Archives of Bone and Joint Surgery
Volume:10 Issue: 3, Mar 2022

Recently, some interesting articles have been published about revision total knee arthroplasty (RTKA). It is important that these articles are known by orthopedic surgeons dedicated to knee surgery and, in general, by all orthopedic surgeons; therefore, I have considered it necessary to write this editorial. My intention is that with this new knowledge, we can optimize the results for our patients when they undergo RTKA.

Chondral defects are frequent and important causes of pain and disability. Cartilage has limited self-repair and regeneration capacity. The ideal approach for articular cartilage defects is the regeneration of hyaline cartilage with sustainable symptom-free constructs. Tissue engineering provides new strategies for the regeneration of functional cartilage tissue through optimized scaffolds with architectural, mechanical, and biochemical properties similar to the native cartilage tissue. In this review, the basic science of cartilage structure, interactions between proteins, stem cells, as well as biomaterials, scaffold characteristics and fabrication methods, as well as current and potential therapies in regenerative medicine will be discussed mostly from a biochemical point of view. Furthermore, the recent trends in scaffold-based therapies and supplementary factors in cartilage tissue engineering will be considered. Level of evidence: I

The main indications for osteochondral allografts (OCA) transplantation of the knee are the following: Symptomatic full-thickness cartilage lesions greater than 3 cm2; deep lesions with subchondral damage; and revision techniques when a previous surgical procedure has failed. Dowel and shell t echniques are the two most commonly used for OCA transplantation. The dowel technique is appropriate in most cartilage lesions; however, geometrically irregular lesions may need the shell technique. Factors related to better outcomes after OCA transplantation are the following: unipolar lesions; patients younger than 30 years; traumatic lesions; and when the treatment is carried out within 12 months from the onset of symptoms. A systematic review found a survivorship rate of 89% at 5 years. Other systematic review showed a mean failure rate of 25% at 12 years with a reoperation rate of 36%. Seventy -two per cent of the failures were conversion to total knee arthroplasty (TKA) (68%) or unicompartmental knee arthroplasty (UKA) (4%). Twenty-eight per cent of failures were graft removal, graft fixation, and graft revision. In this systematic review, patellofemoral lesions (83%) had a higher reoperation rate than lesions affecting the tibial plateau or the femoral condyles. Overall, OCA transplantation showed a successful result in 75% of patients at 12 years follow-up.Level of evidence: III

The use of free cutaneous or myocutaneous flaps in some surgeries, especially in reconstructive surgeries, is routine and imperative; nevertheless, it is controversial because of fear of flap loss due to tissue congestion and partial or complete necrosis. Different mechanisms are discussed in this process, and based on the involved mechanisms, various agents and approaches are suggested for flap salvage. Among these agents and strategies, leech therapy (hirudotherapy) can be a valuable complementary treatment; however, in this way, full attention should be given to all beneficial and harmful aspects to reach the best results.This study included a literature review of the essential complications following free tissue transfer and explained the effects of leech therapy for the respective complications. Based on the review of the literature, the essential complications following free tissue transfer were (I) venous obstruction and congestion, (II) delay in blood flow reestablishment, (III) ischemia/reperfusion injuries, and (IV) thrombus formation. Leech therapy can protect free flaps against the mentioned complications as a complementary treatment. Leech therapy is an appropriate complement, however, not a definite approach for flap salvage. Therefore, in some patients, other alternative methods or even flap removal may be a better option

