Orthopaedic Clinical Practice Research Articles

Orthopaedic Sport Medicine Surgeons and Fellows Value Immersive Virtual Reality for Improving Surgical Training, Procedural Planning, and Distance Learning

BackgroundOverall, the potential utility of iVR technology in orthopaedic surgery is promising. The attitudes of medical students and surgical trainees on VR simulated surgical training have been overwhelmingly positive. However, further research and understanding of the attitudes of practicing orthopaedic surgeons and Fellows are needed to appreciate its benefits for clinical practice. PurposeThe purpose of this study was to assess the attitudes of Canadian orthopaedic surgeons and Fellows on the value of iVR for surgical training, clinical practice, and distance learning. MethodsForty-three orthopedic surgeons and Fellows attended a VRthrscopy™ Knee Module (Conmed Corporation, Largo, USA) demonstration. The view and audio from the lead headset were cast to a large screen so the audience could follow the procedure in real-time. Immediately after the presentation, the audience members were given a paper questionnaire assessing their perceptions and attitudes toward iVR or use in orthopaedic learning, clinical practice and distance education and mentoring. ResultsiVR was perceived to be valuable for the field of orthopaedic surgery. All 13 questions were rated with mean Likert scores of five or greater indicating observed value for all 13 questions. The respondents indicated that iVR had value (score of 5 or greater) in each questionnaire domain, with agreement ranging from 78-98% for teaching and learning, 66-97% for clinical practice, and 88-100% for distance education and mentoring questions. ConclusionThis study has demonstrated that a group of Canadian sport medicine orthopedic surgeons and Fellows had favourable attitudes towards, and perceived that iVR has value in, orthopaedic surgical training, clinical practice, and distance learning and mentorship. The potential for utilizing iVR technology for distance learning, mentorship and global education appears promising.

Gender Representation Among Foot & Ankle Conference Presenters and Research Authors: A 10-Year Analysis (2012-2022)

Introduction/Purpose: Today women are over 50% of medical school matriculants but remain underrepresented in orthopaedic surgery (~15% of residents and < 6% of practicing surgeons). Moreover, despite different and sometimes controversial reports, the rate of female society memberships and national and international meeting speakers as well as their contribution to leadership positions including moderating sessions, podiums, and symposiums are believed to be low. The objective of this study was to assess whether there is a gap in female representation among invited speakers at American Orthopaedic Foot & Ankle Society (AOFAS) national meetings relative to research productivity as reflected by article authorship in Foot & Ankle International journal (FAI). Methods: Programs for AOFAS specialty days and annual meetings and FAI articles from January 2012 to December 2022 were obtained. Industry-hosted programs were excluded. Gender was identified through personal acquaintance or online search on the biographies of the authors. Presentations and articles were categorized as “technical” or “non-technical”, where technical was defined as relating to basic science or the clinical practice of orthopaedics. Comparisons were done using the Chi-Square Test (significance level= p< 0.05). Results: 1,020 AOFAS presentations and 2,230 FAI articles were analyzed. Gender was unavailable for 0.19% of AOFAS speakers, 4.48% of FAI first authors and 4.13% of FAI senior authors. 11.08% of AOFAS invited national meeting speakers, 15.18% of FAI first authors and 7.40% of FAI senior authors were female. Overall, the proportion of female speakers was significantly lower than female first authors (p= 0.0036), and significantly higher than female senior authors (p < 0.001). In 2018 and 2019, women were more likely to have given “non-technical” AOFAS presentations. There was no significant difference in other years or among FAI articles. The average annual change was +2.00% female AOFAS presenters, +0.31% FAI female first authors and -0.37% FAI female senior authors per year. Conclusion: Women represented 15.16% of first authors in FAI between 2012 and 2022 but 11.08% of invited speakers at AOFAS meetings. Meanwhile, the percentage of female AOFAS membership in the organization as a whole increased from 7.5% to 13%. Thus, despite historically low rates of representation, female Foot & Ankle surgeons were proportionally represented in 2021 and 2022 among invited national conference presentations and research compared to female society membership and female research publications in FAI. There is still room to increase representation of deserving historically under-represented groups, however the increase in female AOFAS presenters demonstrates a positive trend. Figure 1. Percentage of AOFAS Female Podium Speakers and FAI Female 1st Authors, 2012 - 2022

Conventional vs Augmented Reality-Guided Lateral Calcaneal Lengthening Simulated in a Foot Bone Model.

