Archives of Bone and Joint Surgery
Volume:12 Issue: 3, Mar 2024

Brachial plexus injuries (BPI), although rare, often results in significant morbidity. Stem cell was thoughtto be one of BPI treatment modalities because of their nerve-forming regeneration potential. Although there is a possibility for the use of mesenchymal stem cells as one of BPI treatment, it is still limited on animal studies. Therefore, this systematic review aimed to analyze the role of mesenchymal stem cells in nerve regeneration in animal models of brachial plexus injury.

This study is a systematic review with PROSPERO registration number CRD4202128321. Literature searching was conducted using keywords experimental, animal, brachial plexus injury, mesenchymal stem cell implantation, clinical outcomes, electrophysiological outcomes, and histologic outcomes. Searches were performed in the PubMed, Scopus, and ScienceDirect databases. The risk of bias was assessed using SYRCLE's risk of bias tool for animal studies. The data obtained were described and in-depth analysis was performed.

Four studies were included in this study involving 183 animals from different species those are rats and rabbits. There was an increase in muscle weight and shortened initial onset time of muscle contraction in the group treated with stem cells. Electrophysiological results showed that mesenchymal stem cells exhibited higher (Compound muscle action potential) CMAP amplitude and shorter CMAP latency than control but not better than autograft. Histological outcomes showed an increase in axon density, axon number, and the formation of connections between nerve cells and target muscles.

Mesenchymal stem cell implantation to animals with brachial plexus injury showed its ability to regenerate nerve cells as evidenced by clinical, electrophysiological, and histopathological results. However, this systematic study involved experimental animals from various species so that the results cannot be uniformed, and conclusion should be drawn cautiously. Level of evidence: N/A

The medial collateral ligament (MCL) injury is one of the possible complications of primary total knee arthroplasty (TKA), which can lead to coronal-plane instability that requires surgical revision. Injured MCL can result in joint instability and polyethylene wear. Different strategies have been proposed for MCL reconstruction based on the location of the injury. However, there is a lack of clarity regarding the optimal method for handling an iatrogenic MCL injury throughout a TKA.

A PRISMA flow diagram was used to guide the systematic literature review. An extensive search was conducted in PubMed, Embase, Scopus, Web of Science, and Google Scholar. Newcastle Ottawa scale checklist was used to assess the methodological quality of the articles.

A total of 19 qualitative studies, including non-cadaveric patients with MCL injury during TKA, were identified after analyzing the full text of the articles. All included studies were either retrospective, observational cohort or case series. A total of 486 patients were studied to gather information on the methods used to repair the MCL and their results. Most injuries arose in the tibial attachment, which surgeons mostly realized during the final stages of surgery. Used techniques can be categorized into three main groups: Primary repair, Repair with augmentation, and changing prosthesis characteristics.

This systematic review demonstrated that the most popular management of iatrogenic MCL injury was using suture anchors, staples, screws and washers, and more constrained prostheses. The proper method should be decided considering the site of the MCL injury. Level of evidence: I

We aimed to report radiological and clinical features of single bone intramedullary fixation of the radius in pediatric both bone forearm fractures using straight stainless steel Kirschner (K) wire. Fifty-eight children (42 boys and 16 girls) referred to our hospital with both bone diaphyseal forearm fractures were operated on by using the single bone rigid K-wire intramedullary fixation and mini-open technique. The mean follow-up time was 8.9 months (6-12). The mean age of the patients was 7.4 years (4-12). More than 2/3 of the fractures were in the right hand. Around 63% of the fractures were in the middle third, 28% in the distal third, and 9% in the proximal third. Moreover, 12% were open type I Gustilo-Anderson fractures. The mean time from injury to surgery was two days (1-4), and the mean length of hospital stay was 2.8 days (2-5). The mean duration of surgery was 24.7 minutes (18-38), and the mean follow-up time was 8.9 months (6-12). All fractures united within 4-16 weeks (mean: 7.62). The cast and implant were removed simultaneously as the radiographic fracture union. There was no serious complication. Superficial infection of the pin track and loosening of the pin occurred in three cases (5%), all controlled by antibiotics and timely removal of the pins. Mild restriction of elbow extension (less than 20 degrees) was observed in three cases, which returned to normal at the last follow-up. Limitation of dorsiflexion of the wrist by more than 20° occurred in two patients (35° and 45°), which reverted to 25° and 25°, respectively, at the last follow-up. In both bone forearm fractures in children, open reduction and internal fixation of only the radius with a stainless steel straight Kirschner wire could be a promising method with good results. This retrograde technique of intramedullary fixation is a simple and cost-effective method with minimal complications and acceptable outcomes in children aged 4-12 years. Level of evidence: IV

