Publications by authors named "Vaida Glatt"

65 Publications

Increased Posterior Slope of the Medial and Lateral Meniscus Posterior Horn Is Associated with Anterior Cruciate Ligament Injuries.

Arthroscopy 2021 May 6. Epub 2021 May 6.

Department of Anatomy, School of Medicine, Faculty of Health Sciences, University of Pretoria, South Africa; Department of Anatomy and Cellular Biology, College of Medicine and Health Sciences, Khalifa University, Abu Dhabi, United Arab Emirates.

Purpose: To measure the slope of the medial and lateral posterior horn of the meniscus and its contribution to the overall resulting posterior tibial slope (bone and meniscus combined slope) in anterior cruciate ligament-intact (ACLI) and -deficient (ACLD) knees.

Methods: Magnetic resonance images of intact menisci in patients 16 to 60 years old were included. Posterior tibial bone slope (PTS) and meniscus slope (MS) were measured 25%, 50%, and 75% from the medial and lateral borders of the tibial plateau. Analysis of variance was used to determine differences in posterior tibial slopes between ACLD and ACLI knees and between sexes for ACLD and ACLI knees.

Results: 192 ACLI patients (age 35.2 ± 9.6 years, mean ± standard deviation) and 159 ACLD patients (age 34.2 ± 10.3 years) were included. Medial and lateral PTS in ACLD was significantly (P = .00001) higher at 25%, 50%, and 75%. Medial and lateral MS in ACLD was significantly (P = .00001) lower at 25%, 50%, and 75%. There were no significant sex differences for medial or lateral MS in ACLD or ACLI patients (P = .51). The resultant combined medial and lateral slope in ACLD patients was significantly (P = .00001) lower at 25%, 50%, and 75%. There were no significant sex differences in PTS (P = .68), MS (P = .51), or resultant slope (P = .79) CONCLUSIONS: The results of this study strongly suggest that lower meniscal slopes of both the medial and lateral posterior horns are associated with ACL injuries in both males and females. Although the posterior horns reversed the bone PTS to an anterior inclined slope in both ACLD and ACLI patients, both the meniscus slope and the combined resultant slope were significantly lower and more positive at all 6 measured locations in ACLD knees.

Level Of Evidence: III, retrospective cohort study.
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http://dx.doi.org/10.1016/j.arthro.2021.04.066DOI Listing
May 2021

The posterior horn of the medial and lateral meniscus both reduce the effective posterior tibial slope: a radiographic MRI study.

Surg Radiol Anat 2021 Feb 9. Epub 2021 Feb 9.

Faculty of Health Sciences, Department of Anatomy, School of Medicine, University of Pretoria, Pretoria, South Africa.

Purpose: The purpose of this study was to quantify the posterior horn meniscal slope and determine its contribution to the reduction in posterior tibial slope.

Methods: Patients aged between 16 and 60 years and had intact menisci with no evidence of previous injury or surgery were included. Patients with radiological evidence of osteoarthritis Grade II-IV, any acute or chronic meniscus injuries, fractures, and ligamentous injuries were excluded. The posterior bony slope (PTS) and the meniscus slope (MS) of the posterior horns were measured at 25, 50, and 75% from the medial and lateral borders of the tibial plateau.

Results: 325 MR images (mean age 37.1 ± 10.9 years) were included. There were 194 males and 131 females, with 162 left and 163 right knees. The PTS in the medial compartment ranged from (-) 2.8° to 3.7° and from (-) 1.3° to 1.9° in the lateral compartment (p = 0.0001). The MS in the medial compartment ranged from 27.4° to 28.2°, and from 27.8° to 28.7° in the lateral compartment (p > 0.05). The differences between the medial and lateral knee compartment were statistically significant. At the 25% interval the p level was 0.037, at 50% p = 0.00001, and at 75% p = 0.0001. There were no significant between gender differences.

Conclusions: The results of this study demonstrated a significant reduction in posterior tibial bone slope by the posterior horns of both the medial and lateral meniscus, from a mean of (-) 1° to 2° to a more horizontal anterior slope. The posterior bone slope was larger in the medial compartment by 1°, resulting in a smaller slope reduction in the lateral compartment.
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http://dx.doi.org/10.1007/s00276-021-02696-8DOI Listing
February 2021

The anatomical relationship of the common peroneal nerve to the proximal fibula and its clinical significance when performing fibular-based posterolateral reconstructions.

Arch Orthop Trauma Surg 2021 Mar 3;141(3):437-445. Epub 2021 Jan 3.

Department of Anatomy, Faculty of Health Sciences, School of Medicine, University of Pretoria, Pretoria, South Africa.

Purpose: The common peroneal nerve (CPN) can be injured during fibular-based posterolateral reconstructions due to its close relationship to the neck of the fibula. Therefore, the purpose of this study was to observe the course of the CPN and its branches around the fibular head and neck and quantify the position in relation to relevant bony landmarks and observe the relation between tunnel drilling for posterolateral corner reconstruction and both the tunnel entry and exit at the proximal fibula and the CPN and its branches was observed.

Methods: In 101 (mean age = 70.6 ± 16 years) embalmed cadaver knees, the relationship between bony landmarks (tibial tuberosity, styloid process of fibula (APR)) and the CPN and its branches were established and 8 (M1-M8) distances from these landmarks measured; mean, SD and 95% CI were recorded. In 21 of these knees, a fibula tunnel was drilled as in PLC reconstruction and the association of the CPN and its branches to the tunnel entry and exit were judged by two independent observers. Fisher's exact test of independence was used to determine significant differences between genders. Tunnel intersection was analysed in a binary yes/no fashion and was described in frequencies and percentages.

Results: The mean distance from the APR to where the CPN reaches the fibula neck (M1) was 31.4 ± 8.9 mm (CI:29.8-33.0); from the apex of the styloid process (APR) to where the CPN passes posterior to the broadest point of the fibular head (M3) was 21.7 ± 12.6 mm (CI:19.4-24.0); from the apex of the APR to the most proximal point of the CPN/CPN first branch in the midline of the fibular head (M2) was 37.0 ± 6.7 mm (CI: 35.4-37.7). Out of the 21 randomly selected knees for drilling, the first branch of the CPN was damaged at the tunnel entry point in 7 (33%), and in 5 knees (24%), the CPN was damaged at the tunnel exit. In one knee, at both the tunnel entry and exit, the first branch of the CPN and the CPN were intersected, respectively.

Conclusion: The results of this study strongly suggest that the CPN is at risk when drilling the fibula tunnel performing fibula-based posterolateral corner reconstructions. The total injury rate was 57% with a 33% incidence of injury to the first branch of the nerve at the tunnel entry and 24% to the CPN at the tunnel exit.

Clinical Relevance: Due to the high incidence of injury, percutaneous placement of guide pins and tunnel drilling is not recommended. The nerve should be visualized and protected by either a traditional open approach or minimally invasive techniques. With a minimally invasive approach, the nerve should be identified at the fibula neck and then followed ante- and retrograde.
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http://dx.doi.org/10.1007/s00402-020-03708-9DOI Listing
March 2021

Reverse Dynamization Accelerates Bone-Healing in a Large-Animal Osteotomy Model.

J Bone Joint Surg Am 2021 Feb;103(3):257-263

Center for Limb Lengthening and Reconstruction, Nationwide Children's Hospital, Columbus, Ohio.

Background: Reverse dynamization is a mechanical manipulation regimen designed to accelerate bone-healing and remodeling. It is based on the hypothesis that a fracture that is initially stabilized less rigidly allows micromotion to encourage initial cartilaginous callus formation. Once substantial callus has formed, the stabilization should then be converted to a rigid configuration to prevent the disruption of neovascularization. The aim of the present study was to investigate whether bone-healing can be accelerated using a regimen of reverse dynamization in a large-animal osteotomy model.

