The Increased Tibiofemoral Rotation: A Potential Contributing Factor for Patellar Maltracking in Patients with Recurrent Patellar Dislocation

ObjectiveThe purpose of this study was to analyze the relationship between tibiofemoral rotation and patellar maltracking in patients with recurrent patellar dislocation.MethodsA total of 143 consecutive knees (118 patients) with clinically diagnosed recurrent patellar dislocation from January 2018 to December 2019 were retrospectively analyzed. Patellar tilt angle and bisect offset index were recorded on axial CT to assesses the severity of patellar maltracking. Tibiofemoral rotation angle is measured by comparing the angle between the posterior femoral and tibial condylar lines on three‐dimensional CT. The Pearson correlation was calculated to investigate the association between tibiofemoral rotation angle and patellar maltracking. Patients were divided into the rotation group (≥15°) and control group (<15°) based on the value of tibiofemoral rotation and a further comparison was performed. To further clarify the complicated relationship among tibial tubercle‐trochlear groove (TT‐TG), tibial tubercle‐posterior cruciate ligament distance (TT‐PCL), tibiofemoral rotation, and patellar maltracking, patients were divided into four subgroups according to the value of TT‐TG and TT‐PCL.ResultsThe mean preoperative tibiofemoral rotation angle was 12° ± 6° (range, 0°–31°). Pearson correlation between patellar maltracking parameters (bisect offset index, patellar tilt angle) and various bony deformities found that the tibiofemoral rotation angle was moderately correlated with bisect offset index (r = 0.451, p < 0.001) and patellar tilt angle (r = 0.462, p < 0.001). Further results demonstrated that bisect offset index (152.1 vs 121.2, p < 0.001) and patellar tilt angle (41.2° vs 33.5°, p < 0.001) were significantly higher in the rotation group than that in control group. For patients with a TT‐TG distance of >20 mm, the increased TT‐TG distance was mainly caused by tibiofemoral rotation angle in group C (TT‐TG > 20 mm, TT‐PCL < 24 mm) and predominantly induced by tibial tubercle lateralization in group D (TT‐TG > 20 mm, TT‐PCL > 24 mm). Bisect offset index and patellar tilt angle were significantly higher in the group C than group D.ConclusionThe increased tibiofemoral rotation angle is associated with patellar maltracking in patients with recurrent patellar dislocation. Patients with increased tibiofemoral rotation angle usually have more severe patellar maltracking.     

Patellar Resurfacing in Primary Total Knee Arthroplasty: A Meta‐analysis and Trial Sequential Analysis of 50 Randomized Controlled Trials

ObjectiveDuring total knee arthroplasty, femur and tibia parts are regularly replaced, while resurfacing the patellar or not is an ongoing discussion. To compare revision rate, anterior knee pain rate, patient‐reported outcome measures, complication, radiographic, and clinical outcomes after patellar resurfacing versus non‐resurfacing in total knee arthroplasty.MethodsPubMed, Medline, EMBASE, CENTRAL, and CINAHL databases were searched on 25 April 2021 to enroll randomized controlled trials that compared patellar resurfacing versus non‐resurfacing. We used the grading of recommendations assessment, development and evaluation (GRADE) framework to assess the certainty of evidence. Our primary outcome was revision rate and secondary outcomes was anterior knee pain rate. Outcomes were pooled using the random‐effect model and presented as risk ratio (RR), or mean difference (MD), with 95% confidence interval (CI).ResultsFifty studies (5586 knees) were included. Significant reductions in patellar revision rate (RR 0.41, 95% CI [0.19, 0.88]; P = 0.02; I ² = 24.20%) and non‐patellar revision rate (RR 0.64, 95% CI [0.55, 0.75]; P < 0.001; I ² = 0%) were seen after patellar resurfacing. Patellar resurfacing significantly reduced the anterior knee pain rate than nonresurfacing (RR 0.72, 95% CI [0.57, 0.91]; P = 0.006; I ² = 69.5%). Significant differences in patient‐reported outcome measures were found. However, these differences were inconsistent and lacked clinical importance. Patellar resurfacing resulted in a significant lower rate of patellar clunk (RR 0.58, 95% CI [0.38, 0.88]; P = 0.01; I ² = 0%), a higher patellar score (MD 1.24, 95% CI [0.67, 0.81]; P < 0.001; I ² = 73.8%), but prolonged surgical time (MD 8.59, 95% CI [5.27, 11.91]; P < 0.001; I ² = 88.8%).ConclusionsThe clear relationship is that patellar resurfacing reduces revisions, anterior knee pain, and patellar clunk. It will be interesting to compare the initial cost with the revision cost when required and cost‐utility analysis with long‐term results in future studies.     

An Accuracy Comparison of Minimally Invasive Transclavicular‐Transcortical Drilling with Free‐Hand,C‐Shape and Assembly‐Type Guide Device: An In Vitro Study

