Exogenous Crosslinking of Tendons as a Strategy for Mechanical Augmentation and Repair: A Narrative Review.

Collagens constitute a family of triple-helical proteins with a high level of structural polymorphism and a broad diversity of structural and chemical characteristics. Collagens are designed to form supporting aggregates in the extracellular spaces of our body, but they can be isolated from animal sources and processed to become available as biomaterials with wide applications in biomedicine and bioengineering. Collagens can be conveniently modified chemically, and their propensity for participating in crosslinking reactions is an important feature. While the crosslinking promoted by a variety of agents provides a range of collagen-based products, there has been minor interest for therapies based on the crosslinking of collagen while located within living connective tissues, known as exogenous crosslinking. Currently, there is only one such treatment in ocular therapeutics (for keratoconus), and another two in development, all based on mechanical augmentation of tissues due to ultraviolet (UV)-induced crosslinking. As seen in this review, there was some interest to employ exogenous crosslinking in order to reinforce mechanically the lax tendons with an aim to arrest tear propagation, stabilize the tissue, and facilitate the healing. Here we reviewed in details both the early stages and the actual status of the experimental research dedicated to the topic. Many results have not been encouraging, however there is sufficient evidence that tendons can be mechanically reinforced by chemical or photochemical exogenous crosslinking. We also compare the exogenous crosslinking using chemical agents, which was predominant in the literature reviewed, to that promoted by UV radiation, which was rather neglected but might have some advantages.

Correlation between Inflammatory Systemic Biomarkers and Surgical Trauma in Elderly Patients with Hip Fractures.

The treatment for hip fractures consists of a wide variety of orthopedic implants ranging from prosthesis to intramedullary nails. The purpose of this study is to determine the correlation between blood-count-derived biomarkers such as the neutrophil-to-lymphocyte ratio (NLR), the platelet-to-lymphocyte ratio (PLR), the monocyte-to-lymphocyte ratio (MLR) and the systemic immune-inflammation index (SII) and the level of aggression sustained by elderly patients during these surgical procedures. A total of 129 patients aged over 70 and diagnosed with acute hip fractures who underwent surgical treatment between November 2021 and February 2023 were included in our observational retrospective cohort study. Two groups were formed depending on the anatomic location of the fracture for statistical comparison: group 1 with extracapsular fractures, who received a closed reduction internal fixation (CRIF) with a gamma nail (GN) as treatment, and group 2 with intracapsular fractures, who received a bipolar hemiarthroplasty (BHA) as treatment. The length of hospital stay (LHS), duration of surgery, preoperative days, pre- and postoperative red blood count (RBC) and hemoglobin (HGB) levels and postoperative NLR, PLR and SII were significantly different between the two groups (p < 0.05). Furthermore, the multivariate analysis indicated that the postoperative NLR (p = 0.029), PLR (p = 0.009), SII (p = 0.001) and duration of surgery (p < 0.0001) were independently related to the invasiveness of the procedures. The ROC curve analysis demonstrated that a postoperative SII > 1564.74 is a more reliable predictor of surgical trauma in terms of specificity (58.1%) and sensitivity (56.7%). Postoperative SII as a biomarker appears to be closely correlated with surgical trauma sustained by an older population with hip fractures.

A Comprehensive Research on the Prevalence and Evolution Trend of Orthopedic Surgeries in Romania.

