Arthroscopic ACL Avulsion Fixation With Adjustable Loop Length Cortical Endobutton.

Various surgical management techniques have been introduced to treat anterior cruciate ligament avulsion fractures. There is disagreement among orthopedic surgeons about which fixation device to use during arthroscopy. Recently, there has been an increase in the use of arthroscopic techniques for fixation, and different devices such as sutures, screws, and fiber wires are being considered. The development of fiber wires has made it possible to use them in comminuted avulsions with satisfactory stability, whereas screws cannot be used in such cases. Sutures do not provide adequate stability for early range of motion compared to other methods. The article then goes on to describe a specific arthroscopic fixation technique that uses an adjustable loop cortical button to manage the avulsed fragment and provide stability.

Black discoloration of the knee articular cartilage in a patient with pigmented villonodular synovitis: A case report.

In this case report, total knee arthroplasty was performed in a patient with pigmented villonodular synovitis. During surgery, severe black discoloration of the articular cartilage and menisci was observed in the patient. According to literatures, this is the first case report of severe articular cartilage pigmentation in a patient with pigmented villonodular synovitis.

Cross-Cultural Adaptation and Validation of the Persian Version of the Harris Hip Score.

Background: The Persian language, also known as Farsi, is a pluricentric language spoken in Iran, Afghanistan, and Tajikistan by about 140 million people. This study aims to translate the Harris hip score (HHS) into Persian with cross-cultural adaptation and to evaluate its validity and reliability. Methods: One hundred fifty-six total hip arthroplasty patients completed the Persian version of the HHS, Western Ontario and McMaster Universities Osteoarthritis Index, Forgotten Joint Score, and visual analog scale (VAS) for pain and satisfaction postoperatively. Using Cronbach's alpha (α) coefficient, internal consistency was evaluated. Correlations (Spearman's Rho) were used to assess validity. A test-retest reliability assessment of the Persian HHS was conducted (n = 47) using the intraclass correlation coefficient. Content validity was evaluated using the floor and ceiling effects of the HHS. Results: The final translation of the Persian HHS was approved to be used. The preoperative and postoperative Cronbach's alpha were 0.71 and 0.70, respectively, and showed acceptable internal consistency. The intraclass correlation coefficient was excellent (0.869, P < .001). Insignificant ceiling effects (13.5%) and no floor effects (0) were observed. The HHS score was significantly and strongly correlated with Western Ontario and McMaster Universities Osteoarthritis Index (r = 0.696, P < .001), VAS pain (r = 0.654, P < .001), VAS satisfaction (r = 0.634, P < .001), and Forgotten Joint Score (r = 0.648, P < .001). Conclusions: The Persian HHS demonstrated excellent reliability and validity properties. Accordingly, Persian HHS may be a helpful tool for assessing patients undergoing total hip arthroplasty.

Bilateral total hip arthroplasty in a case with fibrous dysplasia: a case report.

BACKGROUND: Fibrous dysplasia (FD) is a benign neoplasm with a broad spectrum of presentations. The treatment of FD in the hip region is controversial among orthopedic surgeons. Several treatment options exist, including curettage and grafting, valgus osteotomy, medial displacement osteotomy, and so on. Performing total hip arthroplasty (THA) on these patients and their subsequent outcome is still in infancy. CASE PRESENTATION: The patient is a 32-year-old white female with bilateral proximal femur FD who underwent bilateral THA with long stem implants. A year following surgery, she had no complications and had satisfactory radiological, pain, and functional outcomes. CONCLUSION: A bilateral THA with a long stem prosthesis showed promising results when performed following appropriate curettage of the proximal bone in an FD case. A cementless long stem could have enabled better diaphyseal fixation distal to the lesion site.

Early versus late physiotherapy following arthroscopic repair of small and medium size rotator cuff tear: a randomized clinical trial.

PURPOSE: We compared early and late physiotherapy for patients with small and medium size rotator cuff tears following arthroscopic repair. METHODS: A single-centre, single-blinded, prospective parallel RCT was performed with two arms: early physiotherapy (start within the first week) versus late physiotherapy (start 4 weeks after surgery). Patients with small- to medium-sized isolated full-thickness superior rotator cuff tears were included and followed for 12 months. The primary outcome measures were shoulder function and range of motion (ROM) measured by the Constant-Murley score (CMS) at three months, six months, and 12 months. The other outcomes were the visual analog scale (VAS) pain and the rotator cuff ultrasound (US) evaluation by the Sugaya classification. RESULTS: In three and six month follow-ups, CMS was significantly superior in the intervention group compared to controls (P < 0.05). However, only at the three month follow-up between-group difference met the minimal clinically important difference (MCID) (MCID = 10.4) (59.8 vs. 48.9). The intervention group experienced less pain than controls in the first six months (P < 0.001), and only the three month follow-up was clinically meaningful based on MCID (MCID = 1.4). Moreover, in the first six months, the shoulder ROM favoured the intervention group (P < 0.05). US grading of the supraspinatus and infraspinatus was similar between groups (P = 0.07). One retear occurred in the intervention group and another in the controls, detected by examination and US evaluation. CONCLUSION: Following the arthroscopic repair of a small- to medium-sized rotator cuff tear, early physiotherapy showed promising results for pain, function, and range of motion. LEVEL OF EVIDENCE: Level I therapeutic.

