist evaluation (PRWE), and visual analogue scale (VAS), and to interview regarding satisfaction and progress in daily activities. Eleven patients out of 13 could be reached with a median followup time of 60 months (range: 2 to 102 months). No patient required removal of the prosthesis. Only two patients underwent secondary surgeries in which both required debridement of the screw tip over the radius. The median DASH score, PRWE score, VAS, and satisfaction were 1.3, 2.5, 0, and 10, respectively. The mean range of flexion, extension, supination, and pronation was 62, 54, 51, and 64, respectively. Distal radioulnar joint injuries are disabling and patients usually undergo one or more salvage surgeries prior to receiving an arthroplasty. The Scheker prosthesis has shown satisfactory results with 100% survival rate in all reports. The constrained design of this prosthesis gives enough stability to prevent painful subluxation.

This study tested the null hypothesis that nonoperatively treated patients would not show disease progression of carpal tunnel syndrome (CTS) over time according to median nerve distal motor latency (DML) on two electrodiagnostic tests. This retrospective study analyzed sixty-two adult nonoperatively treated patients who were diagnosed with CTS confirmed by a minimum of two electrodiagnostic tests at our institution between December 2006 and tober 2012. A Wilcoxon signed-rank test was conducted to test the difference between electrodiagnostic measurements between the first and last test. The mean time between the first and last electrodiagnostic test was 26±12 months (range, 12 to 55 months). The only electrodiagnostic measurement that increased significantly was the difference between median and ulnar DML on the same side (r=0.19, P =0.038). The time between the electrodiagnostic tests was significantly longer for patients with at least 10% worsening of the DML at the second test compared to cases of which the DML did not worsen or improve a minimum of 10% (P =0.015). There is evidence that—on average—idiopathic median neuropathy at the carpal tunnel slowly progresses over time, and this can be measured with electrodiagnostics, but studies with a much longer interval between lectrodiagnostic tests may be needed to determine if it always progresses.

The primary aim of this study was to determine predictors of missed research appointments in a prospective andomized placebo injection-controlled trial with evaluations 1 to 3 and 5 to 8 months after enrollment. This study represents a secondary use of data from 104 patients that were enrolled in a prospective randomized ontrolled trial of dexamethasone versus lidocaine (placebo) injection for various diagnoses. Patients were enrolled between June 2003 and February 2008. Sixty-three patients (61%) had lateral epicondylosis, 17 patients (16%) had trapeziometacarpal arthrosis, and 24 patients (23%) had de Quervain syndrome. Each patient completed a set of questionnaires at time of enrollment. Bivariable and multivariable analyses were used to determine factors associated with missed research appointments. Fourteen patients (13%) did not return for the first follow-up and 33 patients (32%) did not return for the second follow-up. The best multivariable logistic regression model for missing the first research visit explained 35% of the variability and included younger age, belief that health can be controlled, and no college education. The best model for missing the second research visit explained 17% of the variability and included greater pain intensity, less personal responsibility for health, and diagnosis (trapeziometacarpal arthrosis and de Quervain syndrome). Younger patients with no college education, who believe their health can be controlled, are more likely to miss a research appointment when enrolled in a randomized placebo injection-controlled trial.

Research projects are presented at the Annual Meetings of the American Society for Surgery of the Hand (ASSH). It is unknown how many achieve publication in peer-reviewed journals. We sought to determine current rates of publication of podium and poster presentations. All ASSH podium and poster presentations from 2000 to 2005 were reviewed, and an Internet-based search using PubMed and Google was conducted to determine whether the presented studies had been published. Times to publication and journal names were recorded. Data were analyzed with descriptive statistics. Fisher’s exact test was conducted to compare current trends with previous trends. Of 1127 podium and poster presentations reviewed, 46% were published in peer-reviewed journals. Forty-seven percent of published presentations (242 presentations) were in Journal of Hand Surgery, and 11% (59 entations) were in Journal of Bone and Joint Surgery. Forty-five percent of presentations were published within 2 years and 66% within 3 years. The publication rate for podium presentations was significantly higher than that previously reported for Journal of Hand Surgery, at 54% compared with 44% (P=0.004). Currently, fewer than half of the studies presented at Annual Meetings of the ASSH achieve publication in peer-eviewed journals. Presentations are most likely to be published within 3 years, and almost half are published in Journal of Hand Surgery.

