Archives of Bone and Joint Surgery
Volume:7 Issue: 1, Jan 2019

Dr. Seyed Taghi Noorbakhsh died in a tragic car accident on Nov 15th 2018, while on an official mission in Golestan Province in Iran. There is a great emptiness left by Dr.Noorbakhsh’s passing. He will be missed by his colleagues and
thousands of his patients whom he helped during his career.
In addition to being a board member of Iranian Orthopedic Association (IOA), for consecutive terms & Chief of the Iran Social Security Organization since 2013, Dr.Noorbakhsh served as an AO Trauma Faculty member for several years. He was a great leader in his field. Besides his official roles throughout his career, Dr.Noorbakhsh served in many social positions, receiving numerous prestigious awards.

Reality does not recognize borders. Why we should use the very general term of “reality” and not science, because the borders that we draw are pure delusions, and on the opposite side there is the reality. The laws of the universe, either the physical nature of the world which the scientist studies or metaphysics which is the territory of philosophers, it is
the same reality that rules.
Today maybe we believe more in delusions than realities, we believe that our slightly different brothers and sisters separated from us by the seas and borders must be categorized and stay separated. In fact nature does not recognize the difference of language or thoughts that we have, it treats us the same in the good and bad days.

The management of irreparable rotator cuff tears remains challenging. Since its introduction by Mihata in 2012, superior capsule reconstruction (SCR) has grown in popularity at an astonishingly rapid rate. The aim of this article is to provide a comprehensive review of the available literature, in order to highlight what has so far been published on SCR, covering all aspects including biomechanical, clinical and radiological studies as well as descriptions of the various techniques for performing the procedure. The short-term clinical results of SCR are promising, but there is need for further long-term studies, as well as randomised controlled trials comparing SCR to other treatment modalities for irreparable rotator cuff tears. Further imaging studies looking at graft healing rates are also required as the healing rates published so far are variable. Additionally, the mechanism of action by which SCR delivers good short-term functional outcomes needs further clarification, as does the importance of the choice of graft type and thickness.

The purpose of this study was to determine a correlation between surgical case order and the length of operative time, total length of time in the operating room, time until discharge from the hospital, and the incidence of intraoperative complications for primary total shoulder arthroplasty cases. A retrospective review was conducted of records for all individual primary total shoulder arthroplasty and reverse total shoulder arthroplasty at a single hospital. In order to compare true parameters and minimize variables, only the cases performed by one senior author were analyzed. Operative and hospital records were reviewed. There were 162 primary TSA and with the following order: 55 first order cases, 46 second order cases, 34 third order cases, 21 fourth order cases, and six fifth order cases. There were 71 primary rTSA patients included (27:27:10:6:1). Length of stay was statistically increased for both female gender (8.3%; 95% confidence interval (CI)= 0.5- 16.7%; P=0.0386) and fourth case order compared to first case (13.3%; 95% CI = 0.6%; 27.6%) P=0.041). For reverse TSA, there was no analyzed predictor that was significant. Even between anatomic TSA and reverse TSA patients, there was variability in what factors played a part in case inpatient length of stay. As such, we believe that this study highlights that case order can have an effect on operating room parameters for shoulder arthroplasty patients. The need for larger studies remains to better define that effect.

While outcomes of primary anatomic total shoulder arthroplasty (aTSA) are generally favorable, results after revision procedures are less reliable. This study examines the functional outcomes, complications, and implant survival in patients who underwent revision of aTSA to aTSA. Patients who underwent revision aTSA were identified from 2008-2015. Demographic, clinical, surgical, and outcomes data were analyzed. Patient-reported outcomes including the American Shoulder and Elbow Surgeons Score (ASES), Single Assessment Numerical Evaluation (SANE), Visual Analog Scale for pain (VAS), the Short Form- 12 Health Survey (SF-12), and patient satisfaction were recorded. Twenty patients underwent revision from a primary aTSA to aTSA (55% male, 62.0±6.8 years-old). Revision aTSA occurred at 2.5±3.4 years after index surgery. Seven (35%) required future revision at 1.8±1.9 years after revision aTSA. Among the 13 patients who did not undergo revision, twelve (92.3%) had over two-year follow-up (4.0±2.4years). Average ASES score was 70.1±23.5, SANE 66.0±29.4, VAS 2.7±3.0, SF-12 Mental 52.4±10.5, SF-12 Physical 36.8±8.9, and satisfaction of 3.6±1.2. Results of revision aTSA to aTSA were unpredictable and the revision rate was high. The cases that do not undergo revision had satisfactory, but inconsistent functional results. Reverse arthroplasty may be more reliable in this patient population.

