Archives of Bone and Joint Surgery
Volume:7 Issue: 2, Mar 2019

The key principle of gene delivery to articulations by direct intra-articular injection is to release complementary DNA(cDNA)-encoding medical products that will lead to maintained, endogenous production of the gene products withinthe articulation. In fact, this has been accomplished for both in vivo and ex vivo gene delivery, using several vectors,genes, and cells in some animal models. Some clinical trials for rheumatoid arthritis and osteoarthritis (OA) usingretrovirus vectors for ex vivo gene delivery and adeno-associated virus (AAV) for in vivo delivery have been reported.AAV is of special attention because, contrary to other viral vectors, it can enter deep within joint cartilage and transducechondrocytes in situ. This quality is of special significance in OA, in which modifications in chondrocyte metabolismare believed to be crucial to the pathophysiology of the disease. The clinical effectiveness of TissueGene-C (TG-C), acell and gene therapy for OA consisting of nontransformed and transduced chondrocytes (3:1) retrovirally transducedto overexpress TGF-β1 has been reported in patients with knee OA. The most common complications of TG-C wereperipheral edema (9%), arthralgia (8%), articular swelling (6%), and injection site pain (5%). TG-C was associatedwith relevant ameliorations in function and pain. Gene therapy appears to be a viable method for the management ofarticular cartilage defects and OA.Level of evidence: III

Lateral epicondylitis (LE) also known as tennis elbow is a common disease of middle-aged population.Surgery is a treatment of choice in patients not responded to the conservative management. Open and arthroscopicrelease are the two main choices for LE surgery; however, an overall consensus is not available. This study was aimedto compare the clinical outcomes after conventional open and arthroscopic procedures. An electronic search of databases including, Medline, Web of Science, Embase, Cochrane Library, andScopus was conducted to identify all eligible studies describing the post-operative clinical outcomes of patients withLE, up to October 2018. All studies considering the non-pediatric cases who received at least 6-month preoperativeconservative treatment and were followed more than 6 months after surgery were included. Data on patient satisfaction,functional outcomes, pain, and complication rates, were extracted for each study. If appropriate, the meta-analysiswas performed to combine the results for all outcomes that were reported in a minimum of 3 studies utilizing the samesurgical technique. A total of 34 eligible articles including 15 open studies, 13 arthroscopic studies, and 6 studies in bothtechniques were enrolled. Studies were from different parts of the world with a whole sample size of 1508 cases.Various outcome measuring methods including Quick DASH and VAS, and different clinical outcomes were reported.The results indicated no significant difference between arthroscopic and open surgery methods in terms of VAS,DASH score, time for returning to work, overall outcomes, and patients’ satisfaction (P >0.05). However, postoperativecomplications were significantly higher in the open group when compared with the arthroscopic procedure (57.3%vs 33.4% P=0.001). The present study suggests that despite no superiority for each techniques regarding the pain relief,subjective function, and better rehabilitation, arthroscopic method have been associated with less complications.Level of evidence: II

The aim of this study was to evaluate functional outcome and complications with a long term followup (minimum of 2 years post-operative) in patients with mid-shaft clavicle fractures treated with precontoured lockingplates. We included 41 patients. Goniometric measurement of shoulder range of motion (ROM) was performed,as well as functional evaluation using the rating scale shoulder of the University of California (UCLA), the Constantscale, score of disability of the arm, shoulder and hand (DASH) and visual analog scale (VAS). Postoperativecomplications, implants removal rates and new x-rays were analized. The mean postoperative follow-up was 41.5 (24; 69. SD 13.4) months. Mean shoulder anterior elevationwas 168.5º (120; 180. SD 22.9). The average value obtained for abduction was 175.2° (150; 180. SD 27.8), as tointernal and external rotations, these were not affected. DASH 1.27% (0%; 25%. SD 4.3), UCLA 33.6 points (20;35. SD 3.5), Constant 90.5 points (50; 100. SD 11.2) and VAS was 0 in 34 patients (83%). Complications: mildresidual pain (3), hypoesthesia of the infraclavicular area (2), and rupture (1) and loosening (1) of the implant.hardware removal due to intolerance (2 cases) and new osteosynthesis due to acute implant rupture (1 case). Our experience after a mean follow-up of 41.5 months with precontoured locking plates for the treatmentof displaced mid-shaft clavicle fractures has shown good functional results, with low complication and reoperationrate.Level of evidence: IV

