Orthopaedic Management Research Articles

Decoding ferroptosis: transforming orthopedic disease management

As a mechanism of cell death, ferroptosis has gained popularity since 2012. The process is distinguished by iron toxicity and phospholipid accumulation, in contrast to autophagy, apoptosis, and other cell death mechanisms. It is implicated in the advancement of multiple diseases across the body. Researchers currently know that osteosarcoma, osteoporosis, and other orthopedic disorders are caused by NRF2, GPX4, and other ferroptosis star proteins. The effective relief of osteoarthritis symptoms from deterioration has been confirmed by clinical treatment with multiple ferroptosis inhibitors. At the same time, it should be reminded that the mechanisms involved in ferroptosis that regulate orthopedic diseases are not currently understood. In this manuscript, we present the discovery process of ferroptosis, the mechanisms involved in ferroptosis, and the role of ferroptosis in a variety of orthopedic diseases. We expect that this manuscript can provide a new perspective on clinical diagnosis and treatment of related diseases.

Achilles Pain, Stiffness, and Muscle Power Deficits: Midportion Achilles Tendinopathy Revision - 2024.

The Academy of Orthopaedic Physical Therapy (AOPT) has an ongoing effort to create evidence-based clinical practice guidelines (CPG) for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization's International Classification of Functioning, Disability, and Health (ICF). The 2024 Achilles Pain, Stiffness, and Muscle Power Deficit: Midportion Achilles Tendinopathy Clinical Practice Guideline (CPG) is a revision of the 2018 CPG and represents the third CPG from AOPT on this topic. The goals of the revision were to provide a concise summary of the contemporary evidence and to develop new recommendations or revise previously published recommendations to support evidence-based practice. This current CPG covers prevalence, pathoanatomical features, risk factors, clinical course, diagnosis, examination, imaging, and physical therapy interventions for the management of midportion Achilles tendinopathy. J Orthop Sports Phys Ther 2024;54(12):CPG1-CPG32. Epub 27 November 2024. doi:10.2519/jospt.2024.0302.

ADVANCES IN ORTHOPEDIC SURGERY

Orthopaedic surgery has undergone significant evolution with the development of minimally invasive techniques (MIT) for the treatment of complex lower limb fractures. These innovations have transformed orthopaedic management, offering less traumatic and more effective alternatives to traditional procedures. IMTs are designed to reduce tissue damage, speed up recovery and minimize post-operative complications, making them increasingly relevant in today’s orthopaedic scenario. The aim of this study is to discuss recent advances in minimally invasive techniques in orthopaedic surgery for complex lower limb fractures. The research explores the benefits of these techniques, the challenges faced in clinical practice and the future prospects for their widespread adoption. The research was based on a literature review, with a qualitative approach, using the PubMed, Google Scholar, and Scielo databases. For a comprehensive and relevant analysis of the advances and challenges of minimally invasive techniques in orthopaedic surgery, specific descriptors reflecting the area of study were applied, with a time frame covering publications from 2018 to 2023. The analysis is based on a review of up-to-date literature, including clinical studies and meta-analyses that demonstrate the efficacy and safety of minimally invasive techniques. Innovations such as the use of external fixators, locked intramedullary rods and surgical navigation systems are highlighted. These approaches allow for precise stabilization of fractures with smaller incisions and less impairment of soft tissue vascularization. In addition, advances in intraoperative imaging and surgical instrumentation are discussed, which have improved the precision of procedures and reduced operative time. Challenges such as the learning curve and the cost of the technologies are also addressed. Thus, advances in minimally invasive techniques have revolutionized orthopaedic surgery, offering effective solutions for the treatment of complex lower limb fractures. Despite the challenges, such as the need for specialized training and investment in new technologies, the benefits for patients, including shorter recovery times and better functional results, are undeniable. The future of orthopaedic surgery will continue to benefit from these innovations, with the potential to further increase access and the quality of treatments.