Methods: Transverse 2-mm tibial osteotomies were created in 18 goats, stabilized using circular external fixation, and divided into groups of 6 goats each: static fixation (rigid fixation), dynamic fixation (continuous micromotion using dynamizers), and reverse dynamization (initial micromotion using dynamizers followed by rigid fixation at 3 weeks postoperatively). Healing was assessed with the use of radiographs, micro-computed tomography, and mechanical testing.

Results: Radiographic evaluation showed earlier and more robust callus formation in the dynamic fixation and reverse dynamization groups compared with the static fixation group. After 8 weeks of treatment, the reverse dynamization group had reduced callus size, less bone volume, higher bone mineral density, and no evidence of radiolucent lines compared with the static fixation and dynamic fixation groups. This appearance is characteristic of advanced remodeling, returning closest to the values of intact bone. Moreover, the tibiae in the reverse dynamization group were significantly stronger in torsion compared with those in the static fixation and dynamic fixation groups.

Conclusions: These findings confirmed that tibial osteotomies under reverse dynamization healed faster, healed objectively better, and were considerably stronger, all suggesting an accelerated healing and remodeling process.

Clinical Relevance: This study demonstrates that the concept of reverse dynamization challenges the current understanding regarding the optimal fixation stability necessary to maximize the regenerative capacity of bone-healing. When reverse dynamization is employed in the clinical setting, it may be able to improve the treatment of fractures by reducing the time to union and potentially lowering the risk of delayed union and nonunion.
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http://dx.doi.org/10.2106/JBJS.20.00380DOI Listing
February 2021

Anterior Minimally Invasive Plate Osteosynthesis for Humeral Shaft Fractures is Safer than Open Reduction Internal Fixation: A Case-Match Controlled Comparison.

J Orthop Trauma 2020 Nov 25. Epub 2020 Nov 25.

Department of Orthopaedic Surgery, The Royal Brisbane and Women's Hospital, Brisbane, Australia.

Objective: Compare anterior minimally invasive plate osteosynthesis (MIPO) to open reduction/internal fixation (ORIF) for humeral shaft fractures, assessing complications and clinical outcomes.

Design: Retrospective matched case-controlled cohort.

Setting: Tertiary referral trauma centre.

Patients/participants: Humeral shaft fractures identified retrospectively over 5-years; 31 were treated by MIPO and 54 by ORIF. Case-matched cohort assembled according to fracture pattern, gender, age, and comorbidities, with 56 total patients (28 per group).

Interventions: MIPO and ORIF MAIN OUTCOME MEASURES:: Complication rate was the primary outcome (radial nerve injury, nonunion, infection, and re-operation). Radiographic alignment and the DASH Score were secondary outcomes.

Results: Cumulative complication rates were 3.6% following anterior MIPO, and 35.7% after ORIF (p=0.0052). The only complication following anterior MIPO was a nonunion, managed with revision ORIF and bone graft. The ORIF group had 10 complications, including 5 superficial infections, 4 iatrogenic radial nerve injuries, and 1 nonunion. The mean DASH score following MIPO was 17.0 ± 18.0, and after ORIF was 24.9 ± 19.5. The mean coronal plane angulation following MIPO was 1.8 ± 1.3, and after ORIF was 1.0 ± 1.2. The mean sagittal plane angulation following MIPO was 3.0 ± 2.9, and after ORIF was 1.0 ± 1.2.

Conclusions: The cumulative complication rate was 10 times higher following ORIF of humeral shaft fractures compared to the MIPO technique. MIPO achieved nearly equivalent radiographic alignment, with no clinically meaningful differences observed. MIPO is the safer option, and should be considered for patients with humeral shaft fractures that would benefit from surgical intervention.

Level Of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000002021DOI Listing
November 2020

What is the optimal timing for bone grafting during staged management of infected non-unions of the tibia? A systematic review and best evidence synthesis.

Injury 2020 Dec 10;51(12):2793-2803. Epub 2020 Oct 10.

Department of Orthopaedic Surgery, Royal Brisbane Hospital, Herston, Australia; Department of Surgery, School of Medicine, University of Queensland, Australia; Queensland University of Technology, Australia; Orthopaedic Research Centre of Australia, Australia. Electronic address:

Purpose: To summarize the best available evidence with regards to timing of staged bone grafting for infected tibial non-union, and to extract evidence-based criteria indicating when bone grafting can be safely performed.

Methods: Medline, Embase, Scopus, and Google Scholar were searched, and publications of evidence Level I-IV from 2000 to 2020 were included. Risk of bias was assessed with the Cochrane Collaboration's Risk of Bias Tool and ROBINS-I tool. Study quality was assessed with the GRADE system, Coleman methodology score, and Methodological Index for Non-Randomized Studies (MINORS). Heterogeneity was assessed with the I statistic. A forest plot was used to pool the timing of bone grafting for all included studies. For data synthesis and analysis, a best evidence synthesis was used.

Results: A total of 15 studies were included (353 cases). Risk of bias was high in 8 studies and the quality for 14 studies was assessed as very low, with a mean Coleman score of 33.5 and a mean MINORS score of 7.9. The mean time from the index surgery to bone grafting was 7.03 weeks ranging from 2 to 15 weeks (lower limit 6 weeks, upper limit 8.07 weeks). Best evidence analysis demonstrated that 8 of the 15 studies (53%) with 237 cases (67%) performed staged bone grafting inside this window. Union was achieved in 92%.

Conclusion: The results of this best evidence systematic review suggest that, for most infected tibial non-unions, secondary bone grafting can be successfully performed between 6-8 weeks with expected union rates over 90%.
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http://dx.doi.org/10.1016/j.injury.2020.10.043DOI Listing
December 2020

Platelet-Rich Plasma Versus Corticosteroids for the Treatment of Plantar Fasciitis: A Systematic Review and Meta-analysis.

Am J Sports Med 2021 04 21;49(5):1381-1393. Epub 2020 Aug 21.

Orthopaedic Research Centre of Australia, Brisbane, Australia.

Background: Plantar fasciitis is a common cause of heel pain. Corticosteroid injections are commonly used and proven to be effective, and lately platelet-rich plasma (PRP) has been used with mixed results.

Purpose: To perform a systematic review and meta-analysis comparing intralesional injections of PRP and steroid infiltration.

Study Design: Systematic review and meta-analysis.

Methods: A systematic review of Medline, Embase, Scopus, and Google Scholar including all level 1 and 2 studies from 2010 to 2019 was perfomed. American Orthopaedic Foot and Ankle Society and visual analog scale for pain scores were used as outcome variables. Publication bias and risk of bias was assessed with the Cochrane Collaboration tools. The Grading of Recommendations, Assessment, Development and Evaluations system was used to assess the quality of the body of evidence. Heterogeneity was assessed with χ and statistics.

Results: Fifteen studies were included in the analysis. Nine studies had a high risk of bias. There was 1 study with high quality, 9 with moderate, 2 studies with low, and 3 with very low quality. The pooled estimate for the American Orthopaedic Foot and Ankle Society score demonstrated nonsignificant differences at 1 month ( = .4) and 3 months ( = .076). At 6 months ( = .009) and 12 months ( = .009), it indicated significant differences in favor of PRP. The pooled estimate for visual analog scale demonstrated nonsignificant differences at 1 month ( = .653). At 3 months ( = .0001), 6 months ( = .002), and 12 months ( = .019), it yielded significant differences in favor of PRP.

