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Romy Deviandri,1– 3 Hugo C van der Veen,1 Andri MT Lubis,4 Ghuna A Utoyo,5 Inge van den Akker-Scheek,1 Maarten J Postma6– 9 1Department of Orthopedic Surgery, University of Groningen/ University Medical Center Groningen, Groningen, the Netherlands; 2Department of Physiology-Faculty of Medicine, Universitas Riau, Pekanbaru, Indonesia; 3Department of Orthopedics-Sports Injury, Arifin Achmad Hospital, Pekanbaru, Indonesia; 4Department of Orthopedics-Faculty of Medicine, Universitas Indonesia/Cipto Mangunkusumo Hospital, Jakarta, Indonesia; 5Department of Orthopedics-Faculty of Medicine, Universitas Padjadjaran/ Hasan Sadikin Hospital, Bandung, Indonesia; 6Department of Health Sciences, University of Groningen/ University Medical Center Groningen, Groningen, the Netherlands; 7Department of Economics-Faculty of Economics & Business, University of Groningen, Groningen, the Netherlands; 8Department of Pharmacology & Therapy, Universitas Airlangga, Surabaya, Indonesia; 9Department Center of Excellence in Higher Education for Pharmaceutical Care Innovation, Universitas Padjadjaran, Bandung, IndonesiaCorrespondence: Romy Deviandri, Department of Orthopedic Surgery, University of Groningen/ University Medical Center Groningen, Hanzeplein 1, Groningen, 9713 GZ, the Netherlands, Email r.deviandri@rug.nl; romydeviandri@lecturer.unri.ac.idObjective: The number of anterior cruciate ligament reconstruction (ACLR) procedures is increasing. However, ACLR procedures are likely to be underbudgeted in a developing country like Indonesia. This study aimed to analyze costs for ACLR procedures in Indonesia’s resource-limited context, determine the burden of ACLR, and suggest national prices for ACLR reimbursement.Methods: A retrospective observational study was conducted between 1 January and 31 December 2019 on the cost of ACLR from a payer perspective using inpatient billing records in four hospitals. The national burden of ACLR was calculated, and projected national prices for reimbursement were determined.Results: Of 80 ACLRs, 53 (66%) were isolated ACLRs and 27 (34%) ACLRs were combined with meniscus treatment. Mean hospital costs incurred per ACLR procedure were US$ 2853, with the dominant cost relating to orthopedic implant prices (US$ 1,387.80). The costs of ACLR with combined meniscus treatment were estimated as being 35% higher than isolated ACLR. The national burden of ACLR showed a total budget of US$ 367.4 million per 100,000 patients (0.03% of GDP) for ACLR with additional meniscus treatment and US$ 271.3 million per 100,000 patients (0.02% of GDP) for isolated ACLR.Conclusion: ACLR procedures in Indonesia are likely underbudgeted. Adjustments of reimbursement prices for ACLR are needed to facilitate adequate access of Indonesians to the procedures. This study demonstrated varying costs determined for ACLR in Indonesia, which entails that a new reimbursement system with improvement of national prices should become the core of transformation.Keywords: ACL tear, meniscus injury, cost, developing countries, BPJS

Andri Maruli Tua Lubis, Adisa Yusuf Reksoprodjo, Mohamad Walid Kuncoro, Nadia Nastassia Ifran Department of Orthopedic & Traumatology Cipto Mangunkusumo Hospital, Faculty of Medicine Universitas Indonesia, Jakarta, IndonesiaCorrespondence: Andri Maruli Tua LubisDepartment of Orthopaedic & Traumatology Cipto Mangunkusumo National Central Hospital - Faculty of Medicine Universitas Indonesia, Jl. Diponegoro No. 71, Jakarta, IndonesiaTel +62 816-1177-078Fax +62 21 3905894Email andrilubisresearch@gmail.comIntroduction: Pain and instability following an anterior cruciate ligament (ACL) reconstruction remain a significant issue. Common causes include infection and inflammation, and mechanical issues such as graft failure.Case Presentation: A 36-year-old male with an ACL reconstruction six years prior was admitted due to pain and swelling. The ACL graft that had ruptured was found arthroscopically. Numerous gout crystals and tophus were observed inside. This finding is suggested as a cause of this kind of complication.Discussion: Biological failure is one of the causes of graft failure. Gout arthritis is associated with internal derangement of the joint structures, which is reported in advanced case.Conclusion: Severe gouty arthritis, even though rare, could be an etiology of graft failure following ACL reconstruction and cause significant morbidity.Keywords: ACL reconstruction, graft failure, gout, tophus