All previous studies comparing the blood sparing efficacy oral and intravenous tranexamic acid (TXA) in total knee arthroplasty have involved two or more patient cohorts, outcomes of which may be limited by inter-individual variability in human drug response. The purpose of this study was to evaluate if both oral and intravenous preparations of TXA are equivalent at reducing blood loss in the same patients undergoing staggered bilateral total knee arthroplasty. 40 patients undergoing staggered bilateral total knee replacement were recruited. They received 2 g of oral TXA 2 hours preoperatively for the first knee and 1 g of bolus intravenous TXA 15 minutes before skin incision for the second knee. 7 patients were excluded for protocol deviation, leaving 33 participants for the study. The second knee was operated within 5-6 days of the first knee. The primary outcome was reduction in hemoglobin. Equivalence was tested with a two one-sided test (TOST) and a P < 0.05 indicated equivalence between oral and intravenous modes of TXA administration.  The mean reduction in hemoglobin was similar between oral and intravenous mode of TXA administration (2.18 and 2.16 g/dl respectively, P<0.0001, equivalence). There was no significant difference in the total hemoglobin loss and total red blood cell volume loss {(104 and 102 g, P=0.86) and (865 and 863 ml, P=0.53) respectively}.  Oral and intra venous TXA have equal blood sparing properties in patients undergoing staggered bilateral total knee arthroplasty.Level of evidence: II

Ulnar collateral ligament(UCL) fracture-avulsion of the thumb which involves small osseous fragments is among common injuries to the thumb metacarpophalangeal (MCP) joint. This case series was conducted on 11 patients (9 males and 2 females) with a mean age of 25.4±4.8 years with acute traumatic UCL fracture-avulsion with instability and Stener Lesion. A low-profile 2-mm stainless steel hook plate with a 2-mm screw was used for the internal fixation. Immobilization was performed for 10 days. Range of motion movements (ROM), grip power, and pinch strength were measured after three months. At the end of the follow-up period, functional outcomes were determined by the visual analog scale (VAS), and Quick Disabilities of the Arm, Shoulder, and Hand (Quick DASH).  The mean follow-up period was reported as 12.4±2.3 months. the union of avulsed small osseous fragments occurred at the end of the three-month follow-up. A number of 10 patients were treated by one hole 2-mm plate with a screw and a mean VAS score of 22.5±2.4, while a female patient had more severe pain with a mean score of 45. This patient complained about the irritation of the plate, especially in the thumb grip. The mean Quick DASH score was 9.6±1.4. The postoperative ROM was similar to that of the other side. Grip power and pinch strength were lower in the treated thumb, as compared to that in the opposite side; nonetheless, the difference was not statistically significant.  As evidenced by the obtained results, it can be concluded that the hook plate technique is a strong fixation method for thumb UCL fracture-avulsion, raising the possibility of earlier joint movements and rapid recovery; nevertheless, in some cases, it can reduce efficiency and induce painful grip.Level of evidence: I

This study aimed to prevent and control the pain after arthroscopy that leads to patient satisfaction, rehabilitation, and return to normal life as soon as possible. It is hypothesized that there is no difference between intraarticular injection of dexmedetomidine and placebo after knee arthroscopy regarding pain level. 

This double-blind randomized clinical trial was conducted on 70 patients aged 18-60 years who were candidates for elective knee arthroscopic surgery with the American Society of Anesthesiologists Classification I-II. All patients underwent spinal anesthesia equally and were randomly divided into two groups of 35 cases per group. The drug group (D) received 2 μg/kg dexmedetomidine with 0.9% normal saline reached to a volume of 20 ml, and 20 ml of 0.9% normal saline was injected into the knee joint through the cannular sheath in the control group (C). Postoperative pain intensity was recorded 1, 2, 4, 8, 16, 24 h after injection using the Visual Analogue Scale. The time of requesting the first analgesic and the amount of analgesics consumed were recorded after 24 h.

There was no significant difference between the two groups in terms of age, height, weight, duration of spinal anesthesia, and duration of surgery (P>0.05). In group D, there was a decrease in postoperative pain, a decrease in the amount of analgesic consumed, and an increase in the time of the first analgesic request, compared to group C (P<0.05).

