Cartilage Restoration for Isolated Patellar Chondral Defects: An Updated Systematic Review.

Background: Patellar chondral lesions can be particularly challenging to manage in younger and more active populations. Purpose: To synthesize, organize, and summarize the results and complication rates of various patellar cartilage restoration techniques. Study Design: Systematic review; Level of evidence, 4. Methods: We performed this systematic review according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using the Medline, Embase, Scopus, and Cochrane databases. Studies were included that reported on surgical treatment of patellar chondral defects with ≥5 patients and 12 months of follow-up data. Relevant demographic data from the included studies were extracted, and patient-reported outcome scores, visual analog scale for pain results, return-to-sport rate, complications, and concomitant procedures were documented. Results: There were 24 studies that met the inclusion criteria, with a total of 575 patients (male, n = 239; female, n = 336). In total, 6 surgical techniques were utilized. In 9 studies, the surgical procedure of choice was osteochondral autograft transplantation (OAT); 8 studies evaluated autologous chondrocyte implantation (ACI); 3 evaluated advanced microfracture/autologous matrix-induced chondrogenesis; 1 evaluated osteochondral allograft transplantation (OCA); 1 evaluated particulate juvenile articulated cartilage; and 2 evaluated a synthetic osteochondral graft. No uniform functional outcome score or assessment was utilized across studies. OAT was predominantly used for smaller chondral lesions (<2 cm2) and demonstrated minimal complication rates and satisfactory outcome scores. Advanced microfracture techniques showed promise, with improvement in outcome scores and zero complications. Matrix-induced ACI consistently exhibited higher mean improvement in the measured outcome scores and resulted in fewer complications when compared with previous generations of ACI. Conclusion: OAT and ACI were the most studied procedures for isolated patellar chondral defects. Advanced microfracture techniques showed promise, but indications (ie, size) and variability in techniques need to be elucidated in higher-level studies. Further prospective studies comparing OCA and matrix-induced ACI for larger patellar defects are necessary to determine the superior technique.

Treatment options for complex shoulder osteoarthritis with posterior humeral head subluxation and glenoid bone loss (Walch B): A systematic review.

Background: Shoulder osteoarthritis (OA) with eccentric (B) glenoids has generally been associated with poor patient-reported outcomes and increased complications. The purpose of this study was to outline all the described treatment options and their outcomes and complications in order to better guide treatment. Methods: This systematic review was performed according to the Preferred Reporting Items for Systematic review and Meta-analysis guidelines. Searches were performed up to December 19, 2019, using Medline, EMBASE, Scopus, and Cochrane databases. Inclusion criteria included studies for glenohumeral OA reporting posterior humeral head subluxation and/or posterior glenoid erosion. Studies were excluded if they were review papers, abstracts, or conference papers; had heterogeneity of included Walch types; or were not written in English. Results: Twenty-one studies met inclusion criteria. The mean follow-up duration was 47.5 months (range, 14-300), and the mean patient age 62 years (38-88). Six different discernible techniques were identified: asymmetric reaming with onlay glenoid (AROG) in 267 shoulders, posterior glenoid bone grafting (PGBG) with onlay glenoid in 79 shoulders, augmented glenoid (AG) in 160 shoulders, reverse shoulder arthroplasty (RSA) with or without bone grafting in 118 shoulders, hemiarthroplasty with concentric reaming (HACR) in 57 shoulders, and humeral head arthroplasty with inlay glenoid (HAIG) in 36 shoulders. All techniques reported improved patient outcomes and range of motion. Short-term (<5 years) studies reported glenoid loosening leading to revisions in 3% of AROG, 2.7% PGBG, 0.8% AG, 1.4% RSA, and 0% HAIG shoulders. HACR had a high revision rate (12.3%) due to persistent pain and stiffness. Midterm (>5 years) studies demonstrated increased rates of glenoid loosening with AROG (14.5%), PGBG (21% loose, 23.8% "at risk"), and AG (18.9% "at risk"), as well as increased rates of subluxation or revision due to instability. HAIG did not demonstrate loosening, subluxation, or revision at 55.2 months. Conclusion: Various techniques exist to manage complex primary glenohumeral OA with posterior subluxation and posterior glenoid erosion. Glenoid component survival is a concern with ASOG, PGBG, and AG. HACR has the highest early revision rate. RSA offers promising short-term and midterm results likely due to the advantage of more secure fixation as well as a constrained design to prevent posterior subluxation. HAIG has the lowest complication and revision rates although further long-term studies are needed.

Patellar Tendon Reconstruction for a Chronic Extensor Mechanism Deficit Using an Achilles Tendon Allograft With Hamstring Autograft and Suture Augmentation.