There is still controversy regarding the best technique for ankle arthrodesis to acheive stable rigid fixation along with reconstructing a functional plantigrade foot. Moreover, existing techniques have complictions related to stability, soft tissue covering, fusion rate, and exposure. With the anterior approach exactly on the tibialis anterior sheath, the joint was exposed and previous hardware, if any, was removed and with the safe direct approach, the ankle, hindfoot, and indirectly the subtalar joints were accessed. Then fresh cancellous bone was obtained and complete denudation was preformed. Lastly, a narrow 4.5 millimeter plate was carefully placed on what was determined to be the best final position.In this prospective study, 12 patients with severe ankle pain and arthritis enrolled from February 2010 to January 2012. Eight of them had posttraumatic arthritis and deformity with hardware, two had rheumatoid arthritis, one had poliomyelitis with severe deformity of the foot and knee, and another had chronic ulcerative ynovitis of the ankle joint. The patients were assessed clinically and radiographically for an average of two years (range: 13 months to 4 years) for functional recovery, range of motion, stability of the ankle, and imaging evidence of union. Ankle deformities and pain in all 12 cases were corrected. With a short healing time and rapid recovery period, after six weeks all of the patients could walk independently. Also, scores of the Manchester–Oxford Foot Questionnaire (MOXFQ) improved significantly from 69 preoperatively to 33 postoperatively). Anterior ankle arthrodesis with molded plating can be an easy and safe way to manage deformities and it has excellent fusion rate and sufficient rigid fixation.

Clavicle fractures are common and usually heal without complications. In this study, we evaluated the outcomes of non-operative versus operative management of displaced fractures. In a prospective clinical trial study, sixty-five patients with displaced clavicle mid-shaft fractures were nonrandomly divided in two treatment groups. The first group underwent non-operative treatment with figure of 8 bandage (30 patients), and the other underwent operative treatment with plate fixation (35 patients). Figure of 8 bandage and 3.5 millimeter DCP plate with at least six cortical screws were used in non-operative and operative groups respectively. We followed up all patients at weeks 2, 6 and 12, and at month sixth. In addition to clinical examination and x-ray evaluation, we assessed satisfaction, DASH and Constant Shoulder Score for each individual. The average durations of union were 19.3 and 24.4 weeks in operative and non-operative groups respectively (P=0.006). Satisfaction with operative treatment was 74.3% and with non-operative treatment was 66.7%, showing no significant difference (P=0.500). The non-union rate was 5.7% in the operative group and 13.3% in the non-operative group (P=0.518). A significant difference between the two groups in terms of DASH and Constant Shoulder Scores after the six-month follow-up was not found (P=0.352). According to our results, we recommend operative treatment in mid-shaft clavicle fractures only when there is a definitive indication.

The glenohumeral joint becomes dislocated more than any other major joint because it maintains a wide range of motion and its stability is inherently weak. The most common complication following acute initial shoulder dislocation is recurrent dislocation or chronic instability. Imbalance of strength and range of motion in individuals with anterior dislocation can be a contributing factor in recurrent dislocation as well. This case-control study consisted of 24 individuals with a mean age of 24.29±4.33 years, and a mean dislocation rate of 5.37±3.62 times. Isometric cuff strength was measured using a handheld dynamometer and for range of motion, the Leighton flexometer was used in internal and external rotational motions of both upper extremities. Independent t-test was used for data analysis. The internal and external range of motion of the injured glenohumeral joint was lower than the uninjured joint (P<0.001). Similarly, the internal and external rotation strength of the injured joint was lower than the uninjured joint (P<0.001). According to previous data, imbalance of strength and range of motion in individuals with anterior shoulder dislocation can be a contributing factor in long-term disability and increased recurrent dislocation and our finding confirm decreased range of motion and strength in our patients. Hence, proper exercise and rehabilitation plans need to be developed for those suffering from this complication.

