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

Medial knee injuries are prevalent, especially in young athletes. A detailed history and physical examination areneeded to accurately diagnose injuries to the superficial medial collateral ligament (sMCL), deep medial collateralligament (dMCL), and posterior oblique ligament (POL). The mechanism of medial knee injury often involves acoupled valgus and external rotation force with pain and tenderness across the medial joint line. Valgus stressradiographs assist with the diagnosis of medial knee injuries based on the quantitative extent of medial jointgapping. Specifically, 3.2 mm of increased medial gapping is observed with an isolated grade-III sMCL injury andgreater than 9.8 mm of gapping indicates a complete medial knee injury. Nonoperative treatment is recommendedfor grade-I and II medial knee injuries. Patients with chronic medial knee instability, or a complete tear of the medialknee structures, may require operative treatment. Anatomic surgical techniques have proven to be highly effectivein restoring functional knee stability. 

This narrative review of the literature aims to analyze the utilization of stromal vascular fraction (SVF)and decellularized extracellular matrices (dECMs) in various pathologies related to orthopedic surgery.

A literature search was carried out in PubMed on February 15, 2022, using “Stroma Vascular Fraction andOrthopedic Surgery” and “Decellularized Extracellular Matrices and Orthopedic Surgery” as keywords. A total of 278articles were found, of which 28 papers were selected because they seemed to be the most appropriate concerningthe title of the article.

The reported results have shown that intra-articular injection of SVF seems to be a safe and efficaciousmethod for managing knee osteoarthritis (OA). Platelet-rich plasma (PRP) and SVF are safe and effective managementfor intractable Achilles tendinopathy in humans, although subjects treated with SVF recover earlier. There are promisingresults in utilizing adipose-derived mesenchymal stromal cells in chronic lateral epicondylitis of the elbow in athletes.Ready-to-use ECM/SVF gel seems to be a good therapeutic option promoting the regeneration of the articular cartilagein subjects with injuries of the cartilage. The SVF can safely be used to treat diabetic subjects suffering from chronicfoot ulcers.

There are scarce high-quality data for utilizing cell-based approach in soft tissue injuries of the knee inathletes. Experimental studies indicate that SVF could be a new option to osseous regeneration. Other experimentalstudies support the utilization of dECMs as a scaffold for the regeneration of large osseous defects, cell-derived dECMsscaffolds to repair articular cartilage injuries, and utilization of xenogeneic acellular muscles to manage volumetricmuscle loss where there is a lack of donor site.Intra-articular injections of SVF seems to be a safe and efficacious method for managing OA of the knee joint. Plateletrichplasma (PRP) and SVF are safe and efficacious methods for the management of intractable Achilles tendinopathyin humans, although subjects treated with SVF recover earlier. 

Repair of massive rotator cuff tears remains a challenging process with mixed success. There is agrowing interest in the use of patches to augment the repair construct and the potential to enhance the strength,healing, and associated clinical outcomes. Such patches may be synthetic, xenograft, or autograft/allograft, and avariety of techniques have been tried to biologically enhance their integration and performance. The materials used arerapidly advancing, as is our understanding of their effects on rotator cuff tissue. This article aims to evaluate what wecurrently know about patch augmentation through a comprehensive review of the available literature.

We explore the results of existing clinical trials for each graft type, new manufacturing methods, noveltechniques for biological enhancement, and the histological and biomechanical impact of patch augmentation.

There are promising results in short-term studies, which suggest that patch augmentation has greatpotential to improve the success rate. In particular, this appears to be true for human dermal allograft, while porcinedermal grafts and some synthetic grafts have also had promising results.

However, there remains a need for high-quality, prospective clinical trials directly comparing each type ofgraft and the effect that they have on the clinical and radiological outcomes of rotator cuff repair. 

A superior labrum from anterior to posterior (SLAP) repairs can be performed in either beach chair (BC) orlateral decubitus (LD). The purpose of this study was to perform a systematic review and meta-analysis to compare theoutcomes of surgical repair of type II SLAP injuries between the BC vs. LD positions. We hypothesized no statisticallysignificant differences in the functional, pain, and motion outcomes between the BC vs. LD positions after type II SLAP repair.