Conclusion: The results of this systematic review and meta-analysis suggest that PRP is superior to corticosteroid injections for pain control at 3 months and lasts up to 1 year. In the short term, there is no advantage of corticosteroid infiltration. However, the low study quality, high risk of bias, and different protocols for PRP preparation reduce the internal and external validity of these findings, and these results must be viewed with caution.
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http://dx.doi.org/10.1177/0363546520937293DOI Listing
April 2021

Outcomes Following Treatment of Complex Tibial Fractures with Circular External Fixation: A Comparison between the Taylor Spatial Frame and TrueLok-Hex.

Strategies Trauma Limb Reconstr 2019 Sep-Dec;14(3):142-147

Medical School, University of Pretoria, Pretoria, Gauteng, South Africa.

Aim: The purpose of this study was to compare the functional and radiological outcomes of complex tibia fractures treated with two different hexapod fixators.

Material And Methods: This is a retrospective comparative study of patients treated for complex tibial fractures between 2010 and 2015. Inclusion criteria was patients between 18 years and 60 years of age, who sustained a complex comminuted open or closed tibial fracture with or without bone loss, who had a minimum of 12 months' follow-up, and who have been treated definitively using either Taylor Spatial Frame (TSF) or TrueLok-Hexapod System (TL-HEX). The outcome measures were Association for the Study and Application of the Method of Ilizarov (ASAMI) score, foot function index (FFI), EQ5-D, four-step square test (FSST), and timed up and go (TUG) test. Descriptive statistics were used to assess patient demographic information. Categorical variables (ASAMI and EQ5D-5L) were analysed using the test. Continuous variables (FFI, functional tests, and radiographic outcomes) were analysed with two-tailed Student's tests.

Results: In all, 24 patients were treated with the TL-HEX and 21 with the TSF. The mean time for external fixation was 219 ± 107 days (TL-HEX) and 222 ± 98 days (TSF). Union occurred in 92% (TL-HEX) and 100% (TSF). The mean follow-up was 777 ± 278 days (TL-HEX) and 1211 ± 388 days (TSF). Using the ASAMI scores, there were 17 excellent and 6 good results for the TL-HEX and 10 excellent and 11 good results for the TSF ( = 0.33). The FFI was 30 ± 28.7 (TL-HEX) and 26.1+23.9 (TSF) ( = 0.55). The EQ5D was 0.67 ± 0.3 (TL-HEX) and 0.73 ± 0.2 (TSF) ( = 0.43). The mean TUG and FSST were 9.2 ± 3.2 and 10 ± 2.9 seconds (TL-HEX) and 8.4 ± 2.3 and 9.6 ± 3.1 seconds (TSF) ( = 0.34 and 0.69).

Conclusion: The results of this study suggest that both hexapod external fixation devices have comparable clinical, functional, and radiographic outcomes. Either fixator can be used for the treatment of complex tibial fractures, anticipating good and excellent clinical outcomes in approximately 80% patients.

Level Of Evidence: Therapeutic level III.

How To Cite This Article: Naude J, Manjra M, Birkholtz FF, Outcomes Following Treatment of Complex Tibial Fractures with Circular External Fixation: A Comparison between the Taylor Spatial Frame and TrueLok-Hex. Strategies Trauma Limb Reconstr 2019;14(3):142-147.
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http://dx.doi.org/10.5005/jp-journals-10080-1443DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7368362PMC
August 2020

Classification of Bone Defects: An Extension of the Orthopaedic Trauma Association Open Fracture Classification.

J Orthop Trauma 2021 02;35(2):71-76

Orthopaedic Research Centre of Australia, Brisbane, QLD, Australia.

Objectives: To develop a post-traumatic bone defect classification scheme and complete a preliminary assessment of its reliability.

Design: Retrospective classification.

Setting: Tertiary referral trauma center.

Patients/participants: Twenty open fractures with bone loss.

Intervention: Assignment of a bone defect classification grade.

Main Outcome Measurements: Open fractures were classified based on orthogonal radiographs, assessing the extent and local geometry of bone loss, including D1-incomplete defects, D2-minor/subcritical (complete) defects (<2 cm), and D3-segmental/critical-sized defects (≥2 cm). Incomplete defects (D1) include D1A-<25% cortical loss, D1B-25%-75% cortical loss, and D1C->75% cortical loss. Minor/subcritical (complete) defects (<2 cm) (D2) include D2A-2 oblique ends allowing for possible overlap, D2B-one end oblique/one end transverse, and D2C-2 transverse ends. Segmental/critical-sized Defects (≥2 cm) include D3A-moderate defects, 2 to <4 cm; D3B-major defects, 4 to <8 cm; and D3C-massive defects, ≥8 cm. Reliability was assessed among 3 independent observers using Fleiss' kappa tests.

Results: Interobserver reliability demonstrated the classification scheme has very good agreement, κ = 0.8371, P < 0.0005. Intraobserver reliability was excellent, κ = 1.000 (standard error 0.1478-0.1634), P < 0.00001. Interobserver reliability for the distinction between categories alone (D1, D2, or D3) was also excellent, κ = 1.000 (standard error 0.1421-0.1679), P < 0.00001.

Conclusions: This classification scheme provides a robust guide to bone defect assessment that can potentially facilitate selection of the most appropriate treatment strategy to optimize clinical outcomes.
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http://dx.doi.org/10.1097/BOT.0000000000001896DOI Listing
February 2021

The Association Between Anterior Cruciate Ligament Length and Femoral Epicondylar Width Measured on Preoperative Magnetic Resonance Imaging or Radiograph.

Arthrosc Sports Med Rehabil 2020 Feb 18;2(1):e23-e31. Epub 2019 Dec 18.

School of Medicine, University of Pretoria, Pretoria, South Africa.

Purpose: To determine whether femoral epicondylar width (FECW) obtained from either magnetic resonance imaging (MRI) or plain radiographs could be used to predict anterior cruciate ligament (ACL) length. A secondary purpose was to develop a formula to use maximum FECW on either MRI or plain radiographs to estimate ACL length preoperatively.

Methods: The MRIs and radiographs of 40 patients (mean age 41.0 years), with no apparent knee pathology, surgery, or trauma were included. The ACL length was measured on MRI followed by FECW on both MRI and radiograph of the same patient. This allowed the development of equations able to predict ACL length according to the FECW measured on either an MRI or radiograph.

Results: The mean ACL length was 40.6 ± 3.6 mm. FECW measured on both MRIs and radiographs was sufficient to predict ACL length. Pearson's correlations revealed a high positive relationship between ACL length and FECW on MRI (r = 0.89, < .0001) and ACL length and FECW on radiograph (r = 0.83, < .0001). The coefficient of determination (R) was calculated to be MRI: R = 0.78 and radiograph: R = 0.68 and confirmed that FECW measured on both MRI and radiograph were sufficient to predict ACL length. Based on these models, ACL length can be predicted by FECW using the following formulas: MRI: ACL length = 0.47 (FECW) + 1.93 and radiograph: ACL length = 0.31 (FECW) + 11.33.

Conclusions: This study demonstrated that FECW measured on either MRI or anteroposterior radiograph could reliably estimate ACL length on a sagittal MRI. There was a high positive relationship between ACL length and FECW on both MRI and radiographs, although MRIs do predict ACL length more reliably.

Clinical Relevance: Preoperative ACL length assessment, using FECW on MRI or radiograph, is useful in graft selection and in preventing inadequate graft harvesting for ACL reconstruction, especially if an individualized anatomical approach is pursued.
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http://dx.doi.org/10.1016/j.asmr.2019.10.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7120849PMC
February 2020

Is platelet-rich plasma effective for the treatment of knee osteoarthritis? A systematic review and meta-analysis of level 1 and 2 randomized controlled trials.