Rigid intramedullary nailing of lower limb segments in children and adolescents with metabolic bone disease.

Children and adolescents with metabolic bone disease present to the orthopedic surgeon with pain, fractures (which may be impending), and deformity. Different modalities of orthopedic management are available. Scant literature exists on the use of rigid intramedullary nailing in this population. This study sought to evaluate the utilization of this treatment modality in the pediatric cohort, focusing on indications, techniques, and outcomes of the procedures. A retrospective review was performed over an 11-year period at a single tertiary pediatric institution in the UK. Medical records and radiographs were reviewed. Preoperative surgical and medical management, time to bony union, and complications were specifically ascertained. Twenty-seven patients (63 lower limb segments) had rigid intramedullary nailing over the specified period. The majority of patients had an underlying diagnosis of osteogenesis imperfecta or fibrous dysplasia (including McCune Albright Syndrome). Surgical indications included acute fractures, prophylactic stabilization, previous nonunion and malunions, deformity correction, and limb lengthening. All fractures healed and deformity correction was successful. In one patient, delayed union occurred after deformity correction and was successfully treated with dynamization. Fractures healed faster than corrective osteotomies. Complications included implant prominence, cortical penetrance, and screw loosening. Nonunion occurred with limb lengthening in one patient. Rigid intramedullary nailing is a safe and effective method of treatment for lower limb fractures and deformities in children and adolescents. This technique is, therefore, recommended for patients with metabolic bone disease. However, care must be taken in preoperative surgical planning and a multidisciplinary approach should be utilized.

The Rising Popularity of Growth Hormone Therapy and Ensuing Orthopedic Complications in the Pediatric Population: A Review.

The utilization of recombinant human growth hormone therapy in pediatric populations, originally approved to treat diseases of growth hormone deficiency, has expanded to encompass a broader range of indications, leading to a threefold increase in its utilization in the last two decades. However, concerns regarding its safety, particularly those that are orthopedic in nature, have grown alongside its increasing popularity. Growth hormone usage has been reported to predispose patients to a multitude of common orthopedic conditions, including carpal tunnel syndrome, Legg-Calve-Perthes disease, little league shoulder, Osgood-Schlatter disease, osteochondritis dissecans, scoliosis, Sever's disease, and slipped femoral capital epiphysis. The pathways by which growth hormone therapy can precipitate orthopedic pathology has been shown to be multifactorial, involving mechanisms such as hormonal changes, growth plate instability, rapid growth, and increased susceptibility to overuse injury. This review examines the orthopedic consequences of growth hormone therapy in pediatric patients by discussing these potential pathophysiologic mechanisms of injury and analyzing subsequent clinical manifestations. By examining processes underlying these complications, we highlight the need for orthopedic surveillance and management in children receiving GHT, particularly those with pre-existing musculoskeletal comorbidities or high levels of physical activity. Our findings underscore the importance of a multidisciplinary approach involving co-management by pediatricians, endocrinologists, and orthopedic surgeons to optimize safety and outcomes for these patients. Directions for future research include correlating pathophysiologic mechanisms to injury patterns, investigating long-term complications in recently approved growth hormone therapy indications, and informing clinical guidelines on the management of orthopedic injuries in this patient population.

Achilles Pain, Stiffness, and Muscle Power Deficits: Midportion Achilles Tendinopathy Revision – 2024

The Academy of Orthopaedic Physical Therapy (AOPT) has an ongoing effort to create evidence-based clinical practice guidelines (CPG) for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization's International Classification of Functioning, Disability, and Health (ICF). The 2024 Achilles Pain, Stiffness, and Muscle Power Deficit: Midportion Achilles Tendinopathy Clinical Practice Guideline (CPG) is a revision of the 2018 CPG and represents the third CPG from AOPT on this topic. The goals of the revision were to provide a concise summary of the contemporary evidence and to develop new recommendations or revise previously published recommendations to support evidence-based practice. This current CPG covers prevalence, pathoanatomical features, risk factors, clinical course, diagnosis, examination, imaging and physical therapy interventions for the management of midportion Achilles tendinopathy.