Accurate knowledge of the prevalence and trends of orthopedic surgeries can facilitate the design of medical plans for effective treatments. The National Endoprosthetic Registry (NER) in Romania provides statistics on endoprosthetic activity (hip, knee), cases of fractures and bone tumors as a result of the legal obligations to report interventions performed by all orthopedic traumatology hospitals/wards in the country. The aim of this study is to describe the annual volumes of orthopedic surgeries between 2001 and 2022 in Romania and analyze the current and future evolution trends of the studied surgeries, gender differences and regional differences based on a complete survey carried out at a national level. For the period 2001-2022, we extracted from the NER the annual volumes of orthopedic interventions performed. With these data, we studied the prevalence and estimated, with the support of an original calculation methodology, the variation trends of orthopedic surgeries in two situations: over the entire 21-year period, respectively, and over the period 2001-2020, which does not include the pandemic period. For hip replacement surgery and knee replacement surgery, we showed the prevalence by subcategory of interventions, gender distribution, regional prevalence and regional density calculated by the annual averages of the total number of cases reported per 100,000 people in the 40 counties of the country and the capital, Bucharest. We also determined the variations in hip and knee arthroplasty revision burdens, calculated as a percentage between the number of revisions and the number of primary interventions in the same period. We determined the regional densities of revision burdens. The total number of orthopedic surgeries in the period 2001-2022 was 1,557,247, of which 189,881 were hip replacement surgeries; 51,035 were knee replacement surgeries; 11,085 were revision hip arthroplasty; 1497 were revision knee arthroplasty; 541,440 were operated fractures; and 16,418 were operated bone tumors. The growth rates of surgical interventions are hip replacement surgery, +8.19%; knee replacement surgery, +19.55%; revision hip arthroplasty, +9.43%; and revision knee arthroplasty, +28.57%. With these data, we have estimated a doubling of the volume of primary and revision interventions of the hip until 2034 and the knee until 2027, respectively. Operated bone tumors register an annual decrease of -4.52% thanks to modern treatments. There are clear gender differences; for primary hip interventions, the proportion of women is 58.82%, and for knee interventions, the proportion of women is 76.42%. This is the first research that, with the support of exhaustive data from the NER, analyzes for the period 2001-2022 the annual number of orthopedic surgeries in Romania. It allows knowledge of the large, anticipated increases in orthopedic surgery and provides a quantitative basis for future policy decisions related to the need for medical personnel and material resources.

Assessment of Labor Practices in Healthcare Using an Innovatory Framework for Sustainability.

Background and Objectives: The concept of sustainability in healthcare is poorly researched. There is a perceived need for new theoretical and empirical studies, as well as for new instruments to assess the implementation of new labor practices in the field. Such practices address unmet social needs and consolidate the sustainable development systems which promote health equity. The objective of the research is to design an innovative reference framework for sustainable development and health equity of healthcare facilities, and to provide a practical validation of this framework. Materials and Methods: The research methods consist of designing the elements of the new frame of reference, designing an indicator matrix, elaborating indicator content, and assessing the reference framework. For the assessment stage, we used sustainable medical practices reported in the scientific literature as well as a pilot reference framework that was implemented in healthcare practice. Results: The new reference framework suggested by the present study is composed of 57 indicators organized in five areas: environmental responsibility, economic performance, social responsibility, institutional capacity, and provision of sustainable healthcare services. These indicators were adapted and integrated into the seven basic topics of the social responsibility standard. The study presents the content of the indicators in the field of labor practices, as well as their evaluation grids. The innovative format of the evaluation grids aims to describe achievement degrees, both qualitatively and quantitatively. The theoretical model was validated in practice through its implementation at the Emergency Hospital in Targu Mures. Conclusions: The conclusions of the study reflect the usefulness of the new reference framework, which is compatible with the requirements in the healthcare field, but differs from other existing frameworks, considering its objective regarding the promotion of sustainable development. This objective facilitates the continuous quantification of the sustainability level, the promotion of sustainable development strategies, and sustainability-oriented approaches on the part of interested parties.

An Investigation for Future Practice of Elective Hip and Knee Arthroplasties during COVID-19 in Romania.

Background and Objectives: Elective arthroplasty in Romania has been severely affected by the COVID-19 pandemic, and its effects are not quantified so far. The aim of this paper is to determine the impact of COVID-19 on arthroplasty interventions and how they varied in Romania. Materials and Methods: We performed a national retrospective analysis of patients who underwent primary and revision elective hip and knee interventions at the 120 orthopedic-traumatology hospitals in Romania that are registered in the National Endoprosthesis Registry from 1 January 2019 to 1 September 2022. First, we examined the monthly trend in the number of surgeries for seven categories of arthroplasties. We calculated the percentage change in the average number of cases per month and compared them with other types of interventions. We then examined the percentage change in the average monthly number of arthroplasty cases, relative to the number of COVID-19 cases reported nationwide, the influence of the pandemic on length of hospital stay, and the percentage of patients discharged at home who no longer follow recovery protocols. Finally, we calculated the impact of the pandemic on hospital revenues. Results: There was an abrupt decrease in the volume of primary interventions in hip and knee patients by up to 69.14% with a low degree of patient care, while the average duration of scheduled hospitalizations increased. We found a 1-2-day decrease in length of hospital stays for explored arthroplasties. We saw an increasing trend of home discharge, which was higher for primary interventions compared to revision interventions. The total hospital revenues were 50.96% lower in 2020 compared to 2019, and are currently increasing, with the 2022 estimate being 81.46%. Conclusions: The conclusion of this study is that the COVID-19 pandemic severely affected the volume of arthroplasty of the 120 hospitals in Romania, which also had unfavorable financial implications. We proposed the development of new procedures and alternative clinical solutions, as well as personalized home recovery programs, to be activated if necessary, for possible future outbreaks.

