Archives of Bone and Joint Surgery
Volume:12 Issue: 7, Jul 2024

3D-printing is a rapidly developing technology with applications in orthopaedics including pre-operative planning, intraoperative guides, design of patient specific instruments and prosthetics, and education. Existing literature demonstrates that in the surgical trea tment of a wide range of orthopaedic pathology, using 3D printing shows favourable outcomes. Despite this evidence 3D printing is not routinely used in orthopaedic practice. We aim to evaluate the advantages of 3D printing in orthopaedic surgery to demonstrate its widespread applications throughout the field.

We performed a comprehensive systematic review and meta-analysis. AMED, EMBASE, EMCARE, HMIC, PsycINFO, PubMed, BNI, CINAHL and Medline databases were searched using Healthcare Databases Advanced Search (HDAS) platform. The search was conducted to include papers published before 8th November 2020. Clinical trials, journal articles, Randomised Control Trials and Case Series were included across any area of orthopaedic surgery. The primary outcomes measured were operation time, blood loss, fluoroscopy time, bone fusion time and length of hospital stay.

A total of 65 studies met the inclusion criteria and were reviewed, and 15 were suitable for the metaanalysis, producing a data set of 609 patients. The use of 3D printing in any of its recognised applications across orthopaedic surgery showed an overall reduction in operative time (SMD = -1.30; 95%CI: -1.73, -0.87), reduction in intraoperative blood loss (SMD = -1.58; 95%CI: -2.16, -1.00) and reduction in intraoperative fluoroscopy time (SMD = -1.86; 95%CI: -2.60, -1.12). There was no significant difference in length of hospital stay or in bone fusion time post-operatively.

The use of 3D printing in orthopaedics leads to an improvement in primary outcome measures showing reduced operative time, intraoperative blood loss and number of times fluoroscopy is used. With its wide-reaching applications and as the technology improves, 3D printing could become a valuable addition to an orthopaedic surgeon’s toolbox. Level of evidence: I

Imaging techniques have significantly impacted physicians ’ capability for diagnosis and differential diagnosis for decades. The aim of this review is to update our knowledge regarding the use of US in orthopedic pediatric patients for diagnostic purposes or procedural/therapeutic purposes. This review demonstrates the application of US in trauma (long bone fractures, radial neck fractures, etc.), developmental anomalies such as developmental dysplasia of the hip and congenital dislocation of the patella, soft tissue pathologies (ganglion cyst, popliteal cyst, hemangioma, lipoma, etc.), tumors, apophysitis, joint effusion, and femoral acetabular impingement. US aid in musculoskeletal procedures has also been reported; US-guided procedures such as aspiration, injection, biopsy, foreign body removal, and peripheral nerve block reduce complications, thus making the procedures safer for the patient. Sonography is a fast, low-cost, mobile, non-invasive, and radiation-free diagnostic tool. Even though US requires a skilled operator and has a long learning curve, in experienced hands is the “orthopedic surgeon’s stethoscope”. Level of evidence: IV

The rising popularity of reverse total shoulder arthroplasties (RTSA) demands attention to its growing costs on the healthcare system, especially with the implementation of bundled payments. Charges associated with patients’ inpatient stays can be mitigated with a better understanding of the drivers of cost following RTSA. In this study, we evaluate potential pre -operative and post-operative factors associated with higher inpatient costs following RTSA. We identified 59,925 patients who underwent RTSA using the National Inpatient Sample between 2016 and 2019. Total inpatient hospital charges were collected, and patients were divided into “normal cost” or “high cost”groups. The high cost group was defined as patients with total costs greater than the 75th percentile. Univariate and multivariate analyses were performed on pre-operative demographic and comorbidity variables as well as postoperative surgical and medical complications to predict factors associated with higher costs. T-tests and Chi-squared tests were performed, and odds ratios were calculated. The mean total charges were $141.213.93 in the high cost group and $59,181.94 in the normal cost group. Following multivariate analysis, non-white patients were associated with higher costs by 1.31-fold (P<0.001), but sex and age were not. Cirrhosis and non-elective admission had higher odds of higher costs by 1.56-fold (P<0.001) and 3.13-fold (P<0.001), respectively. Among surgical complications, there were higher odds of high costs for periprosthetic infection by 2.43-fold (P<0.001), periprosthetic mechanical complication by 1.28-fold (P<0.001), and periprosthetic fracture by 1.56-fold (P<0.001). Medical complications generally had higher odds of high costs than surgical complications, with deep vein thrombosis having nearly five times (P<0.001) and myocardial infarction almost four times (P<0.001) higher odds of high inpatient costs. Post-operative medical complications were the most predictive factors of higher cost following RTSA. Pre-operative optimization to prevent infection and medical complications is imperative to mitigate the economic burden of RTSA’s. Level of evidence: III

