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INTRODUCTION: Periprosthetic fractures are a devastating complication following total knee arthroplasty. Little is known about the effect of mechanical factors on the incidence of periprosthetic fractures. The aim of this study was to examine the correlation between pre-operative mechanical factors, like side of surgery, coronal alignment and pre-operative range of motion and intra-operative factors, and the incidence of a periprosthetic fracture, following primary total knee arthroplasty (TKA). MATERIALS AND METHODS: Forty-two patients with periprosthetic fractures (PPF) after primary TKA were identified from our hospital arthroplasty registry. These patients were matched two-to-one for gender and age at primary knee arthroplasty to 84 patients without PPF. The incidence of periprosthetic fracture with regards to laterality, coronal alignment and pre-operative range of motion was analysed. Intra-operative factors like implant type, patellar resurfacing and notching were also analysed using logistic regression. RESULTS: Coronal alignment, pre-operative range of motion and patella resurfacing were not significant predictors of periprosthetic fractures. Anterior femoral notching was found to be significantly higher in the fracture group with an odds ratio of 17. Left sided surgery was also significantly higher in the periprosthetic fracture group. CONCLUSION: Periprosthetic fractures are 17 times more likely to occur in a knee with anterior femoral notching. Preoperative factors like coronal alignment and poor preoperative range of motion do not seem to increase the risk of periprosthetic fractures after TKA.

Importance: In Asian populations, increased prevalence of hip dysplasia as well as activities of daily living which require increased hip range of motion, such as squatting, may impact outcomes of arthroscopic surgery for femoroacetabular impingement (FAI) when compared to their Western counterparts. Existing literature lacks a comprehensive review and synthesis of knowledge focusing on outcomes of arthroscopic intervention for FAI in the Asian population., Objective: To conduct the first systematic review and meta-analysis that examines outcomes of arthroscopic intervention in Asian patients with FAI., Evidence Review: PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Scopus, and Cochrane Library databases were reviewed. Case series or cohort studies assessing outcomes of arthroscopic intervention in FAI were included. Pooled analysis of modified Harris Hip Score (mHHS), Visual Analogue Scale (VAS), and adverse events were conducted. Rate of revision surgery and conversion to total hip arthroplasty (THA) were analysed as well., Findings: Six studies (5 case series, 1 cohort study) of high methodological quality involving 498 patients were included. Age of patients ranged from 20s to 70s, with a balanced gender ratio. Pooled patient-reported outcomes improved significantly postoperatively. VAS at the last follow-up mark improved by -4.28 (95 ​% CI, -4.49 to -4.08, P ​< ​0.00001), and VAS at the 12-month post-operation mark improved by -4.11 (95 ​% CI, -4.34 to -3.88, P ​< ​0.00001). The mHHS at the last follow-up mark improved by 23.37 (95 ​% CI, 20.29-26.45, P ​< ​0.00001). Revision surgery rate was low at 2.8 ​% and conversion to THA rate was 0.3 ​%., Conclusions and Relevance: Arthroscopic intervention in FAI provides favorable outcomes in the Asian population that is comparable with outcomes seen in the Western population., Level of Evidence: Meta-analysis; Level of evidence, IV., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Objective: Medial meniscus tear (MMT) is a common method to induce osteoarthritis in rats, but mimics secondary osteoarthritis. A novel method of carrying out a medial wedge closing tibial osteotomy (TO) has been recently developed to induce primary osteoarthritis. This study aims to validate it, compared to MMT., Methods: Twenty rats were divided equally into 2 groups. Outcome measures such as histology graded according to Osteoarthritis Research Society International (OARSI) guidelines and computed tomography (CT) scans were analyzed at 6 weeks post-operatively. Observational gait analysis and serum biomarkers such as C-terminal cross-linked telopeptides of type II collagen (CTX-II) and interleukin -1 beta (IL-1β) were collected at 2-weekly intervals up to 6 weeks post-operatively., Results: Serum CTX-II and IL-1β levels did not reveal a statistically significant