Purpose: To evaluate the overall evidence of published health-economic evaluation studies on meniscus tear treatment., Methods: Our systematic review focuses on health-economic evaluation studies of meniscus tear treatment interventions found in PubMed and Embase databases. A qualitative, descriptive approach was used to analyze the studies' results and systematically report them following PRISMA guidelines. The health-economic evaluation method for each included study was categorized following one of the four approaches: partial economic evaluation (PEE), cost-effectiveness analysis (CEA), cost-benefit analysis (CBA), or cost-utility analysis (CUA). The quality of each included study was assessed using the Consensus on Health Economic Criteria (CHEC) list. Comparisons of input variables and outcomes were made, if applicable., Results: Sixteen studies were included; of these, six studies performed PEE, seven studies CUA, two studies CEA, and one study combined CBA, CUA, and CEA. The following economic comparisons were analyzed and showed the respective comparative outcomes: (1) meniscus repair was more cost-effective than arthroscopic partial meniscectomy (meniscectomy) for reparable meniscus tear; (2) non-operative treatment or physical therapy was less costly than meniscectomy for degenerative meniscus tear; (3) physical therapy with delayed meniscectomy was more cost-effective than early meniscectomy for meniscus tear with knee osteoarthritis; (4) meniscectomy without physical therapy was less costly than meniscectomy with physical therapy; (5) meniscectomy was more cost-effective than either meniscus allograft transplantation or meniscus scaffold procedure; (6) the conventional arthroscopic instrument cost was lower than laser-assisted arthroscopy in meniscectomy procedures., Conclusion: Results from this review suggest that meniscus repair is the most cost-effective intervention for reparable meniscus tears. Physical therapy followed by delayed meniscectomy is the most cost-effective intervention for degenerative meniscus tears. Meniscus scaffold should be avoided, especially when implemented on a large scale., Level of Evidence: Systematic review of level IV studies., (© 2023. The Author(s).)

Background and Purpose: Mesenchymal stem cells (MSCs), both endogenous and exogenous, enhance chondrocyte proliferation by stimulating collagen type II. Secretome, an MSC derivate, has shown to also provide this mechanism through a paracrine effect. We aimed to evaluate the use of secretome and MSC in the management of early osteoarthritis (OA)., Animals and Methods: 19 (1 control) male sheep (Ovies aries), which were operated on with total lateral meniscectomy to induce knee OA, were divided into 3 groups: the secretome group, hyaluronic acid group, and MSC group. Each group was injected with the respective substances and was evaluated macroscopically and microscopically. The Osteoarthritis Research Society International (OARSI) score was calculated for all subjects and a descriptive and comparative statistical analysis was undertaken., Results: The macroscopic analysis of the treated groups revealed better OARSI score in the secretome group compared with the other 2 groups. The secretome group showed a significantly better microscopic score compared with the hyaluronic acid group (mean difference [MD] 6.0, 95% confidence interval [CI] 0.15-12), but no significant difference compared with the MSC group (MD 1.0, CI -4.8 to 6.8)., Conclusion: Intra-articular injection of secretome is effective in managing early-stage osteoarthritis in the animal model compared with hyaluronic acid and has similar efficacy to MSC injection.