Osteomalacia Prevalence, Biochemical Profile, and Histology in Patients with Low-Energy Hip Fractures Over the Age of 45.

Our objective was to determine the prevalence of osteomalacia in low-energy hip fracture patients over the age of 45, based on biochemical and histological measures. This cross-sectional study included 72 patients over 45 with low-energy mechanism hip fractures. Samples of fasting venous blood were taken for hemograms and serum biochemistry analyses. Bicortical biopsies of the iliac crest were obtained, processed, and evaluated by an expert pathologist for osteomalacia. Biochemical osteomalacia (b-OM) is defined according to a distinct criterion. A low level of serum calcium, phosphorus, albumin, and 25OHD was found in 43.1, 16.7, 73.6, and 59.7% of patients, respectively. 50.0% of patients had high serum alkaline phosphatase (ALP) levels. b-OM was found in 30 (41.7%), and no significant association was found with PTH, Cr, Alb, age, sex, fracture type, side of the trauma, and season were not associated with osteomalacia. Osteomalacia was diagnosed on histopathological analysis in 19/72 (26.7%), and 54/72 (75.0%) of all cases fulfilled b-OM criteria. In the histologic evaluation, osteoid seam width, osteoid surface, and osteoid volume were 28.5 µm, 25.6, and 12.1%, respectively. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the biochemical test for detecting osteomalacia were 73.6, 64.2, 42.4, 87.2, and 66.7%, respectively. Up to 30% of elderly patients with low-energy hip fractures are affected by osteomalacia. A biochemical screening along with a bone biopsy and histopathologic evaluation may be logical in a high-risk population for osteomalacia diagnosis.

Nonunion following valgus subtrochanteric osteotomy for neglected femoral neck fracture: A case report.

INTRODUCTION AND IMPORTANCE: Femoral neck fractures account for roughly half of the two million hip fractures that occur each year worldwide. There is a high rate of neglected cases and potential complications such as nonunion or avascular necrosis (AVN) in developing countries. More than 30 % of patients may experience non-union following a femoral fracture. There is no consensus on the best neglected femoral neck fracture treatment. CASE PRESENTATION: A 30-year-old female known case of rheumatoid arthritis came with a neglected femoral neck fracture to our center. We salvaged the viable hip by subtrochanteric valgus osteotomy and fixation by angled blade plate (ABP). After eight months, she returned with left hip pain and nonunion of the fracture and osteotomy sites. We refixed the fracture with a longer ABP together with autografting of both sites. After two years, she had complete union, full hip range of motion, and painless ambulation. CLINICAL DISCUSSION: Subtrochanteric valgus osteotomy is susceptible to nonunion especially in patients with medical comorbidities. CONCLUSION: Careful selection of osteotomy site and appropriate fixation device might prevent of non-union.

Concomitant septic arthritis of the hip joint and femoral head avascular necrosis in patients with recent COVID-19 infection: a cautionary report.

PURPOSE: At present, concomitant avascular necrosis (AVN) of femoral head and septic arthritis (SA) as a sequel of COVID-19 infection has yet not been documented. By large-scale use of life-saving corticosteroids (CS) in COVID-19 cases, our aim is to warn of the occurrence of hip joint infection in these patients. METHODS: We report a series of five cases in which patients developed septic arthritis concomitant with AVN after being treated for COVID-19 infection. The mean dose of prednisolone used in these cases was 1695.2 mg. The time period of onset of hip symptoms in our cases from the beginning of the COVID-19 infection was 56 days in the first case, 43 days in the second case, 30 days in the third case, 29 days in the fourth case and 50 days in the last case, with an average time of 41.6 days. All patients underwent surgery depending on the extent of articular cartilage damage by direct anterior approach. RESULTS: Clinical and laboratory symptoms improved significantly in all patients. The mean visual analogue pain score of the patients decreased from 9.4 (9-10) before surgery to 2.8 (1-4) after 1 week of operation. CONCLUSION: In any patient with the history of COVID-19 infection specially those who have been treated with corticosteroid as one of the medications prescribed during the disease, any joint symptom specially in the hips should draw our attention to the joint infection, and with timely diagnosis and surgery, their hip joint can be saved.

