Role of Hip Arthroscopy in the Treatment of Avascular Necrosis of the Hip: A Systematic Review.

Background: 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. Methods: 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". Results: 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. Conclusion: 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.

Medial Collateral Ligament Injury of the Knee: A Review on Current Concept and Management.

The medial collateral ligament (MCL) is a major stabilizer of the knee joint, providing support against rotatory and valgus forces; moreover, it is the most common ligament injured during knee trauma. The MCL injury results in valgus instability of the knee and makes the patient susceptible to degenerative knee osteoarthritis. Although it has been nearly a dogma to manage MCL injury nonoperatively, recent literature has suggested operative MCL management as a suitable option for specific patient populations. The present review aimed to assess the current literature on the management of MCL injuries of the knee. In this regard, we go over the anatomy, physical examination, and MCL imaging.

Can the body slope of interference screw affect initial stability of reconstructed anterior cruciate ligament?: An in-vitro investigation.

BACKGROUND: Superior biomechanical performance of tapered interference screws, compared with non-tapered screws, with reference to the anterior cruciate ligament (ACL) reconstruction process, has been reported in the literature. However, the effect of tapered interference screw's body slope on the initial stability of ACL is poorly understood. Thus, the main goal of this study was to investigate the effect of the interference screw's body slope on the initial stability of the reconstructed ACL. METHODS: Based on the best screw-bone tunnel diameter ratios in non-tapered screws, two different tapered interference screws were designed and fabricated. The diameters of both screws were equal to bone tunnel diameter in one-third of their length from screw tip, then they were gradually increased by 1mm, in the lower slope (LSTIS), and 2 mm, in the higher slope (HSTIS) screws. To simulate the ACL reconstruction, sixteen soft tissue grafts were fixed, using HSTIS and LSTIS, in synthetic bone blocks. Through applying sub-failure cyclic incremental tensile load, graft-bone-screw construct's stiffness and graft laxity in each cycle, also through applying subsequent step of loading graft to the failure, maximum load to failure, and graft's mode of failure were determined. Accordingly, the performance of the fabricated interference screws was compared with each other. RESULTS: HSTIS provides a greater graft-bone-screw construct stiffness, and a lower graft laxity, compared to LSTIS. Moreover, transverse rupture of graft fibers for LSTIS, and necking of graft in the HSTIS group were the major types of grafts' failure. CONCLUSIONS: HSTIS better replicates the intact ACL's behavior, compared to LSTIS, by causing less damage in graft's fibers; reducing graft laxity; and increasing fixation stability. Nonetheless, finding the optimal slope remains as an unknown and can be the subject of future studies.

Lockdown of an Orthopedic Department during COVID-19 Epidemics, Our Experience in a General Hospital.

The COVID-19 disease is rapidly spreading around the world, affecting many countries and their healthcare systems. Like many other countries, Iran is struggling with the current situation. In this article, we aim to share our perspectives on confronting obstacles mentioned above using appropriate hospital protocols during the COVID-19 crisis. We investigated and compared the number of referred patients to the emergency room, elective, and emergent orthopedic operations in our hospital, along with a number of residents and faculty participants in the morning reports and virtual classes before and after the outbreak of COVID-19 in our hospital. The number of referred patients to the emergency room was significantly reduced; the number of orthopedic operations was also decreased to almost zero in March 2020. Meanwhile, we managed to dismiss our residents and reduce the number of in-hospital morning reports and conferences. Instead, we designed virtual classes, and the number of participants in our virtual classes grew to almost two-third of the whole participant. We also managed to fortify our virtual office system to reduce the number of in-hospital visits. Since our hospital had become a leading center for the treatment of COVID-19 patients, and the number of referred trauma patients, elective, and trauma operations, along with educational activities, was reduced. There was also a significant concern about the management of elective, trauma, and post-operative patients in this era. Orthopedic faculty members needed to react to the current situation cautiously. We were able to manage the situation with consideration of our educational path, along with the management of personal protective equipment (PPE), and the use of communication technologies and specific protocols to overcome the obstacles mentioned above. Yet involved our staff and With orthopedic faculties active involvement at in-hospital activitie and establishment of hospital protocols considering technological facilities and WHO guidelines, we can improve education, management of PPE, and both orthopedic elective and trauma patients.

