Archives of Bone and Joint Surgery
Volume:7 Issue: 6, Nov 2019

An oversupply of qualified applicants leads to intense competition for the limited number offirst year orthopedic residency positions. Therefore, program directors can be more selective in choosingtheir future residents. However, it is unclear if there are resident characteristics that correspond with traineeperformance. We asked (1) what resident characteristics are associated with subjective residency performancescore? and (2) what resident characteristics are associated with Orthopedic In-Training Examination (OITE)score?A total of 119 orthopedic residents accepted at the Harvard Combined Orthopedic Residency Program from1999 – 2009 were included in this study. The current program director together with two former programdirectors in the selected time period defined the subjective residency performance score based on theclinical skills of the residents during training. Former Olympic or varsity athlete (P=0.018) and Alpha Omega Alpha (AOA) status (P=0.014)were associated with a better subjective residency performance score. Higher USMLE step 1 score(P=0.0038), known person within faculty prior to the residency (did a research rotation, or local medicalstudent) (P=0.041), and AOA (P=0.015) status were associated with a higher OITE score. AOA status of the applicant for orthopedic residency is associated with both a higher OITEscore and a better subjective residency performance score.Level of evidence: IV

This study aimed to analyze national and institutional trends in shoulder arthroplasty utilization basedon patient race. The Nationwide Inpatient Sample (NIS) was employed to determine racial trends in shoulder arthroplastyutilization at a national level. An institutional database was then utilized to retrospectively identify all patients, undergoingshoulder arthroplasty within 2011-2013. Descriptive statistics were used to compare self-identified black and non-blacksubpopulations. The NIS identified 256,832 primary shoulder arthroplasties within 2005-2011. Black patients constituted3.92% (n=10,074) of cases. Utilization increased from 3.36% in 2005 to 4.49% in 2011. Locally, a total number of1,174 primary shoulder arthroplasties were performed, the recipients of 5.96% (n=70) of which were black. Femalesaccounted for 48/70 (68.6%) of black patients. Black patients had a higher body mass index (33.6 vs. 30.1, P<0.0001)and were younger (62.6 vs. 67.2 years, P<0.0001), compared to the non-black patients. Regarding insurance type,1,074 patients (i.e., 65 black and 1,009 non-black) had comprehensive insurance data. Chi-square analysis of fivemajor insurance categories, including private, Medicare, Medicaid, workers’ compensation, and personal injury,indicated no difference in insurance patterns (χ2=3.658, P=0.454). The findings revealed significant racial disparity in shoulder arthroplasty utilization both at national andinstitutional levels. This disparity exists despite the similar rates of osteoarthritis in both white and black patients. Blackpatients in our institution had similar clinical, demographic, and socioeconomic characteristics as in our non-blackpatients. The obtained results highlighted the need for the expansion of black patients’ access to care services relatedto major joint reconstruction.Level of evidence: III

To describe a case series of young adult patients with isolated chronic proximal biceps tendinitisrefractory to conservative care found to have anatomic long head biceps tendon (LHBT) origin variations who underwentarthroscopic-assisted subpectoral biceps tenodesis. Patients were included in this retrospective case series if they met all the following criteria: 1) had ananomalous origin of the LHBT without any pre-operative or concurrent pathologies at the time of surgery, 2) had nontraumaticanterior shoulder pain refractory to conservative care for >6 months, 3) pain relief with ultrasound guidedsteroid injections into the bicipital tendon sheath, and 4) routine radiographs and MRI-arthrogram demonstratingno pathology. All patients underwent arthroscopic assisted mini-open subpectoral biceps tenodesis. Pre- and postoperativeactive range of motion (ROM), strength, visual analog scale (VAS) for pain, and subjective shoulder values(SSV) were evaluated. Statistical analysis was done using repeated measure ANOVA. Seven patients mean age of 18.4 ± 3.5 years old were included in this study. Arthroscopic examinationrevealed anomalous origins of the LHBT in all patients with the following distribution: medial to superior labrum (x2),proximal insertion to the supraspinatus confluent with the superior labrum (x2), insertion into the superior capsulartissues at the rotator interval (x2), and bifid LHBT (x1). VAS score and SSV were significantly improved at 3 months(P Anomalous origins of the LHBT may be a predisposing factor for chronic biceps tendinitis refractory tonon-operative treatment in young adults. Biceps tenodesis seems to offer improvements in function and pain.Level of evidence: IV