Background: The Anterior Cruciate Ligament-Return to Sport After Injury (ACL-RSI) scale measures athletes' emotion, confidence, and risk appraisal when returning to sports after an anterior cruciate ligament (ACL) injury and/or ACL reconstruction (ACLR)., Purpose: To translate the ACL-RSI into the Indonesian language and to assess its validity and reliability in Indonesian-speaking patients after ACLR., Study Design: Cohort study (diagnosis); Level of evidence, 2., Methods: After a forward-and-backward translation procedure, the validity and reliability of the Indonesian version of the ACL-RSI (I-ACL-RSI) were investigated. Patients who had undergone ACLR at a single hospital were asked to complete 4 questionnaires: I-ACL-RSI, Injury-Psychological Readiness to Return to Sport, Tampa Scale of Kinesiophobia, and International Knee Documentation Committee. After a 2-week interval, patients were asked to complete the I-ACL-RSI a second time. Following the COSMIN reporting guidelines (Consensus-Based Standards for the Selection of Health Measurement Instruments), we determined construct validity using hypothesis testing, as well as test-retest reliability, internal consistency, floor and ceiling effects, and measurement error., Results: Of 200 eligible patients, 102 (51%) were included in the analysis. All predefined hypotheses on correlations between the I-ACL-RSI and the other questionnaires were confirmed, indicating good construct validity. An intraclass correlation coefficient of 0.90 (2-way random, type agreement) was found for the first and second I-ACL-RSI scores, indicating good test-retest reliability. A Cronbach α of 0.95 indicated good internal consistency, and no floor or ceiling effects were found. The standard error of measurement was 3.9, with the minimal detectable change calculated as 10.9 points at the individual level and 1.1 points at the group level., Conclusion: Based on the study findings, the I-ACL-RSI can be considered a valid and reliable questionnaire for Indonesian-speaking patients after ACL injury and/or ACLR., Competing Interests: The authors have declared that there are no conflicts of interest in the authorship and publication of this contribution. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2023.)

Introduction: ACL reconstruction is needed to restore the stability and biomechanics properties of the injured knee joints in order to reproduce the function of the native ACL. The single-bundle (SB) and double-bundle (DB) techniques are most commonly used to reconstruct the injured ACL. However, its superiority upon each other is still controversial., Presentation of Case: This study presented a case series of six patients underwent ACL reconstruction, consisted of three patients with SB ACL reconstruction and three patients with DB ACL reconstruction with further T2 mapping for joint instability evaluation. Only two DB patients showed consistent decreased value in every follow-up., Discussion: ACL tear can generate joint instability. Joint instability is resulted from two mechanisms of relative cartilage overloading. First, there is an abnormal load distribution due to shifting of the center of pressure of the tibiofemoral force, resulting in increased stresses on the articular cartilage of the knee joint. There is also an increase of translation between articular surfaces, resulting in increased shear stresses on the articular cartilage. A trauma of knee joint causes cartilage damage and increased oxidative and metabolic stress of chondrocytes, resulting in chondrocyte senescence acceleration., Conclusion: This case series showed inconsistent results to determine either SB or DB has a better outcome in joint instability, thus further larger studies are needed., Competing Interests: Declaration of competing interest NA., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Purpose: To systematically review the literature on health-economic evaluations of anterior cruciate ligament (ACL) injury between reconstruction surgery (ACLR) and non-operative treatment (NO) and suggest the most cost-effective strategy between the two., Methods: All economic studies related to ACLR versus NO post-ACL injury, either trial based or model based, published until April 2022, were identified using PubMed and Embase. The methodology of the health-economic analysis for each included study was categorized according to the four approaches: cost-minimization analysis (CMA), cost-effectiveness analysis (CEA), cost-benefit analysis (CBA), and cost-utility analysis (CUA). The quality of each included study was assessed using the Consensus on Health Economic Criteria (CHEC) list., Results: Of the seven included studies, two compared the strategies of early ACLR and NO alone, and five compared early ACLR and NO with optional delayed ACLR. All studies performed a CUA, and one study performed a CBA additionally. The CHEC scores of the included studies can be considered good, ranging from 15 to 18 from a maximum of 19. Applying the common standard threshold of $50,000 per QALY, six studies in young people with high-activity levels or athletes showed that early ACLR would be preferred over either NO alone or delayed ACLR. Of six studies, two even showed early ACLR to be the dominant strategy over either NO alone or delayed ACLR, with per-patient cost savings of $5,164 and $1,803 and incremental per-patient QALY gains of 0.18 and 0.28, respectively. The one study in the middle-aged people with a moderate activity level showed that early ACLR was not more cost-effective than delayed ACLR, with ICER $101,939/QALY using the societal perspective and ICER $63,188/QALY using the healthcare system perspective., Conclusion: Early ACLR is likely the more cost-effective strategy for ACL injury cases in athletes and young populations with high-activity levels. On the other hand, non-operative treatment with optional delayed ACLR may be the more cost-effective strategy in the middle age population with moderate activity levels., Level of Evidence: Systematic review of level III studies., (© 2022. The Author(s).)