ObjectivesEnsuring the accuracy of transclavicular‐transcoracoid drilling in the anatomical reconstruction of the coracoclavicular ligament complex with minimally invasive incisions remains a major problem for inexperienced surgeons. The purpose of this study was to design an assembly guide device for transclavicular‐transcoracoid drilling with minimally invasive incisions, to manufacture the finished product, and to compare its feasibility and accuracy with the existing C‐shape guide devices and free‐hand techniques.MethodsAn assembly‐type guide device was designed and produced using computer‐aided design and three‐dimensional printing. The specimen data of 54 human shoulders from 27 gross specimen (14 males and 13 females) treated by free‐hand drilling, C‐shape device drilling, and assembly‐type guide device drilling from October 2018 to January 2021 were analyzed in a controlled laboratory study. Fifty‐four human shoulder specimens were randomly assigned into free‐hand (n = 18), C‐shape (n = 18), and assembly (n = 18) groups by drawing lots for transclavicular‐transcoracoid drilling by three inexperienced surgeons. After the drilling procedure was completed and the devices were removed, the operation outcomes were assessed and evaluated. Distances from the tunnel edge to the coracoid''s medial (d _m) and lateral (d _l) edges, operation time, and tunnel location zones on the coracoid''s inferior surface of all specimens in the three groups were measured to evaluate the surgical accuracy and efficiency.ResultsAll specimens in the three groups completed the drilling operation successfully and were correctly measured. The distance differences (d _d) between d _m and d _l in the free‐hand, C‐shape, and assembly groups were 3.2 ± 1.8 mm, 1.8 ± 1.0 mm, 1.0 ± 0.8 mm, respectively. The d _d of the free‐hand group was higher than that of the other two groups (p < 0.001). The tunnel exit points on the inferior coracoid surface located in undesired zones were six (33%), one (6%), and zero in the free‐hand group, C‐shape group, and assembly‐type group, respectively (p = 0.012). The operation time in the free‐hand, C‐shape, and assembly groups were 198 ± 36 s, 256 ± 64 s, and 353 ± 88 s, respectively. The operation time of each group significantly differed from that of the others (p < 0.001).ConclusionThe assembly‐type devices may be the first choice for inexperienced surgeons while both the C shape devices and assembly‐type guide devices achieved higher accuracy than free‐hand techniques.     

Posteromedial Corner Release with the Knee in Figure‐of‐Four Position vs Conventional Position for Varus Knee Arthroplasty

ObjectiveTo introduce posteromedial corner release with the knee in the figure‐of‐four position versus the conventional position for varus knee arthroplasty.MethodsThis is a retrospective study. From March 2015 to September 2019, a series of 123 patients (139 knees) with varus knee were randomly and blindly allocated to experimental group (60 patients; 68 knees) and control group (57 patients; 65 knees). Patients in experimental group underwent posteromedial corner release with the knee in the figure‐of‐four position; and patients in control group with the knee in the conventional position. If soft tissue balance was not completely achieved or the medial gap was still tight, an additional loosening technique were used to achieve symmetric medial and lateral space in both groups. Time for soft tissue balancing was defined as the time from the start of the spacer test to the end of the balance test. Length of release was defined as the distance from the osteotomy surface of the tibial plateau to the farthest structures released. The rating system of Hospital for Special Surgery (HSS) knee score was used to evaluate the clinical results. Quantitative variables were described as mean and standard deviation, and compared by one‐way analysis of variance.ResultsThe mean age of experimental group and control group was 70.2 ± 8.7 years and 68.7 ± 6.2 years, respectively (P > 0.05). Preoperatively, the mean HSS score of the groups was 38.2 ± 11.3 and 39.1 ± 10.7, respectively (P > 0.05). The mean varus knee angle was 19.7° ± 9.3° and 19.3° ± 10.7°, respectively (P > 0.05). The mean time for soft tissue balancing was 8.4 ± 3.3 min and 11.3 ± 6.9 min in experimental and control group, respectively (P < 0.05). The mean length of releasing posteromedial corner structures was 35.5 ± 13.4 mm and 27.3 ± 9.7 mm in experimental and control group, respectively (P < 0.05). Additional special loosening techniques were performed in eight knees in experimental group and seven knees in control group. The HSS scores 5 years after surgery were 95.1 ± 16.9 and 94.8 ± 17.2 respectively (P > 0.05). No complications were found during the follow‐up time, and the clinical symptoms were observed to be significantly improved in the patients.ConclusionThe posteromedial corner can be released more extensively and thoroughly when the knee is placed in the figure‐of‐four position during varus knee arthroplasty.     

Spine‐Pelvis‐Hip Alignments in Degenerative Spinal Deformity Patients and Associated Procedure of One‐Stage Long‐Fusion with Multiple‐Level PLIF or Apical‐Vertebra Three Column Osteotomy–a Clinical and Radiographic Analysis Study

ObjectiveTo explore the spine‐pelvis‐hip alignments in degenerative spinal deformity (DSD) patients, and compare the outcomes in the procedure of long‐fusion with posterior lumbar inter‐body fusion (PLIF) or single‐level three‐column osteotomy (STO) at lower lumbar level (LLL, L₃‐S₁) and thoracolumbar levels (TLL, T₁₀‐L₂) for those patients.MethodsThis is a retrospective study. Following institutional ethics approval, a total of 83 patients (Female, 67; Male, 16) with DSD underwent long‐fusion with PLIF or STO surgery between March 2015 and December 2017 were reviewed. All of those patients were assigned into LLL and TLL groups. The average age at surgery was 65.2 years (SD, 8.1). Demographic (age, gender, BMI, and comorbidities), radiographs (both coronal and sagittal parameters) and health‐related quality of life (HRQOL) assessments were documented. The radiographic parameters and HRQOL‐related measurements at pre‐ and post‐operation were compared with paired‐samples t test, and those variables in the two groups were analyzed using an independent‐sample t test. The relationships between pelvic incidence (PI) and other sagittal parameters were investigated with Pearson correlation analysis. The Pearson χ² or Fisher''s exact was carried out for comparison of gender, incidence of comorbidities and post‐operative complications.ResultsThere were 53 and 30 patients in the LLL and TLL groups respectively. Those spino‐pelvic radiographic parameters had significant improvements after surgeries (P < 0.001). The patients in the two group with different pre‐operative thoracolumbar kyphosis (TLK, P = 0.003), PI (P = 0.02), and mismatch of PI minus lumbar lordosis (PI‐LL, P = 0.01) had comparable post‐operative radiographic parameters except PI (P = 0.04) and pelvic‐femur angle (PFA, P = 0.02). Comparing the changes of those spine‐pelvic‐hip data during surgeries, the corrections of TLK in TLL group were significant larger (P = 0.004). Pearson correlation analysis showed that there were negative relationship between PI and TLK (r = −0.302, P = 0.005), positive relationship between PI and LL (r = 0.261, P = 0.016) at pre‐operation. Those patients underwent the surgical procedure that long‐segment instrumentation and fusion with STO would have higher incidence of complications involving longer operative timing (P = 0.018), more blood loss (P < 0.001), revision surgery (P = 0.008), and cerebrospinal fluid leakage (P = 0.001). All the HRQOL scores significantly improved at final follow‐up (P < 0.001), with no difference of intra‐group.ConclusionPatients suffered de‐novo scoliosis or hyper‐kyphosis with low PI would be vulnerable to significant thoracolumbar degeneration, and have more changes of spine‐pelvis‐hip data after long‐fusion surgery, however, those with high PI would be closed to significant lumbar degeneration. Although spine‐pelvis‐hip alignments in DSD patients can be restored effectively after long‐fusion with PLIF or STO, the incidence of complications in patients underwent STO was significant higher than that in patients performed multi‐level PLIF.     

