Archives of Bone and Joint Surgery
Volume:8 Issue: 2, Mar 2020

Prevention is essential for avoiding the complications of muscle hematomas (pseudotumors, compartment syndromesand peripheral nerve lesions) in hemophilic patients. This is achieved through early diagnosis of muscle hematomasand proper long-term hematological treatment until they have resolved (confirmed by image studies). Ultrasound-guidedpercutaneous drainage could be beneficial in terms of achieving better and faster symptom relief. When suspectinga hemophilic pseudotumor, biopsy will help us confirm the diagnosis and rule out true tumors (chondrosarcoma,liposarcoma, synovial sarcoma) that sometimes mimic hemophilic pseudotumor. Surgical removal of hemophilicpseudotumor is the best solution. As alternatives, there are curettage and filling with cancellous bone and radiotherapy(when surgery is contraindicated). Preoperative arterial embolization (ideally 2 weeks before surgery) helps controlintraoperative bleeding during surgery for giant pelvic pseudotumors.Level of evidence: III

The Brief Pain Inventory-Short Form (BPI-SF) and Revised Short-Form McGill Pain Questionnaire Version-2(SF-MPQ-2) are generic pain assessment tools used in research and practice for pain assessment in musculoskeletal(MSK) conditions. A comprehensive review that systematically analyses their measurement properties in MSK conditionshas not been performed. This review protocol describes the steps that will be taken to locate, critically appraise, compareand summarize clinical measurement research on the BPI-SF and SF-MPQ-2 in pain-related MSK conditions.

Medline, EMBASE, CINAHL and Scopus will be searched for publications that examine the measurementproperties of the Brief Pain Inventory and Revised Short-Form McGill Pain Questionnaire Version-2. Two reviewerswill independently screen citations (title, abstract and full text) and extract relevant data. The extensiveness, rigor,and quality of measurement property reports will be examined with a structured measurement studies appraisal tool,and with the updated COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN)guidelines. Findings will be descriptively summarized, and when possible, a meta-analysis will be performed.

This review will summarize and compare the current level of evidence on the measurement properties of theBPI-SF and SF-MPQ-2 in a spectrum of musculoskeletal conditions. We expect clinicians/researchers dealing with MSKconditions to have synthesized evidence that informs their decision making and preferences. In addition, the review hopesto identify gaps and determine priorities for future research with or on the BPI-SF and SF-MPQ-2 in MSK conditions.Level of evidence: Not Applicable

The anterior approach to the elbow for pediatric lateral condyle fractures (LCF) would provide a bettervisualization of the articular fracture resulting in better functional results, less complications and a more cosmeticallyappealingscar than usually seen with the lateral approach.

Retrospective study of children undergoing an open reduction and internal fixation of a displaced LCFvia an anterior approach with a transverse incision. Bilateral elbow range of motion (ROM), upper limb alignmentand complications were registered. A 4-point ordinal Likert-type scale was employed for parents to rate their level ofsatisfaction with the cosmetic appearance of the scar.

Eighteen children of mean age 76 months (range 27 to 101 months) were included. Fractures were classifiedas Jackob’s Type II in 14 cases and Milch’s type II in all cases. Mean follow-up was 12 (range 4 to19) months.Successful condral fracture visualization and reduction was achieved in every case. No intra-operative or post-operativecomplications occurred. In all cases bone union was obtained 4 to 5 weeks after surgery and at final follow-up, activeelbow ROM of at least 90%, was obtained. All parents claimed to be “very satisfied” with their child’s scar. A lateral spurwas identified in 66.7% o patients.

The anterior approach to the elbow was both a feasible and safe allowing full anatomical cartilagereduction. Complications after this technique might decrease compared to the lateral approach but need futurecomparative studies. The rate of lateral spur did not decreased. Cosmetic scar results seem to be a clear advantage ofthis approach compared to the classical lateral approach.Level of evidence: IV

The projected increase in revision shoulder arthroplasty has increased interest in the outcomes of theseprocedures. Glenoid component removal and conversion to a hemiarthroplasty (HA) is an option for aseptic glenoidloosening after anatomic total shoulder arthroplasty (aTSA). We identified patients who had undergone revision shoulder arthroplasty over a 15-year period. 17 patientsmet inclusion and exclusion criteria, and a retrospective chart review was conducted for pre-surgical and operativedata. We contacted patients at a mean follow-up of 70 months from revision surgery for implant survival, reoperationsand functional outcomes scores. Implant survival was estimated to be 88% at 2 years and 67% at 5 years. Mean ASES score for survivingimplants was 58 ± 22. Mean SANE score was 54 ± 24, and mean VAS pain score was 3.5 ± 2.8. Mean SF-12 Mentaland Physical scores were 46 ± 15 and 38 ± 10, respectively. Five patients (50% of those with surviving implants)reported being either very satisfied or satisfied with the status of their shoulder. There were complications in 6 patients(35%) and 5 patients (29%) required reoperation. HA following failed aTSA due to glenoid loosening produced modest clinical results and satisfaction rates.Reverse arthroplasty may be a more reliable treatment strategy in this patient population.Level of evidence: IV