A Retrospective Study of Ballistic Pelvic Fractures With Focus on Short-Term Clinical Outcomes.

To evaluate the orthopaedic management, associated injuries, and outcomes in patients treated for low-velocity ballistic pelvic fractures. Retrospective chart review. Single, urban, Level I trauma center. Patients 15 years or older treated for low-velocity ballistic pelvic (OTA/AO 61 and 62) fractures from May 2018 to August 2021. Primary study measures included pelvic fracture location, concomitant associated injuries, surgical interventions, and antibiotic treatment. Postinjury sequelae evaluated include infection, neurologic deficit, and need for orthopaedic removal of foreign body. Risk factors of postinjury sequelae were investigated. A total of 156 patients with ballistic pelvic fractures were included. The cohort consisted of 135 (86.5%) male patients with a mean age of 29.8 years. One hundred ten (70.5%) patients sustained 2 or more gunshot wounds. Ninety-eight (62.8%) patients underwent an exploratory laparotomy with 79 (50.6%) having a confirmed concomitant intestinal injury. Additional associated injuries included nerve injury (13.5%), vascular injury requiring repair or embolization (10.9%), and bladder injury (10.3%). Nine (5.7%) patients underwent orthopaedic operative management-five (3.2%) patients for operative fixation and 4 (2.5%) patients for removal of intra-articular foreign bodies. Diabetes (odds ratio [OR]: 33.1, P = 0.025), neurologic deficit on presentation (OR: 525.2, P < 0.001), vascular injury requiring repair or embolization (OR: 8.7, P = 0.033), and orthopaedic pelvic fixation (OR: 163.5, P = 0.004) were positively associated with the defined postinjury sequelae at 30 and 90 days of follow-up. There was not a statistically significant association between infection and retained foreign body (OR: 3.95 [95% CI 0.3-58.7, P = 0.318]) or bowel contamination (OR: 6.91 [95% CI 0.4-58.7, P = 0.178]). Ballistic fractures of the pelvis and acetabulum rarely required operative fixation (3.2%) or irrigation and debridement. Neither retained foreign body nor presumed bowel contamination of pelvic fractures had a statistically significant association with infection, which further supports conservative management of these injuries. Patients with diabetes, neurologic deficit on presentation, vascular injury necessitating intervention, and orthopaedic fixation of pelvic fracture are associated with increased risk of postinjury sequelae. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Phage therapy: A primer for orthopaedic trauma surgeons

Phage therapy (PT) continues to attract interest in the fight against fracture-related infection (FRI), particularly for recurring infections that have not been resolved using conventional therapeutic approaches. The journey PT has taken from early clinical application in the pre-antibiotic era to its recent reintroduction to western clinical practice has been accelerated by the increased prevalence of multi-drug resistant (MDR) pathogens in the clinic. This review will present PT's potential as a precise, adaptable, and effective treatment modality, with a focus on patient and phage selection, as well as the various administration protocols currently applied to patients. The challenges for PT, for example the most optimal application technique and dosing, are also discussed and underscore the importance of personalized approaches and the urgent need for more robust clinical evidence. Future perspectives, including phage engineering and innovative delivery systems will be discussed, as they may broaden the applicability of PT to a point where it may become a standard rather than an option of last resort for orthopedic infection management.

Predictors of Pain Management Outcomes Following Orthopaedic Surgery: A Systematic Review.