This study showed that intra-articular injection of dexmedetomidine relieved postoperative pain, reduced analgesic consumption, and increased the time of first analgesic request after knee arthroscopy. Level of evidence: I

Dislocation after total hip arthroplasty (THA) partly under the surgeon’s control, by appropriate placement of the components. We aimed in this study to determine the accuracy of using intra-operative smartphone applications (Apps) to place the acetabular cup within the safe abduction angle by less experienced surgeons during THA surgery when compared to the conventional freehand technique for cup placement. Sixty primary THAs were performed, 30 using the conventional freehand technique (control group) and 30 using the smartphone app technique (study group) to determine the acetabular cup abduction angle by the same young surgeon with less than one year of experience. Postoperative mean cup abduction angle, mean cup anteversion angle, and the percentage of cups within the safe abduction zone as measured on radiographs were compared between the two groups. In the study group, the mean cup abduction angle was significantly lower (P=0.0008), and the acetabular cup was placed within the safe zone in a significantly higher (P<0.001) percentage of patients (93% vs 63%) when compared to the control group. However, there was no significant difference (P=0.40) between the two groups when the mean cup anteversion angle was compared. The smartphone app technique may help achieve an accurate acetabular cup abduction angle and a higher percentage of cups placed within the safe zone of abduction by a less experienced surgeon when compared to the conventional freehand technique. Using tools such as the smartphone app to measure the acetabular cup positioncan reduce intraoperative errors by young and less experienced surgeons during THA surgery.Level of evidence: IV

Ligamentous laxity is a condition that leads to joints’ hypermobility beyond their average and normal range of motion. It can cause musculoskeletal and joint injuries. This national multi-centered study investigated the epidemiology of generalized ligamentous laxity and its relationship with musculoskeletal disorders among Iranian adults with different ethnic backgrounds. A total of 1,488 people (age range: 17-40 years) were selected from eight cities and six different ethnicities of Iran and included in this cross-sectional study. The presence of ligamentous laxity with clinical examinations was searched according to Beighton score criteria. They were also examined for any kind of musculoskeletal disorders that might accompany ligamentous laxity. The Chi-square test was used to compare the frequency of ligamentous laxity based on gender and ethnicity; moreover, the t-test was utilized to compare the frequency of ligamentous laxity based on age. In total, 280 (18.8%) participants had generalized ligamentous laxity, and it was more prevalent in women (22.7%), compared to men (14.4%). Regarding ethnicity, the highest and lowest prevalence rates were in Gilak (37.9%) and Persian-Arab (6%) ethnicities, respectively (P<0.001). Ligamentous laxity showed a significant relationship with sports injury, joint complaint, joint dislocation, ligament sprain, sciatica and back pain, Baker’s cyst, and varicose veins (P<0.001). Most participants with generalized ligamentous laxity (93.6%) had no knowledge of their problem and its importance in choosing an appropriate sports activity.  The prevalence of generalized ligamentous laxity seems to be relatively high among the 17-40-year-old population of Iran, especially in women. It seems to be significantly related to ethnicity. It is strongly recommended that examinations, screening, and information be provided at an early age in schools or at least in areas with a high prevalence as national programs. Level of evidence: I

There is no agreement on the best surgical strategy to manage multicolumnar tibial plateau fracture. The combined approach used by many investigators has been found to be an effective method. However, combined approaches call for repositioning the patient which lengthens the operation time. The sterility of the field of surgery might be jeopardized by repositioning. Intraoperative fluoroscopic imaging is hard to adjust to both parts of the combined positions. To tackle these problems without sacrificing the concept of three-column tibial plateau, we have started to use a combined medial and lateral approach without repositioning the patients using a modified semi-lithotomy position. Level of evidence: V

Dr. Charles A. Rockwood was born in Oklahoma City, Oklahoma, USA, on September 19, 1929. He was one of the American Orthopedic Association’s (AOA) most distinguished members . Dr. Charles A. Rockwood earned his medical degree from Oklahoma University in 1956. He completed his orthopedic residency in the orthopedic department of Oklahoma University and affiliated hospital in 1961. Finally, in 2016, he celebrated 50 years of service at the University of Texas as a professor and emeritus chairman of the department of orthopedics and director of the shoulder service (3). Sadly, he died on February 1, 2022, at 92, in San Antonio, following a 60-year career. We value his six decades of contributions to the advancement of orthopedic trauma.