Archives of Bone and Joint Surgery
Volume:10 Issue: 6, Jun 2022

This study compares the outcomes of patients undergoing total ankle arthroplasty (TAA) and tibiotalar fusion (ankle arthrodesis) in patients with end-stage osteoarthritis. The primary outcome assessed was Patient Reported Outcome Measures (PROMS); secondary outcomes included the incidence of revision, re-operation, and complications.

A systematic review of studies examining the outcomes of patients undergoing TAA and/or tibiotalar fusion from 2006 to 2020 was conducted. Individual cohort studies and randomized control trials were included. Outcomes were assessed at two and five years.

21 studies were included: 16 arthroplasty (2,016 patients) and 5 arthrodesis (256 patients) studies. No significant difference in PROMS was evident two years post-surgery – American Orthopaedic Foot and Ankle Society (AOFAS) scores were 78.8 (95% CI-confidence interval: 76.6-80.8; n=1548) and 80.8 (95% CI: 80.1-81.5; n=206 patients) for the arthroplasty and arthrodesis groups respectively. Two years post-surgery the revision rates for the arthroplasty and arthrodesis groups were similar – 3.5% (n=9) and 3.7% (n=61) respectively (OR-odds ratio: 1.05; 95% CI: 0.51-2.13); however, the re-operation rate was 2.5 times higher for the arthroplasty group (12.2%) in comparison to the arthrodesis group (5.1%) (OR: 2.57; 95% CI: 1.43-4.62). Documented complications in the arthroplasty group were half those documented in the arthrodesis group two years post-surgery (OR: 0.53; 95% CI: 0.37-0.77). No arthrodesis studies were found which contained mean 5-year follow-up data within the study period.

Despite recent developments in TAA design, we found no clear evidence as to their superiority over ankle arthrodesis when considering patient outcomes two years postoperatively. However, this conclusion could be debatable in some types of patients such as diabetic patients, posttraumatic patients and patients with stiff hindfoot and midfoot.Level of Evidence: III

Avascular necrosis (AVN) or osteonecrosis of the femoral head occurs as a result of a vascular supply disruption that could lead to hip osteoarthritis. Recently, several joint-preserving procedures have been suggested to improve the outcome of AVN, including hip arthroscopy. This systematic review aimed to investigate the role of hip arthroscopy to preserve hip joints suffering from AVN.

This review was conducted to collect data on hip arthroscopy from the available literature for the management of AVN. The collected articles included those that were focused mainly on the management of AVN assisted by arthroscopy and published up to 2020 that were searched in four databases using such keywords as “Avascular Necrosis”, “AVN”, and “Osteonecrosis” in combination with “Hip Arthroscopy” or “Arthroscopic Hip Surgery”. 

In total, 13 articles met the eligibility criteria, and no severe complications were reported after arthroscopy in patients with AVN. Moreover, the Harris scores were higher than 79 after the operation. The majority of the assessments showed that the use of arthroscopy was effective in the diagnosis and treatment of patients with AVN, except for one study, which had been performed on patients with stage IV AVN. 

The findings supported the idea that hip arthroscopy is effective in the treatment of AVN. This approach is becoming more popular for the diagnosis and treatment of hip disorders.Level of evidence: I

Hip fractures are among the most common fractures operated by orthopedic surgeons. Many elderly patients, who account for a significant percentage of hip fractures, suffer from medical conditions requiring antiplatelet and anticoagulant administration. Meanwhile, considerable evidence recommends early surgery within 48b hours of admission. We aim to review the existing evidence regarding the perioperative management of antiplatelet and anticoagulant drugs in hip fractures. It was concluded that surgery for hip fractures in patients with antiplatelet drug consumption should not be delayed unless a clear contraindication exists. Active reversal strategies are indicated for patients with hip fractures and warfarin therapy. However, evidence for the safety of these agents in pregnancy, breastfeeding state, and adolescence has not yet been established. Little data exists about perioperative management of direct-acting oral anticoagulants in hip fractures. Early surgery after 12-24 hours of drug cessation has been suggested in studies; however, it should be employed cautiously. Despite extensive research, the importance of the issue necessitates additional higher-quality studies.Level of evidence: V

The purpose of this case series is to describe surgical decision making and clinical outcomes in posteriorly displaced radial head fractures with a major fragment (more than 50% of the head) located behind the humeral condyle. We also document the outcome of open reduction and internal fixation of completely displaced radial head fractures. A retrospective review of the ICUC® (Integrated Comprehensive Unchanged Complete) database was performed between 2012 and 2020. Patients were included if preoperative radiographs demonstrated a major radial head fracture fragment located posterior to the humeral condyle and a minimum of 2-year follow-up data was available.  Ten patients met inclusion criteria. Two patients had an associated elbow dislocation whereas 8 patients did not. All patients were found to have disruption of the lateral collateral ligament complex intraoperatively. Nine radial head fractures were successfully fixed with interfragmentary screws. One multi-fragmented radial head fracture could not be successfully stabilized with interfragmentary screw fixation and was resected. The average time to final followup was 4.8 years (range 2.2-8.1). At final follow-up, 6 patients demonstrated radiographic evidence of a healed radial head, 1 patient had avascular necrosis, and 2 had post-traumatic arthritis. None demonstrated radiographic instability. The average functional score was 0.64 (SD 0.81) and pain score was 0.45 (SD 0.93). The average elbow extension was 8 degrees (SD 11), elbow flexion was 139 degrees (SD 6), forearm supination was 60 degrees (SD 27), and forearm pronation was 69 degrees (SD 3). Recognition of a posteriorly displaced radial head fracture is essential, as it may be an indirect sign of elbow instability. This instability should be addressed during surgical intervention. Level of evidence: IV