To compare the effect of using custom-made orthosis on improving extension lag and reducing disability in acute and chronic mallet fingers. We recruited 51 patients with acute or chronic Doyle type-1 mallet fingers, who were provided with a custom-made thermoplastic anti-mallet finger orthosis to wear full-time for 6 weeks and an additional 2 weeks at nighttime. The primary outcome, extension lag, was assessed at enrollment as well as six- and twelve-week followups. Secondary outcomes included disability and satisfaction, which were evaluated using the Disability of the Arm, Shoulder, and Hand questionnaire at enrollment and 12 weeks, and a satisfaction scale at 12 weeks follow-up. Data analysis was conducted using univariate analysis of variance (ANOVA), one-way repeated measure mixed model analysis of covariance (ANCOVA), and independent sample t-test. A total of 43 participants, 25 acute and 18 chronic mallet fingers, completed the 12-week evaluation. The study found no significant difference between the two groups in terms of improvement in extension lag at either follow-up time point (P=0.21). Disability improved in both the acute and chronic groups at follow-up (P<0.05). Additionally, both groups expressed satisfaction with the treatment outcome, and no statistically significant difference was observed (t=0.173, P=0.51). We could not identify any clinically significant difference between the two groups in regard to extension lag, disability, or satisfaction at follow-up. Notably, 96% of the patients in the acute group and 88% of the patients in the chronic group demonstrated good to excellent outcomes.  Orthotic intervention with custom-made thermoplastic material in acute and chronic mallet fingers improved extension lag and disability, and both groups were satisfied with the treatment outcomes. The findings of our study indicated that patients with chronic mallet fingers benefited from orthotic interventions in the same way that patients with acute mallet fingers did. Level of evidence: II

The ideal timing for patients undergoing bilateral total knee arthroplasty (TKA) remains unknown. The purpose of this study was to compare 90-day outcomes between unilateral, simultaneous bilateral, and staged bilateral TKA. The PearlDiver database was used to retrospectively identify 231,119 patients undergoing primary TKA during 2015-2020, of which 67,956 (29.4%) were bilateral. Bilateral TKA patients were divided into cohorts of simultaneous bilateral TKA and staged bilateral TKA at 1-14 days, 15-30 days, 31-90 days, and 91-365 days. Each bilateral TKA cohort underwent one-to-one matching with unilateral TKA patients based on age, gender, year, Elixhauser Comorbidity Index (ECI), and a history of obesity, diabetes, and tobacco use. Ninety-day outcomes werecompared between matched groups via univariate and multivariate analysis. In staged bilateral TKA groups, outcomes were collected beginning after the second TKA. Compared to unilateral TKA, simultaneous bilateral TKA was associated with higher rates of venous thromboembolism (VTE; odds ratio [OR] 1.28, 95% confidence interval [CI] 1.07-1.54, p=0.007), acute kidney injury (AKI; OR 1.47, CI 1.17-1.84, p=0.001), blood transfusion (OR 6.81, CI 5.43-8.65, p<0.001), and any complication (OR 1.63, CI 1.49-1.78, p<0.001). Staged bilateral TKA at any time interval studied was associated with a similar or decreased risk of individual complications, emergency department visits, readmissions, reoperations, and any complication relative to unilateral TKA. Simultaneous bilateral TKA is associated with an increased risk of adverse events compared to unilateral TKA. However, bilateral TKA staged at a short interval appears safe in appropriately selected patients. Level of evidence: III

