Whole-body cryotherapy in orthopaedics: current concepts.

The use of whole-body cryotherapy (WBC) for musculoskeletal ailments is growing. WBC, involving brief exposure to extremely low temperatures, is increasingly used for its analgesic, anti-inflammatory, and antioxidant effects. The paper examines the physiological impacts of WBC on cardiovascular, musculoskeletal, hematologic, hormonal, and metabolic systems. Specific orthopaedic applications discussed include its role in the management of fractures, osteoarthritis, osteonecrosis of the femoral head, osteomyelitis, adhesive capsulitis, tendinopathies, rheumatic pathologies, chronic pain syndromes, and fibromyalgia. The study also highlights the benefits and drawbacks of WBC, including its potential to improve athletic performance, recovery, mood, and well-being, while noting risks like frostbite and impaired muscle strength. Clinical evidence from various studies is evaluated, revealing a spectrum of outcomes. For instance, WBC shows promise in enhancing bone health in athletes and providing relief in osteoarthritis and fibromyalgia patients. However, evidence for its efficacy in conditions like chronic pain syndromes and osteomyelitis is less robust. The paper underscores the need for further research to establish standardised protocols and understand long-term effects. While WBC offers significant benefits in orthopaedics, understanding its limitations and potential risks is crucial for its safe and effective clinical application.

Operating room efficiency for a high-volume surgeon in simultaneous bilateral robotic-assisted total knee arthroplasty: a prospective cohort study.

Robotic-assisted total knee arthroplasty (RATKA) has been shown to achieve more accurate component positioning and target alignment than conventional jig-based instrumentation; however, concerns remain regarding its adoption since it is associated with steep learning curves, higher operational costs, and increased surgical time. This study aims to compare the operating times of three cohorts of patients undergoing simultaneous bilateral TKA, i.e., first 50 RATKA, last 50 RATKA (at the end of 1 year), and 50 conventional TKA. This prospective cohort study was conducted at a single high-volume tertiary care center by a single experienced surgeon on 150 patients (300 knees), who were allotted into three equal cohorts of 50, between February 2020 and December 2021. Simultaneous bilateral TKAs were done in all three groups and operative times recorded. We describe the technique for optimizing the surgical time of SB-RATKA for efficient operative room logistics. The operating times of the two robotic-assisted TKA cohorts were compared with the operating times of the conventional SB-TKA cohort. The mean age of the study population was 59(±6.2) years with the majority of females (82%). The mean coronal deformity was comparable between the cohorts. The mean operating time in the conventional CTKA, initial 50 RATKA, and final 50 RATKA cohorts were 115.56 (±10.7), 127.8 (±26), and 91.66 (±13.5) min, respectively, all of which showed a statistically significant difference (p < 0.001). The mean operating times of the final 50 RATKA at the end of 1 year improved by about 36 min with all the SB-RATKA cases being completed in under 120 min. The efficiency of SB-RATKA improved significantly with time and experience, resulting in shorter operational times within a year, revealing the potential of robotic-assisted surgery to surpass conventional approaches in TKA in terms of operating room efficiency.

Adoption of robotics in arthroplasty- a survey of perceptions, utilization and challenges with technology amongst Indian surgeons.

Introduction: Total joint replacement surgeries are standard procedures for managing end-stage hip or knee arthritis. Despite advances in technology, some patients experience dissatisfaction after total knee arthroplasty (TKA). Robotic technology has evolved significantly and has shown promise in improving component positioning, alignment, and surgical outcomes. However, the widespread adoption of robotics in arthroplasty faces challenges such as high costs, a steep learning curve, and limited evidence on long-term outcomes. Methods: This cross-sectional observational study used a structured self-administered online survey to assess the perceptions of Indian arthroplasty surgeons regarding robotic technology. The survey included questions about the surgeon's background, experience, perceptions of robotic joint replacement, and limiting factors for robotic usage. A total of 417 responses were collected from practising arthroplasty surgeons. Results: Most participants(78.1 %) expressed a willingness to adopt robotics in their arthroplasty practice if the cost of installation was reduced. Robotic users were more convinced about the benefits of robotics, including improved alignment, reduced pain, faster rehabilitation, and better outcomes. High-volume robotic surgeons demonstrated a greater belief in the broader potential of robotics beyond implant positioning and alignment. The major barriers to adoption were the high cost of installation and limited insurance coverage for robotic-assisted procedures. Lack of formal robotic training opportunities, resistance from corporate management, patient acceptance issues, and limited published literature supporting robotic advantages were also cited as limiting factors. Conclusion: Robotic technology is increasingly being adopted in India for TKA. The main obstacle to widespread adoption is the high cost of installation. As technology costs decrease, we can expect a rise in the number of installations across the country. Advocacy from national orthopaedic organizations may be needed to address insurance reimbursement challenges. Overall, this study provides valuable insights into the perceptions and challenges associated with the adoption of robotic technology in arthroplasty in India.