Patellar tendon ruptures are the third most common injury to the extensor mechanism. These injuries are debilitating to the patient, and delays in treatment can present a challenge to the treating surgeon. Chronic patellar tendon injuries are rare and are more difficult to manage given proximal patellar retraction, scarring, and atrophy of surrounding tissues. There is no consensus on the optimal approach for treatment, and numerous reconstruction techniques have been described using a variety of graft choices and fixation methods. We describe our surgical technique for a 3-fold reconstruction of a chronic patellar tendon rupture using an Achilles tendon allograft augmented with a vascularized ipsilateral hamstring tendon autograft and additional FiberTape augmentation. The aim of this procedure is to restore patellar height and prevent extensor lag.

Preoperative Evaluation of Intramedullary Tibial Nail Measurements-A Review of the Literature and a New Technique Using Contralateral Radiographs and Digital Planning.

INTRODUCTION: An accurate selection of tibial nail and screws measurements is paramount in purpose to achieve proper tibial fracture reduction and fixation, avoid irritation of the soft-tissue envelope, and enable extraction of the nail in the future, if needed. To this date, many methods were suggested to determine the length and diameter of an intramedullary tibial nail, preoperatively and intraoperatively. Each method has its disadvantages, and most are lacking in accuracy. Digital aids are currently available for preoperative planning for many types of surgeries. METHODS: Retrospectively, 27 patients operated for diaphysial tibial fracture intramedullary nailing were selected. The contralateral leg was imaged using AP and lateral radiograph views. Six orthopaedic trauma surgeons used the TraumaCad program (Voyant Health) to plan the appropriate nail and distal locking screws measurements, while blinded from the actual hardware used in the operation. Later, they also conducted quality review regarding the operation carried out and suggested correction in measurements of the hardware. Intra-observer and inter-observer reliability was calculated. RESULTS: The inter-correlation coefficient for the planned nails was 0.97 and 0.84 (P < 0.001) in AP view for length and diameter, respectively, and similarly 0.98 and 0.86 (P < 0.001) in lateral view. The interclass correlation coefficient (ICC) for the locking screws length was 0.7 (P < 0.02) and 0.82 (P < 0.01) for the proximal and distal medio-lateral screws, respectively, and 0.9 (P < 0.001). The ICC between AP and lateral views was 0.98 for length and 0.96 for diameter (P < 0.001). The scores and corrections given by the examiners to the actual selected nail were ICC of 0.98 and 0.96 (P < 0.001) for length and diameter, respectively. The examiners suggested they would correct, post-factum, the length of the nail in average 28% and the diameter in average 30%. The average observer resulted in ICC of 0.94 and 0.91 (P < 0.001) in length and only 0.77 and 0.67 (P < 0.001) in diameter (AP and lateral views, respectively) when comparing the actual nail used and the post-factum plan. CONCLUSION: Preoperative planning of tibial fractures' nailing using imaging of the contralateral leg and a digital graphic planning program is an accurate and reliable method. It may serve to reduce errors, surgical time, and radiation dose in the operating room. This method could also be applied for surgical debriefing.

The Radiographic Quality of Distal Radius Fracture Reduction Using Sedation Versus Hematoma Block.

INTRODUCTION: Distal radius fractures (DRFs) are treated in the emergency department (ED) with a closed reduction in order to decrease neurovascular and soft tissue injury and as a first definitive step in conservative treatment. The type of anesthesia used may affect the ability to reduce the fracture and remains controversial. OBJECTIVE: The purpose of this study was to compare the quality of radiographic reduction achieved in the ED of DRF reduced using sedation anesthesia to those reduced with hematoma block anesthesia. METHODS: A retrospective case-control study of 240 DRF reductions, 30 treated with sedation and 210 with a hematoma block, was performed. Complications and time spent in the ED were documented. Pre- and postreduction radiographs were reviewed for volar tilt, radial angulation, radial height, and ulnar variance. RESULTS: Both groups were similar in gender, background illnesses, concomitant injuries, surgeon experience, and fracture radiographic classification. Postreduction values of volar tilt were better in the sedation group (P = .03). Volar tilt and ulnar variance improved more in the sedation group (P = .001). The sedation group spent more time in the ED (P = .001). DISCUSSION: Sedation seemed to be more efficient than hematoma block in supporting closed reduction of distal radius fractures in the ED. However, this method requires specialized personnel and more time spent in the ED. CONCLUSION: We suggest using this method when the patient is planned to continue with conservative treatment.