The ultrasound examination of the hip joint is performed in the static (Graf) technique in the lateral recumbent position and in the dynamic technique in the supine position. This study compares the two static and dynamic techniques and assesses the role of the patient's position in the examination of DDH. This cross-sectional study was conducted in 2020-2021 at Akbar Hospital, Mashhad University of Medical Sciences, Iran. 126 patients suspected of having DDH (199 hip) infants were enrolled in the study. All ultrasound examinations were performed with two static and dynamic techniques by a pediatric radiologist. In the static and dynamic ultrasound examinations, the average alpha angle was 51.57 ± 6.41 degrees, and 53.41 ± 6.94 degrees, respectively. These changes were not statistically significant (P = 0.312). The relationship and agreement between instability with dynamic technique and instability with static technique (IIC unstable, D, III, and IV) were investigated. Significant agreement (Kappa=0.77 (95% CI: 0.66-0.87) with excellent clinical significance was obtained between the two ultrasound examination method. Also, in terms of DDH types in the static method with instability types in the dynamic method, a substantial agreement was found between the two examination methods (Kappa =0.67; (95% CI: 0.59-0.75) with good clinical significance. In the ultrasound examination of DDH with static and dynamic techniques, the change in the alpha angle was not statistically significant. Therefore, the hand of the radiologist is open in measuring alpha angles and there is no need to emphasize a specific position. The type of DDH in the static technique completely corresponded to the type of stability or instability in the dynamic technique. Level of evidence: IV

To evaluate the utility and diagnostic performance of portable handheld ultrasound for evaluating fibular rotation at the distal tibiofibular articulation after syndesmotic disruption. Four above-the-knee cadaveric specimens were included. Syndesmotic disruption was precipitated by transecting the Anterior Inferior Tibiofibular Ligament, Interosseous Ligament, and Posterior Inferior Tibiofibular Ligament. Thereafter, a proximal fibular osteotomy was performed, and three conditions were modeled at the distal syndesmosis: 1) reduced, 2) 5 degree internal rotation malreduction, and 3) 5 degree external rotation malreduction. Two blinded observers performed separate ultrasonographic examinations for each condition at the level of both the anterior and posterior distal tibiofibular articular surfaces. Syndesmotic gap penetrance, defined as the ability of the P-US to generate signal between the distal fibula and tibia at the level of the incisura, was graded positive if the sonographic waves penetrated between the distal tibiofibular joint and negative if no penetrating waves were detected. The accuracy measures of the anterior and posterior gap penetrance were evaluated individually. Our preliminary results showed that posterior gap penetrance showed good performance when detecting either internal or external rotational malreduction of the fibula with very good specificity (87.5%) and PPV (90.0%). On the other hand, the anterior gap penetrance showed limited performance when detecting either form of rotational malreduction.  We introduced a novel sign, the “gap penetrance sign”, best measured from the posterior ankle, which can accurately detect syndesmotic malreduction using P-US in a manner that does not require specific quantitative measurements and is readily accessible to early P-US users. Level of evidence: III

The concurrent utilization of an external fixator and intramedullary nail (IMN) for segment transportation may potentially decrease the duration of external fixator implementation and reduce associated complications. This study aimed to report the outcomes of bone transport utilizing a combination of IMN and Ilizarov frame in a cohort of individuals who had tibia or femur critical -sized bone deficiency resulting from nonunion. The present research used a single-arm clinical trial design to enroll a series of patients presenting with critical-sized bone defects resulting from infectious nonunion of the tibia or femur. The study was conducted during the period of 2017-2020 in a referral Orthopedic Surgery Center located in Tehran, Iran. The management of patients with infectious nonunion was carried out through two main stages, including infection eradication and bone transportation. The process of bone healing and segment transportation was evaluated by radiographic assessment throughout the follow-up period. A total of 39 patients with bone defects in the tibia (19 cases) or femur (20 cases) with a mean age of 31.44 (±11.95, range=18-60) were included in this study. Twenty-nine (74.3%) patients had open fractures. The bone defect exhibited an average size of 6.31 ± 1.95 cm. The mean of the consolidation index (CI) was 0.97 (range=0.51–1.32) mo/cm, and the mean of the external fixator index was 0.67 (range=0.41-1.10). Although the CI was longer in patients with open fracture compared to those with closed fracture, the difference was not statistically significant (P=0.353). After the end of the two-year follow-up, complete union was observed in 35 patients (89.7%). Intercalary segmental bone transportation using the Ilizarov technique over an IMN, as well as preserving the advantages of the conventional callotasis method, reduces the complications of long-term use of the Ilizarov frame and increases patient adherence to treatment. Level of evidence: IV