The Functional Outcomes of Delayed Surgical Reconstruction in Nonsport-Induced Multiligament Knee Injuries: A Retrospective Cohort Study.

Multiligament knee injuries (MLKIs) are among the most detrimental injuries, which can cause significant compromise of joint stability and function. Our aim was to investigate the functional outcomes of nonsport-induced MLKIs who presented late after injury and underwent delayed arthroscopic reconstruction. In a retrospective cohort of 18 MLKI patients (19 knees, January 2012-2018) who had undergone arthroscopic reconstruction, we assessed the knee range of motion, return to work/sport, International Knee Documentation Committee (IKDC), Knee Injury and Osteoarthritis Outcome Score, Western Ontario and McMaster Universities Arthritis Index, Lysholm, and Tegner scores. The preoperative scores were retrieved from the patients' registry database. We reviewed their surgical notes and extracted the operation data, including the damaged ligaments, stages of the surgery, and associated meniscal injury. There were 14 males and 4 females with a mean age of 30.57 ± 10.31 years. The mean time from injury to surgery was 17.31 ± 11.98 months. The most common injury was anterior cruciate ligament/posterior cruciate ligament (31.6%). The mechanisms of injury were motor vehicle accidents (72.2%), falls (22.2%), and sports (5.6%). The reconstruction was either single (61.2%) or multiple stage (38.8%). The pre- and postoperative scores were 45.31 ± 7.30 versus 79.16 ± 11.86 IKDC, 3.84 ± 1.26 versus 8.37 ± 1.16 Tegner, and 60.42 ± 7.68 versus 89.42 ± 8.81 Lysholm, respectively. All the scores showed significant improvement at mean follow-up of 24.05 ± 9.55 months (p < 0.001). In conclusion, delayed arthroscopic reconstruction of MLKIs significantly improved the functional outcomes and return to work in patients presenting late to the orthopaedic clinic. There was no relationship between the demographic variables, mechanism of injury, number of injured ligaments, and the stages of surgery and the functional outcomes in this group of patients.

A More Positive Culture by Resin-containing Media Usage after Suspicious Arthroscopic Infections in Patients Receiving Antimicrobial Therapy.

BACKGROUND: Although infections following arthroscopic surgery of cruciate ligament and meniscus are uncommon, they have potentially serious consequences for the graft and articular cartilage. This study aimed to investigate the efficacy of correct sampling and appropriate media, especially resin-containing media, for the detection of infections in patients receiving antibiotics under suspicion of joint infection after arthroscopic anterior cruciate ligament (ACL) and meniscal surgery. In such cases, proper sampling and the use of suitable culture media that cause the neutralization of antibiotics are very effective in isolating microorganisms from the patient samples and positive cultures. METHODS: In total, 10 patients who had received antibiotics with suspected knee infection after arthroscopic ACL and meniscal surgery were identified after referral to surgeons during a period of 10 months and investigated in this study. The sample collection, culture on various media (i.e., resin-containing culture media), microbiological tests, and antibiotic susceptibility tests were performed in this study. The amplification of the mecA gene using PCR assay was accomplished for methicillin-resistant staphylococcus strains. RESULTS: This study was conducted on 10 patients who underwent arthroscopic procedures and had received antibiotics. Overall, joint fluid and tissue culture were positive in 60% of the patients. The resin-containing media revealed a trend toward increased detection of bacteria. Coagulase-negative staphylococcus strains were the most frequently isolated bacteria in arthroscopic ACL surgery infections. Out of five methicillin-resistant staphylococcus strains, four strains were found that were resistant to cefoxitin and positive-mecA designated as methicillin-resistant strains. Except for one case, the rest of the staphylococcal strains were resistant to methicillin but susceptible to vancomycin. CONCLUSION: Despite uncommon and low percentage of infections after arthroscopic ACL and meniscal surgery, the results of our study showed that correct sampling, appropriate cultures, especially aerobic and anaerobic resin-containing media, and microbiological testing remained useful and valuable for diagnosing bacterial infections.

A Modified Technique for Artificial Fusion in Unreconstructable Revision Total Knee Arthroplasty.