Acquired adult flatfoot deformity (AAFD) results in a loss of the medial longitudinal arch of the foot and dysfunction of the posteromedial soft tissues. Hintermann osteotomy (H-O) is often used to treat stage II AAFD. The procedure is challenging because of variations in the subtalar facets and limited intraoperative visibility. We aimed to assess the impact of augmented reality (AR) guidance on surgical accuracy and the facet violation rate. Sixty AR-guided and 60 conventional osteotomies were performed on foot bone models. For AR osteotomies, the ideal osteotomy plane was uploaded to a Microsoft HoloLens 1 headset and carried out in strict accordance with the superimposed holographic plane. The conventional osteotomies were performed relying solely on the anatomy of the calcaneal lateral column. The rate and severity of facet joint violation was measured, as well as accuracy of entry and exit points. The results were compared across AR-guided and conventional osteotomies, and between experienced and inexperienced surgeons. Experienced surgeons showed significantly greater accuracy for the osteotomy entry point using AR, with the mean deviation of 1.6 ± 0.9 mm (95% CI 1.26, 1.93) compared to 2.3 ± 1.3 mm (95% CI 1.87, 2.79) in the conventional method (P = .035). The inexperienced had improved accuracy, although not statistically significant (P = .064), with the mean deviation of 2.0 ± 1.5 mm (95% CI 1.47, 2.55) using AR compared with 2.7 ± 1.6 mm (95% CI 2.18, 3.32) in the conventional method. AR helped the experienced surgeons avoid full violation of the posterior facet (P = .011). Inexperienced surgeons had a higher rate of middle and posterior facet injury with both methods (P = .005 and .021). Application of AR guidance during H-O was associated with improved accuracy for experienced surgeons, demonstrated by a better accuracy of the osteotomy entry point. More crucially, AR guidance prevented full violation of the posterior facet in the experienced group. Further research is needed to address limitations and test this technology on cadaver feet. Ultimately, the use of AR in surgery has the potential to improve patient and surgeon safety while minimizing radiation exposure. Subtalar facet injury during lateral column lengthening osteotomy represents a real problem in clinical orthopaedic practice. Because of limited intraoperative visibility and variable anatomy, it is hard to resolve this issue with conventional means. This study suggests the potential of augmented reality to improve the osteotomy accuracy.

The application of extended reality technology-assisted intraoperative navigation in orthopedic surgery.

Extended reality (XR) technology refers to any situation where real-world objects are enhanced with computer technology, including virtual reality, augmented reality, and mixed reality. Augmented reality and mixed reality technologies have been widely applied in orthopedic clinical practice, including in teaching, preoperative planning, intraoperative navigation, and surgical outcome evaluation. The primary goal of this narrative review is to summarize the effectiveness and superiority of XR-technology-assisted intraoperative navigation in the fields of trauma, joint, spine, and bone tumor surgery, as well as to discuss the current shortcomings in intraoperative navigation applications. We reviewed titles of more than 200 studies obtained from PubMed with the following search terms: extended reality, mixed reality, augmented reality, virtual reality, intraoperative navigation, and orthopedic surgery; of those 200 studies, 69 related papers were selected for abstract review. Finally, the full text of 55 studies was analyzed and reviewed. They were classified into four groups-trauma, joint, spine, and bone tumor surgery-according to their content. Most of studies that we reviewed showed that XR-technology-assisted intraoperative navigation can effectively improve the accuracy of implant placement, such as that of screws and prostheses, reduce postoperative complications caused by inaccurate implantation, facilitate the achievement of tumor-free surgical margins, shorten the surgical duration, reduce radiation exposure for patients and surgeons, minimize further damage caused by the need for visual exposure during surgery, and provide richer and more efficient intraoperative communication, thereby facilitating academic exchange, medical assistance, and the implementation of remote healthcare.