The aim of this study was to assess differences in fracture morphology and displacement between isolated greater tuberosity (GT) fractures (i.e. fractures of the greater tuberosity without other fractures of the proximal humerus) with and without shoulder dislocation utilizing quantitative 3-dimensional CT imaging. Thirty-four CT-scans of isolated greater tuberosity fractures were measured with 3-dimensional modeling. Twenty patients (59%) had concomitant dislocation of the shoulder that was reduced prior to CT-scanning. We measured: degree and direction of GT displacement, size of the main fracture fragment, the number of fracture fragments, and overlap of the GT fracture fragment over the intact proximal humerus. We found: (1) more overlap –over the intact humerus– in patients without concomitant shoulder dislocation as compared to those with shoulder dislocation (P=0.03), (2) there was a trend towards greater magnitude of displacement between those without (mean 19mm) and those with (mean 11mm) a concomitant shoulder dislocation (P=0.07), and (3) fractures were comparable in direction of displacement (P=0.50) and size of the fracture fragment
(P=0.53). We found substantial variation in degree and direction of displacement of GT fracture fragments. Variation in degree of overlap and displacement is partially explained by concomitant shoulder dislocation.

To compare the union times of the uncomplicated tibial shaft fractures, which were distally locked by two coronal and one sagittal screws and by only two coronal screws. 45 patients with tibial shaft treated with intramedullary nailing included in this study. 23 of 45 fractures were treated with uniplanar two distal interlocking (Group 1) and 22 fractures were treated with biplanar three distal interlocking (Group 2). Patients with closed fractures treated by closed nailing and having a full set of radiographs on PACS system was included. Fracture unions were evaluated by two authors. Union time was significantly shorter in biplanar distal interlocking group (Group 2) compared to uniplanar distal interlocking group (Group 1) (P=0.02). Mean union time in groups 1 and 2 were 14.63±4.5 and 10.77±3.0 weeks, respectively .When only distal third tibial shaft fractures were evaluated, Group 2 [11.2±3.1 weeks (n:17)] had significantly lower union time compared to Group 1 [15.07±4.8 weeks (n:14)] (P=0.01). Inter-observer reliability for fracture union times was high with rho= 0.89 with SE of 0.51 (P<0.001). Biplanar distal interlocking procedure had a significantly shorter union time. Biplanar distal interlocking procedure allows a faster fracture union probably because of a more stable fixation construct.

Locking plate fixation provides satisfactory outcome following proximal humerus fractures. None of the previous studies selectively evaluate the outcome in young patients. This study evaluates outcome of locking plate system in the treatment of acute three- and four-part fractures in young patients. In this prospective study we included all patients who were less than 60 years, involved in high velocity trauma, had proximal humerus comminuted three part and four part fractures and were operated using locking plate at our centre, between August 2011 to August 2015. All the patients were followed up regularly. Assessment was done clinically using Constant and Murley scoring system and radiologically using signs of healing in the form of callus formation and cortical continuity. Twenty-five eligible patients were operated during the study period. All patients were involved in motor vehicle collision. Average age of our patients was 41.2. The average duration of follow-up was 18.2 months(8 months to 27 months). 24 out of 25 fractures united clinically and radiologically at three months’ follow-up. Average Constant and Murley score at final follow-up was 78.52. The results were excellent to good in 15 patients, fair in five patients and poor in five patients. Overall complication rate was 24%. Majority of them (20%) were restriction of movements of shoulders. None of our patients needed reoperation. Locking plate system, in three part and four part proximal humerus fractures in young patients, provides secure and stable fracture fixation for early mobilization. Early results with locking plate system were promising in younger patients. In these patients, locking plate system has definite role to preserve the humeral head and there by maintain the functional activity level.

Tibial tuberosity-trochlear groove distance (TT-TGD) measurements play a decisive role in evaluating patellofemoral joint disorders. However, the prevalence of pathological TT-TGD among patients with patellofemoral pain remains unclear. The purpose of this study was to compare the size of TT-TGD among patients with patellofemoral pain syndrome (PFPS) and those with no history of patellofemoral pain. A total of 100 cases participated in this case-control study, among whom 53 individuals were in the case group and 47 individuals were in the control group. TT-TGD was measured by magnetic resonance imaging. The mean TT-TGD was 12.3±3.3 in patients and 9.3±2.4 in controls (P<0.001). Among patients, we had totally 34 patients with TT-TG equal or lower than 13 (64.2%) and in 18 patients, it was higher than 13 (34%). The mean TT-TGD in patients with PFPS was greater than that in the control group (P=0.001). An increase in TT-TGD can be considered one of the factors behind the development of PFPS.