Introduction: Articular cartilage is an avascular, aneural, and lymphatic tissue with limited capacity to regenerate. Numerous techniques have been employed to repair or regenerate; however, the success rate varies. In fact, most of them result in the formation of fibrocartilage, not hyaline cartilage. The future of treating cartilage defects lies in providing biological solutions through cartilage regeneration. Mesenchymal stem cells (MSCs) represent a promising therapy for cartilage regeneration. These cells secrete factors that enhance cartilage repair. This study studied the effects of intra-articular injection of human umbilical cord MSC (hUC-MSC) secretome on cartilage damage in a sheep model., Methods: Standardized rectangular (5x5 mm) full-thickness chondral defects were created in the lateral femoral condyle of 15 adult sheep and debrided down to the subchondral bone plate. Three treatment groups were tested: 4 microfracture perforations using 1.0mm diameter awls (group 1), intra-articular injection of hUC-MSC secretome (group 2), and a combination of microfracture and intra-articular injection of hUC-MSC secretome (group 3). The osteochondral repair was assessed at 6 months using an established macroscopic and histological analyses., Results: Macroscopically, combined therapy application shows significant cartilage repair improvement compared to microfracture alone (p=0.004). Microscopically, the application of combined therapy shows significant improvement of cartilage repair compared to secretome injection alone (p=0.031)., Conclusion: Microfracture combined with injection of hUCB-MSCs secretome could be an effective alternative for repairing articular cartilage defects in vivo., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.net.)

Introduction and Importance: Patellar tendon is one of the most important components of the knee extensor mechanism, which consisted of quadriceps femoris muscle, quadriceps tendon, patellar bone and patellar tendon. The total disruption of patellar tendon will lead to disability and significant morbidity of the patient, or even worse, the patient is disabled to walk. The incidence of patellar tendon rupture is uncommon and most commonly found in the third to fourth decade of life. We present a case of total patellar tendon rupture in a teenager with primary repair with suture anchor., Case Presentation: We presented a case of 14-year-old male with acute patellar tendon rupture accompanied by tibial tubercle avulsion after injury during basketball game. We treated by four-strands Krakow's suture that stitched to three sutures anchor, while cancellous screw plus washer introduced as internal fixation of bony avulsion at tibial tubercle., Clinical Discussion: Range of motion and International Knee Documentation Committee (IKDC) score had been followed up within 2 years with good result. Full range of motion and the IKDC score 89.7 were achieved without major complication such as pain and infection. The patient was able to return into sport activities., Conclusion: The combination of cancellous screw with washer and three suture anchors lead to a good result in acute total rupture of patellar tendon with bony avulsion at tibial tubercle., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Introduction and Importance: Osteoarthritis is a severe joint disease that affects more than 60% of the elderly and more common an idiopathic disease or unknown cause although there is also a secondary cause such as trauma, infection, neurological or metabolic disorders. The usual complaints that perceived by osteoarthritis patients is pain in the affected joint. Many patients and providers think of arthroplasty as the only surgical option for the treatment of osteoarthritis of the knee. However, there are several other surgical options for osteoarthritis which can be therapeutic alternatives. The role of bone