Anterior Cervical Discectomy and Fusion Combined with Foraminotomy Assisted by High‐Definition 3‐Dimensional Exoscope in the Treatment of Cervical Spondylotic Radiculopathy Secondary to Bony Foraminal Stenosis

ObjectiveTo evaluate the outcomes of cervical spondylotic radiculopathy secondary to bony foraminal stenosis treated with anterior cervical discectomy and fusion (ACDF) combined with anterior cervical foraminotomy (ACF) assisted by High‐Definition 3‐Dimensional Exoscope.MethodsIn this retrospective study, a total of 19 consecutive patients (12 males and seven females, with an average of 49.2 years, range from 40 to 59 years) with spondylotic radiculopathy caused by bony foraminal stenosis underwent ACDF combined with ACF assisted by High‐Definition 3‐Dimensional Exoscope in our hospital between January 2019 and December 2019 were included in this study. All patients signed the consent form before the surgery. The patient baseline information such as gender, age, body mass index (BMI), surgery time, blood loss, hospital stay, lesion segment, side, follow‐up time and postoperative complications were recorded. The Japanese Orthopedic Association (JOA), Neck Disability Index (NDI), and Visual Analogue Scale (VAS) were measured and compared before surgery, 1 months and final follow‐up after surgery. The radiographic outcomes were evaluated using the C₂‐C₇ angel, disc height, foraminal height, superior diagonal distance, inferior diagonal distance, and foraminal area.ResultsThe involved levels included C₄‐C₅ (six cases), C₅‐C₆ (10 cases), C₆‐C₇ (three cases). The mean duration of the surgery, mean blood loss, mean hospital stay, and mean follow‐up were 100 ± 11.10 min, 19.4 ± 7.05 mL, 7.1 ± 0.99 days, and 12.1 ± 2.25 months, respectively. The average preoperative JOA score was 11.9 ± 1.31, then improved to 15.7 ± 0.73 (t = −13.45, P < 0.001) and 16.2 ± 0.74 (t = −14.39, P < 0.001) at 1 month after operation and at last follow‐up, respectively. The average preoperative NDI score was 27.3 ± 3.36, then decreased to 5.1 ± 1.79 (t = 20.63, P < 0.001) and 4.5 ± 1.21 (t = 25.53, P < 0.001) 1 month after operation and at last follow‐up, respectively. The average preoperative VAS score was 6.7 ± 0.93, then decreased to 2.4 ± 0.69 (t = 15.05, P < 0.001) and 1.9 ± 0.78 (t = 16.40, P < 0.001) 1 month after operation and at last follow‐up, respectively. As compared with the condition before surgery, there was a significant improvement in the C₂‐C₇ angel, disc height, foraminal height, and foraminal area (P < 0.05). None of the patients developed postoperative vascular injury, nerve injury, loosening and rupture of the internal fixation, displacement of interbody fusion cage, and pseudarthrosis.ConclusionACDF combined with ACF assisted by High‐Definition 3‐Dimensional Exoscope is effective and safe for the treatment of CSR caused by secondary to bony foraminal stenosis.     

Effects of Platelet‐Rich Plasma on Tendon‐Bone Healing After Anterior Cruciate Ligament Reconstruction

ObjectiveTo investigate the effect of platelet‐rich plasma on tendon‐bone healing after anterior cruciate ligament reconstruction.MethodsThis retrospective study included 85 patients (range, 18–50 years; mean age, 33.95 ± 10.53 years; male/female, 49/36) who underwent anterior cruciate ligament reconstruction using autologous hamstring tendons between August 2017 and June 2019 at our institute. The participants in the study group (n = 42) were injected with platelet‐rich plasma at both ends of the tendon graft, while those in the control group (n = 43) received an injection of normal saline. Magnetic resonance imaging signal/noise quotient values of the femoral and tibial ends, knee Lysholm scores, and International Knee Documentation Committee scores were compared at 3, 6, and 12 months postoperatively.ResultsThe signal/noise quotient values of the femoral and tibial ends in both groups were higher at 6 months than at 3 and 12 months postoperatively. The signal/noise quotient values of the tibial end were significantly lower in the platelet‐rich plasma group than in the normal saline group at all follow‐up time points (P < 0.05). The signal/noise quotient values of the tibial and femoral ends in both groups were significantly different at 3, 6, and 12 months postoperatively (P < 0.05). Additionally, the signal/noise quotient values of the tibia were significantly lower than those of the femur in both groups (P < 0.05). The Lysholm and International Knee Documentation Committee scores were significantly better in the platelet‐rich plasma group than in the normal saline group only at 3 months postoperatively. No complications, such as knee joint infection or vascular and nerve injuries, occurred in any of the 85 patients. The knee flexion of all patients were more than 90°, and the straight degree was 0°. No joint stiffness was observed in all patients.ConclusionPlatelet‐rich plasma can promote tendon‐bone healing in grafts and can improve early postoperative knee joint function.     

