Knowledge and attitude toward total knee arthroplasty among senior medical students in comparison to public population in Saudi Arabia: cross-sectional study.

Background: Total knee arthroplasty (TKA) is currently considered one of the most common and successful orthopaedic procedures. It plays an essential role in the long-term treatment of osteoarthritis and enhances the patient's quality of life. Very little is known about public and medical students' perceptions of this procedure. The purpose of the current study was to assess the knowledge and attitudes toward TKA among medical students in comparison with the general population in Saudi Arabia. Method: A cross-sectional study was conducted between February and March 2023. Senior-year (interns and the fifth and sixth year) medical school students (Group A) as well as the general population (Group B) were surveyed online. The distributed questionnaire was divided into three main segments: demographics, knowledge, and the prognosis of TKA. The answers were statistically compared among participants. Results: Three hundred thirty-one participants were involved in this study, of whom 202 were from the general population and 128 were medical students. Most of the participants were males (68.3%), and the mean age was 32.95±15.22. The results were divided into three groups: demographic, knowledge, and prognosis. Medical students demonstrated a higher knowledge score (111.25±42.38) compared to the general population knowledge score (64.68±44.29), (P<0.001). Conclusion: Senior-year medical school students and the general population showed a low level of knowledge regarding TKA. However, the students had a better awareness of the procedure. The authors recommend frequent public education programs for the benefits of TKA. In addition, medical schools are encouraged to emphasize the benefits of TKA as a treatment choice for end-stage knee arthritis in their curriculum and training.

Association of Surgical Adhesive and Glue System With Incidence of Allergic Dermatitis Post Unilateral and Staged Bilateral Total Knee Arthroplasty.

Background Skin closure is an important step in total knee arthroplasty (TKA). Several techniques are described in the literature with emerging interest in skin adhesives. This study aims to highlight the adverse reactions related to skin adhesives and to identify potential risk factors. Methods A retrospective review of 250 patients (295 knees, 45 being staged bilateral TKA) who underwent TKA was conducted at our facility. All patients underwent the same perioperative protocol with application of surgical glue over the wound edges. Postoperative adverse reactions were classified as allergic dermatitis (AD), cellulitis, and superficial infection. Results Incidence of adverse reactions in the form of AD was noted in 4.8% of patients. Demographics and comorbidities had no influence on this occurrence (p>0.05). However, in patients who had bilateral staged TKA, AD manifested after performing the second contralateral TKA in 22% of patients. This incidence of AD was significantly higher when compared to those who had single unilateral TKA (p =0.001) Conclusion The theory of allergic sensitization may explain the higher incidence of AD in bilateral staged TKA due to prior exposure to glue components in the first knee; thus, we recommend avoiding its use if there was previous exposure.

External fixation versus intramedullary nailing for the management of open tibial fracture: meta-analysis of randomized controlled trials.

AIM: Tibial shaft fractures are the most common type of long-bone fractures. External fixation (EF) and intramedullary nailing (IMN) are widely used surgical techniques for the definitive fixation of open tibial shaft fractures. The aim of this systematic review and meta-analysis was to compare EF to IMN for the definitive fixation of open tibial fractures. METHODS: Medline, Embase, and CENTRAL databases were searched for eligible studies. We included randomized controlled trials (RCTs) that compared EF to IMN for skeletally mature adults with open tibial fracture (Gustilo I, II, and III). We evaluated the following outcomes: superficial infection, pin-track infection, deep infection, malunion, nonunion, delayed union, and implant/hardware failure. The risk ratio (RR) was used to represent the desired outcomes. The statistical analysis was performed using the random-effects model. RESULTS: A total of 12 RCTs that enrolled 1090 participants were deemed eligible for the analysis. EF showed a significantly higher rate of superficial infection, pin track infection, and malunion compared to IMN (RR = 2.30, 95% confidence interval (CI): 1.34 to 3.95; RR = 13.52, 95% CI: 6.16 to 29.66; RR = 2.29, 95% CI 1.41 to 3.73, respectively). No substantial difference was found between EF and IMN in terms of deep infection, nonunion, delayed union, or implant/hardware failure (RR = 1.15, 95% CI 0.67 to 1.98; RR = 0.92, 95% CI 0.77 to 1.10; RR = 1.50, 95% CI 0.98 to 3.33; RR = 0.96, 95% CI 0.36 to 2.60, respectively). DISCUSSION: The findings of our meta-analysis are consistent with the previous systematic reviews excepts for the implant/hardware failure which was found to be significant in favour of IMN by one of the previous reviews. CONCLUSION: This meta-analysis confirms that IMN is better than EF with respect to clinical outcomes and complication rate for the definitive fixation of open tibial fracture.