Gold-Induced Cytokine (GOLDIC®) Therapy in the Management of Knee Osteoarthritis: An Observational Study.

BACKGROUND: Current treatment modalities for knee osteoarthritis (OA) provide symptomatic cures rather than reversing the pathology in the long term. An innovative regenerative therapy called "Gold Induced Cytokines" (GOLDIC®) was explored in various musculoskeletal diseases such as knee OA, lumbar canal stenosis, Achilles tendinopathy, and plantar fasciitis. In this study, we explored the safety and functional outcome of GOLDIC® injections in knee OA (KL grades 3 and 4) with visual analog scale (VAS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores. MATERIALS AND METHODS: A multi-center open-label observational study was carried out after screening the cases according to the inclusion criteria. A total of 106 knees in 65 patients were enrolled for four doses of 4 ml of ultrasound-guided intra-articular GOLDIC® injections every three to six days. All cases were followed up with pre- and post-VAS and WOMAC scores at an interval of four weeks, three months, six months, and one year, and the complications (including severe adverse reactions) were monitored throughout. RESULTS: In this study, 66.1% had grade 4 OA knee (without gross varus or subluxation) and 33.8% had grade 3 OA knee. All the participants underwent the GOLDIC® treatment modality. A statistically significant difference was observed in pre- and post-procedural follow-up in VAS and WOMAC scores at one-year follow-up. There were no recorded severe adverse reactions during the entire study period. Three patients failed the treatment in one year. CONCLUSION: The GOLDIC® procedure shows great promise as a novel method for treating moderate to severe OA of the knee, both in terms of pain and functional outcome without any severe adverse reactions, in a sustained manner and is worth exploring as a long-term treatment option.

Evolving Role of Negative Pressure Wound Therapy with Instillation and Dwell Time (NPWTi-d-) in Management of Trauma and Orthopaedic Wounds: Mechanism, Applications and Future Perspectives.

Introduction: Negative Pressure Wound Therapy (NPWT) is a well-established method to promote wound healing by delivering negative pressure (a vacuum) at the wound site. Enhancement of NPWT techniques may allow an innovative way of treating trauma and orthopaedic wounds which provide unique challenges. We explore the role of negative pressure wound therapy with instillation and dwell time (NPWTi-d-) in the management of trauma and orthopaedic wounds. Materials and Methods: A comprehensive search strategy was conducted using databases of PubMed, Web of Science, Google Scholar, and Cochrane Library with the search words of 'NPWTid' or 'NPWTi-d-' or 'NPWT with instillation' or 'Negative pressure wound treatment with instillation' to generate this narrative review. The mechanism of action of NPWTi-d-, installation solutions and current applications in the trauma and orthopaedic wounds is evaluated. Results: NPWTi-d- provides additional mechanism to promote wound healing in a spectrum of acute and chronic orthopaedic wounds. The technique allows local delivery of hydration and elution of antibiotics to support growth of healthy granulation tissue. Various mechanism of actions contribute in drawing the wound edges together, reduce oedema, help decontamination, deliver local antibiotic and promote healing. Conclusion: NPWTi-d- permits an enhanced, supplementary technique to encourage wound healing in challenging traumatic and orthopaedic wounds. Future applications of NPWTi-d- will depend on cost-effectiveness analysis and development of its application guidelines based on longitudinal, randomized controlled research trials.