Returns to the Emergency Department (ED) and unplanned readmissions within 90 days of shoulder arthroplasty represent a significant financial burden to healthcare systems. Identifying the reasons and risk factors could potentially reduce their prevalence.  A retrospective review of primary anatomic (aTSA) and reverse shoulder arthroplasty (rTSA) cases from January 2016 through August 2023 was performed. Demographic patient and surgical data, including age, diagnosis of anxiety or depression, body mass index (BMI), smoking status, age-adjusted Charlson Comorbidity Index (ACCI), modified 5-item fragility index (mFI-5), and hospital length of stay (LOS) was collected. Patient visits to the ED within 12 months prior to surgery were recorded. Predictors for return to the ED within 90 days postoperatively and any readmissions were determined.  There were 338 cases (167 aTSA and 171 rTSA), of which 225 (67%) were women. Patients with anxiety (OR=2.44, 95% CI 1.11–5.33; P=0.026), surgical postoperative complications (OR=3.22, 95% CI 1.36–7.58; P=0.008), ED visit within 3 months prior to surgery (OR=3.80, 95% CI 1.71–8.45; P=0.001), ED visit 3 to 6 months prior to surgery (OR=2.60, 95% CI 1.12–6.05; P=0.027), and ED visit 6 to 12 months prior to surgery (OR=2.12, 95% CI 1.02–4.41; P=0.045) were more likely to have ED visit within 90 days postoperatively. Patients with prior ipsilateral shoulder surgery (OR=3.32, 95% CI 1.21–9.09; P=0.02), surgical postoperative complications (OR=13.92, 95% CI 5.04–38.42; P<0.001), an ED visit within 3 to 6 months preoperatively (OR=8.47, 95% CI 2.84–25.27; P<0.001), and an mFI-5 ≥2 (OR=3.66, 95% CI 1.35–9.91; P=0.011) were more likely to be readmitted within 90 days.  Patients who present to the ED within 12 months prior to shoulder arthroplasty, those with anxiety, those with surgical complications and those with higher fragility should be monitored closely during the early postoperative period to minimize returns to the ED and/or unplanned readmissions.  Level of evidence: III

Reverse total shoulder arthroplasty (RTSA) continues to increase in popularity as a surgical operation in the United States. As indications for this procedure expand, more attention is needed to evaluate perioperative risk factors and patient characteristi cs. Postoperative anemia requiring blood transfusion (BT) is a well-documented risk factor for increased in-house mortality although little has been studied on the relationship between RTSA and postoperative BT. The purpose of this study was to identify comorbidities and patient characteristics as risk factors for BT in patient’s undergoing RTSA. Using the Nationwide Inpatient Sample (NIS) database, 59,925 RTSA patients (2016-2019) were analyzed, with 1.96% requiring postoperative BT. Demographics, comorbidities, and preoperative factors were compared between BT and non-BT groups via univariate and multivariate analyses. Overall prevalence of blood transfusion in all patients was 1.96%. Male sex (OR 1.75, p < 0.001), Asian ethnicity (OR 1.96, p = 0.012), age >80 (OR 1.51, p < 0.001), age >90 (OR 2.26, p < 0.001), CKD (OR 1.94, p < 0.001), and Parkinson’s disease (OR 2.08, p < 0.001) were associated with increased BT odds. Cirrhosis exhibited the highest impact (OR 5.7, p < 0.001). Conversely, Caucasian ethnicity (OR 0.76, p = 0.023), uncomplicated DM (OR 0.73, p = 0.002), tobacco-related disorders (OR 0.43, p < 0.001), BMI >30 (OR 0.8, p = 0.011), and elective procedures (OR 0.16, p < 0.001) decreased BT odds. These results were useful with identifying several risk factors that predispose to a higher risk of postoperative BT in patients undergoing RTSA including male sex, people of Asian descent, age > 80, CKD, Parkinson’s disease, and cirrhosis. These findings provide clinicians with information that may be helpful with preoperative planning and perioperative management of complex patient populations. Level of evidence: III