Direct anterior versus direct lateral hip approach in total hip arthroplasty with the same perioperative protocols one year post fellowship training.

BACKGROUND: Variable results have been reported regarding the clinical outcomes in Total hip arthroplasty (THA) based on the surgical approach. The aim of this study is to compare the clinical outcomes between Direct anterior (DA) and direct lateral (DL) approaches in THA when performed immediately after fellowship training. METHODS: During the 1st year of practice, all consecutive patients who underwent THA via DA and DL hip approaches were retrospectively investigated. Patients'demographics, diagnosis, American society of Anesthesiology (ASA) score, route of anesthesia, length of hospital stay (LOS), leg length discrepancy (LLD), radiographic parameters, operative time, number of opioids refills postoperatively, and complications were collected and compared between the two groups. The short form of Hip Disability and Osteoarthritis Outcome score, Joint Replacement (HOOS, JR) was prospectively collected pre and postoperatively. The minimum follow-up period was 2 years. RESULTS: Forty patients in DA group and 38 patients in DL group were included. No statistically significant difference was found between the two groups in terms of demographics, diagnosis, ASA scores, route of anesthesia at the time of THA, postoperative radiographic parameters, LOS, LLD, opioid refills and HOOS scores (p > 0.05). Patients in the DA group had shorter operative time (83 ± 17 min) when compared to the DL group (93 ± 24 min) (p = 0.03). No major complications were found except for one early deep infection patient in DL group. CONCLUSION: Both DA and DL approaches resulted in satisfactory outcomes in THA when performed by a fellowship trained surgeon.

Common Peroneal Nerve Palsy at the Level of Proximal Fibula After Total Hip Arthroplasty: A Case Report.

Sciatic nerve injury is a well-known devastating complication and is the most commonly involved nerve after total hip arthroplasty (THA). Most of these injuries occur at the level of the hip and surgery site rather than a distal location. In this case report, a 62-year-old male presented with common peroneal nerve (CPN) palsy at the level of the knee immediately after undergoing left THA via posterior hip approach. This likely occurred due to direct compression during the surgical positioning or intraoperative leg manipulation. It was associated with excruciating uncontrolled neuropathic pain around the ipsilateral lateral leg and foot and absence of motor function. The patient's THA was performed elsewhere, seven weeks prior to his presentation to us. His clinical examination and electromyographic (EMG) findings confirmed focal peroneal nerve entrapment around the neck of the fibula. An urgent distal peroneal nerve decompression was performed followed by a dramatic improvement in the pain. Consequently, the patient discontinued all pain medications within three days after the decompression. On follow up, he demonstrated remarkable improvement in his motor and sensory functions. In conclusion, direct or indirect CPN injury at the level of the knee is extremely rare after THA. Early distal peroneal nerve decompression after THA can be beneficial in selected patients based on the clinical presentation and EMG findings.

The Role of Prophylactic Peroneal Nerve Decompression in Patients with Severe Valgus Deformity at the Time of Primary Total Knee Arthroplasty.