Mid‐ to Long‐Term Clinical Outcomes of Cartilage Restoration of Knee Joint with Allogenic Next‐Generation Matrix‐Induced Autologous Chondrocyte Implantation (MACI)

ObjectiveCartilage defect is a common pathology still lacking a unified treating option. The purpose of this retrospective study is to evaluate the safety, efficacy, and clinical and radiological outcome of cartilage restoration of knee joint with allogenic next‐generation Matrix‐Induced Autologous Chondrocyte Implantation (MACI) for the first time, as well as the correlation between postoperative clinical and radiological outcomes and preoperative patient history and demographics.MethodsFrom July 2014 to August 2020, 15 patients who went through cartilage restoration with allogenic next‐generation MACI were included in this study. Patient demographics and PROM including the International Knee Documentation Committee (IKDC) subjective knee score, Lysholm score, Tegner Activity Scale (TAS), and Knee Injury and Osteoarthritis Outcome Score (KOOS) were obtained preoperatively, at 3, 6, 12 months postoperatively and the last follow‐up using an online questionnaire platform. MOCART 2.0 score was calculated at the last follow‐up. Analysis of variance (ANOVA) was used to compare PROM pre‐ and post‐operation, with two‐tailed p < 0.05 defined as statistical significant. Pearson correlation coefficient was used to evaluate correlation between the PROM and MOCART 2.0 score at the last follow‐up with patients demorgraphics.ResultsAll patients were followed for an average of 66.47 ± 24.15 months (range, 21–93). All patients were satisfied with the outcome of the surgery and no complication was reported at the end of the study. No significant improvement was observed until 1 year after the implantation, except for IKDC score at 6 months. All PROM showed significant improvement 1 year post‐op except for Lysholm score and TAS, which also increased significantly at the time of the last follow‐up. Pearson correlation coefficient showed that the size of the defect, before or after debridement, was significantly negatively correlated with final KOOS‐Pain (before debridement: r = −0.57, p < 0.05; after debridement: r = −0.54, p < 0.05) and KOOS‐Symptoms score (before debridement: r = −0.66, p < 0.05; after debridement: r = −0.67, p < 0.05). The MOCART 2.0 score was found significantly and negatively correlated with BMI (r = −0.60, p < 0.05), and significantly and positively correlated with Lysholm score (r = 0.70, p < 0.05).ConclusionThe next generation MACI with autologous chondrocyte and allogenic chondrocyte ECM scaffold could be used to treat focal articular cartilage defect in the knee joint safely and efficiently with lasting promising outcomes for more than 5 years. The size of the defects should be considered the most negatively correlated parameters influencing the postoperative clinical outcomes.     

The Evaluation of Sagittal Pelvic‐Femoral Kinematics in Patients with Cam‐Type Femoracetabular Impingement

ObjectiveTo investigate the sagittal hip‐pelvic kinematics in symptomatic cam‐type femoroacetabular impingement (FAI) patients in the process of sitting down and compare their difference between patients with sitting pain complaint and those without.MethodsTwenty‐nine symptomatic cam‐type FAI patients were recruited from our clinic between May 2018 and October 2018. Patients were categorized into two groups depending on whether they complain of pain in prolonged sitting or not. The pelvic‐femoral measurements were assessed with a set of lateral pelvic radiography in sitting and standing respectively. Pelvic incidence (PI), sacral slope (SS), and proximal femoral shaft angle (PFSA) were measured on lateral pelvic radiography, and then pelvic tilting, apparent hip flexion, true hip flexion, and the pelvic‐femoral ratio were calculated to investigate the kinematic change from standing to sitting position. Demographic measurements, hip morphology measurements, functional measurements, visual analog scale (VAS), and pelvic‐femoral measurements were compared between the two groups.ResultsThirteen cases without sitting pain complaint and 16 cases with sitting pain complaint were stratified to Group N and Group P respectively. No was significant difference in age, body mass index (BMI), and gender between the two groups. Hip morphology measurements (α angle and lateral center‐edge angle) and functional measurements (iHOT‐12) showed no significant difference between the two groups. However, the mean VAS of pain while sitting was 0.5 ± 0.4 and 1.6 ± 0.6 in Group N and Group P respectively (P = 0.005). Patients with sitting pain complaint have increased pelvic PI compared to those without (50.1° ± 6.5° and 44.2° ± 7.6°, P = 0. 042). The changes in SS (pelvic tilting) from standing to sitting in Group N was significantly larger than that in Group P (21.8° ± 7.0° and 15.1° ± 6.5°, P = 0.012). Although no significant difference in apparent hip flexion and true hip flexion was found. Patients without sitting pain complaint demonstrated a higher pelvic‐femoral ratio (22.8% ± 7.9% and 16.1% ± 7.5%, P = 0.010) compared to those with sitting pain complaint.ConclusionSagittal pelvic‐femoral kinematics could have an influence on the symptomology of cam‐type FAI. The small PI and insufficient sagittal pelvic tilting in the process of sitting down could be related to the complaint of sitting pain in patients with symptomatic cam‐type FAI.     

Reduction with Pre‐Drilling Combined with a Finger Reduction Tool in Difficult‐to‐Reduce Intertrochanteric Fracture

ObjectiveTo investigate the feasibility of pre‐drilling combined with a finger reduction tool for the reduction of difficult‐to‐reduce intertrochanteric fractures.MethodsPatients diagnosed with complicated intertrochanteric fractures during the period from July 2016 to May 2021 at the Affiliated Hospital of our College were enrolled in this study. All patients underwent reduction by pre‐drilling combined with a finger reduction tool followed by fixing with proximal femoral nail antirotation. The outcome of reduction was evaluated by intraoperative fluoroscopy. The operation time, intraoperative fluoroscopy frequency, and incidence of postoperative complications (including infection in the incision area, coxa vara, nail withdrawal, nail breakage, blade cut‐out, lower limb vein thrombosis, and pulmonary embolism) were recorded to evaluate the speed of the operation, the difficulty of the operation, and the prognosis of the patient, respectively. The Harris hip score at 9 months after surgery was used to evaluate the hip recovery.ResultsA total of 52 patients (17 men and 35 women), 61–88 (77.54 ± 7.40) years of age were included in the study. There were 14 patients with cardiovascular or cerebrovascular disease, ten patients with diabetes, three patients with Parkinson''s disease, and three patients with respiratory diseases. The fractures included in the study were classified according to the Orthopedic Trauma Association 31 classification system as type A2.2 (n = 36) or type A2.3 (n = 16). The time from injury to surgery was 1–11 (3.35 ± 1.78) days, and the operation time ranged 31–101 (65.67 ± 14.17) min. The intraoperative blood loss ranged from 40 to 100 (67.69 ± 18.24) mL, and the number of intraoperative fluoroscopy images obtained was 12 to 32 (20.42 ± 5.27). The Harris hip score at 9 months after surgery ranged from 84 to 94 (90.06 ± 2.15). Patients were followed for 9–16 (10.63 ± 1.61) months. One patient died of acute myocardial infarction at 9 months after surgery. One patient suffered from nail withdrawal 5 months post‐operation and thus underwent hemiarthroplasty.ConclusionsSatisfactory reduction can be achieved using a pre‐drilling femoral trochanter combined with a finger reduction tool for the management of difficult‐to‐reduce complex intertrochanteric fractures. This technique does not increase surgical trauma and also reduces the dose of radiation administered to the patient.     