marrow stimulation and intraarticular injection with triamcinolone and Hyaluronic acid combination on grade III knee osteoarthritis patient has not been reported., Case Presentation: Three patients who presented to orthopedic department with complaints of bilateral knee pain were identified with grade III osteoarthritis (Kellgren and Lawrence) receiving some kind of analgetic treatment for more than 1 year which provided pain relief for some time but not permanent. They underwent arthroscopic procedure (bone marrow stimulation) and then injected with triamcinolone and hyaluronic acid combination. Pre and post operation outcome scores (WOMAC score, Interleukin 15 and MRI) were assessed. At six-month follow-up, all patients reported improvement in pain and stiffness. WOMAC score and Interleukin 15 serum level decreases, MRI with Amadeus score showed improvement of cartilage defect., Clinical Discussion: This case report showed that our three patients were successfully treated with bone marrow stimulation and intraarticular injection with triamcinolone and hyaluronic acid combination. All three patients have improved in their functional outcome, IL 15 and cartilage defect., Conclusion: Bone marrow stimulation and intraarticular injection with triamcinolone and hyaluronic acid combination can be a valuable treatment option for moderate active patients with grade III knee osteoarthritis., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: The Lysholm knee score and Tegner activity scale are frequently used patient-reported outcome measures in patients with anterior cruciate ligament (ACL) injuries because of their excellent psychometric properties. These questionnaires were originally developed in the English language., Purpose: To translate and cross-culturally adapt these measures into the Indonesian language and study their validity and reliability so that they can be used in the Indonesian-speaking population with ACL injuries., Study Design: Cohort study (diagnosis/symptom prevalence); Level of evidence, 2., Methods: After a forward-backward translation procedure and cross-cultural adaptation, validity and reliability were investigated. A total of 253 patients with an ACL injury were sent 4 questionnaires (36-Item Short Form Health Survey, Kujala anterior knee pain scale, Indonesian Lysholm knee score [I-LK], and Indonesian Tegner activity scale [I-TS]). The responses of those patients were analyzed. Following COSMIN guidelines, construct validity, test-retest reliability, internal consistency, floor and ceiling effects, and measurement errors were determined. The Bland-Altman method was used to explore absolute agreement., Results: A total of 106 patients (42% response rate) were included in this study. Construct validity was considered to be good, as more than 75% of the predefined hypotheses on correlations between the I-LK, I-TS, and other measures were confirmed. Reliability proved excellent, with a high test-retest correlation for both questionnaires (intraclass correlation coefficient = 0.99). Bland-Altman analysis showed no systematic bias between testing and retesting. The internal consistency of the I-LK was good (Cronbach alpha = 0.73). For the I-LK and I-TS, floor and ceiling effects were less than 15% (floor: 0% and 4.7%, respectively; ceiling: 12.3% and 3.8%, respectively); the standard error of measurement was 1.8 and 0.9, respectively; the minimal detectable change at the individual level was 5.1 and 0.6, respectively; and the minimal detectable change at the group level was 2.4 and 0.5, respectively., Conclusion: Both the I-LK and I-TS appear to be good evaluation tools for Indonesian-speaking patients with an ACL injury., Competing Interests: The authors have declared that there are no conflicts of interest in the authorship and publication of this contribution. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2022.)