Functional expectations following the salvage of a failed osteoarticular allograft are poorly described. In this study, we aim to evaluate functional outcomes, implant survival, and complications of the megaprosthesis in salvaging a failed osteoarticular allograft around the knee. We retrospectively reviewed the medical profiles of 21 skeletally mature patients who underwent megaprosthesis reconstruction to salvage a failed osteoarticular allograft around the knee implanted before skeletal maturity. The location of reconstruction was the proximal tibia in 13 patients and the distal femur in eight patients. Knee function was evaluated by the Musculoskeletal Tumor Society (MSTS) score and the Toronto Extremity Salvage Score (TESS). The mean age of patients was 16±1.7 years. The mean interval between the primary (allograft) and secondary (megaprosthesis) reconstructions was 59.4±23.6 months. At an average follow-up of 51.2 months, the mean knee range of motion was 101.2±15.6°. The mean MSTS score and TESS were 83.6±7 and 86.6±7.9, respectively. The mean limb length discrepancy was 2.5±1 cm before and 0.36±0.74 cm after the operation (P<0.001). Six postoperative complications (28.6%) occurred in this series, including one wound dehiscence, one periprosthetic fracture, two acute infections, one aseptic loosening, and one delayed periprosthetic infection. Only the last two complications required revision. Accordingly, the two- and five-year implant survivals were 95.7% and 90%, respectively. Megaprosthesis is a viable option for salvaging failed osteoarticular allografts around the knee. It also provides the opportunity to correct the limb length discrepancy. Level of evidence: IV

The advantages of prophylaxis with intraosseous regional administration (IORA) of vancomycin for periprosthetic joint infection (PJI) in primary and revision total knee arthroplasty (TKA) include the ability to deliver antibiotics directly to the surgical bed and avert systemic delivery; the ability to precisely time and quickly administer vancomycin to achieve the highest concentrations at the beginning and throughout the surgical procedure; and the ability to avert several common and potentially serious adverse effects of intravenous vancomycin. Indications for IORA of vancomycin prophylaxis include the following clinical scenarios: revision TKA; obesity; diabetes; beta-lactam allergy; known colonization with methicillin-resistant Staphylococcus aureus (MRSA); individuals coming from institutions with a high MRSA incidence; previous ligamentous surgical procedure or osteotomy; current or recent smokers; in the primary TKA setting if the individual is considered high-risk as defined by the criteria above; and during reimplantation following 2-stage exchange for PJI. The advantages of prophylaxis with intraosseous regional administration (IORA) of vancomycin for periprosthetic joint infection (PJI) in primary and revision total knee arthroplasty (TKA) include the ability to deliver antibiotics directly to the surgical bed and avert systemic delivery; the ability to precisely time and quickly administer vancomycin to achieve the highest concentrations at the beginning and throughout the surgical procedure; and the ability to avert several common and potentially serious adverse effects of intravenous vancomycin. Indications for IORA of vancomycin prophylaxis include the following clinical scenarios: revision TKA; obesity; diabetes; beta -lactam allergy; known colonization with methicillin-resistant Staphylococcus aureus (MRSA); individuals coming from institutions with a high MRSA incidence; previous ligamentous surgical procedure or osteotomy; current or recent smokers; in the primary TKA setting if the individual is considered high -risk as defined by the criteria above; and during reimplantation following 2-stage exchange for PJI.  Level of evidence: IIILevel of evidence: III