Balance disorder is one of the most-studied fields in low-back pain patients (LBP). However, there is insufficient information regarding the effect of LBP subgrouping on postural control. The purpose of the present study was to compare postural control between subgroups of chronic nonspecific LBP and healthy subjects during lifting. A total of 35 men with chronic LBP (19 active extension pattern [AEP] and 16 flexion pattern [FP]) and 15 healthy controls were enrolled in this cross-sectional study. Pooled LBP was subdivided based on the O’Sullivan’s classification system (OCS). The participants were asked to lift a box from the ground to the waist level and hold it for 20 seconds. The load was 10% of the subject’s weight. Force plate system was used to record balance parameters, including standard deviations (SDs) of center of pressure (COP) amplitude and COP velocity in anterior-posterior and medial-lateral directions and mean total velocity. The test was divided into two static and dynamic phases. Data were analyzed using one-way analysis of variance and independent t-test. There were no significant differences between pooled LBP and control groups in any of the variables, except for the SD of the anterior-posterior direction velocity in the X-plane in the static phase (P=0.017). After classifying LBP, the results showed that the healthy and AEP groups were significantly different in SD of COP velocity in the frontal plane (P=0.021), mean total velocity (P=0.010), and SD of COP velocity in the sagittal plane (P=0.039). The present study showed that postural control was not different between the pooled LBP and normal groups. After classifying pooled LBP based on OCS, we found that the AEP showed different postural control as compared to healthy controls in the dynamic phase. The FP and AEP exhibited different postural control relative to the healthy controls in the static phase, and COP velocity was lower in those groups compared to the control group. The results of this study support the concept of LBP classification.

Due to the obvious differences in the natural course of rheumatoid arthritis (RA) and osteoarthritis (OA), different functional outcomes might be expected after Total Knee Arthroplasty (TKA) in these distinct patients. Although several studies have reported the objective outcome of TKA in RA and OA patients, few studies have compared postoperative patient-satisfaction levels. In this clinical cohort study 171 patients (RA: n=33, OA: n=138) who underwent TKA with posterior stabilizing knee prosthesis were included. The Knee Injury and Osteoarthritis Outcome Score (KOOS) and Oxford Knee Score (OKS) were used to evaluate and compare patients’ satisfaction 6 and 12 months after TKA relative to their preoperative state and to make an assessment between two groups. Both of patient-reported scoring systems showed a statistically significant improvement for OA and RA patients at 6 and 12 months after surgery, relative to their preoperative scores. The results of the OKS and KOOS did  not show statistically significant improvement from 6 to 12 months n RA patients. Unlike RA group, OKS and KOOS revealed further improvement between 6 and 12 months for the osteoarthritic patients. OA patients had continuous improvement in their satisfaction in the first year after TKA with a gentle upward curve. In contrast, in RA patients, recovery was faster and greater in the first six months after surgery and slowed down in the second six months. Patient-reported outcome scores were not significantly different between two groups at the end of the first year.

Arthroscopic reconstruction of ACL is an effective method to restore knee stability after ACL rupture. Postoperative septic arthritis (SA) is very uncommon while the incidence of serious complications range between 0.14% and 1.8%. Some of the devastating consequences of septic arthritis can encompass hyaline cartilage damage, arthrofibrosis, and in rare cases amputation. The purpose of this study was to evaluate the effect of gentamicin irrigation solutions as a process to restrain septic arthritis following arthroscopic ACL reconstruction. In this retrospective cohort study, 1464 patients who underwent ACL reconstruction with hamstring tendon autograft in our institution over 7 years (February 2008 to January 2015) were included. The patients were divided into two groups based on the type of intra-articular irrigation solution used during the surgery. Patients in Group 1 (Saline) received intra-articular irrigation with normal saline (0.9 % sodium chloride) solution, while those in Group 2 (Gentamycin) received intra-articular irrigation with gentamicin (80 mg/L) added to the normal saline solution. Data about postoperative infection, its course, management, and outcome were obtained from patients’ records. Seven patients developed SA, four of whom were from SALINE group (2.2%) and three from Gentamycin group (0.23%). The incidence rate of SA after arthroscopic ACL reconstruction was significantly lower (P <0.05) when irrigated with gentamicin solution than merely with saline solution. Gentamicin irrigation solution has a preservative and protective effect against SA development following arthroscopic ACL reconstruction. We recommend evaluating this technique as a way in order to depreciate the prevalence of SA after ACL reconstruction.

oint replacement is currently on the rise with a high community burden. A registry was designed to evaluate the costs, possible complications, and rate of revisions as well as finding the most effective techniques, risk factors associated with poor results, indications for revision surgeries, and also demographic evaluation of patients undergoing joint replacement surgery in Iran.