Aim of this study was to compare the clinical and radiological long-term outcomes following operativetreatment of comminuted radial head fractures using 1) primary radial head resection arthroplasty, 2) acute radial headresection, or 3) necessary secondary prosthetic removal. Additionally, we evaluated complex radial head fracturescombined with elbow dislocation and verified the hypothesis of whether primary radial head resection arthroplasty couldcontribute to ligament healing. In a comparative retrospective cohort study between 2004 and 2014, 87 (33 female, 54 male) patients withcomminuted radial head fractures with a median age of 45 (range 18-77) years were included and followed-up clinicallyand radiologically. Functional results were evaluated according to MEPS, DASH, Broberg and Morrey, and VAS scores. After a median range of 46 months postoperatively, 48 patients (group 1) obtained an acute radial headresection arthroplasty (MEPS: 70 points, Broberg and Morrey: 63 points, DASH: 34 points, VAS: 3.3 points). Twentypatients (group 2) were treated by radial head resection (MEPS: 63 points, Broberg and Morrey: 50 points, DASH: 49points, VAS 4.2 points) and 19 patients (group 3) needed secondary prosthesis removal (MEPS: 73 points, Brobergand Morrey: 66 points, DASH: 38 points, VAS: 2.8 points). The overall outcome demonstrated a trend towards betterresults and the Kellgren-Lawrence grade of postoperative osteoarthritis was significantly better in groups 1 and 3compared to group 2 (P=0.02). Clinical and radiological long-term results of this study demonstrate a trend towards a better outcomeafter acute radial head resection arthroplasty compared to primary radial head resection, especially in complex fracturesassociated with elbow dislocation. Furthermore, our results encourage the use of primary radial head replacement incases of comminuted non-reconstructable radial head fractures.Level of evidence: III

When the best treatment option is uncertain, a patient’s preference based on personal values should bethe source of most variation in diagnostic and therapeutic interventions. Unexplained surgeon-to-surgeon variation intreatment for hand and upper extremity conditions suggests that surgeon preferences have more influence than patientpreferences. A total of 184 surgeons reviewed 18 fictional scenarios of upper extremity conditions for which operativetreatment is discretionary and preference sensitive, and recommended either operative or non-operative treatment.To test the influence of six specific patient preferences the preference was randomly assigned to each scenario in anaffirmative or negative manner. Surgeon characteristics were collected for each participant. Of the six preferences studied, four influenced surgeon recommendations. Surgeons were more likelyto recommend non-operative treatment when patients; preferred the least expensive treatment (adjusted OR,0.82; 95% CI, 0.71 – 0.94; P=0.005), preferred non-operative treatment (adjusted OR, 0.82; 95% CI, 0.72 – 0.95;P=0.006), were not concerned about aesthetics (adjusted OR, 1.15; 95% CI, 1.0 – 1.3; P=0.046), and when patientsonly preferred operative treatment if there is consensus among surgeons that operative treatment is a useful option(adjusted OR, 0.78; 95% CI, 0.68 – 0.89; P<0.001). Patient preferences were found to have a measurable influence on surgeon treatment recommendationsthough not as much as we expected-and surgeons on average interpreted surgery as more aesthetic. This emphasizesthe importance of strategies to help patients reflect on their values and ensure their preferences are consistent withthose values (e.g. use of decision-aids).Level of evidence: III

