Archives of Bone and Joint Surgery
Volume:11 Issue: 1, Jan 2023

Knee osteoarthritis (OA) is a prevalent joint disease. Clinical prediction models consider a wide range of risk factors for knee OA. This review aimed to evaluate published prediction models for knee OA and identify opportunities for future model development.

We searched Scopus, PubMed, and Google Scholar using the terms knee osteoarthritis, prediction model, deep learning, and machine learning. All the identified articles were reviewed by one of the researchers and we recorded information on methodological characteristics and findings. We only included articles that were published after 2000 and reported a knee OA incidence or progression prediction model.

We identified 26 models of which 16 employed traditional regression-based models and 10 machine learning (ML) models. Four traditional and five ML models relied on data from the Osteoarthritis Initiative. There was significant variation in the number and type of risk factors. The median sample size for traditional and ML models was 780 and 295, respectively. The reported Area Under the Curve (AUC) ranged between 0.6 and 1.0. Regarding external validation, 6 of the 16 traditional models and only 1 of the 10 ML models validated their results in an external data set. 

Diverse use of knee OA risk factors, small, non-representative cohorts, and use of magnetic resonance imaging which is not a routine evaluation tool of knee OA in daily clinical practice are some of the main limitations of current knee OA prediction models. Level of evidence: III

Contemporary treatments for osteoarthritis (OA) pursue only to alleviate the pain caused by the illness. Discovering disease-modifying osteoarthritis drugs (DMOADs) that can induce the repair and regeneration of articular tissues would be of substantial usefulness. The purpose of this manuscript is to review the contemporary role of DMOADs in managing OA. A narrative literature review on the subject, exploring the Cochrane Library and PubMed (MEDLINE) was performed. It was encountered that many publications have analyzed the impact of several DMOAD methods, including anti-cytokine therapy (tanezumab, AMG 108, adalimumab, etanercept, anakinra), enzyme inhibitors (M6495, doxycycline, cindunistat, PG-116800), growth factors (bone morphogenetic protein-7, sprifermin), gene therapy (micro ribonucleic acids, antisense oligonucleotides), peptides (calcitonin) and others (SM04690, senolitic, transient receptor potential vanilloid 4, neural EGFL-like 1, TPCA-1, tofacitinib, lorecivivint and quercitrin). Tanezumab has been demonstrated to alleviate hip and knee pain in individuals with OA but can cause major adverse events (osteonecrosis of the knee, rapid illness progression, augmented prevalence of total joint arthroplasty of involved joints, particularly when tanezumab is combined with nonsteroidal anti-inflammatory drugs. SM04690 (a Wnt inhibitor) has been demonstrated to be safe and efficacious in alleviating pain and ameliorating function as measured by the Western Ontario and McMaster Universities Arthritis Index. The intraarticular injection of lorecivivint is deemed safe and well tolerated, with no important reported systemic complications. In conclusion, even though DMOADs seem promising, their clinical effectiveness has not yet been demonstrated for managing OA. Until forthcoming studies can proved the medications’ capacity to repair and regenerate tissues affected by OA, physicians should keep using treatments that only intend to alleviate pain. Level of evidence: III

Newly symptomatic chronic musculoskeletal illness is often misinterpreted as new pathology, particularly when symptoms are first noticed after a noxious event. In this study, we were interested in the accuracy and reliability of identifying the symptomatic knee based on bilateral MRI reports. We selected a consecutive sample of 30 occupational injury claimants, presenting with unilateral knee symptoms who had bilateral MRI on the same date. A group of blinded musculoskeletal radiologists dictated diagnostic reports, and all members of the Science of Variation Group (SOVG) were asked to indicate the symptomatic side based on the blinded reports. We compared diagnostic accuracy in a multilevel mixed-effects logistic regression model, and calculated interobserver agreement using Fleiss’ kappa.  Seventy-six surgeons completed the survey. The sensitivity of diagnosing the symptomatic side was 63%, the specificity was 58%, the positive predictive value was 70%, and the negative predictive value was 51%. There was slight agreement among observers (kappa= 0.17). Case descriptions did not improve diagnostic accuracy (Odds Ratio: 1.04; 95% CI: 0.87 to 1.3; P=0.65). Identifying the more symptomatic knee in adults based on MRI is unreliable and has limited accuracy, with or without information about demographics and mechanism of injury. With a dispute concerning the extent of the injury to a knee in a litigious, medico-legal setting such as Workers’ Compensation, consideration should be given to obtaining a comparison MRI of the uninjured, asymptomatic extremity.Level of evidence: II