Mycobacterium Tuberculosis infection of the wrist joint: A current concepts review.

Background: Osteoarticular Tuberculosis (TB) of wrist joint is a rare, often misdiagnosed form of site affected by Mycobacterium Tuberculosis infection that can lead to severe disability and morbidity. This review aims to summarize the current literature on the diagnosis and management of Mycobacterium Tuberculosis infection of the wrist joint. Materials and methods: A comprehensive search strategy using the PEO (Population, Exposure, Outcome) framework was conducted on PubMed, Google Scholar, and Web of Science databases from 1967 to 2022, excluding single case reports and correspondence articles. The keywords used for the search included 'Mycobacterium tuberculosis' 'osteoarticular' and 'wrist'. Clinical presentation, demographic details, complementary investigations undertaken, trends, and complications of different management interventions were recorded to generate this review. Results: Osteoarticular Tuberculosis (TB) of the wrist joint accounts for fewer than 1% of all skeletal TB cases across a spectrum of age ranges. Magnetic Resonance Imaging (MRI) represents an excellent modality to reveal the extent of the disease at an early stage of the condition. Synovial fluid analysis has been recommended for microbiological diagnosis. Treatment options include anti-tubercular therapy (ATT), incision and drainage, debridement, synovectomy, and arthrodesis. Conclusion: Early diagnosis and treatment of wrist tuberculosis is crucial for achieving good functional outcomes in patients with this uncommon condition. Polymerase Chain Reaction (PCR) and GeneXpert technology for the detection of Mycobacterium tuberculosis (MTB) have improved diagnostic accuracy in detecting MTB DNA and rifampicin resistance. Anti-Tubercular Therapy (ATT) regime remains a foundation pillar in the overall management of these patients with focused surgical interventions leading to improved clinical outcomes.

Erosion and Failure of the Tibial Post after Posterior-stabilized Total Knee Replacement: A Case Report.

Introduction: Posterior-stabilized (PS) total knee arthroplasty (TKA) prostheses are characterized by an articulation between the polyethylene tibial post and the cam of the femoral component. Tibial post-fractures, traumatic and non-traumatic, are uncommon but catastrophic complications. We report a rare and unusual case of complete atraumatic erosion of the tibial post after PS-TKA. Case Report: We present a case of atraumatic tibial post-failure (complete erosion) in a 73-year-old female after primary TKA. The patient presented with chronic pain, effusion, and instability both in the coronal and sagittal plane over a period of 1 year. There were no signs of component loosening on plain radiography, no fractures, and revealed medial extension laxity on valgus stress views. During revision surgery, polyethylene insert retrieval revealed a completely eroded tibial post, without any obvious fracture. There was no fractured tibial post lying freely in the joint cavity. The patient was subsequently revised with a hinged component due to gross bi-planar instability. Conclusion: In a post-TKR (PS knee) patient with chronic pain and instability, one should consider tibial post-complications after ruling out infection. Chronic instability can cause progressive erosion of the tibial post, which can fail without an obvious fracture. Revision surgery with constrained implants may be needed to manage such cases.

Gel-Based Autologous Chondrocyte Implantation (GACI) in the Chondral Defects of the Knee: An Observational Study.

Introduction: Gel-based autologous chondrocyte implantation (GACI) is known to have superior results when compared to conventional autologous chondrocyte implantation (ACI) in terms of delivery of chondrocytes to the articular cartilage surface with reproducible three-dimensional structural restoration. This study aims to evaluate the short-term outcomes of gel-based autologous chondrocyte implantation (GACI) for the treatment of large focal articular cartilage defects of the knee. Methods: This was a prospective observational study among 25 patients who underwent GACI. Primary outcome measures included Lysholm Knee Scoring Scale and IKDC score and secondary outcome measures included MRI assessment of cartilage repair using MOCART. Results: Mean age of the population was 39.8 ± 7.5 years. The study found a highly significant improvement in both Lysholm knee score (pre-op: 45.1 to post-op: 72.4) and IKDC score (pre-op: 36.7 to post-op: 78.5) (p < 0.001) at the final follow-up of 24 months, even with the mean defect size being 4.5 ± 5.8 cm2. Postoperative MRI showed a mean MOCART score improvement from 39.4 to 67.4 at the final follow-up. No major complications were observed. Conclusion: GACI is an effective and safe treatment option for large focal articular cartilage defects around the knee, with significant improvement in functional scores and low revision rates at medium-term follow-up.