The goal of this study was to evaluate current physician ratings websites (PRWs) to determine whichfactors correlated to higher physician scores and evaluate physician perspective of PRWs. This study evaluated two popular websites, Healthgrades.com and Vitals.com, to gather information onpracticing physician members of the American Shoulder and Elbow Society database. A survey was conducted ofthe American Shoulder and Elbow Society (ASES) membership to gather data on the perception held by individualphysicians regarding PRWs. We found that patients were more likely to give physicians positive reviews and the average overall scorewas 8.35 (3.75-10). Patient wait time (P=0.052) trended toward significance as a major factor in determining theoverall scores, while ratings in both physician bedside manner (P=0.001) and physician/staff courtesy (P=0.002)were significant in reflecting the overall score given to the physician. According to our survey, a majority of therespondents were indifferent to highly unfavorable to PRWs (88%) and the validity of their ratings (78%). As PRWs become increasingly popular amongst patients in this digital age, it is critical to understand thatthe scores are not reflective of a significant proportion of the physicians’ patient population. Physicians can use thisstudy to determine what affects a patient’s experience and focus efforts on improving patients’ perception of quality,overall satisfaction, and overall care. Consumers may use this study to increase their awareness of the potential forsignificant sampling error inherent in PRWs when making decisions about their care.Level of evidence: III

The acromion clavicular joint dislocations are common injuries of the shoulder. The severity is dependentupon the degree of ligamentous injury. Surgical treatment is typically performed in higher grade acromioclavicularseparation with several static and dynamic operative procedures with or without primary ligament replacement. 47 patients with acute Rockwood type III, IV, and V injuries were treated surgically with LARS reconstruction.The success of technique was evaluated by radiographic outcomes for each patient at every follow-up visit (one,three, 12 months), while to assess pain reduction and clinical evaluation Visual Analogue scale score (VAS) andConstant-Murley score (CMA) was performed, respectively. An One Way Analysis of Variance (Kruskal-Wallis test), amultiple comparison Turket test, or a t-test (Mann-Whitney Rank Sum Test) were used when required. Follow-up radiographs revealed maintenance of anatomical reduction in 41 patients, and no bone erosionshas been identified. In short-term joint functional recovery has been observed. Indeed, after 12 months pain on theVAS-scale in all groups decreased significantly (P < 0.05), and the CMS revealed a significant overall improvement(P < 0.05). These data demonstrate that the use of the LARS allows to provide stability to the joint and especially toensure its natural elasticity, relieving pain and improving joint function already one month post-surgery.Level of evidence: III

It is not always clear how to treat glenohumeral osteoarthritis, particularly in young patients. The goals ofthis study were to 1) quantify how patient age, activity level, symptoms, and radiographic findings impact the decisionmakingof shoulder specialists and 2) evaluate the observer reliability of the Kellgren-Lawrence (KL) grading system forprimary osteoarthritis of the shoulder. Twenty-six shoulder surgeons were each sent 54 simulated patient cases. Each patient had a differentcombination of age, symptoms, activity level, and radiographs. Responders graded the radiographs and chose atreatment (non-operative, arthroscopy, hemiarthroplasty, or total shoulder arthroplasty). Spearman correlations andchi square tests were used to assess the relationship between factors and treatments. Sub-analysis was performedon surgical cases. An intra-class correlation (ICC) was used to assess observer agreement. The significant correlations (P<0.01) were: symptoms [0.46], KL grade [0.44], and age [0.11]. In the subanalysisof operative cases, the significant correlations were: KL grade [0.64], age [0.39], and activity level [-0.10].The chi square analysis was significant (P<0.01) for all factors, but the practical significance of activity level wasminimal. The ICCs were [inter](intra): KL [0.79] (0.84), patient management [0.54]. When evaluating glenohumeral osteoarthritis, patient symptoms and KL grade are the factors moststrongly associated with treatment. In operative cases, the factors most strongly associated with the choice of operationwere the patient’s KL grade and age. Additionally, the KL classification demonstrated excellent observer reliability.However, there was only moderate agreement among shoulder specialists regarding treatment, indicating that thisremains a controversial topic.Level of evidence: III