Up to 80% of patients in the United States report dissatisfaction with pain management following orthopaedic surgery. Inadequate pain management is linked to negative outcomes, including increased costs, readmission rates, and chronic pain risk. Traditional pain management protocols often emphasise the biological components of pain, overlooking psychological and social. This systematic review addresses this gap by answering two key questions: (1) What factors are associated with increased risk of unsatisfactory pain management following orthopaedic surgery? (2) What are the key components of successful pain management protocols following orthopaedic surgery? PRISMA guidelines were followed with a search of relevant online databases. Studies were included if they were in English, provided patient feedback/satisfaction with pain management (quantitative studies) or provided satisfaction with pain management or healthcare team feedback (qualitative studies) or explored patient variables associated with satisfaction with pain management. Of the 845 articles screened, 27 met the inclusion criteria. Synthesis suggested that while perceived severity and duration of pain are often assumed to be the primary drivers of patient satisfaction related to pain management, patients with a sense of control over their pain reported higher satisfaction, regardless of actual pain level. History of opioid misuse, patient expectations, and patient mental health were associated with dissatisfaction. Pre-operative education and ongoing communication, particularly regarding patient risk-factors and multi-modal pain management strategies, appear to enhance patients' sense of control and satisfaction. Future research should explore whether individualised pre-operative education can improve satisfaction with post-surgical orthopaedic pain management.

Recent technological advancements in Artificial Intelligence for orthopaedic wound management

In orthopaedics, wound care is crucial as surgical site infections carry disease burden due to increased length of stay, decreased quality of life and poorer patient outcomes. Artificial Intelligence (AI) has a vital role in revolutionising wound care in orthopaedics: ranging from wound assessment, early detection of complications, risk stratifying patients, and remote patient monitoring. Incorporating AI in orthopaedics has reduced dependency on manual physician assessment which is time-consuming. This article summarises current literature on how AI is used for wound assessment and management in the orthopaedic community.

Management of Pediatric Type III Tibial Shaft Fractures: A Cohort Study Utilizing the Trauma Quality Improvement Program Database.

Pediatric open tibial fractures represent a challenging subset of injuries with limited literature to guide management. For children, the epidemiology, management, and outcomes of tibial-shaft fractures have not been fully described. A retrospective analysis of the Trauma Quality Improvement Program Data Bank from 2017-2020 was used to query demographics, injury patterns, and management strategies in pediatric open tibial fractures. Fractures were compared by age group (0-5, 6-12, 13-17 years) and type (I/II vs type III). A subgroup analysis was performed on patients with type III open fractures. A total of 3480 open tibial fractures were identified, 3049 were type I/II, and 431 were type III. Motor vehicle accidents (48%) were the most common mechanism of injury (P < 0.001). Subanalysis of 128 type IIIb/c tibial fractures revealed local flap reconstruction (25%) skin graft (25%), and free tissue transfer were the most common management strategies and soft-tissue coverage was achieved after 162 hours (interquartile range = 109-231). Negative pressure wound therapy was utilized in 63% of cases but used in isolation in only 23% of cases. Immediate fixation with intramedullary nailing was more frequently used in the 13-17 age group while plate fixation was more commonly used in younger age groups. Soft-tissue management patterns following open tibial shaft fractures mirror those seen in adult cohorts. The median time to achieve soft-tissue coverage exceeds the traditional 72-hour target advocated by Godina. Age-based variation is seen in orthopedic management of these fractures based on growth maintenance concerns.

Orthopedic management of Class II with activator: cases’ report

Orthopedic management of Class II with activator: cases’ report

Manejo rehabilitador y ortopédico de las fracturas por compresión vertebral osteoporótica

Osteoporosis represents a public health problem that can be prevented and treated early through health education. Over time, screening techniques, diagnosis and treatments even conservative and surgical, have improved.Through this publication we want to highlight the importance of the medical and orthopedic management of these fractures, describing the benefit of diet and physical exercise as the protagonists of conservative treatment but above all its indications and contraindications, emphasizing the limitations of exercise in a vertebral osteoporotic fracture. The different orthoses prescriptions are also highlighted.