Combination of Intravenous and Intra‐Articular Application of Tranexamic Acid and Epsilon‐Aminocaproic Acid in Primary Total Knee Arthroplasty: A Prospective Randomized Controlled Trial

ObjectiveThere were limited randomized controlled trials (RCTs) of epsilon‐aminocaproic acid (EACA) versus tranexamic acid (TXA) in total knee arthroplasty (TKA). The aim of the study was to compare the efficacy and safety of TXA and EACA in the combination of intravenous (IV) and intra‐articular (IA) administration on reducing blood loss in patients following primary TKA.MethodsFrom January 2020 to January 2021, a total of 181 patients undergoing a primary unilateral TKA were enrolled in this prospective randomized controlled trial. Patients in the TXA group (n = 90) received 20 mg/kg of intravenous TXA preoperatively, 1 g of intra‐articular TXA intraoperatively, and three doses of 20 mg/kg intravenous TXA at 0, 3, 6 h postoperatively. Patients in the EACA group (n = 91) received 120 mg/kg of intravenous EACA preoperatively, 2 g of intra‐articular EACA intraoperatively, and three doses of 40 mg/kg intravenous EACA at 0, 3, 6 h postoperatively. The primary outcomes were total blood loss (TBL), transfusion rates and drop of hemoglobin (HB) level. The secondary outcomes included postoperative hospital stays and postoperative complications. The chi‐square tests and Fisher''s exact tests were utilized to compare categorical variables, while the independent‐samples t‐tests and Mann–Whitney tests were used to compare continuous variables.ResultsThe patients who received TXA averaged less TBL than the patients who received EACA (831.83 ml vs 1065.49 ml, P = 0.015), and HB drop in TXA group was generally less than that of EACA group on postoperative day 1 and 3 (20.84 ± 9.48 g/L vs 24.99 ± 9.40 g/L, P = 0.004; 31.28 ± 11.19 vs 35.46 ± 12.26 g/L, P = 0.047). The length of postoperative stays in EACA group was 3.66 ± 0.81 day, which is longer than 2.62 ± 0.68 day in TXA group (P < 0.001). No transfusions were required in either group. The risk of nausea and vomiting in TXA group was significantly higher than that in EACA group (11/90 vs 0/91, P < 0.01).ConclusionAlthough the TBL and HB drop were slightly greater in EACA group, these results were not clinically important, given that no transfusions were required. EACA could be an alternative to TXA, especially for patients with severe nausea and vomiting after using TXA postoperatively. Further studies are needed to adjust dosage of EACA to make better comparison of the two drugs.     

One‐Stage Arthroscopic Multiple Ligament Reconstruction for Schenck IV Knee Dislocation

PurposeSchenck IV knee dislocation patients have dissatisfactory knee function and return‐to‐sport rate with the existing treatment methods. The purpose of this study was to illustrate a one‐stage arthroscopic multiple ligament reconstruction method for treating Schenck IV knee dislocations.MethodsA retrospective case series study was performed. All patients with a history of Schenck IV knee dislocation who underwent one‐stage arthroscopic multi‐ligament reconstruction from 2010 to 2018 were followed for 24 months. The outcomes, including general patient data, Lysholm scores, International Knee Documentation Committee (IKDC) scores, visual analog scale (VAS) pain scores, knee active range of motion, and complications, were reviewed. The data was analyzed with paired‐samples t‐test.ResultsA total of 12 patients, comprising nine males and three females, were followed up and reviewed. The mean age at the time of the surgical procedure was 40.3 ± 9.0 (22–57) years. The mean body mass index (BMI) was 24.6 ± 4.9 (15.2–32.5) kg/m². The mean IKDC score and Lysholm score before surgery were 30.4 ± 6.1 (21–42) and 28.2 ± 6.2 (22–39), respectively. The average operation time was 121.8 minutes. The mean IKDC score and Lysholm score at the 24‐month follow‐up were 80.6 ± 6.5 (68–92) and 82.0 ± 7.5 (72–95), respectively. There were significant differences in the IKDC and Lysholm scores between the preoperative and 24‐month postoperative time points (p < 0.01). The mean knee range of motion was 124.6° ± 6.6° (115°–135°) at the 24‐month follow‐up. No major complications occurred.ConclusionsThe results of this retrospective study suggest that the new arthroscopic one‐stage multi‐ligament reconstruction technique is an effective way to treat Schenck IV knee dislocation with satisfactory postoperative knee function.     