REAL-WORLD VALIDATION OF A MACHINE-LEARNING ALGORITHM PREDICTING TREATMENT STRATEGY FOR HIP OSTEOARTRITIS

Artificial Intelligence (AI) is becoming more powerful but is barely used to counter the growth in health care burden. AI applications to increase efficiency in orthopedics are rare. We questioned if (1) we could train machine learning (ML) algorithms, based on answers from digitalized history taking questionnaires, to predict treatment of hip osteoartritis (either conservative or surgical); (2) such an algorithm could streamline clinical consultation.Multiple ML models were trained on 600 annotated (80% training, 20% test) digital history taking questionnaires, acquired before consultation. Best performing models, based on balanced accuracy and optimized automated hyperparameter tuning, were build into our daily clinical orthopedic practice. Fifty patients with hip complaints (>45 years) were prospectively predicted and planned (partly blinded, partly unblinded) for consultation with the physician assistant (conservative) or orthopedic surgeon (operative). Tailored patient information based on the prediction was automatically sent to a smartphone app. Level of evidence: IV.Random Forest and BernoulliNB were the most accurate ML models (0.75 balanced accuracy). Treatment prediction was correct in 45 out of 50 consultations (90%), p<0.0001 (sign and binomial test). Specialized consultations where conservatively predicted patients were seen by the physician assistant and surgical patients by the orthopedic surgeon were highly appreciated and effective.Treatment strategy of hip osteoartritis based on answers from digital history taking questionnaires was accurately predicted before patients entered the hospital. This can make outpatient consultation scheduling more efficient and tailor pre-consultation patient education.

Current status of evidence-based nursing in orthopedic clinical practice

Current status of evidence-based nursing in orthopedic clinical practice

Novel Electroactive Mineralized Polyacrylonitrile/PEDOT:PSS Electrospun Nanofibers for Bone Repair Applications.

Bone defect repair remains a critical challenge in current orthopedic clinical practice, as the available therapeutic strategies only offer suboptimal outcomes. Therefore, bone tissue engineering (BTE) approaches, involving the development of biomimetic implantable scaffolds combined with osteoprogenitor cells and native-like physical stimuli, are gaining widespread interest. Electrical stimulation (ES)-based therapies have been found to actively promote bone growth and osteogenesis in both in vivo and in vitro settings. Thus, the combination of electroactive scaffolds comprising conductive biomaterials and ES holds significant promise in improving the effectiveness of BTE for clinical applications. The aim of this study was to develop electroconductive polyacrylonitrile/poly(3,4-ethylenedioxythiophene):polystyrene sulfonate (PAN/PEDOT:PSS) nanofibers via electrospinning, which are capable of emulating the native tissue's fibrous extracellular matrix (ECM) and providing a platform for the delivery of exogenous ES. The resulting nanofibers were successfully functionalized with apatite-like structures to mimic the inorganic phase of the bone ECM. The conductive electrospun scaffolds presented nanoscale fiber diameters akin to those of collagen fibrils and displayed bone-like conductivity. PEDOT:PSS incorporation was shown to significantly promote scaffold mineralization in vitro. The mineralized electroconductive nanofibers demonstrated improved biological performance as observed by the significantly enhanced proliferation of both human osteoblast-like MG-63 cells and human bone marrow-derived mesenchymal stem/stromal cells (hBM-MSCs). Moreover, mineralized PAN/PEDOT:PSS nanofibers up-regulated bone marker genes expression levels of hBM-MSCs undergoing osteogenic differentiation, highlighting their potential as electroactive biomimetic BTE scaffolds for innovative bone defect repair strategies.

Diagnosis Accuracy for Compartment Syndrome: A Systematic Review and Meta-Analysis.

To evaluate whether published studies support basing the diagnosis of compartment syndrome of the lower leg on clinical findings, intracompartmental pressure (ICP) monitoring, or both. A PubMed/MEDLINE, Web of Science, and Embase search of the English literature from 1966 to February 2022 was performed. This used "lower extremity" or "leg" or "tibia" and "compartment syndrome" and "pressure" as the subjects. A manual search of the bibliographies was performed and cross-referenced with those used to formulate the American Academy of Orthopaedic Surgeons clinical practice guidelines. Inclusion criteria were traumatic tibia injuries, presence of data to calculate the sensitivity, specificity, positive and negative predictive values of clinical findings and/or pressure monitoring, and the presence or absence of compartment syndrome as the outcome. A total of 2906 full articles were found, of which 63 were deemed relevant for a detailed review. Seven studies met all eligibility criteria. The likelihood ratio form of Bayes theorem was used to assess the discriminatory ability of the clinical findings and ICP monitoring as tests for compartment syndrome. The predictive value for diagnosing acute compartment syndrome was 21% and 29% for the clinical signs and ICP, respectively. When combining both, the probability reached 68%. The use of ICP monitoring may be helpful when combined with a clinical assessment to increase the sensitivity and specificity of the overall diagnosis. Previously accepted individual inference values should be revisited with new prospective studies to further characterize the statistical value of each clinical finding. Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Effectiveness of nursing intervention in the operating room to prevent wound infections in patients undergoing orthopaedic surgery: A meta-analysis.

