Health-Related Quality of Life and Outcome after Total Knee Replacement: Results from a Cross-Sectional Survey in Jordan

Total knee replacement (TKR) is a common procedure that is considered cost-effective with excellent long-term survivorship. This cross-sectional study, which includes 118 selected patients in Jordan from January 2020 to January 2021, aims to assess health-related quality of life (HQOL), functional status, and associated factors before and after 3 to 12 months of TKR. Furthermore, several demographical factors were included in this study to evaluate the potential association with the procedure’s outcome. Western Ontario and McMaster Universities Osteoarthritis Index scale (WOMAC) and Short Form-36 (SF-36) scale were used in this study. It was found that the main change occurred 6–12 months after the procedure. Gender and age were found to be the primary predictor of quality of life among TKR patients. Patients before the TKR procedure experienced severe pain, joint stiffness, physical impairment, and psychological demand issues. After the TKR procedure, all symptoms were improved significantly. The TKR procedure can improve the quality of life for patients, which can be detected for several months after the procedure. Function and pain are the most critical indicators of improvement in quality of life. Assessing the quality of life is a key indicator for identifying patients without improvement, as well as improving the health care process and comparing other alternative interventions.

Autologous Bone Marrow-Derived Chondrocytes for Patients with Knee Osteoarthritis: A Randomized Controlled Trial

Background and Objective. The aim of this study was to compare the effect of autologous bone marrow-derived chondrocytes (ABMDCs) with pharmacological management of osteoarthritis of knee (OAK) and assess the benefit of the two in the improvement of pain relief, functional betterment, and quality of life (QOL). Patients and Methods. A prospective, randomized study was undertaken in patients with OAK grades II and III of Kellgren–Lawrence grading (KLG) in two groups. Group I had 5 million of intra-articular ABMDC in the affected joint, and Group II continued the nonsteroidal anti-inflammatory drugs (NSAIDs) and physical therapy as needed. Before the treatment, patients were meticulously examined and data were entered for age, sex, Body Mass Index (BMI), Visual Analogue Scale (VAS), Modified Knee Society Score-Short Form (MKSSSF), and QOL. Patients were followed up for 3, 12, and 24 months to assess efficacy, safety, and tolerability. To assess the cartilage regeneration of the damaged cartilage, magnetic resonance imaging (MRI) was used. Results. There were a total of 60 patients who were followed up. Three patients in Group II were removed from the analysis as they underwent total knee arthroplasty (TKA). A notably significant improvement was noticed in the ABMDC group on all scores of VAS and MKSSSF with P < 0.0001 . The control group continued to be dissatisfied with the treatment they were taking. Conclusions. This study reveals that a single injection of 5 million of ABMDC was efficient in reducing the symptoms, improving the functional score and betterment of QOL.

The Necessity of CT Hip Scans in the Investigation of Occult Hip Fractures and Their Effect on Patient Management

The diagnostic challenge of negative plain radiography in the context of a previously ambulatory patient is increasing with the rise in geriatric trauma. These patients are often diagnosed with small undisplaced fractures of the pelvis and femur which may not alter management. This study aims to assess the frequency at which computed tomography (CT) hip scans altered patient management and whether two X-ray projections of the hip affected fracture detection rate. All CT hip scans performed over a three-year period were identified retrospectively. Only CT hips pertaining to the identification of occult fractures were included in the study. A total of 447 (63.6%) CT hips were performed to exclude an occult fracture, which was only detected in 108 (24.1%) of the scans requested. The majority were subcapital (n = 58, 53.7%) or intertrochanteric (n = 39, 36.1%). There was no significant difference between fracture detection rates when comparing one and two views of the pelvis. 82.4% (n = 89) of occult hip fractures were managed operatively. CT imaging led to a change in patient management in 20% of cases. The frequency at which CT scan detects and alters management in occult hip fractures confirms the justification for its use. Increasing the number of X-ray projection views does not decrease the reliance on CT. Pelvic ring fractures are common in nonambulatory patients following trauma, and if confirmed on initial imaging, subsequent imaging to exclude a concurrent occult hip is unnecessary. The focus of further research should be towards the development of investigation algorithms which decrease the reliance on CT and defining the optimal surgical criteria for occult hip fractures.