Effects of a Novel Proprioceptive Rehabilitation Device on Shoulder Joint Position Sense, Pain and Function.

Background and Objectives: Shoulder disorders are associated with pain, restricted range of motion and muscular strength, moderate disability and diminished proprioception. This study aimed to compare the effectiveness of an innovative technology-supported and a classical therapist-based proprioceptive training program in addition to conventional physiotherapy, on joint position sense (JPS), pain and function, in individuals with different musculoskeletal shoulder disorders, such as rotator cuff tear, subacromial impingement syndrome and superior labrum anterior and posterior tear. The innovative element of the proprioceptive training programme consists of the use of the Kinesimeter, a device created for both training and assessing shoulder JPS. Materials and Methods: The shoulder JPS test and the DASH outcome questionnaire were applied to fifty-five individuals (28 females, 27 males, mean age 56.31 ± 6.75), divided into three groups: 17 in the conventional physiotherapy group (control group); 19 in the conventional physiotherapy + classical proprioceptive training program group (CPT group); and 19 in the conventional physiotherapy + innovative proprioceptive training program group (KPT group). Assessments were performed before and after a four-week rehabilitation program, with five physiotherapy sessions per week. Results: When baseline and post-intervention results were compared, the value of the shoulder JPS and DASH outcome questionnaire improved significantly for the KPT and CPT groups (all p < 0.001). Both KPT and CPT groups showed statistically significant improvements in JPS, pain and function, compared to the control group which received no proprioceptive training (all p < 0.05). However, the KPT group showed no significant benefits compared to the CPT group. Conclusions: Our findings indicate that using the Kinesimeter device as a novel, innovative proprioceptive training tool has similar effects as the classical proprioceptive training programs among individuals with different non-operated musculoskeletal shoulder disorders such as: rotator cuff tear, subacromial impingement syndrome, and superior labrum anterior and posterior tear.

The Impact of the COVID-19 Pandemic on the Orthopedic Residents: A Pan-Romanian Survey.

The COVID-19 pandemic has brought unprecedented challenges, with a potential stress which might affect the education of resident doctors in the field of orthopedics and traumatology. Its repercussion on the residents' strain and training routes is not well known. After two years of pandemic, this paper aims to analyze the repercussion of the coronavirus disease 2019 (COVID-19) on education, medical training, and the mental well-being of Romanian resident doctors in orthopedics and traumatology. In January-February 2022, an electronic questionnaire was distributed to all orthopedic resident doctors in the 12 residential training centers in Romania. Participants (n = 236) were resident doctors with an employment contract and professional activity during the COVID-19 pandemic. Resident doctors who did not work during this period were excluded. An online survey generator was used to electronically create the questionnaire. Statistical analysis was performed in Matlab version R2022a, with the support of Statistics and Machine Learning Toolbox Version 12.3. Descriptive statistics were performed for the standardized questions, while for the open questions, answers were collected by topic. The results of the Chi-square test indicate that there is a statistically significant association regarding the prevalence of infection among residents involved in the treatment of patients with COVID-19 (p = 0.028), and the influence of secondment in COVID-19 sections (p = 0.0003). The infection of residents is not related to their affiliation with a particular medical training center (p = 0.608), gender (p = 0.175), the year of study in residency (p = 0.733), the age group (p = 0.178), and the secondment period (p = 0.114). Residents who participated in the study had an overall well-being index of 13.8 ± 5.7, which indicates a low level of well-being for a large number of residents. Residents who would like to choose a new residency specialization, or would choose a non-medical career, had reduced average WHO wellness rates, as the risk of infection is associated with the treatment of patients with COVID-19 and secondment in COVID-19 sections. The findings of this study may help residency training centers to develop robust programs that can alleviate the impact of this pandemic. Some major changes will be needed to be integrated into residency training programs around the world. Emphasis should be placed on electronic educational portfolios, simulation of surgical processes, and distance learning, all of which have a high potential for health and safety, as well as for the moral support of residents.