Surgical site wound infection is one of the most common postoperative complications in orthopaedic clinical practice. This study employed a meta-analysis approach to comprehensively evaluate the effect of operating room nursing interventions on the prevention of surgical site wound infections in orthopaedic surgical patients. A computer search was conducted using PubMed, EMBASE, Cochrane Library, China National Knowledge Infrastructure (CNKI), Chinese Biomedical Literature Database (CBM), VIP, and Wanfang databases from the inception of each database until May 2023 for randomised controlled trials (RCTs) that investigated the application of operating room nursing interventions in orthopaedic surgery. Two reviewers independently screened the literature, extracted data, and assessed study quality. The meta-analysis was conducted using Stata 17.0. A total of 29 studies involving 3567 patients were included, with 1784 patients in the intervention group, and 1783 patients in the control group. The results of the meta-analysis showed that compared with the control group, the use of operating room nursing interventions significantly reduced the incidence of surgical site wound infection after orthopaedic surgery (2.85% vs. 13.24%; odds ratio: 0.18, 95% confidence interval: 0.14-0.25; p < 0.001). Current evidence suggests that operating room nursing interventions reduce the incidence of surgical site wound infections. However, owing to the limited number and low quality of the studies, more high-quality, large-sample RCTs are needed to further verify these findings.

Testing mesenchymal stem cells on biocompatible 3D scaffold

The composite, thermoplastic material composed of polyhydroxybutyrate (PHB) and polylactic acid (PLA) was seeded with stem cells in the experiment. Tests of the polymer were oriented towards biocompatibility in vitro using mesenchymal stem cells isolated from the chorion. PHB/PLA is a currently tested biopolymer for applications in and medicine. Using additive technology, 3D forms of scaffolds in the form of a grid were prepared, which were seeded with stem cells and cultivated in suitable conditions. After an interval of 5 days, the proliferation and viability of the mesenchymal stem cells was tested by the proliferation test. From the results, it was found that the PHB/PLA material was a suitable scaffold and 60-85% stem cell viability was observed. Testing of non-toxic and degradable biopolymers brings new solutions in therapy in clinical orthopedic practice.

OrthopedVR: clinical assessment and pre-operative planning of paediatric patients with lower limb rotational abnormalities in virtual reality

Rotational abnormalities in the lower limbs causing patellar mal-tracking negatively affect patients’ lives, particularly young patients (10–17 years old). Recent studies suggest that rotational abnormalities can increase degenerative effects on the joints of the lower limbs. Rotational abnormalities are diagnosed using 2D CT imaging and X-rays, and these data are then used by surgeons to make decisions during an operation. However, 3D representation of data is preferable in the examination of 3D structures, such as bones. This correlates with added benefits for medical judgement, pre-operative planning, and clinical training. Virtual reality can enable the transformation of standard clinical imaging examination methods (CT/MRI) into immersive examinations and pre-operative planning in 3D. We present a VR system (OrthopedVR) which allows orthopaedic surgeons to examine patients’ specific anatomy of the lower limbs in an immersive three-dimensional environment and to simulate the effect of potential surgical interventions such as corrective osteotomies in VR. In OrthopedVR, surgeons can perform corrective incisions and re-align segments into desired rotational angles. From the system evaluation performed by experienced surgeons we found that OrthopedVR provides a better understanding of lower limb alignment and rotational profiles in comparison with isolated 2D CT scans. In addition, it was demonstrated that using VR software improves pre-operative planning, surgical precision and post-operative outcomes for patients. Our study results indicate that our system can become a stepping stone into simulating corrective surgeries of the lower limbs, and suggest future improvements which will help adopt VR surgical planning into the clinical orthopaedic practice.

A Gel-Based Proteomic Analysis Reveals Synovial α-Enolase and Fibrinogen β-Chain Dysregulation in Knee Osteoarthritis: A Controlled Trial.