BMP-2 has a crucial role in the treatment of extensive bone defect. However, data about the optimaldosage of BMP-2 in the massive bone defect casesis rare. Twenty-five SD rats were randomly allocated into a control group of hydroxyapatite (HA) alone (Group I),HA+BMP-2 1μg/mL (Group II), HA+BMP-2 5 ug/mL (Group III), HA+BMP-2 10 μg/mL (Group IV), and HA+BMP-2 20ug/mL (Group V). Osteotomies were performed in each group with 10 mm bone defect in the right femur, followed byfixation and filling the defect. The fracture healing was evaluated by histomorphometry, and radiographs using RUSTscore. We found there were significant differences in the mean total area of callus between the treatment groups(P<0.001); there were significant differences in the mean area of woven bone between group II, III, IV, and V with thecontrol group (respectively P=0.009, P=0.016, P=0.009 and P=0.016), the area of the cartilage between the treatmentgroups and control group (respectively P=0.009, P=0.009, P=0.009 and P=0.028). A statistically significant differencewas found in the average area of fibrosis between group II and control group, group IV and control group (respectivelyP=0.047 and P=0.009). RUST scores showed significant differences between the control group and group II, III, IV, V(respectively P=0.005, P=0.006, P=0.005 and P=0.006). The administration of BMP-2 stimulates the formation of bone bridging in a massive bone defect. Thebone bridging filling massive bone defect depends on the dose or concentration of BMP-2. Administration of an optimaldose (10 μg/mL) of BMP-2 demonstrates better result than lower or higher dose for massive bone defect healing in SDrate.Level of evidence: II

Optimum component positioning and orientation is required to optimize the functional result during totalhip arthroplasty for dysplastic hips. Sixty-two patients (66 hips) including 33 males and 29 females underwent total hip arthroplasty usingmodular stem prosthesis at an average age of 40.6 years (range 17 to 49 years). Nineteen hips were classifiedas Type I, 24 hips as Type II, 13 hips as Type III and 10 hips as Type IV dysplastic hips according to Crowe’sclassification. Eighteen hips (27.2%) underwent sub trochanteric osteotomy and 23 hips (34.8%) required adductortenotomy at the time of surgery. Sixty-one patients (65 hips) were available for the latest follow up. The median follow-up was 57.4 months(range12 to 100 months). The mean Harris Hip Score was 90.6 (range 72 to 96), which was significant improvementfrom the preoperative Score of 44.8 (range 38 to 62). The clinical outcome was graded as excellent in 39, good in13, fair in 7 patients and poor in 2 patients respectively. Only one hip (1.5%) had underwent revision surgery forthe stem at 18 months following the index surgery. Postoperative dislocation following a fall was seen in one hipof a female patient who was operated on both sides. The radiographs revealed that all the remaining 65 hips hadstable femoral component and the osteotomy sites were healed. The Kaplan-Meier survivorship with revision asendpoint (including open reduction for dislocation) was found to be 96.4% at 100 months (95% Confidence Interval;86.3-99.1). This study in South-Asian patients using the modular stem strengthened the premise that cementlessmodular total hip arthroplasty provides a satisfactory outcome in treating secondary osteoarthritis due to dysplastichips.Level of evidence: IV

Bleeding episodes in severe hemophilia may occur more frequently and spontaneously after mildtrauma or daily activities. An inadequate treatment of that bleeding in hemophilia may result in pseudotumor,usually in the muscle adjacent to the bone. We reported haemophilic pseudotumor treated with various surgicalinterventions. This study was conducted inthe Department of Orthopaedic and Traumatology at a government hospitalover a period of 7 years(2010 –2017). Patients Perioperative management was done in accordance with the IntegratedHemophilia Team of our institution protocol.Diagnosis and management planning of hemophilic pseudotumor wasconfirmed via Integrated HemophiliaTeam meeting. After the surgery, all patients were asked to come for routinefollow up. We reported six Haemophilia-A patients with pseudotumor in the pelvis, proximal femur and lowerleg. One case in pelvic bone underwent hematoma evacuation, acetabular reconstruction using the Harringtonprocedure, and total hip arthroplasty.Two cases, a case in the proximal femur and another case in the distal fibula,were treated with amputation, other two cases, one was soft tissue psedotumor in the pelvic region and wastreated by hematoma evacuation, and the remaining casewas managed with wide excision and followed by defectclosure. Surgery is a preferable treatment for pseudotumors that have been present for years.It’s associatedwith the best outcomes especially when selected as the primary line ofwith preventable and manageable bleedingcomplication. As previously published by many authors, this paper confirms that surgical excision is the treatment ofchoice but should only be carried out in major hemophilia centers by a multidisciplinary surgical team.Level of evidence: IV