This study aimed to estimate post-operative rod angles in both concave and convex sides of scoliosis curvature in patients who had undergone posterior surgery, using neural networks and support vector machine (SVM) algorithms. Radiographs of 72 scoliotic individuals were obtained to predict post-operative rod angles at all fusion levels (all spinal joints fused by rods). Pre-operative radiographical indices and pre-operatively resolved net joint moments of the apical vertebrae were employed as inputs for neural networks and SVM with biomechanical modeling using inverse dynamics analysis. Various group combinations were considered as inputs, based on the number of pre-operative angles and moments. Rod angles on both the concave and convex sides of the Cobb angle were considered as outputs. To assess the outcomes, root mean square errors (RMSEs) were evaluated between actual and predicted rod angles. Among eight groups with various combinations of radiographical and biomechanical parameters (such as Cobb, kyphosis, and lordosis, as well as joint moments), RMSEs of groups 4 (with seven radiographical angles in each case, which is greater in quantity) and 5 (with four radiographical angles and one biomechanical moment in each case, which is the least possible number of inputs with both radiographical and biomechanical parameters) were minimum, particularly in prediction of the concave rod kyphosis angle (errors were 5.5° and 6.3° for groups 4 and 5, respectively). Rod lordosis angles had larger estimation errors than rod kyphosis ones. Neural networks and SVM can be effective techniques for the post-operative estimation of rod angles at all fusion levels to assist surgeons with rod bending procedures before actual surgery. However, since rod lordosis fusion levels vary widely across scoliosis cases, it is simpler to predict rod kyphosis angles, which is more essential for surgeons. Level of evidence: IV

In the treatment of closed intertrochanteric fractures, the two most common treatment options are intramedullary medullary nail (IMN) and dynamic hip screw (DHS), yet the best treatment method remains controversial. The purpose of this study is to determine the difference in mortality and morbidity between IMN and DHS. Secondarily, this study determines which pre -operative risk factors affect rates of morbidity and mortality. American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) 2006-2016 database was used to search for patients with a closed intertrochanteric hip fracture. Bivariate analysis was performed using Pearson’s Chi Square test to determine pre-operative risk factors associated with complications in fixation with IMN and DHS. Significant variables in this analysis, as well as demographic data, were analyzed via binary logistic regression. The results were recorded as odds ratio (OR) and significant differences were based on a P<0.05. After adjusting for demographics and clinical covariates, patients who underwent fixation with IMN had higher 30-day mortality, reintubation, UTI, bleeding, prolonged length of stay, and non-home discharged destination rates compared to DHS. Mortality risk was increased by ascites, disseminated cancer, impaired functional status, history of congestive heart failure, and hypoalbuminemia. Bleeding risk was increased by previous percutaneous coronary (PCI) and transfusions and was decreased by impaired functional status. Myocardial infarction risk was increased by female gender. Our study found that IMN fixation increased risk of mortality, UTI, reintubation, bleeding, prolonged length of stay, and a non-home discharge destination compared to DHS. This study also identified patient risk factors associated with several postoperative complications. These data may better inform orthopaedic surgeons treating closed intertrochanteric fractures. Level of evidence: III