The identification of synovial fluid (SF) biomarkers that could anticipate the diagnosis of osteoarthritis (OA) is gaining increasing importance in orthopaedic clinical practice. This controlled trial aims to assess the differences between the SF proteome of patients affected by severe OA undergoing Total Knee Replacement (TKR) compared to control subjects (i.e., subjects younger than 35, undergoing knee arthroscopy for acute meniscus injury). The synovial samples were collected from patients with Kellgren Lawrence grade 3 and 4 knee osteoarthritis undergoing THR (study group) and young patients with meniscal tears and no OA signs undergoing arthroscopic surgery (control group). The samples were processed and analyzed following the protocol defined in our previous study. All of the patients underwent clinical evaluation using the International Knee Documentation Committee (IKDC) subjective knee evaluation (main outcome), Knee Society Clinical Rating System (KSS), Knee injury and Osteoarthritis Outcome Score (KOOS), and Visual Analogue Scale (VAS) for pain. The drugs' assumptions and comorbidities were recorded. All patients underwent preoperative serial blood tests, including complete blood count and C-Reactive Protein (CRP). The synovial samples' analysis showed a significantly different fibrinogen beta chain (FBG) and alpha-enolase 1 (ENO1) concentration in OA compared to the control samples. A significant correlation between clinical scores, FBG, and ENO1 concentration was observed in osteoarthritic patients. Synovial fluid FBG and ENO1 concentrations are significantly different in patients affected by knee OA compared with non-OA subjects.

Ultrasound Elastography in the Evaluations of Tendon-Related Disorders—A Systematic Review

Tendon-related disorders are a common condition in both sports medicine and orthopedic clinical practice. Ultrasonography, power doppler, and magnetic resonance imaging (MRI) are the most widespread technologies, but the use of ultrasound elastography—including strain elastography and shear wave elastography—has been increasing in the last years. The aim of this paper is to evaluate the use of ultrasound elastography in tendon-related disorders. Research in PubMed, Scopus, and Web of Science databases is performed, and 364 papers are exported. After the study selection process, 38 papers are included in this systematic review. The risk of bias of each paper is evaluated using the RoBANS tool. Blinding, confounding variables, and measurement of exposure are the most affected items. From the included papers, tendinopathy is the most analyzed pathology, followed by tenosynovitis and rotator cuff disease. The Achilles tendon, patellar tendon, and common extensor tendon of the hand are the most analyzed tendons. Ultrasound elastography results in being the method providing good sensitivity and specificity (up to 100% and 100%, respectively, in tendinosis of the long head of the biceps tendon, in transverse plan examination) and accuracy (up to 97.8% in Achilles tendinopathy); furthermore, this technique is able to ensure real-time feedback on tissue elasticity and appears more sensitive than B-mode alone.

Harms Reporting in Randomized Controlled Trials Underpinning the American Academy of Orthopaedic Surgeons Clinical Practice Guidelines for Distal Radius Fractures

The purpose of this study was to measure the harms-related reporting among randomized controlled trials (RCTs) cited as supporting evidence for the American Academy of Orthopaedic Surgeons clinical practice guidelines regarding the management of distal radius fractures. We adhered to the guidance for reporting metaresearch and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines throughout the course of this investigation. We used the American Academy of Orthopaedic Surgeons clinical practice guidelines for distal radius fractures available on Orthoguidelines.org. A linear regression analysis was conducted to model the relationship between the year of publication and the total Consolidated Standards of Reporting Trials percentage adherence over time. Thirty-five RCTs were included in the final sample. The average number of Consolidated Standards of Reporting Trials Extension for Harms items adequately reported across all included RCTs was 9.2 (9.2/18, 50.9%). None of the included trials adequately reported all 18 items. Ten items had a compliance of more than 50% (10/18, 55.6%), 4 items had a compliance of 20%-50% (4/18, 22.2%), and 4 items had a compliance of less than 20% (4/18, 22.2%). The results of the linear regression model showed no significant improvement in Consolidated Standards of Reporting Trials Harms reporting over time. Adverse events are incompletely reported among RCTs cited as supporting evidence for American Academy of Orthopaedic Surgeons clinical practice guidelines for the management of distal radius fractures. Given our findings, specific attention should be paid to improving the standardization of the classification of adverse events to facilitate ease in the reporting process.

