The optimal fluoroscopic views to rule out intra-articular screw penetration during acetabular fracture fixation.

PURPOSE: To determine the ideal view(s) and the minimum number of intraoperative fluoroscopic views required to rule out any intra-articular screw violation in acetabular fractures fixation. METHODS: This study was conducted using a series of fluoroscopic examinations of pelvic synthetic models with screws positioned in different planes around the acetabulum. Ten screws were placed in the synthetic pelvis models in different planes of the acetabulum. Seven views were taken for each screw. Radiographic images were evaluated by 14 orthopaedic surgeons who were asked to assess joint violation and the view(s) required for assessment. RESULTS: The observers' accuracy rate in identifying joint violation was 82.1% for the anterior part of the anterior column and the superior part of the posterior column, 89.3% for the posterior part of the anterior column and the inferior part of the posterior column, and 92.9% for the quadrilateral plate. The sensitivity was 100% for the anterior and posterior parts of the anterior column and the inferior part of the posterior column, 87.5% for the superior part of the posterior column, and 85.7% for the quadrilateral plate. The specificity was 100% for the quadrilateral plate, 80% for the superior part of the posterior column and the posterior part of the anterior column, 78.6% for the inferior part of the posterior column, and 66.7% for the anterior part of the anterior column. There was a strong overall interobserver and intra-observer agreement with intraclass correlation coefficient (ICC) of 0.709 and 0.86, respectively. CONCLUSIONS: This study confirms the hypothesis that in a concave surface/joint fixation, such as the acetabulum, the probability of joint violation is unlikely if there is no evidence of it within a single fluoroscopic view. In acetabulum fracture fixation with a screw violating the joint, the screw's presence was evident within the joint space in all fluoroscopic views. However, the absence of joint violation in one fluoroscopic view was adequate to rule out joint penetration.

Robotic-assisted versus conventional total knee arthroplasty: a systematic review and meta-analysis of randomized controlled trials.

OBJECTIVES: Robotic knee arthroplasty procedures have emerged as a new trend, garnering attention from orthopedic surgeons globally. It has been hypothesized that the use of robotics enhances the accuracy of prosthesis positioning and alignment restoration. The objective of this study was to provide a high-level, evidence-based comparison between robotic total knee replacements and conventional methods, focusing on radiological and functional outcomes. METHODS: We searched five databases from their inception until June 1, 2022, specifically targeting randomized controlled trials (RCTs) that compared the outcomes of robotic and conventional total knee replacements. We were interested in outcomes such as knee range of motion, clinical and function knee society scores, the Western Ontario and McMaster University score (WOMAC), the Hospital of Special Surgery score, complications, and radiological alignment. This review was carried out in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes guidelines. We assessed the risk of bias using the revised Cochrane risk-of-bias tool for randomized trials (RoB 2). RESULTS: Our search returned seven RCTs suitable for our analysis, which included a total of 1942 knees; 974 of these knees were implanted using robotic arms while the remaining 968 utilized jig-based knee systems. Our findings indicated that robotic knees had significantly better post-operative anatomical (OR - 0.82; 95% CI, - 1.027 to - 0.58, p value < 0.00001) and mechanical restoration (OR - 0.95; 95% CI, - 1.49 to - 0.41, p value < 0.0006). While knee range of motion (OR - 2.23; 95% CI - 4.89-0.43, p value 0.1) and femoral prosthesis position (OR - 0.98; 95% CI, - 2.03-0.08, p value 0.07) also favored robotic knees, these differences did not reach statistical significance. Both clinical and functional outcomes, as well as the rate of complications, were found to be statistically similar between the groups undergoing robotic and traditional knee replacement surgeries. CONCLUSION: This meta-analysis indicates that robotic total knee replacements offer superior post-operative anatomical and mechanical alignment compared to conventional total knee replacements. Despite this, clinical and functional outcomes, as well as complication rates, were similar between the two. These findings should be considered in light of potential confounding factors. More randomized controlled trials with the latest robotic systems are needed to confirm any superior functional and clinical outcomes from robotic-assisted surgeries. LEVEL OF EVIDENCE: I.

All-polyethylene versus metal-backed tibial components in total knee arthroplasty: a meta-analysis of randomized controlled trials.