To retrospectively review surgical outcomes of prospectively collected data on a series of patients whounderwent revision of a type II SLAP repair to arthroscopic biceps tenodesis due to an unsuccessful outcome. A retrospective review was performed on a cohort of patients who underwent arthroscopic biceps tenodesisfor a failed type II SLAP repair from 2010 to 2014. Range of motion (ROM) in four planes was measured pre-andpostoperatively. In addition, all patients completed the American Shoulder Elbow Surgeons (ASES) standardizedshoulder assessment form, the Visual Analogue Scale (VAS) for pain, and the Short Form-12 (SF-12) scores. Overall, 26 patients met inclusion criteria. All 26 patients were available for follow-up at a minimum of twoyears (100% follow-up). The mean age of the patients was 37(range 26-54), 85% were male, and 58% were overheadlaborers. Clinical as well as statistical improvement was noted following tenodesis across all outcome measurements(P<0.01). Additionally, ROM improved in all four planes (P<0.01). The rate of return to work was 85% with workers’compensation status leading to inferior outcomes. Two complications were noted which required an additional surgery. Arthroscopic biceps tenodesis demonstrates to be an effective treatment for a failed type II SLAP repairwith improved patient satisfaction, pain relief, and range of motion at two-years follow-up with a low complication rate.Level of evidence: III

Distal tibia fractures are among the most common bony injuries, with a significant rate of nonunion anddelayed union. There are multiple methods for the management of distal tibia fractures. Among the plating methods,there are bridge plating and compression plating techniques. There is still a lack of evidence about whether one methodhas a higher rate of union than the other. The present study aimed to assess the union rate of extra-articular distal tibiafractures using biological fixation with bridge plating and rigid fixation with compression plating. This retrospective analysis was performed on 41 adult patients with distal tibia fractures. The subjectswere divided into two groups based on the fixation method, namely bridge plating and compression plating. Baselinecharacteristics, fracture characteristics, and union status were analyzed and compared in this study. Baseline and fracture characteristics were similar between the groups. Only higher translation in any planeswas noted in the bridge plating group (2.80±3.04 mm; P<0.001). As for union status, the rates of the union during 3months and delayed/no union were similar between the two groups (P=0.18). During a 6-month follow-up, 92% and93.8% of the patients achieved union in the bridge plating and compression plating groups, respectively. Rates of delayed union and nonunion are similar regarding extra-articular distal tibia fractures treatedwith either bridge plating or compression plating.Level of evidence: III

Lateral epicondylitis (LE) most commonly affects the Extensor Carpi Radialis Brevis (ECRB) tendon andpatients are generally treated with injection therapy. For optimal positioning of the injection, as well as an estimation ofthe surface area and content of the ECRB tendon to determine the volume of the injectable needed, it is important toknow the exact location of the ECRB in relation to the skin as well as the variation in tendon length and location. Theaim of this study was to determine the variation in location and size of the ECRB tendon in patients with LE. An observational sonographic evaluation of the ECRB tendon was performed in 40 patients with LE. Thelength of the ECRB tendon, distance from the cutis to the center of the ECRB tendon, the length of the osteotendinousjunction at the epicondyle and the distance from cutis to middle of the osteotendinous junction were measured. The average tendon length was 1.68cm (range 1.27-1.98; SD 0.177). Compared to women, the ECRB tendonof men was on average 0.12cm longer. Overall, the average distance from cutis to the center of the ECRB was 0.75cm(range 0.50-1.46cm; SD 0.210), the average length of the junction was 0.55cm (range 0.35-0.87; SD 0.130), and thedistance from cutis to middle of the osteotendinous junction was 0.73cm (range 0.40-1.25cm; SD 0.210). The size and depth of the ECRB tendon in patients with LE is largely variable. While there are no studiesyet suggesting sono-guided injection to be superior to that of blind injection, the anatomic variability of this studysuggests that the accuracy of injection therapy for LE might be compromised when based solely on bony landmarksand therefore not fully reliable. As a result, there is value in further studies exploring the accuracy of the ultrasoundguided injection techniques.Level of evidence: IV