Eur J Orthop Surg Traumatol 2020 Aug 14;30(6):955-967. Epub 2020 Feb 14.

Orthopaedic Research Centre of Australia, Brisbane, Australia.

Introduction: The purpose of this study was to perform a systematic review and meta-analysis comparing intra-articular knee injection of PRP and hyaluronic acid and investigate clinical outcomes and pain at both 6 and 12 months.

Methods: A systematic review of Medline, Embase, Scopus, and Google Scholar was performed in the English and German literature reporting on intra-articular knee injections for knee osteoarthritis. All level 1 and 2 studies with a minimum of 6-month follow-up in patients with knee osteoarthritis from 2010 to 2019 were included. Clinical outcome was assessed by WOMAC and IKDC scores and pain by VAS and WOMAC pain scores. Subgroup analysis for autologous platelet-rich plasma (ACP) was performed. Publication bias and risk of bias were assessed using the Cochrane Collaboration's tools. The GRADE system was used to assess the quality of the body of evidence. Heterogeneity was assessed using χ and I statistics.

Results: Twelve studies (1,248 cases; 636 PRP, 612 HA) met the eligibility criteria. The pooled estimate demonstrated non-significant differences between PRP and HA for clinical outcomes at 6 months (p = 0.069) and at 12 months (p = 0.188). However, the pooled estimate for pain did demonstrate significant differences in favour of PRP at 6 months (p = 0.001) and 12 months (p = 0.001). For the ACP subgroup (249 cases), the pooled estimate for these studies demonstrated significant differences in favour of PRP (p < 0.0001) at 6 months.

Conclusion: The results of this systematic review and meta-analysis suggest that PRP is superior to HA for symptomatic knee pain at 6 and 12 months. ACP appears to be clearly superior over HA for pain at both 6 and 12 months. There were no advantages of PRP over HA for clinical outcomes at both 6 and 12 months.

Level Of Evidence: Level 2; systematic review and meta-analysis.
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http://dx.doi.org/10.1007/s00590-020-02623-4DOI Listing
August 2020

Degenerative Meniscus Lesions: An Expert Consensus Statement Using the Modified Delphi Technique.

Arthroscopy 2020 02 31;36(2):501-512. Epub 2019 Dec 31.

Orthopaedic Research Centre of Australia, Brisbane, Australia; Department of Orthopaedic Surgery, Royal Brisbane Hospital, Herston, Australia.

Purpose: The purpose of this study was to perform an evidence-based, expert consensus survey using the Delphi panel methodology to develop recommendations for the treatment of degenerative meniscus tears.

Methods: Twenty panel members were asked to respond to 10 open-ended questions in rounds 1 and 2. The results of the first 2 rounds served to develop a Likert-style questionnaire for round 3. In round 4, the panel members outside consensus were contacted and asked to either change their score in view of the group's response or argue their case. The level of agreement for round 4 was defined as 80%.

Results: There was 100% agreement on the following items: insidious onset, physiological part of aging, tears often multiplanar, not all tears cause symptoms, outcomes depend on degree of osteoarthritis, obesity is a predictor of poor outcome, and younger patients (<50 years) have better outcomes. There was between 90% and 100% agreement on the following items: tears are nontraumatic, radiographs should be weightbearing, initial treatment should be conservative, platelet-rich plasma is not a good option, repairable and peripheral tears should be repaired, microfracture is not a good option for chondral defects, the majority of patients obtain significant improvement and decrease in pain with surgery but results are variable, short-term symptoms have better outcomes, and malalignment and root tears have poor outcomes.

Conclusions: This consensus statement agreed that degenerative meniscus tears are a normal part of aging. Not all tears cause symptoms and, when symptomatic, they should initially be treated nonoperatively. Repairable tears should be repaired. The outcome of arthroscopic partial meniscectomy depends on the degree of osteoarthritis, the character of the meniscus lesion, the degree of loss of joint space, the amount of malalignment, and obesity. The majority of patients had significant improvement, but younger patients and patients with short-term symptoms have better outcomes.

Level Of Evidence: Level V - expert opinion.
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http://dx.doi.org/10.1016/j.arthro.2019.08.014DOI Listing
February 2020

Operative Treatment of Neer Type-II Distal Clavicular Fractures: An Overview of Contemporary Techniques.

JBJS Rev 2019 May;7(5):e5

Orthopaedic Research Centre of Australia, Herston, Brisbane, Queensland, Australia.

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http://dx.doi.org/10.2106/JBJS.RVW.18.00046DOI Listing
May 2019

Tissue Morphology and Antigenicity in Mouse and Rat Tibia: Comparing 12 Different Decalcification Conditions.

J Histochem Cytochem 2019 08 15;67(8):545-561. Epub 2019 May 15.

Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia.

Conventional bone decalcification is a time-consuming process and is therefore unsuitable for clinical applications and time-limited research projects. Consequently, we compared the effect of four different decalcification solutions applied at three different temperatures, and assessed the rate of decalcification and the implications on tissue morphology and antigenicity of mouse and rat tibiae. Bones were decalcified with 10% ethylenediaminetetraacetic acid (EDTA), 10% formic acid, 5% hydrochloric acid, and 5% nitric acid at 4C, 25C, and 37C. Decalcification in both species was fastest in nitric acid at 37C and slowest in EDTA at 4C. Histological and immunohistochemical staining confirmed that the conventional protocols of EDTA at 4C and 25C remain the best option regarding the quality of tissue preservation. Whereas formic acid at 4C is a good alternative saving about 90% of the decalcification time, hydrochloric and nitric acids should be avoided particularly in case of rat tibia. By contrast, due to their smaller size, mouse tibiae had shorter decalcification times and tolerated higher temperatures and exposure to acids much better. In conclusion, this study demonstrated that depending on the specific research question and sample size, alternative decalcification methods could be used to decrease the time of decalcification while maintaining histological accuracy.
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http://dx.doi.org/10.1369/0022155419850099DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6669861PMC
August 2019

3D printed titanium cages combined with the Masquelet technique for the reconstruction of segmental femoral defects: Preliminary clinical results and molecular analysis of the biological activity of human-induced membranes.

OTA Int 2019 Mar 12;2(1):e016. Epub 2019 Mar 12.

Orthopaedic Research Centre of Australia, Brisbane, Queensland, Australia.

Introduction: Traumatic femoral segmental bone loss is a complex clinical problem, one that often requires extreme solutions. This study examines a new treatment strategy for segmental bone loss using patient-specific 3D printed titanium cages in conjunction with the Masquelet technique.

Methods: The study was composed of a clinical observational case series, and a basic science investigation to evaluate the biological activity of the induced membranes using histology, immunohistochemistry (IHC), and gene expression analysis. Eligible patients were: adult; post-traumatic; with segmental femoral defects; minimum follow-up 1 year; managed under a 2-stage protocol, with an interim antibiotic poly (methyl methacrylate) (PMMA) spacer. Definitive reconstruction was completed with exchange to a 3D printed custom titanium cage filled with bone graft, and stabilized with either an intramedullary (IM) nail or a lateral locked plate.