This study describes a minimally invasive technique for the reconstruction of the medial collateral ligament (MCL) and posterior oblique ligament (POL) through minimal incisions on the tibial and femoral sides of the ligament using the modified Bosworth technique. This study included 19 consecutive patients who presented with chronic grade III injury; the mean age was 29.6 years (standard deviation ± 7.5 years, range 19–43 years), and five patients (26.3%) had no associated injuries. Ten patients (52.6%) had associated anterior cruciate ligament (ACL) injury and four patients (21.1%) had associated posterior cruciate ligament (PCL) injury. All patients were assessed 18 months postoperatively regarding functional outcome using the Lysholm score and medial joint space opening.  There was a statistically significant improvement in the patient functional outcome as the Lysholm score improved from 55.39 ± 6.9 to 89.42 ± 6.4 at 18 months postoperatively. (P< 0.001). At the end of the follow-up, 16 cases had grade 1 medial laxity, 3 cases with grade II laxity, and no patients with grade III medial laxity. Minimally invasive MCL reconstruction with modified Bosworth technique gives very good results regarding the functional outcome and residual medial laxity of the knee. Level of evidence: IV

Implant removal due to infection is one of the major causes failure following open reduction and internal fixation (ORIF). The aim of this study was to determine trends and predictors of infection-related implant removal following ORIF of extremities using a nationally representative database. Nationwide Inpatient Sample data from 2006 to 2017 was used to identify cases of ORIF following upper and lower extremity fractures, as well as cases that underwent infection-related implant removal following ORIF. Multivariate analysis was performed to identify independent predictors of infection-related implant removal, controlling for patient demographics and comorbidities, hospital characteristics, site of fracture, and year.  For all ORIF procedures, the highest rate of implant removal due to infection was the phalanges/hand (5.61%), phalanges/foot (5.08%), and the radius/ulna (4.85%). Implant removal rates due to infection decreased in all fractures except radial/ulnar fractures. Tarsal/metatarsal fractures (odds ratio (OR)=1.45, 95% confidence interval (CI): 1.02-2.05), and tibial fractures (OR=1.82, 95% CI: 1.45-2.28) were identified as independent predictors of infection-related implant removal. Male gender (OR=1.67, 95% CI: 1.49-1.87), Obesity (OR=1.85, 95% CI: 1.34-2.54), diabetes mellitus with chronic complications (OR=1.69, 95% CI: 1.13-2.54, P<0.05), deficiency anemia (OR=1.59, 95% CI: 1.14-2.22) were patient factors that were associated with increased infection-related removals. Removal of implant due to infection had a higher total charge associated with the episode of care (mean: $166,041) than non-infection related implant removal (mean: $133,110). Implant removal rates due to infection decreased in all fractures except radial/ulnar fractures. Diabetes, liver disease, and rheumatoid arthritis were important predictors of infection-related implant removal. The study identified some risk factors for implant related infection following ORIF, such as diabetes, obesity, and anemia, that should be studied further to implement strategies to reduce rate of infection following ORIF.Level of evidence: III

The deficiency of the triceps tendon has been considered a relative contraindication to performing a total elbow arthroplasty. One of the conditions that may compromise triceps integrity is the presence of an olecranon non-union (ON). In this scenario, the placement of a total elbow arthroplasty in a patient with end-stage elbow arthritis is a complex problem to be solved. The aim of this study is to describe the surgical technique for the placement of a TEA in the context of a previous ON and to report the results of three cases.Surgical technique: the focus of the nonunion is identified, and the olecranon fragment is proximally reflected with the triceps tendon to allow accurate exposure of the medullary canal of the ulna and easy access to the joint. With the elbow in a fully flexed position, the previously assembled test prosthesis is placed and the proximal ulna fragment should then be reduced to match the distal ulna. Osteosynthesis with a tension band technique was performed at 45° of elbow extension. A non-absorbable Krackow suture (Ti-Cron 2-0) from the triceps’s tendon to the hole of the wire in the distal ulna is applied to decrease the triceps tension traction. Bone grafting is performed when a persistent gap is present at the fracture site following reduction. This technique enables us to achieve a stable elbow with little pain and maintains the extensor apparatus’s continuity.Level of evidence: IV

Soft tissue lipoma is one of the most common benign tumors rarely forming in hand. In this study, 11 cases of symptomatic hand lipoma were investigated. The chief complaint was a palpable mass in all 11 patients, out of whom 6 (55%) cases presented with neurological symptoms, including paresthesia and numbness in the median, ulnar, and superficial radial nerve pathways. One patient had an intramuscularly painful forearm with a large mass presentation. In the finger, the clinical manifestations were radial anesthesia of the finger. The mass sizes were above 5 cm3 and less than 5 cm3 in seven and four patients, respectively. The mean follow-up period was 25 months. No patient demonstrated a recurrence during the follow-up period. Although lipoma is a benign tumor and often presents itself as a palpable mass in the hand, it can cause neurological symptoms and decreased function. Regardless of the size of the tumor, mass removal can prevent symptomsLevel of evidence: IV