[Translated article] Rehabilitation and orthopaedic management of osteoporotic vertebral compression fractures

Osteoporosis represents a public health problem that can be prevented and treated early through health education. Over time, screening techniques, diagnosis and treatments even conservative and surgical, have improved.Through this publication we want to highlight the importance of the medical and orthopaedic management of these fractures, describing the benefit of diet and physical exercise as the protagonists of conservative treatment but above all its indications and contraindications, emphasising the limitations of exercise in a vertebral osteoporotic fracture. The different orthoses prescriptions are also highlighted.

2023 American Academy of Orthopaedic Surgeons Management of Osteoarthritis of the Hip Evidence-Based Clinical Practice Guideline: Case Studies.

The American Academy of Orthopaedic Surgeons, together with The Hip Society, American Association of Hip and Knee Surgeons, American College of Radiology, and American Physical Therapy Association, recently released the updated 2023 Management of Osteoarthritis of the Hip Evidence-Based Clinical Practice Guidelines. 8 recommendations and 9 options comprise these guidelines intended to optimize treatment outcomes in a patient population that is growing exponentially over time. In this article, we present case studies that illustrate utilization of the clinical practice guideline workgroup's evidence-based recommendations in clinical practice.

There is no correlation between differences in adverse events and differences in patient-reported outcome measures in orthopaedic trauma randomized controlled trials: A systematic review

IntroductionA recovery without adverse events is a top priority of orthopaedic trauma patients, however many randomized controlled trials (RCTs) are only powered to detect a difference in patient-reported outcome measures (PROMs). While it may be assumed that differences in major adverse event rates between treatment groups will result in differences in PROMs, this has not been established. The purpose of this study was to perform a systematic review of RCTs to evaluate if differences in these outcomes were correlated. MethodsA systematic search was conducted of online databases to identify RCTs in orthopaedic trauma fracture management that reported both major adverse events and PROMs. Adverse events included secondary surgeries or complications that could negatively affect long-term outcomes (nonunion, chronic regional pain syndrome, etc.). The correlation between a difference (p < 0.05) in adverse events and a difference in PROMs was assessed. ResultsThe systematic review yielded 30 RCTs involving 6,769 patients. The primary outcome was a continuous PROM in 70.0 % (21/30). A difference in major adverse events was reported in 23.3 % (7/30) and a difference in PROMs was reported in 6.7 % (2/30). Studies reporting a difference in adverse events, compared to those that did not, were not more likely to report a difference in PROMs (14.3 % (1/7) vs. 4.3 % (1/23); p = 0.42). ConclusionsThere was no correlation between differences in adverse event rates and differences in PROMs in orthopaedic trauma RCTs. Investigators should consider powering studies to detect differences in the major adverse events that both patients and surgeons wish to avoid. Level of evidenceLevel I

Hip Instability in Children With Spinal Muscular Atrophy: A Retrospective Study.

Hip subluxation and dislocation are known problems for children with spinal muscular atrophy (SMA). Medical complexity of these children typically results in absence of monitoring and intervention for pathologic hips. Patterns of hip migration and acetabular morphology in SMA have not been described. This study examines the natural progression of hip instability across all types of SMA in a pediatric population. Following institutional review board approval, a retrospective chart review of all children with SMA at our institution was performed. All x-rays taken before the age of 18 years containing adequate projections of the pelvis were measured for Reimer migration index (MI), acetabular depth ratio (ADR), and acetabular index (AI). Demographics and clinical data were collected including use of nusinersen, ambulatory status, contractures, and hip pain. Linear mixed effects model was fit to serial MI measures of individual hips with fixed effects consisting of SMA type, age at x-ray, and their interaction. ADR and AI measures were similarly modeled following conversion of raw values to z-scores based on the model developed by Novais et al Slope indicated rate of measure change as a function of age. Forty-five children (22 males) with SMA types 1 to 3 were included in this retrospective study. Six children were classified as type 1, 25 were type 2, and 14 were type 3. The interaction of age by SMA type was statistically significant (P=0.01), indicating a difference in the rate of hip subluxation between the 3 SMA types as measured by MI. By age 4, MI values were different from one another across all 3 groups (P<0.01). ADR decreased with age across all SMA types. The slopes of ADR regression lines were negative and statistically significant between the 3 groups (P=0.002). AI values were higher for all types of SMA, which is the opposite of expected in normal hips. Hip subluxation occurs across all SMA types, most rapidly in SMA type 1. Regression lines of ADR and AI compared with those seen in unaffected populations suggest hips in children with SMA demonstrate a difference in morphology of the acetabulum and do not follow normal adaptive remodeling. As treatments advance and the population of SMA patients becomes more mobile, there is an increased need to monitor hip instability in children with SMA, thus making orthopaedic management an important consideration.