Results: Patient-specific 3D printed titanium cages were used in 5 consecutive patients to reconstruct post-traumatic segmental femoral defects. The mean interval between stages was 100.2 days (83-119 days), the mean defect length was 14.0 cm (10.3-18.4 cm), and the mean bone defect volume measured 192.4 cc (114-292 cc). The mean length of follow-up was 21.8 months (12-33 months). There were no deep infections, fractures, nerve injuries, loss of alignment, or nonunions identified during the period of follow-up. All of the patients achieved union clinically and radiographically. Histology and IHC demonstrated a greater number of vessels, cell nuclei, and extensive staining for cluster of differentiation 68 (CD68), platelet and endothelial cell adhesion molecule 1 (PECAM-1), and vascular endothelial growth factor (VEGF) in the induced membranes compared to local fascia controls. Gene expression analysis revealed significant differential regulation of essential genes involved in inflammatory, angiogenic, and osteogenic pathways [interleukin 6 (IL-6), nuclear factor kappa B1 (NF-κB1), receptor activator of nuclear factor kappa-β ligand (RANKL), vascular endothelial growth factor A (VEGFA), angiogenin (ANG), transforming growth factor, beta 1 (TGF-β1), bone morphogenetic protein-2 (BMP-2), growth differentiation factor 5 (GDF-5), growth differentiation factor 10 (GDF-10), and runt-related transcription factor 2 (RUNX-2)] in the induced membranes.

Conclusions: This study demonstrates that the use of a patient-specific 3D printed custom titanium cage, inserted into an induced membrane in a 2-stage protocol, can achieve very acceptable clinical outcomes in selected cases of post-traumatic femoral segmental defects. Patient-specific 3D printed titanium cages, used in conjunction with the Masquelet technique, are a promising new treatment option for managing complex trauma patients with femoral bone loss.

Level Of Evidence: Level IV (observational case series).
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http://dx.doi.org/10.1097/OI9.0000000000000016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7953522PMC
March 2019

Genetic variation in mice affects closed femoral fracture pattern outcomes.

Injury 2019 Mar 13;50(3):639-647. Epub 2019 Feb 13.

Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia; Department of Orthopaedics, University of Texas Health Science Center, San Antonio, TX, USA. Electronic address:

The purpose of this study was to determine whether differences in structural and material properties of bone between different mouse strains influence the fracture patterns produced under experimental fracture conditions. Femurs of C57BL/6 (B6), C3H/HeJ (C3H), and DBA/2 (DBA) strains were evaluated using micro-computed tomography (μCT), measurements derived from radiographic images and mechanical testing to determine differences in the geometry and mechanical properties. A fracture device was used to create femoral fractures on freshly sacrificed animals using a range of kinetic energies (∼20-80mJ) which were classified as transverse, oblique, or comminuted. B6 femurs had the lowest bone volume/total volume (BV/TV) and bone mineral density (BMD), thinnest cortex, and had the most variable fracture patterns, with 77.5% transverse, 15% oblique, and 7.5% comminuted fractures. In contrast, C3H had the highest BV/TV, BMD, and thickest cortices, resulting in 97.5% transverse, 2.5% oblique, and 0% comminuted fractures. DBA had an intermediate BV/TV and thickness of cortices, with BMD similar to C3H, resulting in 92.9% transverse, 7.1% oblique, and 0% comminuted fractures. A binomial logistic regression confirmed that bone morphometry was the single strongest predictor of the resulting fracture pattern. This study demonstrated that the reproducibility of closed transverse femoral fractures was most influenced by the structural and material properties of the bone characteristics in each strain, rather than the kinetic energy or body weight of the mice. This was evidenced through geometric analysis of X-ray and μCT data, and further supported by the bone mineral density measurements from each strain, derived from μCT. Furthermore, this study also demonstrated that the use of lower kinetic energies was more than sufficient to reproducibly create transverse fractures, and to avoid severe tissue trauma. The creation of reproducible fracture patterns is important as this often dictates the outcomes of fracture healing, and those studies that do not control this potential variability could lead to a false interpretation of the results.
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http://dx.doi.org/10.1016/j.injury.2019.02.012DOI Listing
March 2019

The relationship between gait and functional outcomes in patients treated with circular external fixation for malunited tibial fractures.

Gait Posture 2019 02 8;68:569-574. Epub 2019 Jan 8.

Walk-a-Mile Centre for Advanced Orthopaedics, Pretoria, South Africa; School of Medicine, University of Pretoria, South Africa; Valiant Clinic/Houston Methodist Group, United Arab Emirates. Electronic address:

Background: Lower extremity fractures have a profound negative effect on a patient's gait and outcomes. Correction of deformity, and with it normalization of objective gait parameters, may result in better subjective and objective functional outcomes in patients treated with circular external fixation for malunited tibial fractures.

Aim: The purpose of this study was to investigate the relationships between gait parameters, patient reported outcome measures (PROMs), and health related quality of life measures in patients treated with circular external fixation for the correction of deformity related to tibial malunions.

Methods: This retrospective study included patients with posttraumatic tibial deformities, aged 14-65, with a minimum follow-up of 24 months following deformity correction. Patients with congenital deformities, head injuries, spinal cord injury, neurological disorders, or contralateral lower limb amputation were excluded. Functional outcomes were assessed by the Foot Function Index (FFI); Short Form 12 (SF-12); the EQ 5D; and the ASAMI score. Gait analysis was performed using Dartfish® and the Edinburgh Visual Gait Score (EVGS). The relationships between the EVGS and functional outcome scores were analyzed using Pearsons' moment correlations with Bonferroni corrections.

Results: Eleven patients with a mean age of 42 (range 23-57) were analyzed. The mean EVGS was 2.6 ± 2.1, the mean FFI 29.6 ± 33.4, the mean EQ5 Index Value 0.7 ± 0.2, the mean EQ5 VAS 85.4 ± 19.5, the SF12 mean Physical Component Score (PCS) 46.7 ± 11.1, and the mean Mental Component Score (MCS) 55.2 ± 7.5. The following relationships were strong and significant: EVGS and FFI (r = 0.7; P = 0.02), EVGS and PCS (r = -0.82; P = 0.02), and FFI and EQ5 (r = -0.79, P = 0.05).

Significance: The results of this study suggest that correction of deformity with realignment and restoration of normal anatomy was associated with improved functional outcomes and physical well-being. Patient reported quality of life is strongly associated with patient perceived functional outcome, but not with objective gait parameters.
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http://dx.doi.org/10.1016/j.gaitpost.2019.01.008DOI Listing
February 2019

Open versus arthroscopic acromioclavicular joint resection: a systematic review and meta-analysis.

Arch Orthop Trauma Surg 2019 May 14;139(5):685-694. Epub 2019 Jan 14.

University of Texas Health Science Center, San Antonio, TX, USA.

Introduction: The purpose of this study was to perform a meta-analysis comparing open and arthroscopic surgical techniques for distal clavicle resection.

Methods: A systematic review of Medline, Embase, Scopus, and Google Scholar identified relevant publications in the English and German literature between 1997 and 2017. All included studies were levels I-IV, describing both treatments, with a minimum of 12 month follow-up, had at least one validated outcome score and documented patient recruitment, study design, demographic details, and surgical technique. Studies were excluded if they were only abstracts or conference proceedings, involved revision procedures, or the loss to follow-up exceeded 20%. Publication bias and risk of bias were assessed using the Cochrane Collaboration tools, and heterogeneity was assessed using the I statistic.

Results: Four studies (n = 319 patients) met the criteria for inclusion. The pooled estimate for clinical outcomes (Constant, ASES) demonstrated no significant differences (SMD 0.323, I = 0%, p = 0.065) between open and arthroscopic resection, although the analysis favored open resection. The pooled estimate for clinical outcomes (SST) also demonstrated no significant differences (SMD 0.744, I = 49.82%, p = 0.144) between open and arthroscopic resection, but the analysis again favored open resection. The pooled estimate for VAS assessment of pain demonstrated no differences (SMD 0.217, I = 58.96%; p = 0.404) between open and arthroscopic resection.

Conclusion: The results of this study suggest that similar functional and clinical outcomes can be achieved with either open or arthroscopic distal clavicle resection. The observed trend that open resection may have a more favorable outcome warrants further investigation.