Changes in Patellar Morphology Following Soft Tissue Surgical Correction of Recurrent Patellar Dislocation in Children with Low‐Grade Trochlear Dysplasia

ObjectiveTo investigate the changes in patellar morphology following soft tissue surgical correction of recurrent patellar dislocation in children with low‐grade trochlear dysplasia.MethodsThe prospective cohort study was performed between November 2007 and December 2012. Finally, 25 cases, with the mean age of 8.4 years (range from 7 to 10 years), were admitted to the study. All patients were diagnosed as bilateral recurrent patellar dislocation associated with femoral trochlear dysplasia. The knee that suffered injury or was dislocated was treated with medial patellar retinacular plasty (surgery group). The contralateral knee, which served as a control, was treated conservatively (conservative group). Axial CT scans were undertaken in all patients to assess the patellar morphological characteristics.ResultsThe mean follow‐up time was 60.8 months (range 48 to 75 months). Preoperatively, there were no statistically significant differences between the patellar morphology in the two groups (P > 0.05). Many radiological parameters of patellar morphology were significantly different between the two groups at the final follow‐up, including well‐known parameters, such as the mean patellar width (surgery group, 40.58 mm [SD 1.26]; conservative group, 36.41 mm [SD 1.17]; P < 0.05), the mean patellar thickness (surgery group, 11.59 mm [SD 0.74]; conservative group, 9.38 mm [SD 0.56]; P < 0.05) and the mean Wiberg index (surgery group, 0.54 [SD 0.06]; conservative group, 0.72 [SD 0.08]; P < 0.05). There are also little‐known parameters, such as the ratio of length of lateral patella to medial patella (surgery group, 1.26 [SD 0.17]; conservative group, 1.69 [SD 0.21]; P < 0.05), which was a measurement of facet asymmetry. However, the Wiberg angle was not significantly different between the two groups (surgery group, 128.63° [SD 9.05]; conservative group, 125.47° [SD 13.96°]; P > 0.05) at the final follow‐up. No complications were found.ConclusionsThe patellar morphology can be significantly improved by early soft tissue surgical correction in children with patellar instability associated with low‐grade femoral trochlear dysplasia.     

Outcomes of Eight‐Plate Epiphysiodesis for Residual Clubfoot Deformities

ObjectiveThe outcome of congenital clubfoot treatment is still challenging if the feet deformities are not completely corrected. Here we explore a minimal invasive procedure with an eight‐plate implant to correct the residual forefoot adduction deformity after treatment of neglected or relapsed clubfoot.MethodsWe retrospectively reviewed patients with residual forefoot adduction deformity after clubfoot treatment between January 2013 and June 2016. The patients underwent temporary epiphysiodesis of the lateral column of the mid‐foot, which in detail, an eight‐plate was placed on each side of the calcaneocuboid joint. The foot deformities were recorded according to the weight‐bearing radiographic measurements including talo‐first metatarsal angle, calcaneo‐fifth metatarsal angle and medial‐to‐lateral column length.ResultsA total of 13 patients (20 feet) with an average age of 7.8 years old were located with an average duration of 40.8 months follow‐up (range, 28 to 54 months). The average talo‐first metatarsal angle improved from 28.3° (range, 19° to 47°) preoperatively to 8.3° (range, 3° to 18°) and the calcaneo‐fifth metatarsal angle improved from 29.1° (range, 19° to 40°) preoperatively to 8.4° (range, 0° to 21°) at final follow‐up. The mean ratio of the medial‐to‐lateral column length improved from 1.14 ± 0.06 to 1.55 ± 0.09 with statistical significance (t = 3.566; P < 0.001).ConclusionsEight‐plate epiphysiodesis is an easy and effective method for the correction of residual forefoot adduction deformity after clubfoot treatment in growing children without the need of osteotomy.     

Efficacy and Safety of Hyaluronic Acid Intra‐articular Injection after Arthroscopic Knee Surgery: A Systematic Review and Meta‐analysis

ObjectiveHyaluronic acid (HA) intra‐articular injection after arthroscopic knee surgery has been widely applied but its efficacy and safety remain controversial. The aim of this systematic review is to analyze the efficacy and safety of HA intra‐articular injection after arthroscopic knee surgery, and to compare the efficacy of HA with different molecular weights.MethodsWe conducted a systematic literature search in PubMed, Embase, Google scholar and the Cochrane library from inception to 16 September 2022 for English‐written articles, in order to identify randomized controlled trials that evaluated the clinical efficacy and/or safety of HA intra‐articular injection after arthroscopic knee surgery. Then we meta‐analyzed the outcomes of patients given intra‐articular HA injections postoperatively and control patients. We also evaluated the influence of HA with different molecular weights. In every calculation, sensitive analysis was performed. The visual analogue scale (VAS) for pain, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and adverse events were selected as the primary outcome measurements, while Lysholm, International Knee Documentation Committee (IKDC) and Tegner score were selected as the secondary outcome measurements. Publication bias of every outcome was evaluated using egger test.ResultsFifteen studies involving 951 knees were included and 12 of them were used to performed the meta‐analysis. The results showed no significant difference between the HA group and control group according to VAS, whether assessed at less (P = 0.90) or more than 6 months (P = 0.55). Besides, there were no statistical differences between the HA group and control group according to subgroup analysis (Ps = 0.77, 0.91 and 0.81 in anterior cruciate ligament reconstruction, meniscectomy and overall groups, respectively). Compared to control group, the overall effect of WOMAC score showed no significant differences (P = 0.25), nor did in two subgroups (P = 0.37 and P = 0.22). Outcomes measured by Lysholm (P = 0.13), IKDC (P = 0.86) and Tegner (P = 0.42) scores showed no significant differences, either. The analysis of the risk of adverse events indicated no increase in HA groups (P = 0.06). We found no significant differences between high‐ and low‐molecular‐weight HA at 6 (P = 0.96) or 12 months (P = 0.93) postoperatively. Two studies failed to pass the sensitive analysis and the reasons were discussed detailly and acceptable publication bias was observed.ConclusionsAlthough HA injection after arthroscopic knee surgery is safe, the available evidence does not support its efficacy in pain relief and functional recovery. Therefore, the application of HA injection after arthroscopic knee surgery is not recommended.     