A Systematic Review of Sex-Related Differences in Response to Post-Operative Orthopaedic Pain Management Protocols

A Systematic Review of Sex-Related Differences in Response to Post-Operative Orthopaedic Pain Management Protocols

Achondroplasia current concept of orthopaedic management.

Achondroplasia, the most common form of inherited disproportionate short stature, is caused by mutations in the fibroblast growth factor receptor 3 gene. The typical clinical features of achondroplasia include short stature, rhizomelic disproportion, joint hyperlaxity, spinal deformity and deformity of the upper and lower limbs. The latter are among the challenges of state-of-the-art orthopaedic treatment plans and significantly contribute to the burden of the disease in individuals with achondroplasia. Multidisciplinary preoperative individual decision-making concerning surgical interventions should be considered. New medical treatments for achondroplasia have been developed and (some) have been approved for clinical use in several countries. While the number of research articles on achondroplasia is increasing rapidly, many unknown or controversial orthopaedic topics remain. Furthermore, in view of new medical developments with improvements in growth and potentially other effects, the timing and algorithms of orthopaedic treatments (e.g. guided growth, limb lengthening and deformity correction) need to be re-evaluated. While standing height is the primary research focus in medical therapy, it is crucial to comprehensively assess orthopaedic parameters in this multifactorial disease. The current treatment of patients with achondroplasia requires specialised multidisciplinary centres with transitional care and individual orthopaedic counselling.

Current Treatment Process and Challenges for Spinal Muscular Atrophy (SMA)

Spinal muscular atrophy (SMA) presents as a pediatric neuromuscular disorder resulting from mutations in the survival motor neuron 1(SMN1) gene, with an incidence of approximately 10-13 per 100,000 live births. This condition manifests primarily through muscle weakness and atrophy, particularly affecting the proximal limb muscles. A homozygous deletion of exon 7 in the SMN1 gene is the most common genetic mutation in SMA and serves as a sensitive diagnostic marker. This article comprehensively explores various aspects of SMA, including its types, diagnostic methods, and management strategies. Pulmonary care, gastrointestinal (GI) management, nutritional supplementation, orthopedic spinal care, and physiotherapy play crucial roles in delaying disease progression. Current pharmacological treatments for SMA are diverse and evolving. Notable among them is Zolgensma (formerly AVXS-101 or Onasemnogene abeparvovec), a gene replacement therapy utilizing an adeno-associated virus vector to boost functional SMN protein levels. Sodium vanadate, a phosphatase inhibitor, and risdiplam (RO703406) are agents that modulate SMN2 splicing to augment the production of functional SMN protein. Riluzole acts as a neuroprotective agent by preventing SMN deficiency, while reldesemtive (CK-2127107) is under development as a muscle-enhancing therapy to ameliorate skeletal muscle function during fatigue. While pharmacological therapies for SMA are advancing, a holistic approach involving comprehensive multidisciplinary care, encompassing pulmonary support, proper nutritional supplementation, and adept orthopedic management, significantly contributes to the effective management of SMA.