Functional alignment is associated with increased incidence of pre-balance, reduced soft-tissue release, and post-operative pain compared to mechanical alignment in patients undergoing simultaneous bilateral robotic-assisted TKA.

This study aimed to compare two alignment strategies in the same patient undergoing simultaneous bilateral robotic-assisted TKA (SB-RATKA): mechanical alignment (MA), the gold-standard, and functional alignment (FA), a balance-driven, personalized alignment strategy. The outcome measures included quantitative assessment of soft-tissue release, incidence of knee balance, and post-operative pain. This was a prospective, self-controlled, randomized-controlled trial involving 72 patients who underwent SB-RATKA using the MAKO® robotic system with comparable grades of deformity and pain in both knees. 65 patients were finally included with one alignment strategy done per knee, with the patients blinded to the strategy used. The study recorded the additional soft-tissue releases required, incidence of pre-balance, and daily post-operative VAS pain scores. The mean age of the study population was 57.95 years, with a female preponderance (N = 53, 81.6%). MA group had significantly more medial compartment tightness in both flexion (MA-15.6 ± 1.8; FA-17 ± 1.3) and extension (MA-14.9 ± 1.9; FA-17 ± 1.1) (p < 0.0001) compared to the FA group after dynamic balancing. 66% of knees in the FA group (N = 43) achieved pre-balance compared to 32.3% in the MA group (N = 21) (p < 0.0001). VAS scores showed a significant reduction in pain in the FA group up to 72 h post-surgery (p < 0.0001). The requirement for posteromedial release (PM), posterior capsular (PC) release, tibial reduction osteotomy (TRO), and superficial MCL pie crusting (sMCL) were significantly lower in FA (PM-22, PC-13, TRO-8, sMCL-2) compared to MA (PM-44, PC-29, TRO-18, sMCL-8). Functional alignment strategy consistently resulted in a higher incidence of knee balance with a significant reduction in soft-tissue releases and immediate post-operative pain when compared to MA in the same patient undergoing SB-RATKA. Therapeutic Level 1.

Sensor Technology in Fracture Healing.

Introduction: SMART sensor technology may provide the solution to bridge the gap between the current radiographic determination of fracture healing and clinical assessment. The displacement and rigidity between the fracture ends can be accurately measured using strain gauges. Progressively increasing stiffness is a sign of fracture consolidation which can be monitored using sensors. The design of standard orthopaedic implants can remain the same and needs no major modifications as the sensor can be mounted onto the implant without occupying much space. Data regarding various fracture morphologies and their strain levels throughout the fracture healing process may help develop AI algorithms that can subsequently be used to optimise implant design/materials. Materials and Methods: The literature search was performed in PubMed, PubMed Central, Scopus, and Web of Science databases for reviewing and evaluating the published scientific data regarding sensor technology in fracture healing. Results and Interpretation: SMART sensor technology comes with a variety of uses such as determining fracture healing progress, predicting early implant failure, and determining fractures liable for non-union to exemplify a few. The main limitations are that it is still in its inception and needs extensive refinement before it becomes widely and routinely used in clinical practice. Nevertheless, with continuous advances in microprocessor technology, research designs, and additive manufacturing, the utilisation and application of SMART implants in the field of trauma and orthopaedic surgery are constantly growing. Conclusion: Mass production of such SMART implants will reduce overall production costs and see its use in routine clinical practice in the future and is likely to make a significant contribution in the next industrial revolution termed 'Industry 5.0' which aims at personalised patient-specific implants and devices. SMART sensor technology may, therefore, herald a new era in the field of orthopaedic trauma.