OBJECTIVES: The design of tibial trays for total knee arthroplasty (TKA) has been a topic of research for several decades. Although all-polyethylene trays were developed to address issues such as osteolysis and to enhance the longevity of the prosthesis, as well as knee range of motion, metal-backed designs have remained the most commonly used type of prosthesis. This meta-analysis aimed to compare the clinical, radiological, and survival outcomes of both designs. METHODS: Five databases were searched from inception until October 1, 2020, for randomized controlled trials (RCTs) that compared the outcomes of all-polyethylene and metal-backed tibial components in TKA. The outcomes of interest included range of motion, knee society score, stairs climbing scores, radiostereographic analysis, survivorship and complication. This review was conducted in line with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Risk of bias was assessed using the Newcastle-Ottawa tool. RESULTS: A total of 14 RCTs with 1367 TKA were included with a mean age of - years and - years for all-polyethylene and metal-backed tibial components groups, respectively. All-polyethylene group demonstrated statistically significant differences in five-year survivorship (OR 0.27; 95% CI 0.10-0.75; p value 0.01) and stairs climbing score (OR - 2.07; 95% CI - 3.27-0.87; p value 0.0007) when compared to the metal-backed group. The metal-backed design was significantly more radiographically stable in anterior-posterior, varus-valgus, and internal-external rotations at the 2-year follow-up compared to all-polyethylene tibias (OR - 0.09; 95% CI - 0.16 to - 0.02; p value 0.02) as per the pooled radiostereographic analysis. However, ten-year survivorship (OR 0.92; 95% CI 0.53-1.60; p value 0.78), range of motion (OR - 0.57; 95% CI - 2.00-0.85, p value 0.43), knee society scores (OR 1.38; 95% CI - 0.47-3.23, p value 0.14), and complications (OR 0.83; 95% CI 0.5-1.39, p value 0.48) were comparable between both groups. CONCLUSIONS: While this meta-analysis suggests that all-polyethylene tibial components in total knee arthroplasty may offer advantages over metal-backed components in terms of five-year survivorship, and stairs climbing score, this finding should be considered in the context of potential confounding factors. Nonetheless, based on the results, the all-polyethylene implant should be considered a viable choice for primary knee replacement. LEVEL OF EVIDENCE: I.

The impact of obesity on polytraumatized patients with operatively treated fractures.

INTRODUCTION: The objective of this study was to evaluate the effect of obesity on outcomes following operative treatment of fractures in obese polytrauma patients. METHODS: This was a prospective cohort study at a level I trauma centre from January 2014 until December 2017. The eligibility criteria were adult (age >= 18 years) polytrauma patients who presented with at least one orthopaedic fracture that required operative fixation. Polytrauma was defined as having an Injury Severity Score (ISS) >= 16. Out of 891 patients, a total of 337 were included with 85 being obese. The primary outcome variable was the total hospital length of stay in days. The secondary outcome variables were the number of patients who had an intensive care unit (ICU) admission, the ICU length of stay in days, the number of patients who had mechanical ventilation, the duration of mechanical ventilation in days, perioperative complications, and mortality. RESULTS: Obesity was associated with increased total hospital stay (36 vs. 27 days; P<0.001), increased ICU stay (13 vs. 8 days; P = 0.04), increased ICU admissions (83.5% vs. 68.6%; P = 0.008) and increased incidence of mechanical ventilation (64.7% vs. 43.7%; P = 0.001). These findings remained statistically significant following adjusted regression models for age, gender, ISS, and injuries sustained. However, the mechanical ventilation duration was not significantly different between both groups on adjusted and unadjusted analyses. However, an increase per unit BMI significantly increases the duration of mechanical ventilation (P = 0.02). In terms of complications, obesity was only associated with an increase in acute renal failure (ARF) on unadjusted analyses (P = 0.004). Whereas, adjusted logistic regression demonstrated that an increase per BMI unit led to a significant increase in the odds ratio for wound infection (P = 0.03) and ARF (P = 0.024). CONCLUSIONS: This study displayed that obesity was detrimental to polytrauma patients with operatively treated fractures leading to prolonged hospital and ICU length of stay. This highlights the importance of optimizing trauma care for obese polytraumatized patients to reduce morbidity. With 41.1% of our population being obese, obesity presents a unique challenge in the care of polytrauma patients which mandates further research in improving health care for this population group.