A comprehensive literature search was performed using MEDLINE, Scopus, Web of Science, Embase, andCochrane to identify studies reporting outcomes after type II SLAP repair. Outcome measures consisted of pain usingthe visual analog score (VAS), range of motion (ROM), and functional scores, including the University of California at LosAngeles Shoulder (UCLA) score, American Shoulder and Elbow Surgeons (ASES), and Constant score. The outcomeswere pooled and analyzed for eligibility and stratified into two subgroups for a random-effects model meta-analysis.

Of the 8,016 identified studies through a database search, 13 papers (378 patients) were eligible for statisticalanalysis in the BC and 10 articles (473 patients) were included in the LD group. The mean follow-up for BC and LD was35 and 44 months, respectively. The SLAP repair in both positions demonstrated improvements in postoperative clinicaloutcomes and ROM. Comparing the two positions, the LD group demonstrated significantly greater improvements inVAS which contributed to better functional outcomes, while the BC group showed a significantly greater improvement inabduction. No other differences were identified including ASES, UCLA, and Constant score as well as remaining ROM.

Based on the findings of this systematic review and meta-analysis, both the BC and LD positions providepatients better outcomes following operative repair of type II SLAPs. While LD represented a better improvement infunctional outcome measures, the BC position demonstrated better abduction with no other significant differencesbetween both positions. An individualized approach to position selection concerning the patient’s complaint (pain vs.motion) as well as the surgeon’s discretion is recommended.

The purpose of this study is to examine the effect of hypoalbuminemia (HA) on sentinel adverse eventsafter total shoulder arthroplasty (TSA).

Patients who underwent primary TSA from 2015-2018 were collected from the National Surgical QualityImprovement Program (NSQIP) database. Patients with HA (serum albumin < 3.5 g/dL) were compared to patients withnormal serum albumin. A probit regression model was used to estimate a propensity score. Logistic regression wasperformed to evaluate the effect of HA on sentinel adverse events after surgery.

A total of 4,337 patients were included, 8.2% of patients had HA. Patients with HA had higher rates ofsentinel adverse events (14.0% vs 5.5%, P<0.01) compared with patients who had normal serum albumin. Reoperation(4.5% vs 1.5%, P<0.01), readmission (11.2% vs 3.9%, P<0.01), urinary tract infection (0.8% vs 0.03%, P<0.01) andpulmonary embolism (1.1% vs 0.2%, P=0.01) were higher in patients with HA. The odds ratio for a sentinel event forpatients with HA was 2.6 (95% CI: 1.54, 4.44, P<0.01) when compared to a propensity score-matched control group.

Patients with HA are at increased risk of sentinel adverse events following TSA compared to patients withnormal serum albumin levels. 

The purpose of this study is to compare the incidence of complications associated with tension band wiring (TBW) versus plate osteosynthesis (POS) in the treatment of olecranon fractures.

We performed a retrospective cohort study of operatively treated adult olecranon fractures from an integrated healthcare system by multiple surgeons from January 2008 to December 2011. Patients were divided into two cohorts: fractures fixed using the tension band technique and fractures fixed using plate osteosynthesis. The study was limited to the Orthopedic Trauma Association classification of olecranon fracture type 21-B1, with subtypes 1-3. Outcome measures were loss of fracture fixation requiring revision, postoperative infection, stiffness requiring surgery, and symptomatic hardware removal (HWR). Univariate and multivariable logistic regressions were performed to test the associations between the type of internal fixation and outcomes.

A total of 321 olecranon fractures were included (median age: 61 years old, 57 % female); 153 participants were treated with TBW, and 168 patients with POS. There was one failure in the TBW group and two in the POS group (P=0.62). There were no significant differences in the infection rates (TBW 5%, POS 9%, P=0.20) and no reoperations for stiffness. The HWR occurred significantly more often in TBW (29%) than in POS (14%) (OR=0.39, P=0.001). The association between POS and decreased HWR remained highly significant (OR=0.40, P=0.003) after adjusting for clinical variables.