Background: Common peroneal nerve (PN) palsy after total knee arthroplasty (TKA) is a serious complication. Although many authors suggest delayed or immediate PN decompression after TKA in these patients, little is known about the role of prophylactic peroneal nerve decompression (PPND) at the time of TKA. The aim is to report the results of PPND in high-risk patients at the time of TKA. Materials and methods: A multi-institutional retrospective study review of nine patients (10 knees) who underwent PPND at the time of TKA was conducted. Patients who had severe valgus deformities (≥15° of femorotibial angle and not fully correctable by examination under anaesthesia) with or without flexion contractures were included. PPND was performed through a separate 3-4-cm incision at the time of TKA. The demographics, preoperative and postoperative anatomical and mechanical alignments, range of motion, operation time, postoperative neurological function and complications were recorded. Results: All patients had a completely normal motor and sensory neurological function postoperatively and no complications related to PPND were reported. All patients followed the standard physical therapy protocol after TKA without modifications.The mean preoperative femorotibial angle was 20° (range 15-33°) and the mean postoperative femorotibial angle was 6.3° (range 5-9°) (p = 0.005). The mean preoperative flexion contracture was 9 (range 0-20) and the mean residual contracture was 1.2° (range 2-5°) (p = 0.006). Conclusion: PPND at the time of TKA is an option to minimise the risk of PN palsy in high-risk patients. This approach can be considered for patients undergoing TKA in selected high-risk patients with a severe valgus deformity. How to cite this article: Makhdom A, Hamilton AA, Rozbruch SR. The Role of Prophylactic Peroneal Nerve Decompression in Patients with Severe Valgus Deformity at the Time of Primary Total Knee Arthroplasty. Strategies Trauma Limb Reconstr 2022;17(1):38-43.

Prophylaxis and treatment of infection in long bones using an antibiotic-loaded ceramic coating with interlocking intramedullary nails.

Background: The study was done (1) to report on our recent experience with antibiotic-loaded calcium sulfate-coated interlocking intramedullary nails (CS-IMN) for infection prevention or infection eradication and (2) to compare the efficacy of CS-IMN versus antibiotic-loaded polymethylmethacrylate-coated IMN (PMMA-IMN) for infection eradication. Methods: We retrospectively reviewed the medical records of consecutive patients who underwent a limb salvage procedure for infection cure or infection prevention with PMMA-IMN or CS-IMN. We reviewed patient demographics, host-type, pre-operative infecting organisms, intraoperative cultures, as well as our main outcomes: infection control rate, achievement of union/fusion, and limb salvage. Results: 33 patients were treated with CS-IMN: 9 patients with goal of infection cure and 24 patients for infection prophylaxis. When used for infection prophylaxis, there was a 100 % ( 24 / 24 patients) prevention of infection rate, 95.5 % union rate ( 21 / 22 patients), and 100 % ( 24 / 24  patients) limb salvage rate. Nine patients were treated with CS-IMN to eradicate infection and were compared to a cohort of 28 patients who were treated with PMMA-IMN. The infection was eradicated in 7 / 9 patients (77.8 %) in the CS-IMN group versus 21/26 patients (80 %) in the PMMA-IMN group ( p = 0.44 ). Bone union/fusion was achieved in 8 / 9 patients (88.9 %) in the CS-IMN group versus 21/24 patients (87.5 %) in the PMMA-IMN group ( p = 0.11 ). The limb salvage rate in the CS-IMN group was 100 % ( 9 / 9  patients) versus 89 % ( 25 / 28  patients) in the PMMA-IMN group. Conclusions: CS-IMN are safe and easy to use, and we have therefore expended our indications for them. CS-IMN are very effective at infection prophylaxis in high-risk cases where infection is suspected. Early analysis suggests that CS-IMN are non-inferior to PMMA-IMN for infection eradication. This is our preliminary data that show this novel technique to be safe in a small cohort and may be as effective as the more established method. Future studies with larger cohorts of patients will be required to confirm these findings.

Hip-Sparing Equalization Procedures for Leg-Length Discrepancy After Total Hip Arthroplasty: A Retrospective Case Series.