difference across all time points between the 2 groups. CT grading was significantly more severe (2.80 ± 1.10 vs 1.40 ± 0.548, P = 0.0389) in the MMT group compared to the TO group. In addition, histological gradings such as calcified cartilage score (2.10 ± 1.91 vs 0.00 ± 0.00, P < 0.01) and cartilage degeneration score (4.80 ± 5.18 vs 0.00 ± 0.00, P < 0.01) revealed significantly more severe osteoarthritis in the MMT compared to TO group. Synovial membrane score did not reveal a statistically significant difference (1.10 ± 0.994 vs 1.00 ± 0.00, P = 1.00)., Conclusion: TO is a novel method in inducing primary osteoarthritis in the rat model compared to MMT between the 6 and 12 weeks' time frame., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: The use of synthetic bone substitute material (BSM) as osteotomy gap fillers have been reported to improve outcomes in medial opening wedge high tibial osteotomy (MOWHTO). This study aims to evaluate the early radiological outcomes (bone union) and complication rates of the novel patient-specific 3D-printed honeycomb-structured polycaprolactone and tricalcium phosphate (PCL-TCP) synthetic graft compared to allogeneic bone grafts as an osteotomy gap filler in MOWHTO., Methods: A retrospective matched-pair analysis of patients who underwent MOWHTO with either PCL-TCP synthetic graft or allogenic femoral head allograft as osteotomy gap filler was performed. The osteotomy gap was split into equal zones (Zone 1-5), and bone union was evaluated on anteroposterior radiographs based on the van Hemert classification at 1, 3, 6, and 12 months postoperatively. Postoperative complications including infection, lateral hinge fractures, and persistent pain was measured. The study and control group were matched for age, smoking status, diabetes mellitus, and osteotomy gap size., Results: Significantly greater bone union progression was observed in the PCL-TCP group than in the allograft group at 1 month (Zones 1-3), 3 months (Zones 1-4), 6 months (Zones 1-2, 4), and 12 months (Zones 2-3, 5) postoperatively ( P < 0.05). No significant difference in complications rates was noted between the two groups at 1 year., Conclusions: Bone union rates observed in patients who underwent MOWHTO with the PCL-TCP synthetic graft osteotomy gap filler were superior to those in the allograft group at 1 year postoperatively, with no significant difference in complication rates (postoperative infection, lateral hinge fractures, and persistent pain)., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose Midpole patellar fractures are traditionally fixed with an "11-8" metal tension band construct. However, this technique is rife with implant-related complications. This study aims to evaluate the radiographic and functional outcomes following "all-suture" fixation of mid-pole patellar fractures as compared to resorbable screw-augmented suture fixation. Methods We retrospectively studied a consecutive series of 18 patients, 9 each with mid-pole patellar fractures treated with all-suture fixation or suture fixation augmented with bioabsorbable cancellous screws in our institution. The hybrid fixation cohort was significantly older (p<0.01). Radiographic and functional outcomes, such as time to union, postoperative range of motion (ROM), and the presence of complications such as fracture displacement were recorded and evaluated. The minimum follow-up was one year. Results All cases achieved radiographic union by 15 weeks postoperatively except one from the hybrid fixation cohort. The average time to radiographic union was comparable (p=0.30). Twenty-two point two percent (22.2%; 2 out of 9) of the cases from each cohort had an increase in the fracture gap (>2 mm) at around four to six weeks postoperatively, for which all except one case from the hybrid fixation cohort achieved union thereafter. One patient from the hybrid fixation cohort had fibrous non-union and further fracture displacement. There was another case of mild fracture gapping and screw breakage on review of postoperative radiographs at three months from the hybrid fixation cohort. These patients recovered without surgical revision or implant removal. Conclusions Both non-metal fixation methods for mid-pole transverse patellar fractures proved to be radiographically and functionally comparable., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. SingHealth Centralised Institutional Review Board issued approval 2022/2214. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Huang et al.)