The presence of cruciate ligaments is very important for normal knee kinematics. Knee arthroplastyprostheses, in which these ligaments are maintained, have better kinematics. The aim of the present study was toinvestigate the association between femoral intercondylar notch (FIN) narrowing in radiography and clinical andhistopathologic integrity of anterior cruciate ligament (ACL) in patients undergoing knee replacement surgery. FIN index was measured in tunnel view radiography of the knees of 102 candidates of knee replacementsurgery. The anatomical status of ACL was also examined during total knee arthroplasty (TKA). ACL was removed andsent for histopathologic examination to assess its degeneration rate. The association between the FIN index and theclinical and histopathological health of ACL was investigated. Among 102 patients with mean age of 69.73 ± 7.81 years , 39 patients (38.32%) had no or torn ACL, 31patients (30.39%) had weak ACL, and 32 (31.37%) had normal ACL. There was a significant association between ageand clinical status of ACL during surgery (P=0.017). There was a significant difference in FIN and ACL health statusduring surgery between the two groups with an index of more and less than 0.252 (P=0.019 and P=0.019, respectively).There was no significant difference in the mean total degeneration score (TDS) of ACL between the two groups with FINmore and less than 0.252 (P=0.816). There was a significant difference between the age and FIN narrowing (less than 0.252) as well as ACLclinical status during surgery. FIN narrowing had no significant effect on the severity of ACL degeneration and there wasno significant difference in the severity of degenerative histopathologic changes between healthy and attenuated ACLs.This indicates that if ACL exists, although apparently attenuated, it has the histologic characteristic of a healthy ligament.Level of evidence: II

Short-time creep behaviorfor aseries of biodegradable nanocomposites, which areused as implantabledevices inthe body, is a crucial factor.The present study aimed to investigate the effect of bioactive glass nanoparticles(BGn) on creep and creep-recovery behaviors of polylactic acid/polycaprolactone (PLA/PCL) blends at different givenloads and different applied temperatures. A series of biodegradable nanocomposites consisted of PLA/PCL blends (comprising 80 parts PLA and 20parts PCL) with different amounts of modified-BGn (m-BGn) fillers were prepared using the evaporated solvent castingtechnique. Creep and creep-recovery behaviors of all specimens were studied at different valuable stressesof 3 and 6MPa and different given temperatures of 25 and 37°C. In all cases, m-BGn improved the creep resistance of the nanocomposites due to the retardation effectduring the creep behaviors of the nanocomposite systems. The obtained results in terms of creep and creep-recoveryproperties determined that the nanocomposites of PLA/PCL/m-BGn can satisfy the required conditions of an appropriateanterior cruciate ligament reconstruction (ACL-R) screw. The obtained results confirmed that the BGn plays an impeding role in the movement of PLA/PCL chainsleading to in increase the creep resistance. According to the results, it was determined that the nanocomposites of PLA/PCL and m-BGn can satisfy the required circumstances of a proper ACL-R screw.Level of evidence: I

Giant cell tumor of bone (GCTB) is a locally aggressive lesion with an unpredictable behavior. Herein,the aim of this study was to evaluate the epidemiological characteristics, as well as clinical and functional outcomes ofGCTB in a relatively large series of patients. Patients with the diagnosis of GCTB were included in this retrospective study. Whenever the preservationof the articular surface was possible, surgical options included extended curettage; otherwise, wide resection wasimplemented. In case of extended curettage, the cavity was filled with cement or bone graft. In addition, the functionaland oncologic outcomes of these surgical strategies were compared. The functional outcome of the patients wasassessed using the Musculoskeletal Tumor Society (MSTS) scoring system. A total of 120 GCTB patients, including 55 males (45.8%) and 65 females (54.2%), were evaluated. Thethree involved locations with highest frequency included distal femur (26%), distal radius (22%), and proximal tibia(19%). At a mean follow-up of 125.5±49.2 months, two pulmonary metastases (1.6%) and 12 (10%) local recurrenceswere observed. In addition, 6 out of 12 (50%) local recurrences occurred in distal radius (P=0.04). The recurrence ratewas significantly higher in extended curettage than in wide resection (P=0.05), and the same pattern was observedfor allograft, compared to cement filling (P=0.05). The mean MSTS scores for extended curettage and wide resectionwere 94.7 and 89.1, respectively (P=0.04). Furthermore, the mean MSTS scores for bone graft filling and cementaugmentation were obtained as 96 and 93.1, respectively (P=0.07). Based on the findings, wide resection of GCTB was associated with superior oncologic outcome, as wellas inferior functional outcome. In extended curettage, cement augmentation resulted in superior oncologic outcomewhen compared with allograft filling.Level of evidence: IV