There is a high demand for shoulder/elbow experience among hand-fellowship trainees due to theperception that this exposure will improve their professional “marketability” in a subspecialty they perceive as havinghigher compensation. Using Medicare data, we investigated the most common surgeries from these fields and determinedwhich have the highest compensation [work relative value unit (wRVU), payment, charge, and reimbursement(payment-to-charge percentage] rates per operative time. We then determined whether the overall non-weightedand weighted (by surgical frequency/volume) compensation rates of shoulder/elbow surgery are greater than thatof hand surgery. Among 30 shoulder/elbow procedures, arthroplasty and arthroscopic rotator cuff repair had the highest paymentand wRVU assignments. Among 83 hand procedures, upper-extremity flaps, carpal stabilization, distal radius openreduction internal fixation (ORIF), both-bone ORIF, and interposition arthroplasty had the greatest wRVU assignmentswith correspondingly high payments. A non-weighted comparison of the two subspecialties showed that hand surgeryhas a higher mean payment/min ($10.46±3.22 vs. $7.52±2.89), charge/min ($51.02±17.11 vs. $41.96±11.32), andreimbursement (21±4.7% vs. 18±5.1%) compared with shoulder/elbow surgery (all, P<0.01). Non-weighted meanwRVUs/min were similar (0.12±0.03 vs. 0.13±0.03, P = 0.12). When weighted by procedure frequency, hand surgeryhad greater wRVUs/min (0.15±0.036 vs. 0.13±0.032), payments/min ($14.17±4.50 vs. $6.97±2.26), charges/min($75.68±30.47 vs. $42.61±7.83), and reimbursement (20±5.0% vs. 17±6.0%) (all, P<0.01). According to Medicare compensation, and when weighted by procedure frequency, hand proceduresare associated with greater overall mean wRVUs/min, payments/min, charges/min, and reimbursement compared withshoulder and elbow procedures. Hand-surgery fellowship applicants should be aware that subspecialty compensationis complex in nature but should seek shoulder/elbow elective experience to acquire an additional surgical skill-set asopposed to primarily monetary reason.Level of evidence: III

An effective treatment for the elbow recalcitrant lateral epicondylitis is arthroscopic surgery. This studyevaluated the midterm results of treating recalcitrant lateral epicondylitis with arthroscopic surgery. A total of 40 subjects with recalcitrant lateral epicondylitis prepared for arthroscopic surgery on their elbowsparticipated in this study. The elbow function was evaluated using the Quick disabilities of the arm, shoulder, and hand(Quick DASH) score. Pain intensity was assessed before and after the surgery by the visual analog scale (VAS). Gripand pinch strengths were assessed by a dynamometer. In this study, the mean age of the participants was 42.9±6.4 years. The average follow-up time was 42months. The mean of VAS (pain intensities) were 7.05 and 3.20 before and after the surgery, respectively (P=0.001).The Quick DASH score decreased from 63.18 to 25.68 from before to after the surgery (P=0.001). The mean gripstrength of the operated and nonoperated sides was not significantly different after the surgery. Arthroscopic surgery seems to be an effective method with few complications in patients suffering froman elbow recalcitrant lateral epicondylitis in the midterm follow-up.Level of evidence: II

The best method for repairing intertrochanteric fractures is still controversial. The fixation methods includeextramedullary (EM) and intramedullary (IM). Studies that compare IM and EM fixations for unstable hip fractures arerare. In this study, our goal was to compare the efficacy of EM and IM fixation in treatment of unstable intertrochantericfractures. A total of 113 patients with unstable intertrochanteric were randomized in this cohort study between March2016 and June 2018 in trauma center of Kashani and Alzahra Hospitals, Isfahan, Iran. The patients were followed for aperiod of 12 months with sequential clinical and imaging evaluations. Baseline data were recorded at the time of injury.Radiographs were evaluated immediately post-operatively and at the scheduled follow-up intervals. A total of 20 of patients were excluded during the study and finally 93 patients (43 males and 50 females)with mean age of 62.74±16.4 completed the follow-up sessions. Mann-Whitney test indicated a significant difference intip-apex distance between the two groups. While the two groups were homogeneous in the baseline LEM score, it wasnot significantly different between two groups after 1 and 3 months of surgery as well. However, the LEM score wassignificantly higher in IM group after 6 and 12 months of surgery. According to our findings, IM nails (such as the cephalomedullary nail) afforded more advantages overEM devices (such as the DHS and DCS) in the treatment of unstable intertrochanteric fractures. Our results indicatedthat the final LEM scores as well as the time to union were better in IM fixation group.Level of evidence: I

Healthcare is expensive and often inaccessible to many. As a result, surgeons must consider simple, less expensiveinterventions when possible. For wound care, an older but quite effective cleaning agent is Dakin’s solution (0.5%sodium hypochlorite), an easily made mixture of 100 milliliters (ml) bleach with 8 teaspoons (tsp) baking soda into agallon of clean water or 25 ml bleach and 2 tsp baking soda into a liter of water. Gauze is then wet with this solution,placed on the wound, and replaced every 24 hours as needed. Our team of surgeons in Haiti and the United Statesis currently using Dakin’s solution for wound care following orthopedic surgery and finds it to be a low-cost, safe, andeffective treatment for post-surgical wound care for both resource-limited and non-resource strained environments.This report aims to update the current literature and encourage the consideration of Dakin’s solution for modernwound care.Level of evidence: III

Intrathoracic displacement of the humeral head is a very uncommon condition and can be life threatening due to lungor heart injuries. There is a report of this condition where intrathoracic bone fragment was missed. Because of rareincidence there is no guideline for approach and treatment of this condition.We hereby present a case of intrathoracic displacement of fractured humeral head in a man due to a car roll-overaccident.This condition requires a concise team workup of trauma and orthopedic surgeons along with the physical therapistsfor the best possible decision making.Displaced fractured humoral head into the thorax is a rare condition that needs more punctuality for on time diagnosisand team approach.Level of evidence: V