Introduction: Knowledge of femoral and tibial morphology is important for patient-specific surgery in both joint reconstruction and preservation procedures. Studies evaluating morphological variance in femoral and tibial alignments in Asian populations are scarce. This is the first descriptive study evaluating the femoral and tibial phenotypes of varus alignment in a Southeast Asian population., Methods: Long-leg coronal standing radiographs of 2021 limbs were obtained, and the hip-knee-ankle angle, mechanical lateral distal femoral angle, medial proximal tibial angle and joint line convergence angle were measured. Joint line obliquity was calculated, and the knees were classified according to the Coronal Plane Alignment of Knee (CPAK) classification. Descriptive analyses on alignment parameters and demographic data (age, gender, ethnicity and body mass index [BMI]) were performed and entered into a linear regression model., Results: The highest frequency of limb alignment in the population was found to be CPAK type I (52.71%, n = 1003). Tibial varus was the largest contributor of varus malignment. Of the varus knees (n = 1247), varus deformity was found solely in the tibia (68.60%), solely in the femur (2.07%) and was contributed by both the femur and the tibia (4.97%). In the linear regression model, BMI was found to be a strong determinant for femoral varus (P = 0.004) and joint line incongruence (P < 0.001)., Conclusion: The findings of this study will be important to surgeons during planning for joint preservation procedures (such as corrective osteotomies) and joint arthroplasties to restore alignment., (Copyright © 2024 Copyright: © 2024 Singapore Medical Journal.)

Over the past six decades, authorship numbers in academic publications have increased significantly, a phenomenon known as authorship inflation. This study aims to analyze comparative authorship trends and the influence of multicenter collaborations across major orthopedic, medical, and surgical journals. We reviewed metadata from The New England Journal of Medicine (NEJM), Annals of Surgery (AS), and The Journal of Bone and Joint Surgery (JBJS) from January 1, 1960, to December 31, 2019. The number of authors per publication, the prevalence of multicenter studies, and their correlation were analyzed. Data was visualized using heat maps and box plots, and trends were statistically tested using the Jonckheere-Terpstra, Mann-Kendall, and generalized linear mixed models (GLMMs). A total of 73,062 articles were analyzed, with 1,190 articles identified as originating from multicenter studies. The number of multicenter trials was found to have increased significantly over time (p < 0.001), plateauing in NEJM but continuing to rise in JBJS and AS. There was a significant increase in authorship numbers per publication over time, across all journals (p < 0.0001). There was a significant statistical correlation (p < 0.0001) as indicated by the coefficient of determination (r 2 ), for the association between the proportion of publications with >10 authors and the proportion of multicenter publications across all three journals. Authorship inflation in academic publishing may be attributable to the rise in multicenter collaborations. The rate of increase in authorship was more pronounced in medical and surgical journals compared to orthopedic journals, reflecting differing trends across specialties. These findings highlight the evolving nature of research collaboration and authorship practices in academic publishing., Competing Interests: Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Chau et al.)