The use of reverse shoulder arthroplasty (RSA) to treat displaced, unstable 3- and 4-part proximal humerus fractures (PHFs) has traditionally been reserved for patients over 70 years old. However, recent data suggest that nearly one third of all patients treated with RSA for PHF are between 55-69 years old. The purpose of this study was to compare outcomes for patients younger than 70 versus patients older than 70 years of age treated with RSA for a PHF or fracture sequelae. All patients who underwent primary RSA for acute PHF or fracture sequelae (nonunion, malunion) between 2004 and 2016 were identified. A retrospective cohort study was performed comparing outcomes for patients younger than 70 versus patients older than 70. Bivariate and survival analyses were performed to evaluate for differences in complications, functional outcomes, and implant survival. A total of 115 patients were identified, including 39 patients in the young group and 76 patients in the older group. 40 patients (43.5%) returned functional outcomes surveys at an average of 5.51 years (range 3.04-11.0). There were no significant differences in complications, reoperation, implant survival, range of motion, DASH (27.9 vs 23.8, p=0.46), PROMIS (43.3 vs 43.6, p=0.93), or EQ5D (0.75 vs 0.80, p=0.36) scores between the two age cohorts. At a minimum of 3 years after RSA for a complex PHF or fracture sequelae, we found no significant difference in complications, reoperation rates, or functional outcomes between younger patients with an average age of 64 years and older patients with an average age of 78 years. To our knowledge, this is the first study to specifically examine the impact of age on outcome after RSA for the treatment of a proximal humerus fracture. These findings indicate that functional outcomes are acceptable to patients younger than 70 in the short term, but more studies are needed. Patients should be counseled that the long-term durability of RSA performed for fracture in young, active patients remains unknown.

Open Bankart repair plus inferior capsular shift (OBICS) and Latarjet procedure (LA) are considered appropriate treatment alternatives for high-performance athletes. The purpose of this study was to evaluate the functional outcomes and recurrence rate of each surgery. Our hypothesis: there were no differences between the two treatments.  A prospective cohort study was conducted with n=90 contact athletes divided into two groups of 45 patients. One group was treated with OBICS, and the other one with LA. The mean follow-up period was 25 (24-32) months for the OBICS group and 26 (24-31) months for the LA group. Primary functional outcomes of each group were assessed at baseline, six months, one year, and two years after surgery. The functional outcomes were also compared between the groups. The evaluation tools used were the Western Ontario Shoulder Instability score (WOSI) and the American Shoulder and Elbow Surgeons scale (ASES). In addition, recurrent instability and range of motion (ROM) were also evaluated. In each group, significant changes were found in the WOSI score and ASES scale from pre-op to postop. However, there were no significant differences between the functional outcomes of the groups at the final follow-up (P-values 0.73 and 0.19). Three dislocations and one subluxation (8.8%) were reported in the OBICS group, and three subluxations were reported in the LA group (6.6%), revealing no significant differences between the groups (P=0.37). Moreover, there were no significant differences between preoperative and postoperative ROM in each group or in terms of external rotation (ER) and ER in 90º abduction between the groups.   No differences were found between OBICS and LA surgery. Both procedures can be indicated according to the surgeon’s preference to reduce recurrence rates in contact athletes with recurrent anterior shoulder instability.Level of evidence: II

Parkinson’s Disease is a well-known neuromuscular disorder, which affects the stability and gait of elderly patients. With the progressive increase in the life span of patients with PD, the problem of degenerative arthritis and the consequent need for total hip arthroplasty (THA) in this cohort are rising. There is paucity of data in the existing literature regarding the healthcare costs and overall outcome following THA in PD patients. The current study was planned to assess the hospital expenditure, details regarding hospital stay, and complication rates for patients with PD, who underwent THA.  We investigated the National Inpatient Sample data to identify PD patients, who underwent hip arthroplasty from 2016 to 2019. Using propensity score, PD patients were matched 1:1 to patients without PD by age, gender, non-elective admission, tobacco use, diabetes, and obesity. Chi-square and T-tests were used for analyzing categorical and non-categorical variables, respectively (Fischer-Exact test was employed for values<5). Overall, 367,890 (1927 patients with PD) THAs were performed between 2016 and 2019. Before matching, PD group had significantly greater proportion of older patients, males, and non-elective admissions for THA (P<0.001). After matching, PD group had higher total hospital costs, longer hospital stay, greater blood loss anemia, and prosthetic dislocation (P<0.001). The in-hospital mortality was similar between the two groups.  Patients with PD undergoing THA required greater proportion of emergent hospital admissions. Based on our study, the diagnosis of PD showed significant association with greater cost of care, longer hospital stay, and higher post-operative complications. Level of evidence: II