Level Of Evidence: Level 3; systematic review and meta-analysis.
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http://dx.doi.org/10.1007/s00402-019-03114-wDOI Listing
May 2019

Regenerative rehabilitation: The role of mechanotransduction in orthopaedic regenerative medicine.

J Orthop Res 2019 06 16;37(6):1263-1269. Epub 2019 Jan 16.

AO Research Institute Davos, Davos, Switzerland.

Regenerative rehabilitation is an emerging area of investigation that seeks to integrate regenerative medicine with rehabilitation medicine. It is based on the realization that combining these two areas of medicine at an early stage of treatment will produce a better clinical outcome than the traditional linear approach of first administering the elements of regeneration followed, after a delay, by rehabilitation. Indeed, in certain settings, a case can be made for initiating rehabilitation protocols before starting regenerative intervention. This review summarizes the contents of a workshop held during the 2018 annual meeting of the Orthopaedic Research Society. It introduced the concept of regenerative rehabilitation and then provided two orthopaedic examples drawn from the domains of cartilage repair and bone healing. Rehabilitation medicine can supply a variety of physical stimuli, including electrical stimulation, thermal stimulation and mechanical stimulation. Of these, mechanical stimulation has the most obvious relevance to orthopaedics. The mechano-responsiveness of cartilage and bone has been known for a long time, but is poorly understood and has led to only limited clinical application. Improved bioreactor designs that allow multi-axial loading enable new insights into the responsiveness of chondrocytes and chondroprogenitor cells to specific types of load, especially shear. Recent studies on the mechanobiology of bone healing show that modulating the mechanical environment of an experimental osseous lesion by a process of "Reverse Dynamization" soon after injury considerably enhances healing. Future studies are needed to probe the molecular mechanisms responsible for these phenomena and to translate these findings into clinical practice. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:1263-1269, 2019.
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http://dx.doi.org/10.1002/jor.24205DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6546504PMC
June 2019

Swimming induced pulmonary oedema in athletes - a systematic review and best evidence synthesis.

BMC Sports Sci Med Rehabil 2018 1;10:18. Epub 2018 Nov 1.

5Department of Orthopaedic Surgery, Royal Brisbane Hospital, Herston, Australia.

Background: Swimming induced pulmonary oedema is an uncommon occurrence and usually presents during strenuous distance swimming in cold water. The prevalence is most likely underreported and the underlying mechanisms are controversial. The purpose of this study was to summarize the evidence with regards to prevalence, pathophysiology and treatment of swimming induced pulmonary oedema in endurance athletes.

Methods: Medline, Embase, Scopus and Google Scholar were searched and level I-IV from 1970 to 2017 were included. For clinical studies, only publications reporting on swimming-induced pulmonary oedema were considered. Risk of bias was assessed with the ROBINS-I tool, and the quality of evidence was assessed with the Cochrane GRADE system. For data synthesis and analysis, a best evidence synthesis was used.

Results: A total of 29 studies were included (174 athletes). The most common symptom was cough, dyspnoea, froth and haemoptysis. The risk of bias for the clinical studies included 13 with moderate risk, 3 with serious, and 4 with critical. Four of the pathophysiology studies had a moderate risk, 3 a serious risk, and 1 a critical risk of bias. A best evidence analysis demonstrated a strong association between cold water immersion and in increases of CVP (central venous pressure), MPAP (mean pulmonary arterial pressure), PVR (peripheral vascular resistance) and PAWP (pulmonary arterial wedge pressure) resulting in interstitial asymptomatic oedema.

Conclusion: The results of this study suggest a moderate association between water temperature and the prevalence of SIPE. The presence of the clinical symptoms cough, dyspnoea, froth and haemoptysis are strongly suggestive of SIPE during or immediately following swimming. There is only limited evidence to suggest that there are pre-existing risk factors leading to SIPE with exposure to strenuous physical activity during swimming. There is strong evidence that sudden deaths of triathletes are often associated with cardiac abnormalities.
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http://dx.doi.org/10.1186/s13102-018-0107-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6211602PMC
November 2018

Inter- and intraclass correlations for three standard foot radiographic measurements for plantar surface angles. Which measure is most reliable?

Foot Ankle Surg 2019 Oct 26;25(5):646-653. Epub 2018 Jul 26.

Department of Orthopaedic Surgery, University of Texas Health Science Center, San Antonio, TX, USA.

Background: The purpose of this study was to evaluate the reliability and reproducibility of three commonly used radiographic measures for plantar surface angles.

Methods: The calcaneal angle (CA), calcaneal pitch angle (CPA), and length-height index (LHI) was measured by three independent examiners on two occasions on lateral foot radiographs. Intra- and inter-rater correlations were calculated using a general linear estimate model and post-hoc tests for repeated measures. Bland-Altman's plots with limits of agreement were used for observer differences in scores.

Results: The intra-class correlations for the CA ranged from 0.91 to 0.94, for the CPA from 0.93 to 0.98, and for the LHI from 0.96 to 0.97. The inter-class correlations were 0.80 for CA, 0.83 for CPA and 0.93 for LHI.

Conclusions: The results of this study strongly suggest that the length-height index was the most consistent and reliable measure for arch height.

Level Of Evidence: Diagnostic Level II, validity.
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http://dx.doi.org/10.1016/j.fas.2018.07.007DOI Listing
October 2019

Orthopaedic Academic Activity in the United States: Bibliometric Analysis of Publications by City and State.

J Am Acad Orthop Surg Glob Res Rev 2018 Jul 23;2(7):e027. Epub 2018 Jul 23.

Valiant Clinic/Houston Methodist Group, Dubai, United Arab Emirates (Dr. Hohmann); the Faculty of Health Sciences, Medical School, University of Pretoria, Pretoria, South Africa (Dr. Hohmann); the Department of Orthopaedic Surgery, University of Texas Health Center, San Antonio, TX (Dr. Glatt); the Orthopaedic Research Centre of Australia, Brisbane, Australia (Dr. Glatt and Dr. Tetsworth); the Department of Orthopaedic Surgery, Royal Brisbane Hospital, Herston, Australia (Dr. Tetsworth); and the Department of Surgery, School of Medicine, University of Queensland, Queensland, Australia (Dr. Tetsworth).

Background: The purpose of this study was to conduct a bibliometric analysis of orthopaedic academic output in the United States.

Methods: Publications based on city and state origin, corrected for population size, median household income, total number of surgeons, and the number of various subspecialties were evaluated. The 15 highest-ranked orthopaedic journals were audited from 2010 to 2014 and then subdivided into anatomic regions and 14 subspecialties.

Results: A total of 8,100 articles were published during the study period. Most originated from New York, California, Pennsylvania, Massachusetts, and Minnesota. New York published the greatest number by city, followed by Philadelphia, Boston, Chicago, and Rochester. When adjusted for the number of publications per city, surgeons per population, publications per surgeon population, publications per population, and publications per median income per capita, Vail and New York led in two and Stanford in one of the metrics.

Conclusions: New York was the leader for the total publications, greatest activity within subspecialties, and publications per surgeon/population and per median income/capita. Vail was the leader for publications/surgeon and population. The top four cities of New York, Philadelphia, Boston, and Chicago were responsible for 28% of the academic output over the 5-year study period.
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http://dx.doi.org/10.5435/JAAOSGlobal-D-18-00027DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6145550PMC
July 2018

Preliminary results using patient-specific 3d printed models to improve preoperative planning for correction of post-traumatic tibial deformities with circular frames.

Injury 2018 Sep;49 Suppl 2:S51-S59

Orthopaedic Research Center of Australia, Brisbane, Australia; Department of Orthopaedic Surgery, University of Texas Health Science Center San Antonio, TX, USA.