HISTORIQUE: Les fractures distales du radius (FDR) sont traitées en salle d'urgence (SU) au moyen d'une réduction fermée afin de réduire les lésions neurovasculaires et celles des tissus mous. Cette technique représente la première étape décisive d'un traitement prudent. Le type d'anesthésie privilégié demeure controversé, car il peut influer sur la capacité de réduire la fracture. OBJECTIF: La présente étude visait à comparer la qualité des réductions radiographiques des FDR par sédation obtenues en SU à celles effectuées sous anesthésie locorégionale. MÉTHODOLOGIE: Les chercheurs ont effectué une étude rétrospective cas-témoins de 240 réductions de FDR, dont 30 traitées sous sédation et 210, sous anesthésie locorégionale. Ils ont consigné les complications et le temps passé en SU. Ils ont examiné les radiographies avant et après la réduction pour déterminer l'inclinaison palmaire, la déviation radiale, la hauteur radiale et la variance ulnaire. RÉSULTATS: Le sexe, les maladies antérieures, les lésions concomitantes, l'expérience du chirurgien et la classification radiographique des fractures étaient semblables dans les deux groupes. Les valeurs de l'inclinaison palmaire après la réduction étaient supérieures dans le groupe sous sédation (p=0,03). L'inclinaison palmaire et la variance ulnaire s'amélioraient également davantage dans ce groupe (p=0,001), qui passait toutefois plus de temps en SU (p=0,001). EXPOSÉ: La sédation semblait plus efficace que l'anesthésie locorégionale lors de la réduction fermée des fractures distales du radius en SU. Cependant, cette méthode exige la présence de personnel spécialisé et une période plus longue en SU. CONCLUSION: Les chercheurs suggèrent d'utiliser la sédation lorsqu'il est prévu que le patient poursuive un traitement prudent.

[TOTAL ELBOW REPLACEMENT AS AN ALTERNATIVE TO SEVERELY COMMINUTED FRACTURES AROUND THE ELBOW].

BACKGROUND: Intra-articular elbow fractures are considered to be one of the most complex injuries in orthopedic trauma. Some are too comminuted for open reduction and internal fixation. Recently, total elbow replacement (TER) has gained popularity for the treatment of comminuted elbow trauma when other treatment options are not possible. METHODS: Since 2007-2013 we treated 18 patients with TER due to comminuted distal humeral fractures. We used the Disabilities of the Arm, Shoulder and Hand scoring system (DASH) to evaluate the patient's satisfaction. In addition we evaluated the elbow range of motion and collateral stability. CONCLUSIONS: Functional range of motion was achieved with high patient satisfaction. Based on the results we conclude that TER is a reasonable option for complex elbow fractures when open reduction and internal fixation is not suitable.

[NON-ARTHROPLASTY TREATMENT FOR KNEE OSTEOARTHRITIS].

INTRODUCTION: Osteoarthritis is characterized by marked pain, stiffness and reduced range of motion and is one of the most common causes of disability and reduced quality of life. The disease is diagnosed in 20% of the adult population; the prevalence rises to 50% of adults over 65 years of age. There are various treatment options in the early stages of knee osteoarthritis which are intended to postpone the need for arthroplasty, which is the gold standard treatment at the end-stage level of the disease. Evidence based medicine (EBM) facilitates optimized decision-making and treatment for an individual patient based on meta-analysis, randomize control studies and systematic reviews. Based on these studies, physical activity is an effective treatment option resulting in reduced disability and improved quality of life. Among other conservative treatment options, chondroitin, a food supplement, was found to be as effective as anti-inflammatory medication with a lower side effect profile. Similar results were found for intra-articular injections of hyaluronic acid, while intra-articular injections of platelet rich plasma (PRP) were found to be the most effective of all the above. No advantage was reported for knee arthroscopy over conservative treatment options even when examining those patients with combined symptomatic meniscal tear and knee osteoarthritis. Non-steroidal anti-inflammatory medication (NSAIDS) and opiate treatment have limited long term effect on reducing pain, disability and improving quality of life. These drugs can have a high rate of substantial side effect. Hence, their use should be limited, especially in the elderly population, and safer modalities should be explored.

Hyperbaric oxygen for stage I and II femoral head osteonecrosis.

Hyperbaric oxygen therapy is a suggested joint-preserving treatment for symptomatic early-stage osteonecrosis of the femoral head. Limited studies of this treatment have been published. The goal of this study was to evaluate the effectiveness of this treatment in a relatively large patient cohort. The authors reviewed the files of 68 patients with 78 symptomatic joints with Steinberg stage I and II osteonecrosis of the femoral head. All patients were treated with hyperbaric oxygen at the authors' medical health center. Pretreatment and immediate posttreatment magnetic resonance imaging (MRI) findings were compared. On follow-up, a telephone interview was conducted to determine the survival of the joint. Modified Harris Hip Score and Short Form 12 health survey (SF-12) questionnaires of the start of treatment and at follow-up were obtained and evaluated for statistically significant differences. Half of the joints were stage 1 and half were stage II. Seventy-four joints underwent both pre- and posttreatment MRI. Eighty-eight percent of joints showed improvement posttreatment. On follow-up at a mean of 11.1±5.1 years, 54 patients (58 joints) were located and answered the questionnaires. At the time of follow-up, 93% of the joints survived. Mean Harris Hip Score improved from 21 to 81 (P<.0001), the mean physical component of the SF-12 improved from 24 to 46 (P<.0001), and the mean mental component of the SF-12 improved from 54 to 59 (P<.0001). The authors concluded that hyperbaric oxygen treatment is effective in preserving the hip joint in stage I and II osteonecrosis of the femoral head.