To explain the role of arthroscopic release in intractable frozen shoulders. We used different questionnaires and measuring tools to understand whether arthroscopic release is the superior modality to treat patients with intractable frozen shoulders. Between 2007 and 2013, in a prospective study, we enrolled 80 patients (52 females and 28 males) with recalcitrant frozen shoulder, who underwent arthroscopic release at Ghaem Hospital, a tertiary referral center, in Mashhad, Iran. Before operation, all patients filled out the Disability of Arm, Shoulder and Hand (DASH), Constant,University of California Los Angeles (UCLA), ROWE and Visual Analogue Scale (VAS) for pain questionnaires. We measured the difference in range of motion between both the normal and the frozen shoulders in each patient. The average age of the patients was 50.8±7.1 years. In 49 patients, the right shoulder was affected and in the remaining 31 the left side was affected. Before surgery, the patients were suffering from this disease on average for 11.7±10.3 months. The average time to follow-up was 47.2±6.8 months (14 to 60 months). Diabetes mellitus (38%) and history of shoulder trauma (23%) were the most common comorbidities in our patients. We did not find any significant differences between baseline characteristics of diabetics patients with non-diabetics ones. After surgery, the average time to achieve maximum pain improvement and range of motion were 3.6±2.1 and 3.6±2 months, respectively. The VAS score, constant shoulder score, Rowe score, UCLA shoulder score, and DASH score showed significant improvement in shoulder function after surgery, and shoulder range of motion improved in all directions compared to pre-operation range of motion. According to our results, arthroscopic release of recalcitrant frozen shoulder is a valuable modality in treating this disease. This method could decrease pain and improve both subjective and objective mid-term outcomes.

Hand injuries are among the most common childhood injuries. No study has been performed regarding the epidemiology of hand injuries in the pediatric population of Iran. This study aimed to examine the epidemiology of hand injuries among children in southeast of Iran. This cross-sectional study was performed via census sampling on patients, aged 16 years or less, with a final diagnosis of hand injury. Patients presenting to the orthopedic department of Khatam-al-Anbia General Hospitalof Zahedan, Iran, were selected from March 2012 to December 2013. Data were analyzed trospectively, using a chart review. Two-hundred patients (136 males and 64 females with the mean age of 13±2.8 years) with 205 hand injuries were included in this study. As the results indicated, door-related injuries were the most common type (25%), accounting for 24% and 28% of injuries in male and female patients, respectively (P=0.016). Most injuries occurred at home (64%) and the lowest number was reported at school(22%) (P=0.012). Compared to boys, girls were more likely to be injured at home (78% vs. 57%) (P=0.13). In addition, the dominant hand was mostly injured by doors (28%). The most common type of injury was laceration(81%) and the least common type was finger amputation (7%); also, children with finger amputation were significantly younger than those with other types of hand injuries (P<0.001).Thumb alone (20%) and index and middle fingers together with anequal percentage (3.5%) were the most commonly injured digits. Also, the mean hospitalization cost was 297± 38 dollars. Most hand injuries occurred at home and were door-related; they were also more frequentamong younger children. Prospective studies in order to identify specific protective door devices could potentially decrease the frequency of these injures.

Ganglion cysts commonly occur around the shoulder, mostly in the spinoglenoid and suprascapular notches. We report a very rare case of intra articular Ganglion cyst of the long head of the biceps tendon that originated from the bicipital groove as a rare cause of shoulder pain.

Osteoid osteoma is a benign bone tumor that when located on the base of the coracoids process of the scapula is very rare and diagnosis and treatment is often delayed because of its rarity. Almost any bone can be involved, but half of cases involve the femur or tibia. The radiologic features of osteoid osteoma are well known, but these tumors may present with unusual features and be easily misdiagnosed. In this report, we present a case of osteoid osteoma of the neck of the left scapula that took almost 27 months to be diagnosed accurately.

A case of bilateral intraosseous tumor of the calcaneus with different MRI imaging is presented. On the left, radiological findings suggest intraosseous lipoma, but on the right-sided lesion, imaging studies were not convincing. The microscopic report showed foreign body granulomatous reaction, a rare clinical pathological discordant.

A seven year-old boy with several painless masses on the ribs and shoulder was referred to our hospital. The masses were so prominent that they prevented the child’s sleep. Since the patient had been ridiculed by his friends due to the rib prominences, he had refused to attend school. After clinical and radiological evaluations, the masses were diagnosed as hereditary multiple exostoses of the shoulder and ribs. He underwent surgery for cosmetic reasons resulting in the patient’s return to a normal life.