Primary MSCs for Personalized Medicine: Ethical Challenges, Isolation and Biocompatibility Evaluation of 3D Electrospun and Printed Scaffolds.

Autologous cell therapy uses patients' own cells to deliver precise and ideal treatment through a personalized medicine approach. Isolation of patients' cells from residual tissue extracted during surgery involves specific planning and lab steps. In the present manuscript, a path from isolation to in vitro research with human mesenchymal stem cells (MSCs) obtained from residual bone tissues is described as performed by a medical unit in collaboration with a research center. Ethical issues have been addressed by formulating appropriate harvesting protocols according to European regulations. Samples were collected from 19 patients; 10 of them were viable and after processing resulted in MSCs. MSCs were further differentiated in osteoblasts to investigate the biocompatibility of several 3D scaffolds produced by electrospinning and 3D printing technologies; traditional orthopedic titanium and nanostructured titanium substrates were also tested. 3D printed scaffolds proved superior compared to other substrates, enabling significantly improved response in osteoblast cells, indicating that their biomimetic structure and properties make them suitable for synthetic tissue engineering. The present research is a proof of concept that describes the process of primary stem cells isolation for in vitro research and opens avenues for the development of personalized cell platforms in the case of patients with orthopedic trauma. The demonstration model has promising perspectives in personalized medicine practices.

An Innovative Framework for Sustainable Development in Healthcare: The Human Rights Assessment.

Healthcare providers are investing considerable resources for the development of quality management systems in hospitals. Contrary to these efforts, the number of tools that allow the evaluation of implementation efforts and the results of quality, security and sustainable development is quite limited. The purpose of the study is to develop a reference framework for quality and sustainable development in healthcare, Sanitary-Quality (San-Q) at the micro system level, which is compatible with applicable national and international standards in the field. The research method consisted of the study of literature, identification and analysis of good sustainability practices in healthcare, which allowed identification of the areas of the new San-Q framework: quality, economic, environmental, social, institutional and healthcare. These areas are incorporated into the core topics of social responsibility mentioned by ISO26000. A total of 57 indicators have been defined that make up the new reference framework. The evaluation format of the indicators is innovative through a couple of values: completion degree-significance. In the experimental part of the research, a pilot implementation of the San-Q framework at an emergency hospital was performed, the results recorded in terms of responsibility for human rights being presented. The conclusions of the study reveal the innovative aspects of the framework that facilitate the development of a sustainability strategy promoted through performance indicators, the results obtained after evaluation being useful in establishing a reference level of sustainability but also in developing sustainability policies.

Effects of Adding Aquatic-to-Land-Based Physiotherapy Programs for Shoulder Joint Position Sense Rehabilitation.

There is limited evidence regarding the effects of aquatic-based physiotherapy on shoulder proprioception following post-traumatic injury to the joint. The main aim of this study was to investigate the effects of additional aquatic-based rehabilitation to a land-based physiotherapy program on shoulder joint position sense (JPS) rehabilitation. Forty-four individuals (mean age 44.50 ± 10.11) who had suffered a post-traumatic shoulder injury less than five months previously were pseudo-randomly allocated equally into a control group (9 females, 13 males) and experimental group (6 females, 16 males). Both groups received individualized standard land-based physiotherapy on average for 50 min per session, with five sessions per week for four consecutive weeks. The experimental group received an additional 30 min of personalized aquatic-based therapy during each session. Shoulder JPS was assessed by flexion (60°), extension (25°), abduction (60°), internal rotation (35°) and external rotation (35°) positions prior, halfway through, and after the intervention. Shoulder JPS improved significantly for all positions for both the control group (p < 0.03) and the experimental group (p < 0.01). No significant differences between the control group and the experimental group were found for change in shoulder JPS over time. Our results indicate that shoulder JPS can be significantly improved among individuals with post-traumatic injury to the joint through four weeks of personalized physiotherapy. The addition of aquatic-based exercises to standard land-based therapy did not, however, show significant benefits, and thus cannot be recommended for the improvement of shoulder JPS based on our findings.