At-risk patients continue to experience a high likelihood of graft rupture after anterior cruciate ligament (ACL) reconstruction (ACLR). This narrative review seeks to provide the reader with an evidence-based synopsis of state-of-the-art concepts related to secondary restraint lesions, and how addressing them surgically might result in improved outcomes of ACLR., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background & Aims: Knee osteoarthritis (KOA) is a progressive degenerative disease of chronic nature. The mainstay of surgical management for KOA would be total knee arthroplasty. Joint preserving options like High Tibial Osteotomy (HTO) and Proximal Fibular Osteotomy (PFO) have been offered as an inexpensive option by knee preservation surgeons. Current literature on PFO outcomes lack of clarity for specific indications for offering PFO based on degree of severity of KOA. Therefore, this systematic review aims to critically evaluate clinical and radiological outcomes of PFO stratified by severity of KOA., Methods: PubMed, Scopus, CINAHL and Google Scholar databases were searched. Eligible studies included those published up till August 2023, with 271 studies obtained. After duplicate removal, title-abstract screening, and a full text screen based on inclusion and exclusion criteria, 11 papers were included. 46 papers were further identified from snowballing of 7 existing systematic reviews, with 2 additional papers subsequently included., Results: 13 included articles analysed 788 knees. Our study found that indications based on KL grading of KOA do not seem to differ in terms of post-operative clinical outcomes (VAS score) and radiological measures also found that hip knee alignment was improved regardless of KL grading of KOA. Additionally, the most common post-operative complication reported was deep peroneal nerve palsy., Conclusion: PFO is a viable knee joint preserving surgery for medial compartment KOA, however given the high risk for complications reported in the literature, surgeons should pay close attention to the neuroanatomical landmarks and techniques to avoid neurovascular injury., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 Delhi Orthopedic Association. All rights are reserved, including those for text and data mining, AI training, and similar technologies.)

Background: Cartilage defects are debilitating injuries that can reduce quality of life in patients. However, the poor regenerative properties of cartilage mean that cartilage repair remains challenging, and many methods have arisen to address that. Autologous matrix-induced chondrogenesis (AMIC®) is a popular technique to manage cartilage defects. Recent advances have allowed AMIC® to be done arthroscopically, instead of a mini-open arthrotomy approach. This systematic review and meta-analysis aims to investigate whether the arthroscopic approach to AMIC® provides better clinical outcomes than does the mini-open approach, in hopes of delineating a gold standard in cartilage repair., Methods: With reference to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, a systematic search of the following databases (PubMed, Embase, Scopus, and Cochrane Library) was performed on 26th October 2022 using a combination of the following search terms: "autologous matrix induced", "chondrogenesis", and "knee". A total of 390 studies were identified, of which, 24 studies were included in our final analysis., Results: The arthroscopic approach achieves lower Visual Analogue Scale for pain scores. The International Knee documentation Committee) score and Knee Injury and Osteoarthritis Outcome Score were comparable between arthroscopic and open approaches. The open approach achieves a higher Magnetic Resonance Observation of Cartilage Repair Tissue score. Incidence of reported postoperative complications of revision surgery and knee stiffness was higher for the open approach than for the arthroscopic approach, whereas deep vein thrombosis was higher in the arthroscopic approach., Conclusion: The AMIC® repair outcomes indicate that the arthroscopic approach does not hold a distinct advantage over the open approach. The choice of approach should consider surgeon expertise, location of lesion, and patient-specific factors., Level of Evidence: Systematic review and meta-analysis; Level III., Competing Interests: Declaration of competing interest The authors declare no conflicts of interest., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Introduction: ChatGPT (Chat Generative Pre-trained Transformer), developed by OpenAI (San Francisco, CA, USA), has gained attention in the medical field. It has the potential to enhance and simplify tasks, such as preoperative planning in orthopedic surgery. We aimed to test ChatGPT's accuracy in measuring the angle of correction for high tibial osteotomy for cases planned and performed at a tertiary teaching hospital in Singapore., Materials and Methods: Peri-operative angular parameters from 114 consecutive patients who underwent medial opening wedge high tibial osteotomy (MOWHTO) were used to query ChatGPT 3.0. First ChatGPT 3.0 was queried on what information it required to plan a MOWHTO. Based on its response, pre-operative medial proximal tibial angle (MPTA) and joint line congruence angle (JLCA) were provided. ChatGPT 3.0 then responded with its recommended angle of correction. This was compared against the manually planned surgical correction by our fellowship-trained surgeon. A root mean square analysis was then performed to compare ChatGPT 3.0 and manual planning., Results: The root mean square error (RMSE) of ChatGPT 3.0 in predicting correction angle in MWHTO was 2.96, suggesting a very poor model fit., Conclusion: Although ChatGPT 3.0 represents a significant breakthrough in large language models with extensive capabilities, it is not currently optimized to effectively perform complex pre-operative planning in orthopedic surgery, specifically in the context of MOWHTO. Further refinement and consideration of specific factors are necessary to enhance its accuracy and suitability for such applications., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2024, Gengatharan et al.)