BACKGROUND: Leg-length discrepancy (LLD) after primary THA is not uncommon. Little is known, however, about the role of hip-sparing procedures for equalization of LLD after THA. QUESTIONS/PURPOSES: The aim of this study is to report our experiences with these techniques in patients presenting at one institution over a 10-year period. METHODS: We retrospectively reviewed records at one institution to find patients who had sought surgical treatment for LLD after THA between January 2007 and August 2017. Patients who had LLD related to conditions other than the THA, such as bone loss or traumatic defects, were excluded. We recorded the time after THA, laterality, and LLD. Assessment of LLD was performed using clinical and radiographic examinations. Patient demographics and true LLD were recorded, as were prior conservative treatment, equalization procedure performed, final leg length after equalization surgery, time to healing, and complications. RESULTS: After exclusion of patients with LLD related to other causes, eight patients in whom conservative treatment had failed and who had undergone hip-sparing leg-length equalization surgery were included in the study. The average age was 44.6 years (range, 18 to 66 years). Seven of the patients were female. The pre-operative mean LLD was 3.1 cm (range 1.5 to 7 cm). In those who were long after THA, ipsilateral (THA-side) shortening of femur with a retrograde intramedullary nail (IMN; n = 1) or with a plate (n = 1) was performed. In those who were short after THA, ipsilateral femur lengthening with retrograde Precice nails (n = 2), ipsilateral tibial lengthening with Precice nails (n = 2), or contralateral femur shortening with a retrograde IMN (n = 2) was performed. The average time to full consolidation or union was 6.6 months (range, 2 to 19 months). Two patients had delayed union. All patients but one were satisfied with final results. CONCLUSION: We believe that hip-sparing equalization procedures can be part of the treatment algorithm of LLD after THA. These advancements in the field are promising and might expand the indications of lengthening and equalization procedures to include LLD after THA.

Antibiotic Cement-Coated interlocking Intramedullary Nails in the Treatment of Septic Complex Lower Extremity Reconstruction; A Retrospective Analysis with Two year Minimum Follow up.

Background: To report on our experience with antibiotic cement coated interlocking intramedullary nails (ACC-IMNs) for limb salvage in septic complex lower extremity reconstruction with a minimum of 2-year follow up. Methods: We retrospectively reviewed the records of all consecutive patients who underwent a limb salvage procedure with ACC-IMNs. We reviewed patients' demographics, the preoperative infecting organism, and host type, time to bone union, complications, limb salvage rates, and infection control rates. Results: There were 28 patients with a mean age of 62 years (range 22-88). The mean follow up period was 40 months (range 28-84). The ACC-IMNs were used in 14 patients (50 %) to achieve knee fusion after failed revisions of infected total knee arthroplasty, in 8 patients (28%) for septic tibial nonunion, and in 6 patients (21%) with ankle fusion nonunions. Bony union/fusion was achieved in 87 % (21/24) of patients. The infection was controlled in 80% (21/26) of patients. Four out the five patients who had recurrent infection were type B hosts (p=0.63). The limb salvage rate was 89% (25/28). The overall complication rate was 32%. Conclusions: The use of ACC-IMNs was an effective treatment strategy and associated with high limb salvage and bone union rates. Furthermore, the infection recurrence rate was low. Knee fusion patients after failed TKA should be counseled preoperatively for a potential high complication rate.

Intraoperative Surgeon Administered Adductor Canal Blockade Is Not Inferior to Anesthesiologist Administered Adductor Canal Blockade: A Prospective Randomized Trial.

BACKGROUND: Controlling postoperative pain and reducing opioid requirements after total knee arthroplasty remain a challenge, particularly in an era stressing rapid recovery protocols and early discharge. A single-shot adductor canal blockade (ACB) has been shown to be effective in decreasing postoperative pain. The purpose of the present study is to compare the efficacy of an anesthesiologist administered ACB and a surgeon administered intraoperative ACB. METHODS: Patients undergoing primary total knee arthroplasty were prospectively randomized to receive either an anesthesiologist administered (group 1) or surgeon administered (group 2) ACB using 15 mL of ropivacaine 0.5%. Primary outcomes were pain visual analog scale, range of motion, and opioid consumption. RESULTS: Thirty-four patients were randomized to group 1 and 29 to group 2. Opioid equivalents consumed were equal on postoperative day (POD) 0, 1, and 2. Patients in group 1 had statistically less pain on POD 0, but this did not reach clinical significance and there was no difference in pain on POD 1 or 2. Patients in group 1 had significantly increased active flexion POD 1, but there was no difference in active flexion on POD 0 or 6 weeks postop. There was no difference in patient satisfaction with pain control or short-term functional outcomes. CONCLUSION: Surgeon administered ACB is not inferior to anesthesiologist administered ACB with respect to pain, opioid consumption, range of motion, patient satisfaction, or short-term functional outcomes. Surgeon administered ACB is an effective alternative to anesthesiologist administered ACB.