Acute compartment syndrome of the thigh (CST) is an ongoing challenge for orthopaedic surgeons as the diagnosis is often difficult to establish. Currently, there is a shortage of studies investigating risk factors for the development of thigh compartment s yndrome following subtrochanteric and diaphyseal femoral fractures. This study aimed to identify risk factors associated with the development of CST following femoral fractures. Retrospective review performed in a level one trauma center from January 2011 to December 2020 for all patients with non-pathological acute subtrochanteric or diaphyseal femoral fractures. Variables collected included demographics, injury severity score (ISS) scores, mechanism of injury, classification of femoral fracture, open versus closed injuries, development of compartment syndrome, time to compartment syndrome diagnosis, number of subsequent surgeries, and primary wound closure versus split-thickness skin graft. The statistical analysis of this study included descriptive analysis, simple logistic regression, paired T-test, and Wilcoxon Signed Rank. Thirty-one (7.7%) patients developed thigh compartment syndrome following 403 subtrochanteric or diaphyseal femoral fractures. The mean (SD) age for those who developed CST was 27.35 (8.42). For every unit increase in age, the probability of developing CST decreased. Furthermore, male gender had 18.52 times greater probability of developing CST (P <0.001). AO/OTA 32-C3 and subtrochanteric femoral fracture patterns demonstrated 15.42 (P = 0.011) and 3.15 (P <0.001) greater probability of developing CST, respectively. Patients who presented to the hospital following a motor vehicle accident (MVA) or gunshot wound (GSW) had 5.90 (P= 0.006) and 14.87 (P < 0.001) greater probability of developing CST, respectively.  Patients who were male, younger in age, and had a 32-C3 and subtrochanteric femoral fractures were at increased probability of developing CST. High energy trauma also increased the risk of developing CST. A high index of suspicion should be expressed in patients with these risk factors. Level of evidence: III

Given the bone sensitivity to mechanical stimulus, bone-loading exercises and applying the Pulsed Electromagnetic Fields (PEMF(s)) are recommended for promoting bone strength. In this context, these two interventions 's effect on bone turnover markers (BTMs) in osteoporosis patients is yet to be clarified; consequently, an attempt is made in this study to compare the effect of these two interventions on bone turnover markers in women with Postmenopausal Osteoporosis (PMOP). This study is design as a randomized, single-center, three-arms, controlled trial. A total of 51 women with PMOP will be randomly assigned to three groups of 17, using opaque, sealed envelopes containing labels for A, B, and C groups. Group A) will receive bone-loading exercises, B) will follow the PEMF(s) and C) will be exposed to the combination of A and B. These three groups will require intervention for 24 sessions (2 sessions/week) next to their routine medical treatment (Alendronate+ Calcium+ Vitamin D). The primary outcome of this study is the serum biomarker of bone formation (bone-specific alkaline phosphatase, BSALP) and resorption (N-terminal telopeptide, NTX). The secondary outcomes consist of thoracic kyphosis angle, fear of falling, and quality of life. The outcomes are measured three times: at baseline, after 24 sessions of intervention, and at 12 weeks follow-up. A primary outcome will be measured and reported by a laboratory expert who is blinded to the participant grouping.  The trial has the code of ethics for research (IR.TUMS.FNM.REC.1401.126) and the code of Iranian Registry of Clinical Trials (IRCT) (IRCT20221202056687N1). Study results are expected to be available by mid-2024. This trial will provide new practical knowledge on the bone-loading exercises and PEMFS(s)’s effect on PMOP women. This knowledge is of the essence for physiotherapists, clinicians, other healthcare professionals, and policymakers in the healthcare system. Level of evidence: Not applicable

Biofilm related implant infection is undoubtedly a relevant challenge in total knee arthroplasty (TKA) with our comprehension steadily progressing and novel management approaches being developed. The aim of this article was to review the most important advances in approaches to combat infections due to biofilm-forming bacteria in TKA. The main conclusions were the following: 1) Fundamental management techniques for infected TKA include open DAIR (debridement, antibiotics, and implant retention), and one and two-stage revision TKA; 2) Continuous local antibiotic perfusion (CLAP) appears to diminish the risk of periprosthetic joint infection (PJI); 3) Restraint of quorum sensing seems to avert PJI after TKA; 4) A recent in vitro study showed promising results in the prevention and management of PJI after TKA using PMMA [poly(methyl methacrylate)] loaded with up to 100 mg of rifampin. Level of evidence: III