Introduction: This paper aims to systematically review and meta-analyse the available evidence regarding the clinical and radiographic outcomes of non-metal fixation methods in treating patellar fractures compared to a control metal fixation group, in the hopes of bringing insight into their effectiveness., Methods: Two investigators systematically reviewed studies across 9 English or Mandarin electronic databases - Cochrane Library, EMBASE, Google Scholar, Medline, PubMed, Scopus, Web of Science, CNKI and Wanfang Data, in adherence to PRISMA guidelines. The inclusion criteria for study selection were: English or Mandarin comparative studies that evaluated clinical (Patient Reported Outcome Measures, incidence of reoperations and postoperative complications) or radiographic (time to union and incidence of secondary loss of reduction) outcomes of metal and non-metal fixation methods for patellar fractures. From an initial pool of 1269 studies, 19 studies involving 1612 patients were included in the meta-analysis after full-text evaluation and accounting for exclusion criteria., Results: Clinically, the reduction in reoperations (OR = 0.22, 95% CI [0.10, 0.51], P = 0.0003), direct (OR = 0.17, 95% CI [0.08, 0.33], P < 0.00001) and indirect (OR = 0.50, 95% CI [0.27, 0.93], P = 0.03) implant-related postoperative complications were significantly in favor of non-metal fixation. Radiographically, the decrease in time to union (SMD = -0.79, 95% CI [-1.11, -0.47], P < 0.00001) in the non-metal group compared to the metal group was also significant. The remaining results were comparable., Conclusion: This meta-analysis suggests that non-metallic internal fixation had similar if not superior outcomes to their metallic counterparts, with fewer implant-related complications and improved postoperative recovery. Given the higher re-operation rates associated with metallic fixation, non-metallic methods may be preferable from economic and safety perspectives. Nevertheless, more homogenous studies with standardised fracture configurations and treatment modalities are needed before declaring non-metallic fixation as the gold standard for patellar fractures., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 Delhi Orthopedic Association. All rights reserved.)

Purpose: To compare the efficacy of a single dose of platelet-rich plasma (PRP) with multiple doses of PRP therapy in the treatment of knee osteoarthritis (KOA)., Methods: The PubMed, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Scopus, and Cochrane Library databases were searched from database inception to May 2022; in addition, the gray literature and bibliographic references were searched. Only randomized controlled trials comparing the effect of a single dose versus multiple doses of PRP for KOA were included. Literature retrieval and data extraction were conducted by 3 independent reviewers. The inclusion and exclusion criteria were based on type of study, research subjects, intervention, outcome, language, and availability of data. Pooled analyses of visual analog scale (VAS) scores, Western Ontario and McMaster Universities Arthritis Index scores, and adverse events were conducted., Results: Seven studies (all randomized controlled trials) of high methodologic quality involving 575 patients were included. The ages of the patients included in this study ranged from 20 to 80 years, and the sex ratio was balanced. Triple-dose PRP therapy resulted in significantly better VAS scores compared with single-dose PRP therapy at 12 months (P < .0001), with no significant change in VAS scores between double-dose PRP and single-dose PRP at 12 months. Regarding adverse events, double-dose (P = .28) and triple-dose (P = .24) therapy showed no significant differences in safety from single-dose therapy., Conclusions: Although there is a paucity of large high-quality Level I studies, current best evidence suggests that 3 doses of PRP for KOA are more effective than 1 dose of PRP at providing pain relief up to 1 year after administration., Level of Evidence: Level II, systematic review of Level II studies., (Copyright © 2023 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