Background: No questionnaire is currently available for use in patients with anterior cruciate ligament (ACL) injuries in an Indonesian population. The most-used questionnaire in clinical research for these patients is the International Knee Documentation Committee (IKDC) Subjective Knee Form, as its psychometric properties are considered to be excellent., Purpose: To translate the IKDC into Indonesian and assess its validity for use in Indonesian-speaking patients with ACL injuries., Study Design: Cohort study (diagnosis); Level of evidence, 2., Methods: After a forward-and-backward translation procedure and cross-cultural adaptation, the validity and reliability of the questionnaire were investigated. The responses of ACL injury patients on 3 questionnaires, the Indonesian-IKDC (I-IKDC), 36-Item Short Form Health Survey, and Kujala Anterior Knee Pain Scale, were compared. Following consensus-based standards for the selection of health measurement instruments guidelines, construct validity, test-retest reliability, internal consistency, floor and ceiling effects, and measurement error were determined. The Bland-Altman method was used to explore absolute agreement., Results: Of 253 ACL injury patients, 106 (42%) responded to the invitation. Construct validity was considered good, as all predefined hypotheses on correlations between the I-IKDC and other scores were confirmed. Reliability proved excellent, with a high test-retest correlation (intraclass correlation coefficient = 0.99). Bland-Altman analyses showed no systematic bias between test and retest. Internal consistency was good (Cronbach α = .90). There were no floor or ceiling effects. Standard error of measurement was 2.1, and the minimal detectable change was 5.8 at the individual level and 0.7 at the group level., Conclusion: The I-IKDC, as developed, appeared to be a good evaluation instrument for Indonesian patients with ACL injuries., Competing Interests: The authors declared that there are no conflicts of interest in the authorship and publication of this contribution. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto., (© The Author(s) 2021.)

One of the main causes of acute respiratory distress syndrome in coronavirus disease 2019 (COVID-19) is cytokine storm, although the exact cause is still unknown. Umbilical cord mesenchymal stromal cells (UC-MSCs) influence proinflammatory T-helper 2 (Th 2 ) cells to shift to an anti-inflammatory agent. To investigate efficacy of UC-MSC administration as adjuvant therapy in critically ill patients with COVID-19, we conducted a double-blind, multicentered, randomized controlled trial at four COVID-19 referral hospitals in Jakarta, Indonesia. This study included 40 randomly allocated critically ill patients with COVID-19; 20 patients received an intravenous infusion of 1 × 10 6 /kg body weight UC-MSCs in 100 ml saline (0.9%) solution (SS) and 20 patients received 100 ml 0.9% SS as the control group. All patients received standard therapy. The primary outcome was measured by survival rate and/or length of ventilator usage. The secondary outcome was measured by clinical and laboratory improvement, with serious adverse events. Our study showed the survival rate in the UC-MSCs group was 2.5 times higher than that in the control group (P = .047), which is 10 patients and 4 patients in the UC-MSCs and control groups, respectively. In patients with comorbidities, UC-MSC administration increased the survival rate by 4.5 times compared with controls. The length of stay in the intensive care unit and ventilator usage were not statistically significant, and no adverse events were reported. The application of infusion UC-MSCs significantly decreased interleukin 6 in the recovered patients (P = .023). Therefore, application of intravenous UC-MSCs as adjuvant treatment for critically ill patients with COVID-19 increases the survival rate by modulating the immune system toward an anti-inflammatory state., (© 2021 The Authors. STEM CELLS TRANSLATIONAL MEDICINE published by Wiley Periodicals LLC on behalf of AlphaMed Press.)

Background: To date, no recommendations have been published on when and how to start again carrying out elective, non-urgent surgery on COVID-19-negative patients after the epidemic peak has been reached in a given country or region and the pressure on healthcare facilities, healthcare workers and resources has been released by so far that elective surgery procedures can be safely and ethically programmed again. This study aims to investigate whether elective orthopaedic surgery will increase the risk of developing COVID-19., Materials and Methods: This was a combined retrospective and prospective studies performed at a national tertiary hospital in Jakarta, Indonesia. Subjects were patients who underwent elective orthopaedic surgeries at our institution from April to May 2020. Those who were previously infected with COVID-19 from polymerase chain reaction (PCR) reverse transcriptase (RT) examination obtained via nasopharynx and oropharynx swab, as well as those who were reluctant to participate were excluded from the study., Results: A total of 35 subjects (mean age 32.89 ± 17.42) were recruited. Fifteen (42.9%) subjects were male, and 20 subjects (57.1%) were female. Mean duration of surgery was 240 min with the longest and shortest duration of 690 and 40 min, respectively. General anaesthesia was performed in the majority of cases in 18 surgeries (51.4%) with local anaesthesia as the least in 2 surgeries (5.7%). Length of stay of our study was 6 days of average. None of the patients developed symptoms suggestive of COVID-19 infection., Conclusion: We found that elective orthopaedic surgery may not be associated with increased cases of COVID-19 cases. However, our study was limited by short duration of follow-up. Further studies are required in order to investigate the affect of undergoing elective surgery and the number of COVID-19 cases., Competing Interests: None., (© 2020 The Authors.)