Patella non-resurfacing in primary total knee arthroplasty provides good functional results-a retrospective review of nine thousand three hundred forty six knees.

PURPOSE: Patellar resurfacing has long been a contentious subject in TKA with no consensus and the literature yielding disparate results. The aim of this study was to evaluate the long-term functional outcomes and complications of patients undergoing primary TKA without patellar resurfacing (non-resurfacing). METHODS: This study retrospectively analysed 9346 patients who underwent primary manual jig-based TKA without patellar resurfacing at a single high-volume arthroplasty centre between 2010 and 2018. Patients with a minimum three year follow-up irrespective of disease etiology and implant manufacturer were included in the study. Primary outcome was measured using Oxford knee score and patellofemoral Feller score. Secondary outcomes included determining the incidence of patellofemoral complications and re-operation rates following TKA. RESULTS: A total of 8695 knees were eligible for final evaluation having a mean follow-up of 6.6 years. Mean age of the patients was 62.6 (SD-7.5) years with female predominance of (N-6619, 70.8%). The majority of the patients had primary OA (N-8792, 94.1%) with varus deformity (N-8642, 92.46%). Depuy was the most used manufacturer (n = 2592, 26.4%) with the posterior stabilised (N-4127, 44.2%) design being the most predominant. The mean Feller score of the study population was 24.5 (SD = 3) with a majority of patients having good to excellent outcomes (86.95%, N-8424) and mean Oxford knee score was 36.9 (SD-6.9) with a majority of the patients having an OKS greater than 30 (87.1%, N-8133) with anterior knee pain (AKP) reported in only 4.8% patients (N-418). Most common complications included patellar clunk (N-56, 0.7%), traumatic patellar fractures (N-62, 0.8%), quadriceps tendon tear (N-54, 0.7%) and patellar dislocation (N-4, 0.05%) CONCLUSION: Patellar non-resurfacing has no detrimental impact on functional outcomes and incidence of AKP. We conclude that it is a safe, cost-effective and satisfactory approach in primary TKA with no significant complications.

Biological Therapy for Avascular Necrosis of Femoral Head - A Case Report.

Introduction: Avascular necrosis (AVN) of the femoral head is a type of osteonecrosis with the disruption of blood supply to the head of the femur. Management of AVN femoral head depends on the stage of the disease. In this case report, we elaborated on the biological therapy for bilateral AVN of the femoral head. Case Report: A 44-year-old male presented with pain in both hips for 2 years with a history of rest pain in both hips. Radiologically, the patient was diagnosed with bilateral AVN of the femoral head. The patient was offered bone marrow aspirate concentrate (BMAC) in the right femoral head, followed up for 7 years, whereas the adult autologous live cultured osteoblasts in the left femoral head, followed up for 6 years. Conclusion: Biological therapy with differentiated osteoblasts remains a viable option for AVN femoral head when compared with an undifferentiated BMAC cocktail.

Correction: Gold-Induced Cytokine (GOLDIC®) Therapy in the Management of Knee Osteoarthritis: An Observational Study.

[This corrects the article DOI: 10.7759/cureus.46231.].

Correction: Gold-Induced Cytokine (GOLDIC®) Therapy in the Management of Knee Osteoarthritis: An Observational Study.

[This corrects the article DOI: 10.7759/cureus.46231.].

Scapholunate Advanced Collapse Wrist - Keeping it Simple - A Case Report.

Introduction: Scapholunate advanced collapse is a rare condition of progressive deformity, instability, and arthritis that affects the radiocarpal and mid-carpal joints of the wrist. It occurs as a result of injury to the scapholunate ligament being left untreated. Case Report: We present the imaging of a 50-year-old woman who complained of pain in her right wrist for 2 years. Radiographs of the wrist revealed scapholunate diastasis (Terry Thomas Sign), arthritis of the radio-scaphoid joint, dorsal intercalated segment instability, radial styloid beaking, and proximal migration of capitate. We also demonstrate the measurement of radiological parameters such as scapholunate angle. Conclusion: A complete in-depth radiological analysis can thus demonstrate several signs that can prevent missed diagnosis. Increased awareness regarding these radiological signs can avoid the unnecessary higher imaging modalities being performed.