In this large study comparing POS and TBW for 21-B1 olecranon fractures, no difference in fixation failure, infection, or postoperative stiffness was noted. A significantly greater risk of symptomatic hardware occurred in TBW. These findings may assist surgeons and patients in considering the risks and benefits of TBW and POS as treatment options for displaced olecranon fractures.

The COVID-19 pandemic brought about the placement of severe social restrictions in the UnitedKingdom, limiting activity and impacting public behavior. Limited studies have been published on the relationship ofthe coronavirus pandemic with the presentation and management of upper limb fractures. The aims of this studywere first to assess the change in the incidence of upper limb fractures at key points during the COVID-19 pandemicsuch as the enactment and lifting of lockdowns, and second to evaluate the relationship between local COVID-19burden and measures of service efficiency across our trust.

We undertook a retrospective analysis of all upper limb fracture referrals, admissions, and surgical proceduresfrom the 1st of March 2020 to the 28th of February 2021. Changes in upper limb fracture incidence were mapped tosignificant changes in social restrictions. Measurements of service efficiency including time from admission to theatreand length of stay for admitted upper limb fracture patients were mapped to local COVID-19 burden. Subgroup analysiswas undertaken to compare across age groups, including the pediatric population, all adults, and the elderly.

The study involved 1251, 659, and 641 patients with upper limb fracture referrals, admissions, and proceduresacross the trust, respectively. Referrals (n=128) and procedures (n=72) both peaked in August 2020. Admissions peakedin both May and December 2020 (63 for both). Admissions and procedures both demonstrated a decrease in March andApril 2020 compared to the rest of the study period (40 and 38 admissions, as well as 48 and 29 procedures respectively).Across the cohort, referrals and admissions did not demonstrate a statistically significant relationship with the relaxing ofsocial restrictions (P=0.504). There were statistically significant differences among referrals, admissions, and procedureswhen stratifying patients by age (P=<0.001). Length of stay demonstrated an inverse relationship with COVID-19 burdenthroughout the study period, with the shortest average length of stay recorded in months with the highest number of localCOVID-19 cases. The average time from injury occurrence to theatre increased during the winter months (P=0.001).

There is a relationship between changes in social restrictions and the incidence of upper limb fractures.These changes also had differing impacts on upper limb fracture rates when stratifying by patient age groups. Theorthopedic service demonstrated adaptability in response to the local COVID-19 burden, and further research isneeded to determine what effect this had on clinical outcomes.

Corticosteroid injection is frequently used for chronic coccydynia management. Ultrasonography canbe used to improve the accuracy of the injection. This study aims to assess the clinical outcome of ultrasound-guidedcompared to blind coccygeal injection in chronic coccydynia.

Thirty patients with chronic coccydynia were randomized into two groups and received a coccygealcorticosteroid injection at maximum tenderness point: 15 patients with and 15 patients without ultrasound guidance. Thepatient’s pain was evaluated with the visual analog scale (VAS) at 1-, 4-, 8-, and 24-week postinjection. Furthermore,the Dallas Pain Questionnaire was assessed before injection; also, four and eight weeks after treatment. The quality oflife of patients was evaluated before an assessment and four weeks after the intervention by the SF-36 questionnaire.

The VAS score decreased significantly 24-week after the intervention in both ultrasound-guided and blindedgroups (P < .001), without any significant difference between the groups (P = .964). Similarly, the Dallas pain scale hada significant decrease at eight weeks after intervention in both groups (P < .001) with no significant difference betweenthe groups (P = .972). Although there was a significant improvement in the patient’s quality of life in each group eightweeks after the intervention, it was not significantly different between the two groups. Neither of the treatment groupshad any adverse effects associated with the injection.

There were no significant differences in the clinical outcome of coccygeal ultrasound-guided vs. blindsteroid injection for chronic coccydynia.

Evaluating responsiveness and calculating minimally important change (MIC) for the Persian-versionof the Patient-Rated Tennis Elbow Evaluation (PRTEE) questionnaire following physiotherapy in patients with lateralelbow tendinopathy (LET).

We enrolled 82 patients with LET to complete the PRTEE. After completing four weeks of physiotherapy,all patients were reevaluated by the PRTEE. The patients also rated their changes on a 7-point global rating of changescale (GRoC). The receiver operating characteristic (ROC) curve and correlation analysis were used for evaluating theresponsiveness. The MIC was determined by determining a desirable cutoff on the ROC curve.