Purpose: Up to now, there is no feasible solution for stopping or reversing the degenerative process of osteoarthritis (OA). Our study evaluated the effect of intra-articular injection of growth hormone (GH) in OA-induced rabbit knees compared to hyaluronic acid (HA) and placebo., Materials and Methods: A total of 21 male, skeletally mature, New Zealand rabbits received an intra-articular type II collagenase injection for OA induction. Two weeks later, the rabbits were randomized into three groups based on the weekly intra-articular injection to be received: GH, HA, and saline. Injections were done for three consecutive weeks. Evaluation was done at 8 weeks after treatment, clinically using the lameness period, macroscopically using the Yoshimi score and microscopically using the Mankin score., Results: The shortest period of lameness was found in the GH group (15.9±2.12 days), compared to the HA group (19.4±1.72 days) and placebo group (25.0±2.94 days). There was a statistically significant difference in macroscopic scoring between groups (p=0.001) in favor of the GH group. There was also significant difference in the microscopic score between groups (p=0.001) also in favor of the GH group., Conclusions: Intra-articular injection of GH showed better clinical, macroscopic and microscopic results as compared to HA and placebo.

Introduction: Neglected shoulder dislocation is a rare case and may be accompanied by pathological changes in bony and soft tissue structure. Therefore, it requires extensive surgical procedure. Until now, there is no standard treatment protocol to overcome this case and it is still a challenging case., Presentation of Case: We presented a 27-year-old male patient with deformity on his left shoulder. The patient has suffered a ten-month-neglected anterior shoulder dislocation with a Hill-Sachs lesion. The treatment was open reduction combined with Latarjet procedure. Evaluation of treatment was performed three months after surgery., Discussion: Management of a neglected shoulder dislocation, especially with significant bony defects, is challenging and cannot be managed with standard surgical technique because of severe soft-tissue contracture and imbalance as well as bone deficiency. Chronic locked anterior shoulder dislocation is a difficult condition for both patient and clinician. In addition to that, the treatment results can be unsatisfactory. Latarjet procedure has been shown to be effective for the treatment of recurrent anterior shoulder dislocation with a large glenoid osseous defect which might justify the application of this procedure for the treatment of neglected anterior shoulder dislocation., Conclusion: Open reduction combined with Latarjet procedure performed for treatment of neglected anterior shoulder dislocation was found to have a high rate of successful in preventing further dislocation of the shoulder joint although the high risk of osteoarthritis of the shoulder joint can still persist., (Copyright © 2019 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Introduction: Recurrent patellar dislocation can lead to articular cartilage injury. We report a 21-year old male with left patella instability and articular cartilage defect., Presentation of Case: A 21-year-old male presented with left patellar instability and pain. Knee range of motion (ROM) was limited when patella was dislocated (0-20°). The J-sign positive, patellar apprehension test was positive, with medial patella elasticity/patellar glide >2 quadrants. The Q angle, in the 90° flexed knee position was still normal. The plain radiograph imaging showed no abnormality. Insall-Salvati index was 1.12. The patient was diagnosed with recurrent patellar dislocation and cartilage lesion of the left knee, and was treated with combining Fulkerson osteotomy with the lateral retinacular release and percutaneous medial plication, followed by microfracture procedure and MSCs implantation., Discussion: Recurrent patellar dislocation is uncommon problem while cartilage lesions following recurrent patellar dislocations are quite common, but still no consensus on the management., Conclusion: Combination of Fulkerson osteotomy with the lateral retinacular release and percutaneous medial plication was effective in treating chronic patellar