Archives of Bone and Joint Surgery
Volume:11 Issue: 9, Sep 2023

One decade ago I was honored to be invited to compose an editorial for the inaugural issue of the Archives of Bone and Joint Surgery. I was made aware of the high quality and innovative Orthopedic and Trauma surgery in Iran initially through the current editor Mohammad H. Ebrahimzadeh M.D. who spent an extended visiting Fellowship within our Hand and Upper Extremity Service within the Department of Orthopedic Surgery at the Massachusetts General Hospital and Harvard Medical School.

Bibliometric analysis is one of the most prevalent methods for analyzing and predicting the research trends of particular subjects. Through a bibliometric analysis, this study sought to look into and depict the hotspots and research trends in knee arthroplasty research over the previous five years.

The Web of Science Core Collection database was used to find research articles on knee arthroplasty published between 2018 and 2022. The VOS viewer, Cite Space, and Bibliometrix were used to carry out the bibliometric study and network visualization

During the previous five years, 7,422 included knee arthroplasty publications were cited 57,087 times. The United States and the Journal of Arthroplasty were the top countries and journals regarding the number of articles. The top 10 global high-impact documents were determined using the citation ranking and citation burst. The most frequently referenced article revealed that the epidemiological characteristics of knee arthroplasty, perioperative care in knee arthroplasty, prosthetic joint infections, and opioid medications were the hot topics in knee arthroplasty research. Keyword burst analysis showed that the research trends in knee arthroplasty through 2022 were racial disparity, limb alignment, tibial slope, and meniscectomy. The analysis of the subject areas revealed the close connections and relationships between different subject areas, as demonstrated by the figures.

The knee arthroplasty research community is highly productive and centralized. Recent hotspots in knee arthroplasty research were unicompartmental knee arthroplasty, periprosthetic joint infection, kinematic alignment, outpatient total knee arthroplasty (TKA), bariatric surgery, payment model, tranexamic acid, RoboticAssisted TKA, patient-reported outcome measures, metaphyseal cone, opioid use, and patient-specific instrumentation. Research trends in knee arthroplasty research were racial disparity, limb alignment, tibial slope, and meniscectomy. Level of evidence: IV

Quantitatively define the radiographic locations of the major soft-tissue attachments about the elbow. In 10 cadaveric elbows, the attachments of the medial ulnar collateral ligament, lateral ulnar collateral ligament, annular ligament, triceps, and biceps were marked with radiopaque spheres. Measurements were made on calibrated AP and lateral fluoroscopic images from known osseous landmarks. On AP radiographs; the anterior bundle of the MUCL (aMUCL) measured 28.6mm (95% CI, 27. 5-29.8mm) from the humeral attachment to the midpoint of the MUCL ridge on the ulna and 14.3mm, (95% CI 13.0-15.5) to the olecranon. The LUCL was 39.9mm (95% CI, 38.6 – 41.1mm) from the humeral attachment to the supinator crest attachment and 8.9mm (95% CI, 8.1-9.8mm) to the lateral epicondyle. On the lateral radiographs, the humeral attachment of the aMUCL to the medial coronoid was 27.1mm (95% CI, 25.9-28.2mm) and 9.3mm (95%CI, 17.5 -21.2mm) to the tip. The LUCL humeral attachment to the supinator crest was 45.4mm (95%CI, 44.1-46.8mm). The LUCL humeral attachment was located 8.9mm (95%CI, 8.0-9.7mm) posterior from the anterior humeral line. The soft-tissue attachments about the elbow were reproducibly demonstrated on radiographs in relation to osseous landmarks and radiographic lines. The radiographic relationships will allow for improved identification of the ligament and tendon attachment sites of the elbow for intraoperative assessment and postoperative evaluation following reconstruction. Level of evidence: V

Rotator Cuff Tear (RCT) is a multifactorial disease, but an important one is the increased collagen degradation that would lead to a higher chance of tear. MMP-8 is a protein that degrades type I collagen, and it is known that MMP-8 has a polymorphism in which a T allele in the gene promoter region increases its transcription activity. This study aims to investigate the association between MMP -8 polymorphism g.-799 C>T (rs11225394) and RCT. To do that, we collected DNA samples from buccal epithelial cells of 128 patients (separated into RCT group and control group in a proportion 1:1) and genotyped the DNA using PCR. The statistical analyses were done using the ARLEQUIN Version 2.0, and the data normality was tested with the Shapiro-Wilk test. The results showed a significantly higher frequency of T/T genotype in the test group (29% in the control group and 39% in the test group, p=0.0417), and that would represent a risk factor for increased collagen degradation. The MMP-8 g.-799 C>T (rs11225394) SNP was associated with RCT. With the description of a new risk factor, future research can be done to analyze how to prevent RCT or develop new treatment strategies since the disease's failure index is currently high. Level of evidence: II

We aimed to assess the most effective route for Tranexamic acid (TXA) administration among Intraarticular (IA), Intravenous (IV), and combined IA/IV for Total Knee Arthroplasty (TKA) surgeries. A double-blinded clinical trial was run on 147 TKA candidates. Blood loss and hemoglobin (Hb) drop were evaluated using the Gross and Nadler formula in three matched case groups administered TXA during the TKA through IV, IA, or combined IA/IV route. Tourniquet was used on all operations for controlling intraoperative blood loss. No drainage catheter was used for the cases.  The combined group showed an average blood loss of 630±252 ml, which was significantly lower than that in the IV group (878±268 ml, P<0.01) and the IA group (774±288 ml, P=0.03). Furthermore, the mean Hb and hematocrit drop were significantly lower in the combined group, compared to the other two groups, 48 and 72 h postoperatively (P<0.05). The combined IA/IV route had a 28% and 19% reduction of blood loss, compared to the IV or IA methods, respectively. Therefore, using TXA via the combined IA/IV route may be more effective for reducing perioperative blood loss following TKA surgery using a tourniquet without drain placement. Level of evidence: I