Rotational alignment errors can occur in unicompartmental knee arthroplasty if anatomical landmarks are misused: A preoperative CT scan analysis.

BACKGROUND: Accurate implant positioning, including rotation, is essential for successful unicompartmental knee arthroplasty (UKA). This study defined the rotational error that would result in medial UKA when using the medial edge of the tibial tubercle (TT) rather than the medial tibial spine for determining tibial component rotation, and in lateral UKA when aligning the anterior edge of the sagittal tibial cut with the lateral edge of the patellar tendon. METHODS: Preoperative computed tomography (CT) scans were reviewed in 88 knees undergoing medial (n = 71) and lateral (n = 17) UKAs. In medial UKA, the angle between a line along the long axis of the medial tibial spine and a line drawn to the medial edge of the TT was measured. In lateral UKA, the angular relationship between the longitudinal axis of the lateral tibial spine and the lateral edge of the patellar tendon was measured. RESULTS: In medial UKA, an average angular error of 9.6° of external rotation could result if the medial edge of the TT is used to set tibial implant rotation. In lateral UKA, the error of the sagittal tibial cut was an average of 7.1° of excessive external rotation if it is referenced on the lateral edge of the patellar tendon. CONCLUSIONS: The preoperative CT scan analysis showed that using the medial edge of the TT and lateral edge of the patellar tendon to set tibial implant rotation may result in excessive external rotation in medial and lateral UKAs, which could result in kinematic mismatch, suboptimal contact areas and rotational malalignment.

Utility outcome assessment of pes planus deformity.

BACKGROUND: Despite being a common condition, there are no objective measures in the literature to reflect the burden of pes planus on affected individuals. Our primary objective was to evaluate this burden by recruiting a sample from the general population using validated utility outcome measures. METHODS: Participants were recruited online and filled a questionnaire to help measure the health burden of pes planus. Three recognized utility outcome scores were used to compare the health burden of monocular blindness, binocular blindness, and pes planus. These included the standard gamble (SG), time trade-off (TTO), and visual analogue score (VAS). Paired t test, independent t test, and linear regression were used for statistical analysis. RESULTS: Ninety-two participants were included in the final analysis. The utility outcome scores (VAS, TTO, SG) for pes planus were 73±17, 0.90±0.08, and 0.88±0.12, respectively. The linear regression analysis showed that age was inversely proportional to the time trade-off. However, race, educational level, and income were not significant predictors of utility outcome score for pes planus. CONCLUSIONS: This study shows that the perceived burden of living with pes planus is comparable to living with some debilitating conditions. Our participants were willing to sacrifice 3.6 years of life, and have a procedure with a theoretical 12% mortality risk to attain perfect health.

Strategies of enhancing bone regenerate formation in distraction osteogenesis.

Distraction osteogenesis (DO) is a commonly used technique in multiple orthopedic sub-specialties, including trauma, oncology and pediatrics. This technique aims to produce new bone formation in the distraction gap in a controlled manner. The issue with this technique has been the high risk of complications, one of which is poor regenerate formation during the distraction process. Although several factors (including patient and operative factors) and techniques (including surgical, mechanical and pharmacological) have been described to ensure successful regenerate formation during the process of DO, these factors are sometimes difficult to control clinically. Our aim from this review is to highlight the different factors that affect DO, modalities to assess the regenerate and review treatment options for poor regenerate in the distraction gap. In addition, we propose a management protocol derived from the available literature that can be used to facilitate the management of inadequate regenerate formation.

Assessment of the effect of systemic delivery of sclerostin antibodies on Wnt signaling in distraction osteogenesis.