Neglected Elbow Dislocation leading to Ankylosis of Elbow: A Case Report.

Introduction: Neglected elbow dislocation is defined as a dislocation that is present for 3 weeks or longer. There is no available literature on neglected elbow dislocations, leading to ankylosis of the elbow joint. Case Report: A 17-year-old female sustained a road traffic accident. Anteroposterior and lateral view radiographs of the forearm were done and deemed to be normal at another hospital. Six months after the injury, she presented to us with complaints of absent elbow movements. Examination revealed the elbow to be fixed in 30° of flexion. Radiographs of the elbow revealed an ankylosis of the ulnohumeral articulation in an abnormal position. Conclusion: This case demonstrates that neglected elbow dislocations can lead to ankylosis of the joint. It also shows how radiographs of the forearm are inadequate to assess for elbow dislocations even if the elbow region is covered in the radiograph.

Avoiding Lateral Laxity in Robotic Arm-Assisted Total Knee Arthroplasty-A Surgical Technique Describing a New Method of Gap Capture and Balancing Strategy.

INTRODUCTION: Optimal flexion-extension gap balancing is an important factor in outcomes after total knee arthroplasty. Knees with varus deformities are commonly associated with a greater degree of lateral laxity both in extension and flexion. Residual lateral laxity could be encountered by surgeons during component trialling after robotic-assisted total knee arthroplasty (RATKA), necessitating additional medial soft tissue release for a thicker insert. This study describes a new technique of gap assessment during RATKA and we propose a functional alignment based balancing strategy to avoid residual lateral laxity. MATERIALS AND METHODS: This surgical technique was prospectively employed in 105 patients undergoing primary MAKO® (Stryker, Kalamazoo, Michigan) RATKA for osteoarthritis of the knee with varus deformity, between January 2021 and July 2021. Patients included had an initial lateral extension laxity of more than 24mm. Surgical data points collected consisted of characterization of the laxity profile of the knee using the medial and lateral extension and flexion initial gap captures, final gap captures after dynamic balancing with a functional alignment strategy, and residual lateral extension gap laxity in millimeters at the end of implantation. RESULTS: The mean initial lateral extension gap was 25.76mm (standard deviation [SD]=1.47) and the mean lateral flexion gap was 24.4mm (SD=1.94). Balance was achieved in all the patients with a 9 or 11mm insert, with a mean residual lateral laxity of 0.51mm (SD=0.73, range 0-2mm). The majority of patients (n=66, 62.85%) had zero lateral laxity at the end of final implantation while 24 patients (22.8%) had 1mm of residual lateral laxity. CONCLUSION: Residual lateral joint laxity can be avoided consistently and predictably in RATKA cases with initial gap capture of up to 30mm in lateral extension and flexion with this new technique of gap capture and employing various steps of balancing strategy described.

Unusual Failure of Modular TKA Prosthesis and Screw Migration following Revision Total Knee Arthroplasty.

Introduction: The use of modular implants for revision TKA are ever increasing in number due to their definitive advantage over their monoblock counterparts by providing the surgeon with the versatility needed to achieve equal gaps and manage bone defects. This superiority comes at the cost of certain unique complications attributable to its modular design such as loosening and fractures at the areas of component coupling that are prone to fatigue failure with suboptimal fixation. Case Report: We present a case of modular femoral component failure in a 59-year man of Asian decent after revision TKA secondary to disengagement and migration of the extension stem locking bolt of a Total Condylar-III prosthesis. Patient presented with pain, effusion, and instability 2.5 years after stage-2 revision TKA. Radiographs revealed migration of the femur-stem locking bolt into the joint cavity. The femoral component and stem were loose. The locking bolt was extracted, and he underwent re-revision surgery with revised femoral components. Conclusion: Stem-condylar junction of modern modular TKA implants are prone to early loosening and failure. This diagnosis should be anticipated on serial follow-up radiographs and in patients who complain of sudden onset of instability following revision surgery.