Limb salvaging surgeries are current surgical treatment of extremity bone sarcomas. Resected bonereplacement consists of two main methods; tumor prosthesis versus structural allograft. Biological reconstruction withan allograft is an economic cheap method in young sarcoma patients, however, the surgeons are more convinced withtumor prosthesis replacement. We evaluated the short-term complications and functional results of 40 patients with aggressive extremitytumors in a retrospective cohort study. The mean age of cases was 25 and we followed them for 24 months. 17patients underwent tumor prosthesis replacement after wide resection of limb sarcomas. 16 cases had structuralallograft reconstruction and 7 patients treated with amputation. We matched confounders including age, sex, bloodcell count and chemotherapy treatment in the study groups. We found 15 major complications (45.5%) in limb salvage surgeries composing infection, allograft nonunion,allograft fracture, prosthesis fracture, prosthesis loosening and device failure that needed another surgery to beresolved. We had 10 major complications in allograft group (62%) and 5 in tumor prosthesis group (29.4%). Althoughthe rate of complications was higher in allograft group, it didn’t statistically indicate strong correlation (Fisher’s exact:0.084). Mean Musculo-Skeletal tumor rating Scale (MSTS) score was 25.8(73.7%) and 22.3(63.7%) in allograftgroup and prosthesis cases respectively. MSTS score had a normal distribution in the different groups with nosignificant difference between them. Although complications were higher in the allograft group, allograft could be offered to bone sarcomapatients, whom are predicted to have short life expectancy.Level of evidence: III

Acetabular Retroversion (AR) is a hip disorder and one of the causes of pain in this area. Evaluationof positive Cross Over Sign (COS) on AP X-Rays of the hip is currently the best method of diagnosis of AR. Severalstudies have measured co-existence of Ischial Spine Sign (ISS) in patients with AR. In this study we evaluated thediagnostic value of ISS in confirmation of AR and compared it with the diagnostic value of COS. In this study, 4120 AP hip X-Rays from Akhtar Hospital, Shahid Beheshti University of Medical Sciences,Tehran, were studied. Based on radiologic criteria, 1180 X-Rays were considered as standards and evaluated for ISS,COS and PWS (Posterior Wall Sign). Data analysis was done for correlation between ISS and COS. A total of 1180 out of 4120 X-Rays were considered as standard; among which, 86 were diagnosed withAR based on positive COS in presence of PWS. Both ISS and COS were positive concurrently in 69 X-Rays. ISSwas positive in absence of COS in 11 X-rays. No significant difference in diagnostic value for diagnosis of acetabularretroversion was found between ISS and COS (P<0.05). According to our results, both ISS and COS signs can be employed for diagnosis of AR (acetabularretroversion). Considering the absence of a significant difference between these two signs in confirmation of AR, it canbe perceived that the diagnostic value of ISS in confirmation of AR is equal to COS. Validation of the mentioned resultsrequires further studies.Level of evidence: IV

Non-technical skills are interpersonal and cognitive skills involved in safe performance and preventingadverse events during surgery. it is necessary to dominate the non-technical skills to ensure patient safety. This studyhas aimed to assess the validity and reliability of Oxford Non-technical skills 2 system (Oxford NOTECHS 2) in Iran andto evaluate surgical teams’ non-technical skills in orthopedic surgery wards. This cross-sectional study was conducted in Tehran, Iran during 2015. The level of evidence is III based onCanadian Task Force on the Periodic Health Examination. We followed the Beaton’s guideline for Persian translationand cross-cultural adaptation of the checklist. In this study, 60 orthopedic surgical team members working in twoselected public hospitals were selected by cluster random sampling method.Oxford NOTECHS 2 system which isconsisted of four subscales including leadership and management, teamwork and collaboration, decision-makingand problem-solving, and situational awareness was used to collect the data. The overall mean score of non-technical skills was 69.52±6.64. The mean score for surgery, anesthesia, andnursing sub-teams were 24.98±3.71, 21.12±4.29, and 23.42±3.60, respectively. The teams’ scores in total, leadershipand management, teamwork and collaboration, problem solving and decision making, and situational awareness atthe standard level were 74.70%, 76.95%, 73.75%, 66.87%, and 74.70% of maximum score, respectively. The validity and reliability of the Persian version of Oxford NOTECHS 2 scale in Iran was confirmed. Theresults of this study showed that surgical teams’ non-technical skills were at a moderate level in orthopedic surgerywards. The minimum score of the surgical teams’ non-technical skills belonged to anesthesia and maximum to surgerysub-team. Using the training programs and setup workshop is recommended to improve the surgical teams’ nontechnicalskills, especially surgery-nursing sub-team.Level of evidence: III