Comparison between Patellar Resurfacing and Retention in Total Knee Arthroplasty Regarding the Postoperative Satisfaction of Patients and Patellar Crepitus.

BACKGROUND: Patellar crepitus after total knee arthroplasty (TKA) is not uncommon. The choice between patellar resurfacing or retention in TKA has remained controversial. Therefore, this randomized controlled trial aimed to evaluate the impact of patellar resurfacing on the incidence of patellar crepitus. In addition, we compared the clinical outcomes and satisfaction between the patients who underwent patellar retention or resurfacing. METHODS: A total of 63 patients randomly received patellar resurfacing or non-resurfacing TKA by one surgeon at Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Iran during May 2014-February 2017. Finally, 29 patients in the resurfaced group and 44 subjects with retained patella were evaluated pre-op and in an average follow-up period of 8.68 months using the clinical Knee Society Score (KSS), functional KSS, and Knee injury and Osteoarthritis Outcome Score (KOOS). RESULTS: Our findings demonstrated no significant difference between the two groups regarding the satisfaction of patients, KSS, and KOOS. It was shown that the latter scores improved in both groups in the follow-up period. Nonetheless, patellar crepitus was not statistically different between the two groups. CONCLUSION: According to the results of the present study, patellar resurfacing did not lead to decreased patellar crepitus or enhanced clinical outcomes of TKA.

Pre-planning of intramedullary nailing procedures: A methodology for predicting the position of the distal hole.

Inserting the distal locking screws is a challenging step of the intramedullary nailing procedures due to the nail deformation that makes the proximally mounted targeting systems ineffective. A pre-planning methodology is proposed, based on an analytical model of the nail-bone construct, to predict the nail deformation during surgery using orthogonal preoperative radiographs. Each of the femoral shaft and the nail was modeled as a curved tubular Euler-Bernoulli beam. The unknown positions and forces of the nail-bone interaction were found using a systematic trial and error approach, which minimized the total strain energy of the system while satisfying the force and geometrical constraints. The predictions of the model for the nail deformation were compared with the experimental results of five cadaver specimens in 15 test conditions. Relatively large displacements (up to 13 mm) were found for the distal hole in sagittal plane only. The model predictions were in close agreement with the experimental results, with a root mean square error of 1.2 mm. It was concluded that the proposed pre-planning methodology is promising for practical clinical use in intramedullary nailing operations, in order to provide the compensatory information that is required for tuning of proximally mounted targeting systems.

Improvement of Orthopedic Residency Programs and Diversity: Dilemmas and Challenges, an International Perspective.

BACKGROUND: To date, little has been published comparing the structure and requirements of orthopedic training programs across multiple countries. The goal of this study was to summarize and compare the characteristics of orthopedic training programs in the U.S.A., U.K., Canada, Australia, Germany, India, China, Saudi Arabia, Russia and Iran. METHODS: We communicated with responders using a predetermined questionnaire regarding the national orthopedic training program requirements in each respondent's home country. Specific items of interest included the following: the structure of the residency program, the time required to become an orthopedic surgeon, whether there is a log book, whether there is a final examination prior to becoming an orthopedic surgeon, the type and extent of faculty supervision, and the nature of national in-training written exams and assessment methods. Questionnaire data were augmented by reviewing each country's publicly accessible residency training documents that are available on the web and visiting the official website of the main orthopedic association of each country. RESULTS: The syllabi consist of three elements: clinical knowledge, clinical skills, and professional skills. The skill of today's trainees predicts the quality of future orthopedic surgeons. The European Board of Orthopedics and Traumatology (EBOT) exam throughout the European Union countries should function as the European board examination in orthopedics. We must standardize many educational procedures worldwide in the same way we standardized patient safety. CONCLUSION: Considering the world's cultural and political diversity, the world is nearly unified in regards to orthopedics. The procedures (structure of the residency programs, duration of the residency programs, selection procedures, using a log book, continuous assessment and final examination) must be standardized worldwide, as implemented for patient safety. To achieve this goal, we must access and evaluate more information on the residency programs in different countries and their needs by questioning them regarding what they need and what we can do for them to make a difference.

A patient specific finite element simulation of intramedullary nailing to predict the displacement of the distal locking hole.