The Satisfaction and Recovery Index (SRI) is a generic importance-weighted health satisfaction tool to measure the process and state of recovery following musculoskeletal injuries. The objectives of this study are (1) to translate and cross-culturally adapt the SRI to Persian and (2) evaluate its psychometric properties. The forward-backward translation technique was used for translation, and two rounds of cognitive interviews were conducted to assess cultural appropriateness. Participants (n=100, mean age=32.5, 82%male) had acute (i.e.,<30 days) musculoskeletal injuries of any etiology. Structural validity, construct validity, internal consistency, and testretest reliability were evaluated. Participants identified issues in 3/6 areas of a coding system during the cognitive interviews: comprehension/clarity, relevance, and inadequate response definition. These issues informed subsequent changes to arrive at the final version of the SRI-P. The SRI-P had adequate construct validity (P<0.001), the confirmatory factor analysis demonstrated a two-factor structure, the internal consistency was acceptable (Cronbach’s α=0.83), and it was deemed reliable (ICC2, 1=0.72). The psychometric evaluation revealed that the SRI-P has adequate construct validity, internal consistency, and test-retest reliability. Unlike the original English version, the SRI-P has a two-factor structure, which appears to be related to cultural differences in interpreting some of the items. The clinical importance of this study is that the SRI (which captures the state of recovery and how important the various items of the tool are to each patient and how satisfied they are with their recovery) can now be available to surgeons and therapists in the orthopedic and rehabilitation realms in Persian populations.Level of evidence: II

Revision of an intrapelvic migration of the acetabular component of a total hip is a challenging surgery due to the risk of injury to the pelvic viscera. The primary concern is vascular injury due to the risk of mortality and limb loss. The researchers present one case where the acetabular screw was near the posterior branch of the internal iliac artery. A Fogarty catheter was placed in the internal iliac artery preoperatively, and the amount of fluid to inflate the catheter and completely block the artery was determined. The catheter was kept in a deflated condition. The hip reconstruction was performed, and there was no incidence of vascular injury during the procedure; hence, the Fogarty catheter was removed postsurgery. The placement of a Fogarty catheter in the at-risk vessel provides the freedom to proceed with the hip reconstruction through the standard approach. In case of an inadvertent event of a vascular injury, it can be inflated with the predetermined amount of saline to check the bleeding until the vascular surgeons take over the case. Level of evidence: V

First carpometacarpal (CMC1) osteoarthritis can be accompanied by the collapse of the first ray, with hyperextension of the first metacarpophalangeal (MCP1) joint. It is suggested that failure to address substantial MCP1 hyperextension during CMC1 arthroplasty may diminish post-operative capability and increase collapse reoccurrence. An arthrodesis is recommended in case of severe MCP1 joint hyperextension (>400). We describe a novel combination of a volar plate advancement and abductor pollicis brevis tenodesis to address MCP1 hyperextension at the time of CMC1 arthroplasty as an alternative to joint fusion. In 6 women, mean MCP1 hyperextension with pinch before surgery was 450 (range 300-850) and improved to 210 (range 150-300) of flexion with pinch six months after surgery. No revision surgery has been necessary to date, and there were no adverse events. Long-term outcome data is needed to establish the longevity of this procedure as an alternative to joint fusion, but early results are promising. Level of evidence: IV

Genu recurvatum associated with Osgood-Schlatter disease (OSD) has been reported in several studies. In this report, we describe a rare complication of a case of OSD with flexion contracture (tfighat is the exact opposite of the knee deformity classically associated with OSD) and increased posterior tibial slope.In the current article, we report a 14-year-old case of OSD referred to our center with a fixed knee flexion contracture. Radiographic evaluation revealed a tibial slope of 25 degrees. There was no limb length discrepancy. Bracing that was prescribed in the primary centerbefore referring to us was not successful in treating this deformity. He underwent anterior tibial tubercle epiphysiodesis surgery. After a year, the flexion contracture of the patient was significantly reduced. The tibial slope decreased by 12 degrees and reached 13 degrees.The present report suggests that OSD may affect the posterior tibial slope and lead to knee flexion contracture. Surgical epiphysiodesis can correct the deformity.Level of evidence: IV