Mobile-bearing versus fixed-bearing total knee arthroplasty: a meta-analysis of randomized controlled trials.

OBJECTIVE: The purpose of this study was to perform a meta-analysis comparing mobile-bearing with fixed-bearing total knee arthroplasty (TKA) in terms of all-cause revision rates, aspetic loosening, knee functional scores, range of motion and radiographic lucent lines and osteolysis. METHODS: PubMed, Cochrane Library, Google Scholar and Web of Science were searched up to January 2020. Randomized controlled trials that compared primary mobile-bearing with fixed-bearing TKA, reporting at least one of the outcomes of interest, at a minimum follow-up of 12 months were included. All outcomes of interest were pooled at short-term (< 5 years), mid-term (5 to 9 years) and long-term (> = 10 years) follow-up intervals. RESULTS: A total of 70 eligible articles were included in the qualitative and statistical analyses. There was no difference between mobile-bearing or fixed-bearing TKA at short-term, mid-term and long-term follow-ups in all outcome measures including all-cause revision rate, aseptic loosening, oxford knee score, knee society score, Hospital for Special Surgery score, maximum knee flexion, radiographic lucent lines and radiographic osteolysis. CONCLUSION: The current level of evidence demonstrated that both mobile-bearing and fixed-bearing designs achieved excellent outcomes, yet it does not prove the theoretical advantages of the mobile-bearing insert over its fixed-bearing counterpart. The use of either design could therefore be supported based on the outcomes assessed in this study. LEVEL OF EVIDENCE: Level II, Therapeutic.

Total knee arthroplasty for Ochronosis induced knee arthropathy. Case report.

INTRODUCTION: Alkaptunurea is a rare metabolic disorder with autosomal recessive genetic pattern in transmission, it is characterized by accumulation of hemogenistic acid in the tissues due to deficiency of homogentisate 1,2 dioxygenase activity. Characteristically, affected patient will have dark urine and blackish discoloration of connective tissue, especially cartilage and bone and hence it is known as black bone disease. PRESENTATION OF THE CASE: The reported case is for 49 years old gentleman, known to have hypertension, hypothyroidism and Alkaptunurea. He presented to our facility with long standing bilateral knee pain (more in the left) with difficulty in doing daily activities. He presented to our tertiary facility after failure of previous treatment measures. The patient underwent uncomplicated Robotic assisted total knee arthroplasty that resulted in significant improvement of his pain and function. CONCLUSION: Knee arthroplasty is a reliable and reproducible modality in treating Ochronotic knee arthropathy and it would result in pain reduction and better function of patients with such condition.

Rare presentation of lateral meniscus tear with pathognomonic MRI finding.

INTRODUCTION: Meniscal tears are common knee injuries that occur in different populations and particularly among athletes. Either isolated or accompanied with anterior cruciate ligament injury, meniscal tears can be a source of significant knee pain, locking and instability. Different patterns of meniscal tears are described radiologically and arthroscopically, however displacement of the torn part of the meniscus can cause characteristic appearance on MRI. PRESENTATION OF THE CASE: The reported case is of a 27-year-old, previously healthy gentleman who presented to our care with acute sharp left knee pain and infrequent locking symptoms after playing football. The patient was limping and had lateral joint line tenderness along with positive McMurray's test for lateral meniscus. MRI study showed double popliteus tendon sign on the sagittal cuts. The patient was operated on elective list and underwent lateral meniscus posterior flap tear partial meniscectomy as the tear was in the white zone. On follow up after 4 months, the patient was satisfied and had regained full pre-injury functional capacity. CONCLUSION: Displaced lateral meniscus tear into the popliteal hiatus can be seen as a characteristic double popliteal sign in MRI as the displaced meniscus flap runs on the tibial surface parallel to the popliteus tendon.

Open Reduction and Internal Fixation Versus Nonsurgical Treatment in Displaced Midshaft Clavicle Fractures: A Meta-Analysis.