A Novel Method of Making Hinges Using a Newly Designed Sharp Rongeur to Enhance Radiological and Clinical Outcomes in French‐Door Cervical Expansive Laminoplasty

ObjectiveAlthough the lamina open angle of making hinges is closely related to the outcomes of French‐door laminoplasty (FDL) for treatment of cervical spondylosis, there have been no methods to predict the lamina open angle preoperatively as yet. The aim of this study was to investigate the accuracy of predicting the laminal open angle using our newly designed sharp rongeur, and to compare the postoperative outcomes and complications between the methods of making hinges using the newly designed sharp rongeur and the traditional high‐speed micro‐drill during the FDL.MethodsThis was a single‐center retrospective study. Following the approval of the institutional ethics committee, a total of 39 patients (Male: 28; Female: 11) diagnosed with cervical spondylos who underwent FDL in our institution between January 2018 and May 2019 were enrolled. Patients were divided into two groups based on the method of making hinges (sharp rongeur: 22 cases; high‐speed micro‐drill: 17 cases). The average age at surgery was 59.1 years (range: 16–85 years). The radiological parameters, clinical outcomes, modified Japanese Orthopaedic Association (mJOA) scale score, and the recovery rate of mJOA were recorded and compared between the groups, respectively. The radiological parameters and clinical measurements at pre‐ and post‐operation stages were compared using the paired‐sample t‐test, the Wilcoxon signed‐rank test, and the Friedman''s test, and variables in the two groups were analyzed using an unpaired Student''s t‐test or a Mann–Whitney U test.ResultsThe average follow‐up period was 20.4 months (range: 14.0–25.9 months), the postoperative open angle was 60.13° ± 3.69° in the rongeur group with 22.78° ± 4.34° of angular enlargement, which was significantly lower than that of 68.96° ± 1.00° in the micro‐drill group with 32.75° ± 4.22° of angular enlargement (U = 19.000, p < 0.001). The rongeur group showed a higher fusion rate (34.1% vs 14.7%, χ ² = 11.340, p = 0.001), and a lower fracture rate of the lamina (7.8% vs 25.5%, χ ² = 14.185, p < 0.001) at 1‐month post‐surgery, compared to the micro‐drill group. There were no significant differences in the clinical outcomes and postoperative complications between the two groups (p > 0.05), except in the recovery rate of mJOA scores (0.836 ± 0.138 vs 0.724 ± 0.180, U = 115.000, p = 0.042) and neck disability index (NDI) at the final follow‐up (7.55 ± 10.65 vs 14.71 ± 8.72, U = 94.000, p = 0.008).ConclusionsThe special sharp rongeur with a tip angle of 20° could be a preferred method to make hinges during FDL, which can predict the laminal open angle accurately and enlarge it to about 23°, thus reducing the fracture rate and accelerating the bony fusion of hinges compared with the outcomes of the traditional micro‐drill method.     

Failure of Posterior Lower Lumbar/Lumbosacral Hemi‐Vertebra Resection: An Analysis of Reasons and Revision Strategies

ObjectiveTo investigate the causes of failed primary surgery and the revision strategies for congenital scoliosis (CS) patients with lower lumbar/lumbosacral (LL/LS) hemi‐vertebra (HV).MethodsFifteen CS patients with LL/LS HV (seven females and eight males) with a mean age of 20.4 ± 10.4 years undergoing revision surgery in our center were retrospectively reviewed. The radiographic parameters including Cobb angle, distance between C₇ plumb line and center sacral vertical line (C₇PL‐CSVL), thoracic kyphosis (TK), lumbar lordosis (LL) and sagittal vertical axis (SVA) were assessed at pre‐revision, post‐revision and the last follow‐up. The causes of failure in primary operation, and radiographic and clinical outcomes of revision procedures were analyzed.ResultsThe revision rate of patients undergoing LL/LS HV resection and correction surgery was 11.4%. The average time interval between primary surgery and revision surgery was 18.2 ± 10.6 months. The operation duration and estimated blood loss of revision surgery were 194 ± 56 min and 326 ± 74 ml, respectively. Reasons for failed primary operations were as follows: internal fixation fracture in 10 cases, curve progression in two cases, implant loose in two cases and post‐operative coronal imbalance in one case. The post‐revision Cobb angle was significantly improved from 29.9° ± 8.3° to 18.7° ± 6.7° (P < 0.001) with a correction rate of 37.5% ± 12.6%. At the final follow‐up, the average Cobb angle was 18.9° ± 6.2° and the correction was well maintained (P = 0.788). The C₇PL‐CSVL at pre‐revision, post‐revision and at last follow‐up were 23.2 ± 9.3 mm, 14.8 ± 4.8 mm and 14.9 ± 5.4 mm, respectively. Significant improvements (P = 0.004) were observed after revision surgery and there was no evident loss of correction (P = 0.703). There was no significant difference in TK, LL and SVA before and after revision surgery (all P > 0.05). At the last follow‐up, no significant correction loss of above coronal and sagittal parameters were observed (all P > 0.05). The revision methods were individualized according to the primary surgical procedures and the reasons for revision. The recommended revision strategies include incision of pseudarthrosis with sufficient bone graft, fixation of satellite rods, thorough residual HV excision, prolonged fusion to S₂ and transforaminal lumbar interbody fusion at lumbosacral region. Solid bony fusion and no implant‐related complication were detected during the follow‐up.ConclusionsThe causes of revision surgery for patients with congenital scoliosis (CS) due to lumbosacral HV were verified and implant failure with pseudarthrosis was the main reason for failed primary operation.     