Background: Preoperative planning for circular external fixators is considered vital towards achieving the best results for complex post-traumatic tibial deformities, and patient-specific 3D printed (3DP) models were used here as a planning aid. The main goal was to investigate the fidelity of the preoperative planning process, by assessing the potential to reduce operative time and determining the need to adjust pre-constructed frames intra-operatively.

Patients And Methods: Nine patients (10 limbs) underwent treatment for post-traumatic tibial complications using circular external fixation. These were compared to 10 similar cases where a 3DPM was not used as a pre-operative planning aide (Control group). Patient-specific models of affected bones were printed, and preoperative planning was performed using conventional techniques and Hexapod-assisted software. Detailed planning in a virtual procedure determined osteotomy levels and identified sites for wires and half-pins. The prototype of the external fixator was locked in this optimized configuration, removed from the model, and sterilized prior to the actual procedure.

Results: Nine patients with 10 limbs were treated for complications following tibial fractures. Seven were infected non-unions, and three cases were malunions. For all cases a CT based 3DP model of the full tibia was used in the preoperative planning stage. Image analysis required a mean of 1.7 h, with an average of 14.9 h to 3D print each model. In the control group (without a 3D model), the mean surgical time was 329 min (180-680). The mean surgical time in the 3DPM group was only 172.4 min (72-240), (p = 0.024), reducing the surgery time by 48%. For the 3DPM group it was not necessary to modify the preassembled frame in any case, while in the Control group, the pre-constructed frame required intra-operative modifications in 8 of the 10 cases (p = 0.0007).

Conclusion: Using patient-specific 3D models has allowed us to carry out meticulous preoperative planning sessions, eliminating the need to modify or alter the frame assembly in the operating room, saving substantial surgical time and enabling a more precise design of the apparatus. This was especially useful in multiplanar deformities and for the spatial configuration of the foot support, talus ring, and ankle ring.
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http://dx.doi.org/10.1016/j.injury.2018.07.017DOI Listing
September 2018

Minimally Invasive Plate Osteosynthesis of Humeral Shaft Fractures: Current State of the Art.

J Am Acad Orthop Surg 2018 Sep;26(18):652-661

From the Department of Orthopaedic Surgery, Royal Brisbane Hospital, Herston, Australia, and the Department of Surgery, School of Medicine, University of Queensland, Brisbane, Australia (Dr. Tetsworth); the Medical School, University of Queensland, Brisbane, Australia, the Faculty of Health, University of Pretoria, Pretoria, South Africa, and the Valiant Clinic/Houston Methodist Group, Dubai, United Arab Emirates (Dr. Hohmann); and the University of Texas Health Science Center, San Antonio, TX (Dr. Glatt).

Most closed humeral shaft fractures can be successfully managed nonsurgically. However, fractures for which closed treatment is unsuccessful are stabilized using either plates or intramedullary nails. There are shortcomings associated with each technique, including the potential complications of nonunion, infection, shoulder pain, and radial nerve injury. Minimally invasive plate osteosynthesis (MIPO), an innovative alternative treatment, is gaining in popularity. This technique is based on the anterior humeral shaft providing a relatively safe surface for plate application, and limited open exposures proximally and distally allow percutaneous insertion of the necessary implant. More than 40 articles have been published regarding MIPO, and it compares favorably to other available forms of treatment with excellent functional outcomes and a lower rate of iatrogenic radial nerve injury. Larger randomized controlled trials comparing this method with other accepted techniques, including nonsurgical management, are necessary to better define the role of MIPO in the management of humeral shaft fractures.
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http://dx.doi.org/10.5435/JAAOS-D-17-00238DOI Listing
September 2018

The hamstring/quadriceps ratio is an indicator of function in ACL-deficient, but not in ACL-reconstructed knees.

Arch Orthop Trauma Surg 2019 Jan 30;139(1):91-98. Epub 2018 Jul 30.

University of Texas Health Science Center, San Antonio, TX, USA.

Purpose: The purpose of this study was to investigate the isokinetic, eccentric and isometric hamstring/quadriceps (HQ) ratios in patients before and after ACL reconstruction (ACLR) using bone-patellar tendon grafts and to establish the relationships between HQ ratio and knee function.

Methods: Forty-four patients (mean age of 26.6 years) underwent isokinetic testing of quadriceps and hamstring muscles before and after ACLR and HQ ratios were calculated. Lysholm, IKDC and Cincinnati Scores were used to assess function. Isokinetic concentric and eccentric peak torque (Nm/kg) was measured at three different speeds: 60, 120, and 180°/s. Isometric strength was tested at 30° and 60° of knee flexion.

Results: For the isometric tests, the HQ ratio between the involved and non-involved limb was not different for the ACLD knee (p = 0.28) at 30° knee flexion, but significant at the 60° flexion angle (p = 0.02) and for the ACLR knees at 30° and 60° (p = 0.02). For the isokinetic tests, the ratio between involved and non-involved limb was significant for ACL-deficient knees at both 60 (p = 0.039) and 120°/s (p = 0.05). There were significant differences between limbs for all speeds in ACLR knees (p = 0.0003-0.01). For the eccentric tests, the HQ ratio between the involved and non-involved limbs was not significant for both the ACLD (p = 0.19) and ACLR knees (p = 0.29) at the speed of 60°/s. At 120 and 180°/s, there were significant differences between limbs for both the ACLD (p = 0.02) and ACLR knees (p = 0.003). Linear regression did not reveal significant relationships between Cincinnati, Lysholm, and IKDC scores and HQ ratios in the ACLD (R = 0.35, p = 0.58; R = 0.34, p = 0.63; R = 0.38, p = 0.49). In contrast, there were significant correlations between the Lysholm and IKDC scores and HQ ratios in the ACLR knees (R = 0.84, p = 0.002; R = 0.86, p = 0.001).

Conclusions: The findings of this study suggest that the HQ ratio in ACLD patients was not a predictor, but an indicator of patient-perceived knee function following ACLR.

Level Of Evidence: Level IV, case series.
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http://dx.doi.org/10.1007/s00402-018-3000-3DOI Listing
January 2019

Arthroscopic Partial Meniscectomy Versus Physical Therapy for Degenerative Meniscus Lesions: How Robust Is the Current Evidence? A Critical Systematic Review and Qualitative Synthesis.

Arthroscopy 2018 09 20;34(9):2699-2708. Epub 2018 Jul 20.

Department of Orthopaedic Surgery, University of Connecticut, Farmington, Connecticut, U.S.A.

Purpose: The purpose of this systematic review was to investigate study quality and risk of bias for randomized trials comparing partial meniscectomy with physical therapy in middle-aged patients with degenerative meniscus tears.

Methods: A systematic review of Medline, Embase, Scopus, and Google Scholar was performed from 1990 through 2017. The inclusion criteria were at least 1 validated outcome score, and middle-aged patients (40 years and older) with a degenerative meniscus tear. Studies with a sham arm, and acute and concomitant injuries were excluded. Risk of bias was assessed with the Cochrane Risk of Bias Tool. The quality of studies was assessed with the Cochrane GRADE tool and quality assessment tool (Effective Public Health Practice Project). Publication bias was assessed by funnel plot and Egger's test. The I statistics was calculated a measure of statistical heterogeneity.

Results: Six studies were included, and all were assessed as having a high risk of bias. There was no publication bias (P = .23). All studies were downgraded (low, n = 5; very low, n = 1). The Effective Public Health Practice Project assessed 1 study as strong, 2 as moderate, and 3 as weak. The overall results demonstrated moderate to low quality of the included studies. The I statistic was 96.2%, demonstrating substantial heterogeneity between studies.