The results showed a moderate relationship (Spearman’s correlation coefficient= 0.43-0.56) of total PRTEE,pain subscale, and function subscale with the GRoC scale. The total PRTEE, pain subscale, and function subscalerevealed an area under the curve of 0.87, 0.82, and 0.83, respectively. We found the MICs 31.33, 14.5, and 15.5 pointsfor total PRTEE, pain subscale, and function subscale, respectively.

The Persian-version of the PRTEE questionnaire has acceptable responsiveness and can measurechanges in patients with LET following physiotherapy. We advocate using the PRTEE questionnaire in both clinicalsettings and research.

This study aimed to investigate the relationships of lumbar spine-hip discoordination during sit-to-stand(STD) and stand-to-sit (SIT) with pain and functional disability in chronic nonspecific low back pain (CNLBP) patients.

A cross-sectional observational study was conducted in a biomechanics laboratory of the physical therapydepartment located at the School of Rehabilitation Sciences, Iran University of Medical Sciences (Tehran–Iran). A totalof 16 CNLBP patients (men 9, female 7) aged 18–40 years (mean 31.48) were selected according to our eligibilitycriteria. Furthermore, ten reflective markers were placed on the spinous processes of T12 and S2, posterior andanterior superior iliac spines, greater trochanters, and lateral epicondyles. The patients were instructed to performSTD and SIT tasks at a preferred speed without using their hands. Relative phase angle was used as an indicator ofcoordination and was identified as the inverse tangent of angular displacement/angular velocity. Moreover, the relativephase angle between the lumbar spine and right and left hip joints was measured by subtracting the phase angle ofthe hip joint from the lumbar spine joint. The ratios of the total movements of the lumbar spine to the total movementsof the right and left hip joints were also calculated in the sagittal plane. Finally, Pearson correlation coefficients (r) wereutilized to assess the association between variables.

The results of this study indicated that kinematic parameters of the pain had statistically significant directrelationships with functional disability in CNLBP participants during STD and SIT with r values ranging from 0.57(Pvalue = 0.021) to 0.85 (Pvalue<0.001) and 0.54 (Pvalue=0.053) to 0.82 (Pvalue<0.001), respectively.

Out of the results of this study, it could be stated that pain and functional disability play a major role inlumber spine-hip discoordination, and it altered the movement ratio in CNLBP patients during STD and SIT. In clinicalpractice, clinicians should improve lumber spine-hip discoordination in patients with CNLBP since there is a linearrelationship between kinematic parameters of the pain and functional disability in patients with CNLBP.

Anterior shoulder instability with bone loss is a challenging condition. The two most performed procedures, Bankartrepair & Latarjet, are not without issues. We describe a technique where arthroscopic free bone grafting was performedin conjunction with remplissage. We feel that this combined arthroscopic procedure offers advantages that includereduced risk of conventional Latarjet complications, including neurological deficits and metal hardware complicationswhile preserving subscapularis and coracoid. Furthermore, these advantages may not come at the cost of compromisedoutcomes, particularly recurrence rate, as the remplissage may compensate for the possible lack of “sling effect” withfree bone graft reconstruction. 

In total hip replacement (THR), fretting and corrosion at the modular head-neck junction (trunnionosis) may causeadverse local tissue reaction (ALTR). In this report, we presented a 34 years woman with a history of THR eight yearsago, presenting with acute pain and limping. The radiographic assessment revealed stem-head dislocation for whicha revision hip surgery was planned. Surprisingly, we observed pseudotumor and tissue necrosis resulting from thebody’s reaction to cobalt-chromium alloy. The revision surgery entailed pseudotumor debridement and replacing thefemoral head with a new metal head (size 36, long). Due to the separation of the femoral head on a stem, we fixedit on a stem using bone cement. The stem (Omnifit®, Stryker®) was well-fixed and retained to avoid fractures andinfection risk. This technique revealed an acceptable outcome without recurrence of ALTR after a one-year follow-up.Our findings suggest that stem dislocation secondary to trunnionosis might be a long-term complication after THRwith subsequent ALTR.L