The Use of Collagen-Based Materials in Bone Tissue Engineering

Synthetic bone substitute materials (BSMs) are becoming the general trend, replacing autologous grafting for bone tissue engineering (BTE) in orthopedic research and clinical practice. As the main component of bone matrix, collagen type I has played a critical role in the construction of ideal synthetic BSMs for decades. Significant strides have been made in the field of collagen research, including the exploration of various collagen types, structures, and sources, the optimization of preparation techniques, modification technologies, and the manufacture of various collagen-based materials. However, the poor mechanical properties, fast degradation, and lack of osteoconductive activity of collagen-based materials caused inefficient bone replacement and limited their translation into clinical reality. In the area of BTE, so far, attempts have focused on the preparation of collagen-based biomimetic BSMs, along with other inorganic materials and bioactive substances. By reviewing the approved products on the market, this manuscript updates the latest applications of collagen-based materials in bone regeneration and highlights the potential for further development in the field of BTE over the next ten years.

Hyaluronic acid alone versus hyaluronic acid associated with adelmidrol for Intra-articular treatment of knee osteoarthritis: A long-term follow-up

Background: Hyaluronic acid (HA) has been used for many years for intra-articular treatment of knee osteoarthritis with satisfactory results. HA associated with Adelmidrol – an anti-neuroinflammatory compound – have been only recently introduced in orthopedic clinical practice with good preliminary results. Objective: To investigate whether HA associated with Adelmidrol provides better results than HA alone. Methods: Two cohorts of patients with moderate knee osteoarthritis were treated. Cohort 1 received 5 weekly intra-articular injections of HA during 2017 while Cohort 2, 4 weekly intra-articular injections of HA associated with Adelmidrol during 2018. The patients of the two Cohorts were assessed by WOMAC scale, SF-12 questionnaire and PGIC scale at 1 week (T0), 6 months (T1), 1 year (T2), and 2 years (T3) after the end of treatment. All the data were statistically analyzed. A p-value of &lt;0.05 was considered statistically significant. Results: According to the WOMAC Scale Cohort 1 had higher mean scores than Cohort 2 at each follow-up time, with a statistically significant difference between the two cohorts at T3 (p&lt;0.03) for all the WOMAC components, except for Stiffness. WOMAC Total mean score worsened statistically significantly only in Cohort 1, from T1 to T3 (T2 vs T1: p=0.0033; T3 vs T2: p=0.0007). The same happened for WOMAC Physical Function (T2 vs T1: p=0.0146; T3 vs T2: p=0.0046) and WOMAC Pain (T2 vs T1: p=0.0004; T3 vs T2: p=0.0002). WOMAC Stiffness worsened statistically significantly in Cohort 1 from T2 to T3 (T3 vs T2: p=0.0041), while in Cohort 2 no change on WOMAC scale was statistically significant at any time-point, for any components. The mean scores of the SF-12 questionnaire were better in Cohort 2 than in Cohort 1 at each follow-up time for both the Physical and the Mental components, with a statistically significant difference between the two groups for the latter, at T0 (p=0.0001). In both cohorts the mean score of the Physical component decreased from T0 to T3, but the difference was not statistically significant between the two groups (p=0.25). The mean score of the Mental component slightly increased in Cohort 1 and decreased in Cohort 2, without statistically significant differences between the two groups at any time-point. PGIC showed that Cohort 2 scored significantly better than Cohort 1 at T3 (p=0.0336). Conclusions: Overall, HA associated with Adelmidrol gave better long-term results than HA alone. KEY WORDS: Hyaluronic acid, Adelmidrol, Palmitoylethanolamide, Knee, Osteoarthritis, Synovitis, Mastocytes, Intra-articular injections, Visco-induction.

Trends in Venous Thromboembolism After Shoulder Arthroplasty in the United States: Analysis Following the 2009 American Academy of Orthopaedic Surgeons Clinical Practical Guidelines.