Assessment of Shoulder Function after Internal Fixation of Humeral Diaphyseal Fractures in Young Adults: A Prospective Comparative Study

Background. Humeral shaft fractures are commonly encountered in casualties. There are different methods of operative internal fixation with no consensus on the best technique. The objective of this study was to assess shoulder function and rate of complications among two different options of fixation, intramedullary nailing, and minimal invasive plate osteosynthesis (MIPO) in young adults. Methods. Forty-two patients with humeral shaft fractures were included in the study and divided into two equal groups: group A treated with antegrade intramedullary locked nails (IMN) and group B with MIPO. Fracture union was evaluated with serial X-rays, and shoulder function was assessed in both groups using the scale of the American Shoulder and Elbow Surgeons (ASES), University of California at Los Angeles Shoulder Scale (UCLA), and visual analog score (VAS). The mean differences between groups were recorded and considered significant if the P value was ˂0.05. Results. The results were reported prospectively with no significant differences in mean age, sex, side of injury, type of fracture, mechanism of injury, and the follow-up period between the groups studied. Group A had shorter operative time and minimal blood loss than group B. Regarding shoulder function scores (ASES, UCLA, and VAS), the results in the MIPO group were better than the IMN group with shorter time of union and fewer complications. Conclusion. Despite a shorter operative time and lower blood loss during locked intramedullary nail fixation in the management of humeral shaft fractures, MIPO enables more superior shoulder function with better fracture healing and lower morbidities.

Comparison of the Separate and Combined Effects of Physiotherapy Treatment and Corticosteroid Injection on the Range of Motion and Pain in Nontraumatic Rotator Cuff Tear: A Randomized Controlled Trial

Background. Surgical treatment and conservative treatment is the options to improve pain, function, and range of motion following rotator cuff tear. In this study, we aimed to compare the effects of physiotherapy and corticosteroid injections on the function, pain, and range of motion in patients with full-thickness rotator cuff tearing separately and simultaneously. Methods. A total of 96 patients were randomly assigned to the study and divided into 3 groups of 32 patients. DASH questionnaire and VAS criterion were completed by all three groups, and the range of motions of all groups was measured by a goniometer. Then, the first group underwent 12 sessions of physiotherapy twice a week for 6 weeks; the second group received 80 mg of methylprednisolone and 1 ml of lidocaine 2% in two stages, 21 days apart; and the third group received 80 mg of methylprednisolone and 1 ml of lidocaine 2%, and after 2 days, 6 sessions of physiotherapy twice a week for 3 weeks were prescribed. In the end, the questionnaire was filled out by the patient, and the range of emotions was assessed with a goniometer. Results. More than 80% of patients in each group were female. There was no significant difference between the gender and age distribution of the groups. The mean age in physiotherapy, steroid, and physiotherapy + steroid groups was 51.78 ± 7.37, 52.37 ± 6.61, and 50.87 ± 5.65, respectively. The combination of physiotherapy + steroid intervention was more effective in reducing VAS and DASH scores than physiotherapy or steroid injection alone. Goniometric findings showed that treatments that included the steroid injection approach (steroid injection and steroid + physiotherapy) had a more dramatic effect on improving the patients’ range of motion than physiotherapy alone. Conclusions. Among the conservative approaches of treating full-thickness rotator cuff tear, a combination of steroid injection and physiotherapy is more effective significantly in comparison with either treatment alone. This trial is registered with IRCT20200102045987N1.

Operative Fixation of Pediatric Forearm Fractures: Does the Fracture Location Matter?