Knee arthrodesis is an acceptable treatment that leads to a stable joint with a lower rate of recurrence of infection in periprosthetic joint infections. One of the major problems in some revision cases is the bone loss that interferes with the bony union; therefore, some studies suggest artificial arthrodesis, which does not require bony union. The present descriptive retrospective study was conducted by reviewing the medical records of patients with periprosthetic joint infection complications. Patient satisfaction was evaluated after artificial arthrodesis, based on the visualized analog scale score and Oxford Knee Score. The mean Oxford Knee Score was 28, and the mean limb length discrepancy was 11 mm. In this new method, the length of hospitalization and leg length discrepancy was reduced, limb alignment and rotation was adjustable, and periprosthetic joint infection was controlled in nearly all patients.

Middle to long-term results of distal femoral tension band hemiepiphysiodesis in the treatment of idiopathic genu valgum.

Idiopathic genu valgum is a common deformity in children. Guided growth is the treatment of choice in severe or symptomatic cases, although long-term results are mostly unknown. The purpose of this study was to determine the middle- to long-term results and complications of tension band plating in the treatment of idiopathic genu valgum, and the association between obesity and idiopathic genu valgum. A retrospective review of patients with idiopathic genu valgum treated by tension band plating between January 2007 and September 2017 was performed. Data from 99 patients (198 limbs) were reviewed. All underwent bilateral medial distal femoral tension band plating and subsequent plate removal and were followed by a mean of 56.1 months (12-120 months) after surgery. Full correction was achieved in all patients, with a mean correction rate of 0.52° per month. No cases of infection or premature physeal closure were recorded. Screw breakage at the time of removal occurred in five limbs (2.5%). Fifteen limbs (7.5%) developed a minor overcorrection. 44.4% of our patients were either overweight or obese, which is higher than the national average. A third of our patients complained of an unsightly scar at the latest follow-up. Tension band plating is an effective, well tolerated, and reproducible technique in the treatment of idiopathic genu valgum. The risk of premature physeal closure is minimal. We recommend achieving a minor overcorrection before plate removal in patients with more than a year of expected growth. Also, predicting correction based on the mean correction rate is discouraged.

No difference in union and recurrence rate between iliac crest autograft versus allograft following medial opening wedge high tibial osteotomy: a randomized controlled trial.

PURPOSE: Using iliac crest autograft has been considered as gold standard for gap filling in medial opening wedge high tibial osteotomy (MOW-HTO) but is associated with donor site morbidity and pain. The purpose of this study was to compare the results of the use of iliac crest autograft versus allograft from the same anatomic site in terms of union and recurrence. METHODS: Forty-six patients with genovarum with or without medial compartment osteoarthritis were enrolled based on specific inclusion and exclusion criteria and were randomly assigned into two groups. MOW-HTO was done using iliac crest allograft (23 patients) or autograft (23 patients) as void filler. Follow-up visits were done monthly for the first 3 months and then every 3 months until 1 year and then at 5th and 8th postoperative year. The clinical assessment of union, anatomical indices of proximal tibia, complications and WOMAC score were assessed for both groups. RESULTS: The amount of correction (degrees), recurrence, complication rates, time to get symptom-free, radiologic union and knee scores was similar in both groups. The symptom-free time was 6.1 (SD = 0.9) weeks in autograft group versus 6.2 (SD = 0.8) weeks in allograft group (p = 0.73, 95% CI - 0.4 to 0.6). The time to radiologic union had a between-group difference of 0.3 weeks (p = 0.58, 95% CI - 1.6 to 0.9). There was one case of surgical site infection in graft harvest site. No nonunion or delayed union was encountered in either group. Fifty-two percent of the autograft patients reported more intense postoperative pain in iliac graft harvest site than tibial osteotomy site. CONCLUSIONS: According to our results, iliac crest allograft can be safely used in MOW-HTO with comparable efficacy and safety to iliac crest autograft. CLINICAL TRIAL REGISTRY: The clinical trial was approved by clinicaltrial.gov with identifier NCT00595712.

Comments on "New Concerns for Neurocognitive Function during Deep Space Exposures to Chronic, Low Dose Rate, Neutron Radiation".

Evaluations of the biological effects of space radiation must carefully consider the biological system response and the specific nature of the source term. Acharya et al. (2019) review neurocognitive function during deep space exposures to chronic, low dose rate, neutron radiation, but do not use a source term that reflects the actual space environment in terms of radiation types and their respective energies. In addition, important biological effects, including the adaptive response to the space radiation environment, are not addressed.

Tibial Tunnel Preparation in Posterior Cruciate Ligament (PCL) Reconstruction. A Technical Tip to Lessen the Stress.