OBJECTIVES: To compare open reduction and internal fixation (ORIF) and nonsurgical treatment outcomes in displaced midshaft clavicle fractures. DATA SOURCES: PubMed, MEDLINE, EMBASE, Web of Science, Cochrane Library, and ClinicalTrials.gov were searched in September 2017. STUDY SELECTION: Inclusion criteria were randomized controlled trials reporting nonunion, shoulder functional outcomes, and subsequent surgery rates or pain scores. We excluded studies with patients younger than 16 years, maximum follow-up less than 9 months, and inaccessible full text. DATA EXTRACTION: Extracted data included the first author, publication year, number of patients, number of nonunions, Constant scores, disabilities of the arm, shoulder, and hand (DASH) scores, number of subsequent surgeries, and pain measured using the visual analog scale. DATA SYNTHESIS: The risk ratio of nonunion was 0.15 [95% confidence interval (CI), 0.08-0.31] in ORIF compared with that of nonsurgical treatment. Constant and DASH scores were significantly better in ORIF up to 6 months. The mean difference (MD) in DASH scores at 12 months was statistically insignificant in both treatments (MD, -4.19; 95% CI, -9.34 to 0.96). Constant scores remained significant in ORIF (MD, 4.39; 95% CI, 1.03-7.75). Subsequent surgeries and pain scores were similar in both treatments. CONCLUSIONS: Significant reduction in nonunions and favorable early functional outcomes are associated with ORIF. Nevertheless, late functional outcomes, subsequent surgeries, and pain scores are similar to those of nonsurgical treatment. Although patients treated with ORIF mainly had subsequent elective plate removals, nonsurgically treated patients had more surgical fixations for nonunions. As a result, there remains inconsistent evidence regarding the best treatment for displaced midshaft clavicle fractures. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Reverse shoulder arthroplasty for deltoid-deficient shoulder following latissimus dorsi flap transfer. Case report.

INTRODUCTION: The usual indication for reverse shoulder arthroplasty is glenohumeral arthritis with inadequate rotator cuff and intact deltoid muscle. We report here a case of reverse shoulder arthroplasty using a lattisimus dorsi flap in a patient with deltoid-deficient shoulder following a gunshot injury. PRESENTATION OF THE CASE: The patient was an otherwise healthy 51-year-old male with a history of gunshot injury of the left shoulder 2006. Upon presentation in 2011, the patient had a loss of most of his shoulder bony and muscular structures. Due to deltoid muscle deficiency, the patient underwent Lattisimus Dorsi muscle flap followed by reverse shoulder arthroplasty in order to establish an upper limb function. Upon discharge, 11days after the surgery, the patient was able to achieve 150° flexion and 90° abduction while in the supine position and 45° in each direction, while sitting. He was able to perform internal rotation (behind back) up to the level of the L1 vertebra, assisted active abduction of 90°, and external rotation of 20°. Power tests showed power of grade 4/5 for both shoulder flexion and extension and grade 2+/5 for both abduction and adduction. At the last follow up one year after the operation, The patient still had passive pain-free full range of motion, but no progress in active range of motion beyond that upon discharge. CONCLUSION: Reverse shoulder arthroplasty after Latissmus dori flap in patient with deltoid deficient shoulders can be a successful and reproducible approach to treat such conditions.

Concomitant unilateral post-traumatic leg and foot compartment syndrome in a 5 years-old child - Case report.

BACKGROUND: Compartment syndrome is one of the most serious orthopedic emergencies [4]. It is usually anticipated and looked at in every single orthopedic case. Early recognition and management of those cases are quite important in order to avoid the devastating consequences of such condition. CASE SUMMARY: This is a case report of a 5 years old child with concomitant unilateral leg and foot compartment syndrome after a roll over trauma. The patient was presented with significant leg and foot swelling, severe pain and absent distal pulses. He was rushed to operative theatre where compartments decompression and fracture fixation were performed. Vac dressing and secondary closure followed the primary treatment. Post-operatively, the patient improved in a good way with no heeling complications or functional deficits. CONCLUSION: Compartment syndrome in children is a serious complication that can occur after trauma, high index of suspicion is crucial to start early management and to avoid complications. This injury can occur in un-fractured limb and in more than one site at the same time.