Intra-articular hip injections (IHI) are routinely performed for both diagnostic and therapeutic purposes. The procedure can be performed via either an anterior or a lateral approach with fluoroscopic guidance being widely practised. There is a risk of radiation exposure associated with fluoroscopy assisted IHI. This may be influenced either by the surgical approach or the patient ’s body mass index (BMI) or both. This study was undertaken to compare the relationships of the respective approaches to BMI, fluoroscopic exposure time (FET) and radiation dose (RD).  A retrospective study was conducted comprising 74 patients who underwent IHI with 37 patients in each group (anterior and lateral). Patients were assessed pre -operatively and post operatively for any complications. The intra-operative radiation dose, fluoroscopic exposure time and BMI data were collected and analyzed.  The mean age of the patients in anterior and lateral groups was 61.18 ±14.08 and 67.21±14.39 years respectively. No complications were noted in either group. However, there was a significant increase in FET (P=0.002) and RD (P<0.001) in patients with BMI ≥ 30. In the lateral group, this trend was markedly noted with increase in FET (P<0.001) and RD (P<0.001) in patients with BMI ≥ 30. On the other hand, in the anterior group there was no statistically significant increase in FET (P=0.155) and only a moderate increase in RD (P=0.020) in patients with BMI ≥ 30.  Both anterior and lateral approaches to fluoroscopic guided IHI are equally safe in terms of complications involved. There is statistically significant increase in both radiation dose and fluoroscopic exposure time in patients with BMI ≥ 30. This is more pronounced in lateral approach. The anterior approach is most effective in reducing both radiation dose and fluoroscopic exposure time, more so in patients with BMI of 30 and above. Level of evidence: III

This study aimed to analyze and compare the perioperative outcomes of cemented and uncemented hemiarthroplasty in elderly patients with displaced femoral neck fractures by utilizing the data from the National Inpatient Sample database. Data from the National Inpatient Sample Database was analyzed to identify patients who underwent hemiarthroplasty following a displaced femoral neck fracture (cemented and uncemented. Demographic data, comorbidities, length of stay, total charges, and perioperative complications were analyzed. 27390 patients were identified in the cemented group and 29406 in the uncemented group. The patients who underwent uncemented hemiarthroplasty demonstrated a higher incidence of prosthetic dislocation (Odds Ratio (OR) 3.348, p < 0.001), periprosthetic mechanical complications (OR 2.597, p < 0.001), wound dehiscence (OR 2.883, p < 0.001), superficial surgical site infection (OR 2.396, p = 0.043), deep surgical site infection (OR 1.686, p < 0.001), and periprosthetic fractures (OR 2.292, p < 0.001) as compared with patients who underwent cemented hemiarthroplasty. However, patients with uncemented fixation demonstrated a lower incidence of death (OR 0.567, p < 0.001), pulmonary embolism (OR 0.565, p < 0.001), deep vein thrombosis (DVT) (OR 0.746, p < 0.001), myocardial infarction (OR 0.772, p = 0.025) and blood loss anemia (OR 0.869, p < 0.001) as compared with cemented fixation.  Our study on displaced femoral neck fractures utilizing the National Inpatient database found that uncemented hemiarthroplasty was associated with a higher incidence of perioperative surgical complications. Cemented hemiarthroplasty, however, was associated with a statistically significant higher rate of death, pulmonary embolism, deep vein thrombosis, and myocardial infarction. Level of evidence: III

In patients with congenital pubic diastasis, who present with polytrauma injury, pubic diastasis could be falsely attributed to the traumatic event. This generally occurs in asymptomatic patients whose anomaly is not diagnosed before the traumatic event. In this report, we present a case of a 26 -year-old male with fracture-dislocation of the left hip and congenital agenesis of pubic bones that was initially misdiagnosed as post-traumatic pubic diastasis due to the patient’s reduced consciousness. A closer examination led to noticing his micropenis and the scar from the earlier surgical intervention, and thereby, suspicion of the congenital etiology of the pubic diastasis, later confirmed by pre -trauma radiography. This case reveals that the congenital etiology of pubic diastasis could be missed owing to the patient’s reduced consciousness. Therefore, a full inspection of the etiology of pelvic ring injury is necessary before conducting any surgical intervention.  Level of evidence: IV

This case report describes the surgical technique of posterior arthroscopic bone block using the coracoid graft to treat recurrent posterior dislocations and describes preliminary results. Performance of coracoid transfer as a graft for posterior arthroscopic bone block i n one patient (two shoulders) with recurrent posterior glenohumeral instability refractory to clinical treatment for six months, excluding volition dislocation. The patient was followed up weekly for the first three weeks when the stitches were removed. Postoperative computed tomography was performed before the patient was authorized to practice contact and aquatic sports (3–4 months after surgery). Patient returned to previous activities without complaints or limitations. There were no neurovascular compli cations. The initial results using coracoid as a bone graft for posterior instability were positive, and the technique requires reproduction to investigate possible complications. To date, no study has been found in the literature that reports an open or arthroscopic coracoid bone block technique.  Level of evidence: V