This study aimed to evaluate the clinical outcomes following administration of tranexamic acid (TXA) in patients undergoing high tibial osteotomy (HTO) through a systematic review of current available evidence. A systematic database search of PubMed, Embase and Cumulative Index of Nursing and Allied Health Literature (CINAHL) was performed from inception up to December 2022, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA). Inclusion criteria were (i) randomised control trials, cohort studies or case-control studies that had more than 10 patients; (ii) studies reporting outcomes after TXA administration, of any route, before or after HTO, compared to placebo, control and different doses or routes; and (iii) studies reporting blood loss, including haemoglobin (Hb) drop, estimated blood loss, transfusion requirement and complications. Case reports, reviews, abstracts, non-HTO studies, non-human studies and duplicates were excluded. A synthesized comparison of drain output, wound complications, transfusion requirement and pooled analyses of blood loss and Hb drop was performed. Eleven studies involving 974 patients were included. Nine studies had placebo comparison, and two used single-dose TXA versus multiple doses. All studies reported on postoperative hemoglobin and nine on blood loss. In the six TXA versus placebo studies reporting on total blood loss, the TXA group had a pooled, estimated standardised mean difference (SMD) in blood loss of -2.37 (95% confidence interval (CI) -3.67, -1.07; P = 0.0004). For the Hb drop, on postoperative days (PODs) one, two, and five, the SMDs were -0.97 (95% CI -1.19, -0.75; P < 0.00001) for POD1, -0.74 (95% CI -1.03, -0.46; P < 0.00001) for POD2 and -0.87 (95% CI -1.10, -0.64; P < 0.00001) for POD5. TXA administration in HTO significantly reduces perioperative blood loss. This can greatly improve recovery, reduce complications and shorten length of stay. This is especially pertinent given supply shortages of NHS blood resources., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, O'Donnell et al.)

Purpose: This study aims to assess the significance of post-operative change in limb length in medial opening wedge high tibial osteotomy (MOWHTO), and evaluate the correlation between correction angles and changes in limb length. We hypothesize that opening wedge height and correction angles directly correlate to changes in limb length., Methods: The medical records and radiographs of 91 MOWHTO patients were retrospectively evaluated for relevant radiographical parameters both pre- and post-operatively. The exclusion criteria are: (i) concurrent distal femur osteotomy in the same setting, (ii) other previous unilateral lower limb surgeries prior to MOWHTO and (iii) failure to follow-up with post-operative radiographs. A linear regression model was performed and a line of best fit, Pearson's correlation coefficient (r) and coefficient of determination (R 2 ) were computed. Chi-squared test was also performed, and results with P < 0.05 were considered statistically significant., Results: There is a statistically significant increase in post-MOWHTO limb length (Absolute Δ = 4.3 ± 2.86 mm, % Δ = 0.652% ± 0.434%, p < 0.001). There was no significant difference in the limb length change between patients with larger (> 8 mm) and smaller (< 8 mm) opening widths. There was a weakly positive correlation between limb length change versus actual (R 2  = 0.140, 95%CI [-0.068, 0.336]) and planned correction angles (R 2  = 0.196, 95%CI [-0.012, 0.387])., Conclusion: In conclusion, post-MOWHTO change in limb length is statistically significant, but the clinical significance is minimal. Further studies are required to assess other factors. Development of a reliable mathematical model that predicts post-MOWHTO limb length change would be useful in predicting the anatomical outcomes., Level of Evidence: Level III. Retrospective Cohort Study., (© 2023. European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA).)