In 2009, the American Academy of Orthopaedic Surgeons released a consensus recommending venous thromboembolism (VTE) prophylaxis after total shoulder arthroplasty (TSA). The purpose of this study was to examine the (1) change in incidence of 90-day VTE, deep vein thrombosis (DVT), and pulmonary embolism; (2) change in utilization of chemoprophylaxis; and (3) change in the economic burden associated with VTE after TSA from 2010 to 2019. Using the PearlDiver database, national data from 2010 to 2019 were used to identify patients who underwent primary TSA for osteoarthritis and/or rotator cuff arthropathy. Exclusions entailed liver pathology, coagulopathy, or those on prior prescribed blood thinners before TSA. Multivariable regression was used controlling for age and Charlson Comorbidity Index for all years with 2010 as the reference year. From 2010 to 2019, there was a reduction in VTE rates from 0.89% in 2010 to 0.78% in 2019. Regarding implant type, there was no notable change in incidence of VTE, DVT, and pulmonary embolism within 90 days after anatomic TSA. Notable reductions were observed in both VTE and DVT after reverse TSA from 2010 to 2019. Prescribed chemical VTE prophylaxis utilization after TSA markedly increased from 4.41% in 2010 to 11.70% utilization in 2019. The utilization of aspirin markedly increased from 17.27% in 2010 to 65.17% in 2019. Among anticoagulants, the utilization of direct factor Xa inhibitors increased from 0.0% utilization in 2010 to 66.09% utilization in 2019. The added reimbursements associated with VTE after TSA markedly decreased from $14,122 in 2010 to $4,348 in 2019. The incidence and economic burden associated with VTE after TSA have markedly declined following the 2010 American Academy of Orthopaedic Surgeons clinical practice guidelines. This reduction can be attributed to both an increase in VTE prevention through increased utilization of prescribed chemoprophylaxis and improvement in VTE treatment strategies. Therapeutic, III.

Activating Wnt/β-Catenin Signaling in Osteocytes Promotes Osteogenic Differentiation of BMSCs through BMP-7.

Bone formation is critically needed in orthopedic clinical practice. We found that, bone morphogenetic protein-7 (BMP-7) gene expression was significantly increased in fractured mice, which activates canonical Wnt signaling exclusively in osteocytes. Wnt and BMP signaling appear to exhibit synergistic or antagonistic effects in different kinds of cells. However, the communication between Wnt/β-catenin signaling and BMP signaling in osteocytes is almost unknown. Our study verified in vitro that BMP-7 expression was significantly increased when Wnt signaling was activated in osteocytes. Next, BMP-7 in osteocytes was overexpressed using an adenovirus, the osteogenesis of bone marrow stem cells (BMSCs) was enhanced, when cocultured with osteocytes. On the contrary, BMP-7 in osteocytes was silenced using an adenovirus, the osteogenesis of bone marrow stem cells (BMSCs) was weakened. In addition, the osteogenesis of BMSCs was no longer promoted by Wnt-activated osteocytes when BMP-7 was silenced. Therefore, the results showed that BMP-7 mediated the anabolic actions of Wnt/β-catenin signaling in osteocytes. Our study provides new evidence for the clinical application of BMP-7-overexpressed osteocytes.

Quality of patient-reported and proxy-reported outcomes for children with impairment of the lower extremity: systematic review protocol

IntroductionAs patient-reported outcome measures (PROMs) have become of significant importance in evaluation of care and clinical research, adequately selecting the appropriate instrument is an integral part of paediatric orthopaedic research...

Magnesium implants in orthopaedic surgery create a diagnostic conundrum: A radiology case series and literature review.

During a routine post-operative orthopaedic radiograph reading session, repeated unusual radiographic soft tissue and bone appearances became evident. It was discovered that these patients had received biodegradable magnesium implants which have recently been introduced into orthopaedic clinical practice. To the untrained eye, the combination of peri-metallic bone resorption with associated soft tissue gas, could easily be mistaken for post-operative infection. The aim of this study is to properly characterise the radiographic post-operative appearances of biodegradable magnesium orthopaedic hardware. We retrospectively evaluated radiographs of all patients who underwent magnesium screw implantation for fractures over a 6 month period. Four patients, mean age of 9.75 (range: 6-15) years who underwent magnesium screw fixation following fracture were included in the study. Follow up duration was 100 days (range: 75-122) with a mean of 2.5 postoperative radiographs being performed per patient during this period. All cases demonstrated post-operative peri-metallic radiolucency which developed around the magnesium screws on x-ray, which subsequently resorbed over time. Peri-metallic soft tissue gas was observed in all patients. In two cases, magnesium implants fractured. As the use of biodegradable metal implants becomes more common, it is important for radiologists to be aware of their imaging characteristics. Prior to reporting a case, it would be prudent to know if biodegradable screws have been utilised and whether there exists a clinical concern for post-operative infection in patients with these particular implants, in which case it would be critical not to dismiss peri-prosthetic radiolucencies and soft tissue gas as merely a sequela of the natural metal degradation process.