Distal locking is a challenging subtask of intramedullary nailing fracture fixation due to the nail deformation that makes the proximally mounted targeting systems ineffective. A patient specific finite element model was developed, based on the QCT data of a cadaveric femur, to predict the position of the distal hole of the nail postoperatively. The mechanical interactions of femur and nail (of two sizes) during nail insertion was simulated using ABAQUS in two steps of dynamic pushing and static equilibrium, for the intact and distally fractured bone. Experiments were also performed on the same specimen to validate the simulation results. A good agreement was found between the model predictions and the experimental observations. There was a three-point contact pattern between the nail and medullary canal, only on the proximal fragment of the fractured bone. The nail deflection was much larger in the sagittal plane and increased for the larger diameter nail, as well as for more distally fractured or intact femur. The altered position of the distal hole was predicted by the model with an acceptable error (mean: 0.95; max: 1.5 mm, in different tests) to be used as the compensatory information for fine tuning of proximally mounted targeting systems.

Low Back Pain in Athletes.

CONTEXT: Low Back Pain (LBP) in athletes is common and has a broad spectrum of differential diagnoses that must be taken in to account when a clinician approaches the patient with LBP. The physicians should take into account spinal and extra spinal causes of low back pain in athletes. EVIDENCE ACQUISTION: A literature review was performed for the years 1951 through 2013. Keywords used were Low Back Pain and Athletes. We searched MEDLINE, EMBASE, OVID, PUBMED, the Cochrane Library, ELSEVIER, and the references of reviewed articles, for English-language of Low Back Pain in Athletes. RESULTS: The two most common causes of LBP arising from spine in athletes are degenerative disc disease and spondylolysis with or without listhesis. Although most athletes, respond well to conservative treatment, surgical treatment is indicated when conservative treatment failes. CONCLUSIONS: The major concern in athletes with LBP is return to play and previous level of their activity after treatment. There is insufficient evidence regarding this issue in literature to define the optimal time of return to play following treatment.

The impact of patellar resurfacing in two-stage revision of the infected total knee arthroplasty.

Evidence for optimal management of the patellofemoral joint in revision surgery for the infected TKA is limited. We reviewed 69 infected TKAs undergoing two-stage revision. Fifty four patellae were resurfaced, 11 had patelloplasty performed, two were augmented with trabecular metal, one had impaction grafting, and one knee underwent patellectomy. Average follow-up was 4.5 years. The patients that received patellar resurfacing at re-implantation experienced statistically significant improvements in KSS pain score, functional KSS, and patellar score (P < 0.03). One further patient treated with impaction grafting improved significantly in terms of pain and function. Patients treated with patelloplasty, trabecular metal augmentation, or patellectomy did not have significant improvements in clinical or functional outcome. Patient age, use of dynamic vs. static spacer, use of extensor mechanism release, and differences in Charlson index did not seem to statistically affect outcome. We recommend that every effort should be made to minimize patellar bone loss in first stage resection, as inability to resurface the patella at time of reimplantation may adversely affect patient outcome.

Culture-negative periprosthetic joint infection does not preclude infection control.

BACKGROUND: Periprosthetic joint infection (PJI) is a devastating complication after total joint arthroplasty. Lack of confirmation of an infecting organism poses a challenge with regard to the selection of an appropriate antibiotic agent and surgical treatment. It is unclear whether patients with negative cultures presumed to have infections achieve similar rates of infection-free survival as those with positive cultures. QUESTIONS/PURPOSES: The purposes of this study were (1) to report the infection control rates using irrigation and débridement and two-stage exchange for treatment of culture-negative PJIs; and (2) to compare infection control rates in culture-negative cases with those in culture-positive cases. METHODS: We retrospectively reviewed 55 patients with culture-negative PJI treated between 2000 and 2007. We compared the infection-free survival rate in the culture-negative patients with that of 295 culture-positive cases of PJI. RESULTS: Overall infection control rate in culture-negative cases was 73% at minimum 1-year followup (mean, 47 months; range, 12-119 months). We found similar infection control rates in culture-negative and culture-positive PJI. Infection-free survival rates in both groups were highest after two-stage exchange arthroplasty and postoperative vancomycin therapy. CONCLUSION: Our observations suggest aggressive two-stage exchange arthroplasty and postoperative parenteral vancomycin therapy in patients with culture-negative PJI achieves similar rates of infection-free survival as with patients having culture-positive PJI. LEVEL OF EVIDENCE: Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.