Sclerostin is a known inhibitor of the Wnt signaling pathway which is involved in osteogenesis and, when inactivated, stimulates bone formation. To our knowledge, this effect has not been studied in the context of distraction osteogenesis (DO). Tibial DO was conducted on a total of 24 wild-type mice, which were then divided into 2 groups-a saline injection group (control) and an anti-sclerostin (Scl-Ab) injection group (treatment). The mice in the treatment group received 100 mg/kg intravenous injections of the antibody weekly until killing. The 12 mice in each group were subdivided into four time points according to post-osteotomy time of killing-11 days (mid-distraction), 17 days (late distraction), 34 days (mid-consolidation) and 51 days (late consolidation), with 3 mice per subgroup. After killing, the tibia specimens were collected for immunohistochemical analysis. Our results show that the group injected with anti-sclerostin had an earlier peak (day 11) in the distraction phase of the osteogenic molecules involved in the Wnt signaling pathway in comparison to the placebo group. In addition, downregulation of the inhibitors of this pathway was noted in the treatment group when compared with the placebo group. Furthermore, LRP-5 showed a significant increase in expression in the treatment group. Sclerostin inhibition has a significant effect on the DO process through its effect on the Wnt pathway. This effect was evident through the decreased effect of sclerostin on LRP-5 and earlier upregulation of the osteogenic molecules involved in this pathway.

Factors Associated With Clinical Outcomes After Lumbar Interbody Fusion With a Porous Nitinol Implant.

STUDY DESIGN: A retrospective cohort study. OBJECTIVE: The aim of this study is to assess the association of demographic and perioperative factors with clinical outcomes of lumbar interbody fusion with a porous nitinol (TiNi) implant for degenerative disc disease. METHODS: Forty-one patients with degenerative lumbar disease were prospectively followed for a mean of 4.8 years. All patients were instrumented with porous TiNi interbody fusion devices. The Oswestry Disability Index (ODI) and return to work were used to assess clinical outcomes. Factors including age, body mass index, smoking status, insurance status, number of comorbidities, duration of surgery, estimated blood loss, number of levels fused, time since surgery, and preoperative ODI score were assessed. A multiple linear regression analysis was performed to look for demographic and perioperative factors associated with clinical outcome. RESULTS: All patients except one (98%) showed complete fusion on radiography at 1 year. Estimated blood loss and duration of surgery were significantly associated with higher postoperative ODI scores (P = .002 and P = .019, respectively). Smoking status, salary insurance status, age, body mass index, number of comorbidities, number of levels fused, time since surgery, and preoperative ODI score were not significantly associated with outcome. CONCLUSIONS: Porous nitinol permitted fusion rates similar to those reported in the literature for alternative fusion cages. Poor functional outcome of patients was strongly associated with intraoperative blood loss and duration of surgery. We believe that estimated blood loss should be carefully evaluated in studies of postoperative outcome, as it may affect midterm outcomes. LEVEL OF EVIDENCE: Level 3.

Locking Screw Migration to the Palm Four Years Following Surgical Implantation of Distal Radius Locking Plate.

Hardware-related complications are rare in patients with distal radius fractures who were surgically fixed with volar-locking plates. In this report, we present a case of locking screw loosening and migration to the palm four years following the treatment of type 23-C1 distal radius fracture with a volar locking-plate. This complication occurred without evidence of trauma, infection, non-union or plate breakage. Orthopaedic surgeons should be aware of such rare complication and add it to the list of potential postoperative complications when counseling their patients preoperatively.

Dual mobility acetabular cup for total hip arthroplasty: use with caution.

INTRODUCTION: Dual-mobility cups were introduced to reduce the incidence of dislocation after total hip arthroplasty (THA). The biomechanics of dual-mobility cups allow for greater range of motion, jump distance and better stability when compared to conventional cups in THA. These cups can be very beneficial in THA particularly when the hip instability is a concern such as elderly patients, obese, hip fracture patients, those with neuromuscular diseases, or patients undergoing revision THA for instability. Areas covered: An extensive search is conducted in PubMed and Google scholar to find past five years publications relevant to dual-mobility cups in THA. 225 articles were found which many of those were excluded because of: written in other languages, nearly same cohort in different journals, unavailable full text, and were not covering main fields of this article. We categorized the articles to four different aspects of the biomechanics, outcomes in primary, revision, and after hip fracture THA. Expert commentary: While the important role of the dual-mobility in addressing recurrent instability and reduction of instability in high risk patients undergoing primary THA has been demonstrated, the concern regarding the release of metal ion release, particularly in the younger and active patients, and prosthetic malfunction are worrisome.