instability. The microfracture procedure and MSCs implantation was safe and could improve the cartilage regeneration in patients with articular cartilage defect due to recurrent patellar dislocation., (Copyright © 2019 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Acute pain is the most common early complication after total knee arthroplasty causing delayed mobilization and increased demands of morphine, leading to higher operative cost. Several studies have assessed the effectiveness, side-effects, and ease of use of various analgesics. Preemptive analgesia with combined celecoxib and pregabalin has been reported to yield positive outcomes. In this randomized, double-blind controlled clinical trial, 30 subjects underwent surgery for total knee arthroplasty using 15-20mg bupivacaine 5% epidural anesthesia. All subjects were divided into three groups. Group 1 was given celecoxib 400mg and pregabalin 150mg 1 hour before the operation, Group 2 was given celecoxib 200mg and pregabalin 75mg twice daily starting from 3 days before the operation, and Group 3 was given a placebo. The outcome was measured with Visual Analog Scale, knee range of motion, and postoperative mobilization. There was a significant difference in postoperative morphine usage between the groups that were administered with preemptive analgesia and the placebo group, but no significant difference was found between Group 1 and Group 2 that were given preemptive analgesia at different doses. ROM and postoperative mobilization were not significantly different among the three groups. Two patients in the first group, one patient in the second group, and one patient in the third group developed nausea. Preemptive analgesia is proven to reduce postoperative usage of morphine independent of the dosage. We recommend the use of combined celecoxib and pregabalin as preemptive analgesia after the total knee arthroplasty procedure. This trial is registered with NCT03523832 (ClinicalTrials.gov).

Background: Glucosamine, chondroitinsulfate are frequently used to prevent further joint degeneration in osteoarthritis (OA). Methylsulfonylmethane (MSM) is a supplement containing organic sulphur and also reported to slow anatomical joint progressivity in the knee OA. The MSM is often combined with glucosamine and chondroitin sulfate. However, there are controversies whether glucosamine-chondroitin sulfate or their combination with methylsulfonylmethane could effectively reduce pain in OA. This study is aimed to compare clinical outcome of glucosamine-chondroitin sulfate (GC), glucosamine-chondroitin sulfate-methylsulfonylmethane (GCM), and placeboin patients with knee osteoarthritis (OA) Kellgren-Lawrence grade I-II., Methods: a double blind, randomized controlled clinical trial was conducted on 147 patients with knee OA Kellgren-Lawrence grade I-II. Patients were allocated by permuted block randomization into three groups: GC (n=49), GCM (n=50), or placebo (n=48) groups. GC group received 1500 mg of glucosamine + 1200 mg of chondroitin sulfate + 500 mg of saccharumlactis; GCM group received 1500 mg of glucosamine + 1200 mg of chondroitin sulfate + 500 mg of MSM; while placebo group received three matching capsules of saccharumlactis. The drugs were administered once daily for 3 consecutive months VAS and WOMAC scores were measured before treatment, then at 4th, 8th and 12th week after treatment., Results: on statistical analysis it was found that at the 12th week, there are significant difference between three treatment groups on the WOMAC score (p=0.03) and on the VAS score (p=0.004). When analyzed between weeks, GCM treatment group was found statistically significant on WOMAC score (p=0.01) and VAS score (p<0.001). Comparing the score difference between weeks, WOMAC score analysis showed significant difference between GC, GCM, and placebo in week 4 (p=0.049) and week 12 (p=0.01). In addition, VAS score also showed significant difference between groups in week 8 (p=0.006) and week 12 (p<0.001)., Conclusion: combination of glucosamine-chondroitinsulfate-methylsulfonylmethane showed clinical benefit for patients with knee OAK ellgren-Lawrence grade I-II compared with GC and placebo. GC did not make clinical improvement in overall groups of patients with knee OA Kellgren Lawrence grade I-II.