BACKGROUND: The purpose of this study was to introduce a technical tip for the preparation of tibial tunnel in a posterior cruciate ligament (PCL) reconstruction to reduce the chance of popliteal artery injury and duration of the surgery. METHODS: This study included 18 patients who underwent PCL reconstructions at Imam Khomeini University Hospital, Tehran, Iran, between 2016 and 2017. In all patients, the PCL tibial aimer device was inserted from the anteromedial portal and its tip aimed 8-9 mm below shiny white fibers in PCL facet. Subsequently, the smooth guide pin was inserted from anteromedial tibial cortex and advanced just to the posterior cortex but not through it based on the measurement of tibial tunnel length. Thereafter, the reaming was done over the guide pin. As the pin was engaged in the posterior cortex, it was assured that it would not run before the reamer to the popliteal fossa. The pin was removed when the reamer touched the posterior cortex, and the reaming continued until reamer's head appeared in the PCL facet. Other steps of standard arthroscopic PCL reconstruction were done in this study. All patients were subjected to computed tomography scans. RESULTS: The mean age of the patients and the mean duration of surgery were 25±3 years and 95 min, respectively. There was no vascular injury, and the position of the tibial tunnel in all cases was accurate. Moreover, the mean distance between the centers of the tibial tunnel to champagne-glass drop-off of the posterior cortex of tibia was obtained at 7.42 mm (range: 4.6-10.4 mm). CONCLUSION: This study showed that avoiding the penetration of posterior cortex of the tibia by means of the pin during tibial tunnel preparation for PCL reconstruction is a safe, reproducible, and time-saving technique. This technique eliminates the need for fluoroscopy during the procedure.

Acute Compartment Syndrome After Knee Synovectomy in a Patient with Hemophilia A: A Case Report.

CASE: A 19-year-old man with severe hemophilia A underwent open surgical synovectomy to treat recurrent hemarthrosis of the knee. He developed symptoms and signs of acute compartment syndrome (ACS) despite receiving full-dose factor replacement. Arthrotomy was performed twice, and massive hemarthrosis was evacuated. The symptoms subsided after supplementing clotting factor with prednisone. CONCLUSIONS: ACS may complicate hemophilia. Diagnosis is mainly based on clinical judgment. Proper factor replacement is the mainstay of treatment. Surgery is reserved for patients with no improvement following factor administration.

DNA hypermethylation of GDF5 in developmental dysplasia of the hip (DDH).

INTRODUCTION & OBJECTIVE: Developmental Dysplasia of the Hip (DDH) is one of the most common congenital skeletal anomalies. Body of evidence suggests that genetic variations in GDF5 are associated with susceptibility to DDH. DDH is a multifactorial disease and its etiology has not been entirely determined. Epigenetic changes such as DNA methylation could be linked to DDH. In this scheme, we hypothesized that changes in GDF5 DNA methylation could predispose a susceptible individual to DDH. METHODS: This study consisted of 45 DDH patients and 45 controls with healthy femoral neck cartilage, who underwent hemi-, or total arthroplasty for the femoral neck fracture. A cartilage sample of 1 cm in diameter and 1 mm in the thickness was obtained for DNA extraction. DNA was extracted and DNA methylation of GDF5 was evaluated by metabisulfite method. RESULTS: Methylation analysis showed that the promoter of GDF5 in cartilage samples from DDH patients was hypermethylated in comparison to healthy controls (p = .001). CONCLUSION: Our study showed that the methylation status of the GDF5 in patients with DDH is dysregulated. This dysregulation indicates that adjustment in the methylation might modify the expression of this gene. Since this gene plays an essential role in cartilage and bone development, thus reducing its expression can contribute to the pathogenesis of DDH. Further studies are needed to elucidate the role of GDF5 in this disease.

Unapproved Weight Gain Supplement as a Cause of Avascular Necrosis: A Cautionary Report.

Avascular necrosis of the femoral head (AVNFH) is a leading cause of end-stage joint disease in the young population that can lead to total hip replacement in early life. There are various risk factors, including trauma, corticosteroids, thrombosis, hypertension, and alcohol. There is a growing number of patients with AVNFH and history of self-medication with herbal supplement used for weight gain in Iran. The present study aimed to demonstrate the prevalence rate of using unapproved weight gain supplements (UWGS) in patients with AVNFH. An observational and cross-sectional study was conducted to estimate the prevalence rate of using UWGSs in patients with osteonecrosis at Imam Khomeini Hospital, Tehran, Iran, from January 2012 to 2018. The data were analyzed in SPSS software (version 24) through descriptive statistics and tests of means. Out of 207 patients with AVNFH, 115 cases were male. In total, 44 patients (20.95%) had a history of using UWGSs, and there had no other risk factors of osteonecrosis of FH. In conclusion, UWGSs can be a risk factor for AVNFH, and it is necessary to develop educational programs to alert young population about the side effects of these supplements.