Repair of bone defects is challenging for reconstructive and orthopedic surgeons. In this study, we aimedto histomorphometrically assess new bone formation in tibial bone defects filled with octacalcium phosphate (OCP),bone matrix gelatin (BMG), and a combination of both. A total of 96 male Sprague Dawley rats aged 6-8 weeks weighing 120-150 g were randomly allocatedinto three experimental (OCP, BMG, and OCP/BMG) and one control group (n=24 in each group). The defects inexperimental groups were filled with OCP (6 mg), BMG (6 mg), or a combination of OCP and BMG (6 mg, 2:1 ratio).No material was used to fill the defects in the control group and the defect was only covered with Surgicel. Sampleswere taken on days 7, 14, 21, and 56 after the surgery. The sections were stained with hematoxylin-eosin (H&E) andassessed using light microscopy. In our experimental groups, bone formation was started from the margins of the defect towards the centerwith an increasing rate during the study period. Moreover, the formed bone was more mature. Bone formation in ourcontrol group was only limited to the margins of the defect. The newly formed bone mass was significantly higher inthe experimental groups (P=0.001). OCP, BMG, and OCP/BMG compound enhanced osteoinduction in long bones.Level of evidence: III

The use of eponymous terms in orthopedic trauma surgery is common. In an assessment pre-training versus posttrainingat an AO Advanced Elbow Trauma Course, we aimed to report on (1) the accuracy and (2) reliability of 10common eponymous terms used for surgical approaches and fractures in elbow surgery. Before training, eponymswere described correctly in 38% of questions versus 47% after training. The percentage of correct answers onlyimproved significantly in one question (P<0.005). A generalized kappa of 0.37 before training versus 0.31 aftertraining represents an overall fair reliability of the eponymous terms. In conclusion, the accuracy and reliabilityof eponymous terms used in elbow surgery is disappointing. Moreover, this type of standardized training formatdoes not seem to improve the knowledge of eponymous terms of experienced trauma- and orthopedic surgeons.Therefore, we suggest considering descriptive terms or standardized fracture classifications instead of eponymousterms.Level of evidence: II

Fetal rhabdomyomas (RM) are extremely rare benign mesenchymal tumours that occur primarily in the head and neck.This tumour exhibits immature skeletal muscle differentiation. The patients’ median age is four years and surgical resectionis the recommended treatment.Fetal RM of limbs are rare and not well described in the literature and if, predominantly in form of case reports. We reportthe second case of a fetal RM in the upper extremity in a 31-year old male patient.One should be aware of this skeletal muscle tumour and fetal RM should be considered as a differential diagnosis to itsmalignant counterpart rhabdomyosarcoma.Level of evidence: V

The management of recalcitrant patellar tendinopathies in the athletic population can be vexing to both the surgeonand patient. To date the majority of treatments for this disease pathology are non-surgical in nature. When surgicalintervention is required, open debridement and/or tendon take-down with repair has been necessary. We proposea novel technique for the treatment of insertional patellar tendinopathies and symptomatic partial tearing utilizing abio-inductive implant.Level of evidence: V

Dear Editor, We read with great interest the timely study by Satish et al., How Much Bone Cement Is Utilized for Component Fixation in Primary Cemented Total Knee Arthroplasty? (1). We applaud the authors, yet we hope they can clarify some points to make this study more applicable to a wider population.