Structured Integration and Alignment Algorithm: A Tool for Personalized Surgical Treatment of Tibial Plateau Fractures.

The planning of the surgical treatment in orthopedics, with the help of three-dimensional (3D) technologies, arouses an increasing scientific interest. Scientific literature describes some semi-automatic reconstructive attempts at fragmented bone fractures, but the matching algorithms presented are likely to improve. The aim of this paper is to develop a new method of aligning fragments of comminutive fractures. We have created a structured integration process and an alignment algorithm integrated in a clinical workflow for personalized surgical treatment of fractures. The provided solution is able to align the surfaces of bone fragments derived from the segmentation process of volumetric tomographic data. Positional uncertainties are eliminated interactively by the user, who selects the corresponding pairs of fracture surfaces. The final matching and the right alignment are performed automatically by the innovative alignment algorithm. The paper solves a challenging problem for the reconstruction of fractured bones, namely the choice of the optimal matching option from the situation in which surface portions of a fracture fragment correspond to multiple high fragments. The method is validated in practice for preoperative planning of a 49-year-old male patient who had a tibial plateau fracture of Schatzker type VI.

Integration of Three-dimensional Technologies in Orthopedics: A Tool for Preoperative Planning of Tibial Plateau Fractures.

BACKGROUND: There is a growing scientific interest in the use of three-dimensional (3D) technologies in orthopedic surgery. Digitalization makes research in orthopedics more accurate and quantitative. Scientific literature describes an overview of current 3D technologies applications in orthopedics, without any emphasis on integrating available technologies as a clinical workflow. OBJECTIVE: To develop a clinical workflow integrating 3D technologies for patient-specific applications in orthopedics validated in practice by employment of a free 3D software solution with the aim of minimizing the intervention. METHOD: By exploring the applications of 3D technologies in orthopedic surgery, we have created a clinical workflow integrating 3D technologies for patient-specific applications in orthopedics. It is validated in practice for preoperative planning of a 49-year-old male patient who had a tibial plateau fracture of Schatzker type VI in his right leg. The software solution we have used is Democratiz3D, from Embodi3d platform, which allows patient-specific modeling and surgical planning. RESULTS: By using the proposed methodology we obtained the model of the tibial plateau fracture Schatzker type VI, as a "solid" representation in stl type files, which represents a numerically defined geometry of the bones fragments. It helps surgeons in planning the surgical approach. The time from the beginning to the end of the analysis was 193 min, which is 15% lower than times reported in similar studies. CONCLUSION: The planning potential of the 3D solution is a valuable instrument for surgeons in exploring the nature of tibial plateau fractures and the formulation of a suitable surgical plan for surface alignment, design and screw fixation guides, strength calculations of bone fragments, and printing surgical objects.

Predictive factors for postoperative deformity in thoracolumbar burst fractures: a statistical approach.

OBJECTIVE: To assess, using statistical analysis, if and to what extent the final outcome of surgical treatment for burst fractures depends on operation type, fracture level and initial deformity severity. METHODS: A database of 287 patients with single-vertebral-level thoracic and lumbar spine fractures analysed using simple and multiple linear regression analyses models. The dependent variable was last follow-up (LFU) kyphotic angle and the predictor variables were operation type [anterior approach (AA), posterior short-segment fixation (PSSF) and posterior monosegmental fixation (PMF)], fracture level (T11-L1, L2-L3 and L4-L5) and preoperative kyphotic angle. The models were applied on either the whole sample or on the operation type subgroups. RESULTS: In simple linear regression analysis models, fracture level accounted for 32% and 18% of the variation in LFU kyphotic angle in the AA and PMF subgroups, respectively. In the multiple linear regression models for the same subgroups, up to 40% of the variation in LFU kyphotic angle was accounted for by fracture level. Surgical treatment, as predictor variable, indicated that patients treated by PSSF developed a post-surgical kyphotic angle 8.51° more severe than those treated by AA. However, the model accounted for only 2% of the variation in LFU kyphotic angle. Simple linear regressions performed on each subgroup with preoperative kyphotic angle as the independent variable revealed that the variable accounted for 15% (PSSF subgroup), 17% (AA subgroup) and 34% (PMF subgroup) of the variation in LFU kyphotic angle. CONCLUSION: All valid regression models displayed modest explanatory power, suggesting that factors other than those taken into consideration are involved.