Conclusions: The results of this systematic review strongly suggest that there is currently no compelling evidence to support arthroscopic partial meniscectomy versus physical therapy. The studies evaluated here exhibited a high risk of bias, and the weak to moderate quality of the available studies, the small sample sizes, and the diverse study characteristics do not allow any meaningful conclusions to be drawn. Therefore, the validity of the results and conclusions of prior systematic reviews and meta-analyses must be viewed with extreme caution. The quality of the available published literature is not robust enough at this time to support claims of superiority for either alternative, and both arthroscopic partial meniscectomy or physical therapy could be considered reasonable treatment options for this condition.

Level Of Evidence: Level II, systematic review of Level I and II studies.
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http://dx.doi.org/10.1016/j.arthro.2018.04.018DOI Listing
September 2018

Image Analysis Software as a Strategy to Improve the Radiographic Determination of Fracture Healing.

J Orthop Trauma 2018 09;32(9):e354-e358

Department of Orthopaedic Surgery, University of Texas Health Science Center San Antonio, TX.

Objectives: To develop and validate an unbiased, accurate, convenient, and inexpensive means of determining when an osseous defect has healed and recovered sufficient strength to allow weight bearing.

Methods: A novel image processing software algorithm was created to analyze the radiographic images and produce a metric designed to reflect the bone strength. We used a rat femoral segmental defect model that provides a range of healing responses from complete union to nonunion. Femora were examined by x-ray, micro-computed tomography and mechanical testing. Accurate simulated radiographic images at different incident x-ray beam angles were produced from the micro-computed tomography data files.

Results: The software-generated metric (SC) showed high levels of correlation with both the mechanical strength (τMech) and the polar moment of inertia (pMOI), with the mechanical testing data having the highest association. The optimization analysis yielded optimal oblique angles θB of 125 degrees for τMech and 50 degrees for pMOI. The Pearson R values for the optimized model were 0.71 and 0.64 for τMech and pMOI, respectively. Further validation using true radiographs also demonstrated that the metric was accurate and that the simulations were realistic.

Conclusions: The preliminary findings suggest a very promising methodology to assess bone fracture healing using conventional radiography. With radiographs acquired at appropriate incident angles, it proved possible to accurately calculate the degree of healing and the mechanical strength of the bone. Further research is necessary to refine this approach and determine whether it translates to the human clinical setting.
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http://dx.doi.org/10.1097/BOT.0000000000001234DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6103842PMC
September 2018

The mechanical properties of fresh versus fresh/frozen and preserved (Thiel and Formalin) long head of biceps tendons: A cadaveric investigation.

Ann Anat 2019 Jan 4;221:186-191. Epub 2018 Jun 4.

Department of Orthopaedic Sports Medicine, Technical University of Munich, Germany.

Human cadaveric specimens commonly serve as mechanical models and as biological tissue donors in basic biomechanical research. Although these models are used to explain both in vitro and in vivo behavior, the question still remains whether the specimens employed reflect the normal in vivo situation. The mechanical properties of fresh-frozen or preserved cadavers may differ, and whether they can be used to reliably investigate pathology could be debated. The purpose of this study was to therefore examine the mechanical properties of cadaveric long biceps tendons, comparing fresh (n=7) with fresh-frozen (n=8), formalin embalmed (n=15), and Thiel-preserved (n=6) specimens using a Universal Testing Machine. The modulus of elasticity and the ultimate tensile strength to failure was recorded. Tensile failure occurred at an average of 12N/mm in the fresh group, increasing to 40.1N/mm in the fresh-frozen group, 50.3N/mm in the formalin group, and 52N/mm in the Thiel group. The modulus of elasticity/stiffness of the tendon increased from fresh (25.6MPa), to fresh-frozen (55.3MPa), to Thiel (82.5MPa), with the stiffest being formalin (510.6MPa). Thiel-preserved and formalin-embalmed long head of biceps tendons and fresh-frozen tendons have a similar load to failure. Either the Thiel or formalin preserved tendon could therefore be considered as alternatives for load to failure studies. However, the Young's modulus of embalmed tendons were significantly stiffer than fresh or fresh frozen specimens, and these methods might be less suitable alternatives when viscoelastic properties are being investigated.
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http://dx.doi.org/10.1016/j.aanat.2018.05.002DOI Listing
January 2019

Functional outcomes of the failed plate fixation in distal tibial fractures salvaged by hexapod external fixator.

Eur J Orthop Surg Traumatol 2018 Dec 24;28(8):1617-1624. Epub 2018 May 24.

School of Medicine, University of Pretoria, Pretoria, South Africa.

Purpose: The purpose of this study was to evaluate the clinical and functional outcomes of failed plate fixation in distal tibia fractures salvaged with hexapod circular fixators.

Materials And Methods: The database of a specialized limb reconstruction center was searched for all patients with failed plate fixation undergoing limb reconstruction with a circular external fixator between 2008 and 2017. Patients between the ages of 18-65 years, with a symptomatic distal tibia malunion or non-union following plate and screw fixation were included. The SF-12 and Foot Function Index (FFI) scoring systems were used to measure clinical and functional outcomes.

Results: Ten patients with a mean age of 38 ± 13 years met the inclusion criteria. Seven patients had an infected non-union, two hypertrophic non-unions, and one a malunion. The mean follow-up was 41.7 ± 28.3 months. The mean duration of external fixation was 232.9 ± 146.6 days. The SF-12 demonstrated a mean score of 49.4 ± 7.7 for the physical component and a mean score of 55.3 ± 8.1 for the mental component. Five patients (50%) scored above 45 points for the SF12 physical component, and nine patients (90%) scored above 45 points for the mental component, indicating good outcome can be achieved. The mean FFI score was 24.9 ± 19.9, and six patients had a score below 14 points (good outcome). Radiological union was observed in all 10 patients at a mean of 29 ± 14 months.

Conclusions: The results of this study suggest that hexapod circular external fixation is an attractive surgical alternative for the treatment of failed plate fixation of distal tibial fractures, and can reliably achieve bony union and result in very satisfactory clinical outcomes.

Level Of Evidence: Level IV case series.
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http://dx.doi.org/10.1007/s00590-018-2231-xDOI Listing
December 2018

Two-Stage Osseointegrated Reconstruction of Post-traumatic Unilateral Transfemoral Amputees.

Mil Med 2018 03;183(suppl_1):496-502

Royal Brisbane Hospital, Level 7, Ned Hanlon Building Butterfield street, Herston, Brisbane, QLD 4029, Australia.

A new technique called osseointegration was introduced recently by intimately connecting the artificial limb prosthesis to the residual bone, eliminating the problematic socket-residuum interface. The objective here is to describe the two-stage strategy for the osseointegrated reconstruction of amputated limbs and discuss the clinical outcomes of the procedure. This is a prospective case series of 37 post-traumatic unilateral transfemoral amputees with a minimum 2-yr follow-up. Outcome measures included the Questionnaire for persons with a Transfemoral Amputation (Q-TFA), the Short Form Health Survey 36 (SF-36), the 6 Minute Walk Test (6MWT), and Timed Up and Go (TUG) tests. Adverse events including infection, revision surgery, fractures, and implant failures were reported. Clinical outcomes for all outcome measures were significantly improved at follow-up. Twelve participants were wheelchair bound pre-operatively; however, all 12 were able to ambulate after osseointegrated reconstruction. Sixteen patients experienced infection episodes but were managed successfully without the need for implant removal. One periprosthetic fracture occurred due to increased activity, which was revised successfully. These results confirm that the procedure is a suitable alternative for post-traumatic unilateral transfemoral amputees experiencing socket-related discomfort, with the potential to reduce recovery time compared with other treatment protocols.
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http://dx.doi.org/10.1093/milmed/usx185DOI Listing
March 2018