Background. Flexible intramedullary nails (FNs) are successfully used to treat pediatric forearm fractures, especially midshaft fractures. Distal forearm fractures have been described as “difficult to manage” with FN insertion. The purpose of this study was to report the clinical and radiographic outcomes of using flexible nails in pediatric forearm fractures and the impact of fracture location on the outcome of the procedure. Methods. This is a retrospective review of pediatric patients who presented with forearm fractures that were surgically treated with flexible nails between 2009 and 2018. Patient demographics, fracture location, and classification were reported. Intraoperative and postoperative complications were reported. The primary outcomes were fracture radiographic union, intraop and postop complications, and the need for additional surgical procedures. Results. Fifty-nine patients were included, with a mean age of 11 years. All fractures healed with patients regaining full range of motion. The authors were able to use flexible nails successfully in 48/59 (81%) patients. In eleven cases (19%), FN fixation was not able to provide adequate fixation to maintain reduction. The method of fixation was changed from FN insertion to another method in nine cases. In two cases, FN fixation was augmented with another fixation method. Fractures within 3 inches of the distal articular surface were at a higher risk of intraoperative change/augmentation of the fixation method (29%) compared with fractures that occurred more than 3 inches from the distal articular surface (11%). Conclusion. The majority of pediatric forearm fractures can be treated successfully with flexible nails. Surgeons involved in treating these fractures should pay attention to distal third fractures. Stabilizing the distally located fractures using FN fixation can be challenging. Surgeons should be prepared to use an alternative fixation method when needed.

Prophylactic Topical Antibiotics in Fracture Repair and Spinal Fusion

Introduction. The objective of this systematic review with meta-analysis is to determine whether prophylactic local antibiotics prevent surgical site infections (SSIs) in instrumented spinal fusions and traumatic fracture repair. A secondary objective is to investigate the effect of vancomycin, a common local antibiotic of choice, on the microbiology of SSIs. Methods. An electronic search of PubMed, EMBASE, and Web of Science databases and major orthopedic surgery conferences was conducted to identify studies that (1) were instrumented spinal fusions or fracture repair and (2) had a treatment group that received prophylactic local antibiotics. Both randomized controlled trials (RCTs) and comparative observational studies were included. Meta-analysis was performed separately for randomized and nonrandomized studies with subgroup analysis by study design and antibiotic. Results. Our review includes 44 articles (30 instrumented spinal fusions and 14 fracture repairs). Intrawound antibiotics significantly decreased the risk of developing SSIs in RCTs of fracture repair (RR 0.61, 95% CI: 0.40–0.93, I2 = 32.5%) but not RCTs of instrumented spinal fusion. Among observational studies, topical antibiotics significantly reduced the risk of SSIs in instrumented spinal fusions (OR 0.34, 95% CI: 0.27–0.43, I2 = 52.4%) and in fracture repair (OR 0.49, 95% CI: 0.37–0.65, I2 = 43.8%). Vancomycin powder decreased the risk of Gram-positive SSIs (OR 0.37, 95% CI: 0.27–0.51, I2 = 0.0%) and had no effect on Gram-negative SSIs (OR 0.95, 95% CI: 0.62–1.44, I2 = 0.0%). Conclusions. Prophylactic intrawound antibiotic administration decreases the risk of SSIs in fracture surgical fixation in randomized studies. Therapeutic efficacy in instrumented spinal fusion was seen in only nonrandomized studies. Vancomycin appears to be an effective agent against Gram-positive pathogens. There is no evidence that local vancomycin powder is associated with an increased risk for Gram-negative infection.

Shoulder Arthrodesis versus Upper Trapezius Transfer for Traumatic Brachial Plexus Injury: A Proportional Meta-Analysis

Shoulder arthrodesis and upper trapezius transfer are two surgical options for secondary shoulder reconstruction for traumatic brachial plexus injury (BPI). There is a lack of comparative evidence to guide the choice for one procedure over the other. The objectives of this study were to compare (1) rates of complications and reoperation and (2) shoulder range of motion and functional outcome scores following shoulder arthrodesis versus upper trapezius transfer for traumatic BPI. A systematic review and meta-analysis were conducted by a search of four databases of studies assessing shoulder arthrodesis and/or upper trapezius transfer for shoulder reconstruction following adult traumatic BPI. A proportional meta-analysis was performed using a random effects model in anticipation of unobserved heterogeneity. The final meta-analysis included 374 patients from 17 studies, including 232 patients from 11 studies on shoulder arthrodesis and 142 patients from 6 studies on upper trapezius transfer. Shoulder arthrodesis had higher rates of complications and reoperations than upper trapezius transfer for traumatic BPI, but these differences did not reach a statistical significance. Due to the limited sample size, variations in reporting, and study heterogeneity in the published literature, we were not able to draw conclusions regarding shoulder range of motion and functional outcome scores between these two procedures. Shoulder arthrodesis and upper trapezius transfer are both viable options for secondary shoulder reconstruction for traumatic BPI, but with different complications and reoperation profiles. Patients should be counseled on the risk of nonunion and humerus fracture following shoulder arthrodesis.