This study was conducted to evaluate the clinical outcomes of the acromioclavicular joint (ACJ)fixation with hook plate (HP) and continuous loop double endobutton fixation (CLDE) in the treatment of acute ACJdislocation. This retrospective study was conducted on eight patients with HP and nine patients with CLDE fixations foracute ACJ dislocations. The subjects were evaluated by various criteria, including disabilities of the Arm, Shoulder,and Hand (DASH), American Shoulder and Elbow Surgeons Standardized Shoulder Assessment (ASES), Universityof California, Los Angeles (UCLA) shoulder rating scale, Shoulder Constant score, Simple Shoulder Test (SST), andcoracoclavicular (CC) distance. The differences between the mean scores of the visual analog scale for pain, DASH, ASES, UCLAshoulder rating scale, and Shoulder Constant, and SST were statistically significant in favor of the CLDE group.Mean difference of CC distance was 8.6±0.9 mm in the HP group; however, it was 11.6±1.2 mm in the CLDE group.The operation time was shorter in the HP fixation, compared to that in the CLDE fixation (51±13.3 versus 105±9.7min; PHP group. The CLDE fixation was reported with better clinical outcomes than HP fixation; however, it was a technicallydemanding procedure. The HP maintained the CC distance better than CLDE with a technically easy application. TheHP requires a second surgery for the removal and development of subacromial erosion and osteoarthritis of the ACJthat can be regarded as major concerns.Level of evidence: III

Osteoarthritis is one of the most prevalent joint diseases in older adults. Since hands play a key role indaily activities, their impairment causes disability and reduction of independency. The present study aimed to investigatethe effect of using Kinesio tape on pain, range of motion (ROM), hand strength, and functional abilities in patient withhand osteoarthritis (HOA). In this randomized clinical trial study, 38 patients with the diagnosis of HOA were selected and randomlyassigned to Kinesio tape plus exercise (KT-EXE) and exercise (EXE) groups. Each group included 19 subjects whoparticipated in an 8-week intervention. Visual analog scale, Disabilities of the Arm, Shoulder, and Hand questionnaire,as well as goniometer and dynamometer measurements, were used to assess pain severity, upper extremity functionaldisabilities, ROM, and grip strength, respectively, before and after the intervention and at 2 months of follow-up. There was no significant difference in pre-intervention scores between the two groups. Statistical analysisrevealed significant improvement in pain, ROM, hand strength, and upper-extremity functional abilities after theintervention in KT-EXE and EXE groups. In addition, the follow-up analysis showed significant changes, compared tothe initial assessments except for the pain in the EXE group. Results of the independent t-test revealed that changewas significantly greater in KT-EXE group than that in the EXE group at post-intervention and 2-month follow-upassessments except for the wrist flexion and upper-extremity functional abilities at final evaluation. Obtained results of this study showed that Kinesio taping and hand exercise may have a positive effect onthe improvement of pain, ROM, hand strength, and upper-extremity functional abilities in patients with HOA. In addition,these two methods can be simultaneously used for the rehabilitation of this condition.Level of evidence: III

Avascular necrosis of the femoral head (AVNFH) is a leading cause of end-stage joint disease in the young populationthat can lead to total hip replacement in early life. There are various risk factors, including trauma, corticosteroids,thrombosis, hypertension, and alcohol. There is a growing number of patients with AVNFH and history of self-medicationwith herbal supplement used for weight gain in Iran. The present study aimed to demonstrate the prevalence rate ofusing unapproved weight gain supplements (UWGS) in patients with AVNFH.An observational and cross-sectional study was conducted to estimate the prevalence rate of using UWGSs in patientswith osteonecrosis at Imam Khomeini Hospital, Tehran, Iran, from January 2012 to 2018. The data were analyzed inSPSS software (version 24) through descriptive statistics and tests of means.Out of 207 patients with AVNFH, 115 cases were male. In total, 44 patients (20.95%) had a history of using UWGSs,and there had no other risk factors of osteonecrosis of FH.In conclusion, UWGSs can be a risk factor for AVNFH, and it is necessary to develop educational programs to alertyoung population about the side effects of these supplements.Level of evidence: III

Osteoid osteoma (OO) is a small tumor of bone that affects the spine in 10% of the cases. The tumor has a tendency toneural arc, and the lumbar spine is the most common site of presentation. Lesions of the odontoid process are very rare.We presented the case of a 20-year-old man who had cervical pain for 8 months. The pain responded to medical therapy.After investigation, there was a lytic lesion at the odontoid process with the characteristic features of OO in computedtomography scan and magnetic resonance imaging. Firstly, medical treatment was initiated with the administration ofnonsteroidal anti-inflammatory drugs; however, due to adverse effects and worsening of his pain, the patient underwentsurgical treatment with intralesional curettage from the transoral approach. In addition, the posterior fusion of the firstand second cervical vertebrae was performed. The pain disappeared, and the patient was symptom-free after one yearof follow-up.Level of evidence: V