Fourth‐Generation Ceramic‐on‐Ceramic THA in Patients with Ankylosing Spondylitis: A Minimum 10‐Year Follow‐Up

ObjectiveTo report the long‐term outcomes of total hip arthroplasty (THA) with fourth‐generation ceramic‐on‐ceramic (CoC) bearing in patients with ankylosing spondylitis (AS).MethodsWe retrospectively identified 180 primary THAs performed in 110 patients with AS, including 100 (90.9%) men and 10 women (9.1%), from 2009 to 2011.The mean age of the patients at surgery was 33 years (range, 16 to 65 years). Cementless prostheses with fourth‐generation CoC bearings were used in all patients. Survivorship of the implants and postoperative complications were calculated. Functional improvement was assessed by the hip flexion‐extension range of motion (ROM) and Harris hip score (HHS). A special noise assessment questionnaire was performed at the last follow‐up. The cumulative incidence of noise was calculated by the Kaplan–Meier method with 95% confidence intervals (CIs). Clinical characteristics and functional outcomes were compared in the hips with noise to those without noise.ResultsThe mean follow‐up was 11 years (range, 10 to 12 years), and survivorship of the implants was 99.4% at the most recent follow‐up. The complications included dislocation (one hip, 0.6%), periprosthetic joint infection (one hip, 0.6%), mild to moderate pain (five hips, 2.8%), heterotopic ossification (12 hips, 6.7%), and noise (52 hips, 28.9%). The flexion‐extension ROM improved significantly with a median from 10° (range, 0 ~ 130°) to 100° (30 ~ 130°) after THA (p < 0.001), and the HHS increased significantly from 41 ± 20 to 90 ± 8 (p < 0.001). The cumulative incidence of noise at 0.5, 5, and 10 years was 6.1% (95% CI, 2.6 ~ 9.6), 16.7% (95% CI, 11.2 ~ 22.1), and 28.9% (95% CI, 22.2 ~ 35.5), respectively, and that of squeaking at 0.5, 5, and 10 years was 4.4% (95% CI, 1.4 ~ 7.4), 13.3% (95% CI, 8.4 ~ 18.3), and 23.9% (95% CI, 17.6 ~ 30.1), respectively. None of the patients with noise generation in the hip reported it affecting daily activities or causing dissatisfaction. No differences in age, sex, BMI, disease duration, bilateral THA, the frequency of bony ankylosis, the proportion of using a 36‐mm‐diameter femoral head, pre/postoperative flexion‐extension ROM, or pre/postoperative HHS were found between hips with noise and those without noise (p > 0.05).ConclusionTHAs with fourth‐generation CoC bearings exhibit excellent long‐term survival and clinical outcomes in patients with AS, with a very low dislocation rate. The incidence of noise associated with CoC bearings in THA performed in patients increases over time, but it does not affect postoperative hip function or daily activities.     

The Effects of COVID‐19 on Geriatric Hip Fracture Management and 1‐Year Mortality in Beijing

ObjectivesConcerns about the coronavirus disease 2019 (COVID‐19) pandemic resulted in unprecedented challenges to the management of geriatric hip fractures. We aimed to evaluate the effects of the COVID‐19 surge on the time to surgery and 1 year mortality in geriatric patients with hip fracture at a large, urban Level 1 trauma center in Beijing, and to guide the management of geriatric hip fracture patients throughout the COVID‐19 pandemic.MethodsThis single‐center retrospective study included consecutive patients aged ≥65 years and injured 3 weeks prior to admission. Demographic and surgical data were collected between January 20 and May 31, 2020, and from the same period in 2019. Mortality data and functional status were collected at follow‐up of 1‐year after surgery. The primary outcomes were time to surgery and 1 year mortality.ResultsThere were no significant differences in sex, fracture type, and surgical pattern between the 2020 (n = 261) and 2019 time‐matched (n = 307) cohorts. The time from admission to surgery was significantly delayed in the 2020 cohort compared with that in the 2019 cohort (48.9 h vs 20.5 h, p < 0.001). Fewer patients underwent surgery within 48 h in the 2020 cohort (65.5% vs 87.6%, p < 0.001). Surgical delay was also associated with an increased risk of inpatient complications (30.2% vs 20.8%, p = 0.010), however there was no significant difference in the 1‐year mortality rate, nor between pre‐injury and 1 year follow‐up mobility as assessed by Parker score. Only approximately half of the patients in both groups completely returned to their pre‐injury mobility levels.ConclusionsThe COVID‐19 pandemic has significantly increased the surgery waiting time for geriatric patients with hip fractures, which resulted in increased inpatient complications without a higher mortality rate within 1 year. This reinforces the importance of maintaining timely and protocolized care for geriatric hip fractures throughout any subsequent waves of the pandemic.     

Arthroscopic Modified Double‐Row Biceps Tenodesis versus Labral Repair for the Treatment of Isolated Type II SLAP Lesions in Non‐Overhead Athletes

ObjectiveTo evaluate the postoperative efficacy and the clinical outcomes of arthroscopic modified double‐row biceps tenodesis versus labral repair.MethodsA retrospective study was conducted in 56 patients with isolated type II superior labrum anterior and posterior (SLAP) lesions from March 2015 to November 2018. Thirty patients (male:female = 17:13) were treated with labral repair, and 26 patients (male:female = 15:11) were treated with modified double‐row biceps tenodesis. The average age of the labral repair group and the modified double‐row biceps tenodesis group were 42.8 ± 10.6 and 40.9 ± 10.2 years, respectively. Pre‐ and postoperative assessments with the visual analog scale (VAS), University of California Los Angeles (UCLA), and American Shoulder and Elbow Surgeons (ASES) scores were compared between the two treatment groups. Additional outcome measures included patient satisfaction, the time to return to previous activities, workers'' compensation status, and postoperative complications.ResultsAt a 2‐year follow‐up, the tenodesis group showed significant differences in postoperative VAS (1.5 to 1.8, respectively; p = 0.008), patient satisfaction (92.3% vs. 46.7%, p < 0.001), and recovery time to return to their previous activities (6.8 ± 1.8 vs. 8.1 ± 1.5, p = 0.007) compared to the labral repair group; however, there was no significant difference in postoperative ASES and UCLA scores between the two groups. Additionally, one patient in the tenodesis group developed persistent postoperative stiffness, which was resolved by conservative treatment. In the labral repair group, two patients presented with persistent postoperative night pain, three developed persistent postoperative stiffness, and two required a subsequent capsular release.ConclusionsCompared with the labral repair group, the arthroscopic modified double‐row biceps tenodesis showed more encouraging postoperative pain reduction, earlier recovery to previous activities, and higher patient satisfaction.