Institutionally Adopted Perioperative Blood Management Program Significantly Decreased the Transfusion Rate of Patients Having Primary Total Hip Replacement Surgery

Perioperative transfusion in patients undergoing orthopedic surgery increases the number of postoperative complications. Thus, we have introduced an institution-tailored perioperative blood management program (PBM) to decrease the amount of blood transfused in patients going through primary total hip replacement (THR) surgery. We have conducted a before-after observational cohort study in two predetermined observational periods. Demographic and clinical data, ASA scores, laboratory parameters, features of surgical procedure, and anesthesia were registered. Parameters of perioperative fluid administration, transfusion rate, and postoperative complications were also assessed. One hundred patients in the first and 108 patients in the second observational period were enrolled. Eventhough the ratio of posttraumatic THR procedures increased (9% vs. 17%), the PBM protocol has been utilized effectively and a significant decrease in perioperative blood transfusion rate has been observed (61% vs. 21%). The abolishment of routine preoperative LMWH prophylaxis (90% vs. 16%), intraoperative use of tranexamic acid (10% vs. 84%), and the encouraged exploitation of our postoperative observational facility (5% vs. 39%) were abided by our colleagues. Patients still requiring transfusion had lower preoperative hemoglobin levels (129 vs. 147 g/l), scored higher in ASA (ASA III: 46% vs. 19%), and more often presented postoperative hypotension (40% vs. 7%), oliguria (23% vs. 5%), and infections (9% vs. 2%). We conclude that the individualized perioperative blood management protocol was successfully implemented and yielded a lower transfusion rate and better outcomes. Our study suggests that a partial, institution-tailored PBM program may be suitable and beneficial in countries where the modalities of perioperative blood management are limited.

A Review of Total Hip Arthroplasty Comparison in FNF and OA Patients

Background. Worldwide, total hip arthroplasty (THA) has become one of the most commonly performed surgical procedures. Femoral neck fracture (FNF) and osteoarthritis (OA) are two of the medical conditions necessitating a hip replacement, most frequently carried out. The preoperative and postoperative pathways for patients suffering from these two diseases differ, yet worldwide, many national healthcare systems underestimate or misinterpret the (more than nuanced) care plan differences of the two. Factors and Criteria. Analyzed material was gathered from studies published between 2013 and 2019. Various strands of data demographics, comorbidities, and complications, as well as treatment outcomes, were tabulated to compare and contrast THA patients suffering from FNF and OA to collate their findings. Outcomes were cross-checked and validated for reliability and then were presented in a table format. Results. All five retrospective cohort studies fitted the required criteria for inclusion in this work, four US-based study groups and one European-based study group. Data were gathered from three separate databases. The “average” FNF patient is 76.8 years old. There was a 68.96% female probability. The “average” OA patient is 69.15 years old. There was a 5.24% female probability. 59.57% operated for athrosis, and only 34.63% operated for fracture which received grade lower than the third in the American Society of Anaesthesiologist (ASA) classification. There was more than 3 times higher prevalence of complications in the trauma group. FNF patients’ hospitalization was approximately 3 days longer. On average, 3.7% of patients operated for trauma and 1.5% of patients with elective THA required a second surgery. 6.57% FNF and 2.93% OA patients had unplanned readmission. Conclusions. In general, patients who suffer a femoral neck fracture are an extremely fragile group. They require additional perioperative and postoperative care. To meet these desired expectations, more FNF cost-comprehensive systems need to be initiated.