Chondral lesions of the knee are common orthopedic issues encountered in daily practice. Hyalofast ®  (Anika Therapeutics, Bedford, Massachusetts) grafting with bone marrow aspirate concentrate (BMAC) has been shown, in numerous studies, to be clinically efficacious in the surgical treatment of these lesions. We describe a case of chondral lesions in the knee initially successfully treated with arthroscopic chondroplasty and Hyalofast ® grafting with BMAC, but who subsequently developed patellar cartilage bossing, causing anterior patellofemoral joint pain eight months after surgery. A 48-year-old gentleman underwent arthroscopic chondroplasty and mini-open cartilage repair with Hyalofast ® and BMAC after presenting with right knee pain and swelling affecting his ability to participate in sports. His initial recovery was unremarkable, but he subsequently developed anterior knee pain exacerbated by stair climbing and jogging eight months after the initial surgery. Magnetic resonance imaging revealed bossing of the Hyalofast ® graft over the central patella, and intraoperative testing confirmed the impingement. The patient's symptoms resolved immediately following arthroscopic debridement. While Hyalofast ® grafting and BMAC remain viable options in the treatment of chondral lesions in the knee, the inability to predict the amount of cartilage repair and recovery may result in pain and impingement symptoms, and surgeons should be aware of such possible complications., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Cheong et al.)

Background: There is a significant dissatisfaction rate in patients undergoing total knee arthroplasty (TKA), and poor mental health in patients is increasingly recognized as a major contributor to dissatisfaction. The aim was to review the effectiveness of cognitive behavioural therapy (CBT) in improving pain and functional outcomes of patients undergoing TKA and highlight important aspects that may be crucial for improvement., Methods: A systematic search was conducted in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Studies were included if they were randomized control trials that included patients undergoing unilateral or bilateral TKA, with CBT as an intervention compared against usual care, and reported outcomes in pain, knee function and any psychological outcomes as measured., Results: Eight RCTs were selected which included 683 participants. The timings of CBT delivery, profiles of therapists, and outcome measures reported varied across the studies. Overall, 3 studies reported significant improvement in pain outcomes, 3 studies reported significant improvement in functional outcomes and 5 studies reported significant improvements in psychological outcomes., Conclusion: Current evidence does not support the efficacy of CBT as current literature is too heterogenous. Further studies with homogenous CBT methods are required to further ascertain the true relationship between CBT and postoperative outcomes of TKA. Future studies should consider the points set out in this review, such as the importance of revisiting CBTskills, providing individualized therapy, having a supervisory team to support the fidelity of interventions, and identifying which group of patients would best benefit from CBT., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 Delhi Orthopedic Association. All rights reserved.)

Purpose: To evaluate the clinical outcomes of anterior cruciate ligament reconstruction (ACLR) with meniscal allograft transplantation (MAT) through a systematic review of current available evidence., Methods: A systematic database search of PubMed, Embase, Web of Science, and CINAHL was performed from inception up to December 7, 2021, in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses. Follow-up studies (inception cohort studies/nonrandomized controlled trials/retrospective cohort studies) and case series that had more than 10 people published in English and involved patients who underwent a combination of ACLR and MAT were included. The quality of these studies was appraised using the Cochrane Risk Of Bias In Non-randomized Studies of Interventions tool. Systematic review of International Knee Documentation Committee (IKDC), Lysholm, and Tegner activity scores were conducted., Results: Seven studies involving 363 patients were included. The average mean follow-up time was 4.08 years, ranging from 1.75 to 14 years. All studies used the Lysholm Knee Scoring system to report clinical outcomes, whereas 2 studies and 4 studies used the IKDC Questionnaire and Tegner activity scale respectively to measure clinical outcomes postoperatively. Comparing postoperative with preoperative scores, we found an improvement above the minimal clinically important difference for the Lysholm (mean difference [MD] range 16.00-26.10) and Tegner activity scores (MD range 1.50-1.90). All but one study reported an increase above the minimal clinically important difference for IKDC scores postoperatively (MD range 5.60-23.00)., Conclusions: Combined MAT and ACLR have good 2- to 14-year clinical outcomes postoperatively and is an optimal procedure for patients with concurrent ACL injuries with irreparable meniscus injuries., Level of Evidence: IV, systematic review and/or meta-analysis of studies with Levels I to IV., (Copyright © 2022 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: A large proportion of hip fractures involve inter-trochanteric fractures which are managed by cephalomedullary nails. There is ongoing debate about the advantages and disadvantages of locked versus unlocked long cephalomedullary femoral nails in the treatment of intertrochanteric fractures. The objectives of our study are to evaluate the biomechanical effects of a distal interlocking bolt on the type of peri-implant fractures in a healed intertrochanteric fracture with long cephalomedullary nail fixation., Methods: 20 femoral sawbone specimens were prepared with the TFN-ADVANCED Proximal Femoral Nailing System (TFNA) and divided into 2 groups: locked and unlocked. The specimens were subjected to axial loading force until failure. Compressive forces, strain and fracture patterns were compared between the 2 groups., Results: There was no significant difference in the mean load to failure of the unlocked specimens compared to locked specimens. However, there was significant difference in the mean compressive stress at the time of failure with the unlocked specimen (1.79±0.17 MPa) compared to the locked group (1.92±0.05 MPa) (p < 0.05). Video review analysis showed unlocked specimens consistently having basi-cervical type peri-implant fractures while locked specimens showed complex, compound fractures of the head-neck region with 2 or more fracture propagation points., Conclusion: Distal-locked long cephalomedullary nails in a healed intertrochanteric fracture model are able to tolerate higher compressive stress at the point of failure but demonstrate more complex peri-implant fracture patterns in the femoral head-neck region as compared to unlocked specimens., Competing Interests: Declaration of Competing Interest This manuscript is original research and has not been previously published, nor submitted for publication elsewhere. There are no conflicts of interests between authors related to this paper. SSS and HRBAR obtained the SingHealth Musculoskeletal Sciences ACP Pitch-for-fund grant which contributed funding for the study. All authors contributed to the intellectual development of this paper and approved of the final manuscript. Synthes Singapore Pte Ltd contributed both implants and surgical sets used in the project. No honoraria was granted in support of this project and all authors do not have any employment, consultancy or stock ownership with the company., (Copyright © 2022. Published by Elsevier Ltd.)

Background: Physical rehabilitation after total knee arthroplasty (TKA) is important for long-term functional recovery. Recently, sensor-based home rehabilitation (SHR) has gained prominence as a promising method that allows monitoring and guidance that is both structured and accessible, compared to traditional methods of physical rehabilitation. Despite the advent of wearable sensor systems, there is a paucity of evidence regarding SHR in the current literature. Thus, this systematic review aimed to evaluate the effect of wearable SHR on post-TKA outcomes., Methods: We performed a systematic search of three electronic databases from the beginning of record to March 12, 2021. Primary outcomes were patient-reported outcome measures (PROMs) after rehabilitation, including the Knee Injury and Osteoarthritis Outcome Score (KOOS), Western Ontario and McMaster Universities Arthritis Index (WOMAC) and Knee Society Score (KSS). Secondary outcomes were physical activity levels and functional performance including range of motion (ROM) and Timed Up and Go Test (TUG)., Results: A total of 16 studies involving 1321 subjects were included. All wearable sensors in our included studies involved a combination of accelerometers, gyroscopes and magnetometers as functional units. These studies reported favourable outcomes for all three PROMs, although the extent of improvement in specific domains varied among studies. Moreover, physical activity in terms of daily steps and time spent on physical activity increased post-rehabilitation. Similarly, there were improvements in ROM and TUG that reflected a favourable post-operative trajectory during rehabilitation., Conclusion: SHR is effective for improving subjective and objective outcomes post-TKA. The role of SHR should be evaluated by a dedicated cost-benefit analysis to facilitate its wider adoption in healthcare systems.

Background: Our study aims to validate a commercially available inertial measurement unit (IMU) system against a standard laboratory-based optical motion capture (OMC) system for shoulder measurements in a clinical context., Methods: The validation analyses were conducted on 19 healthy male volunteers. Twelve reflective markers were placed on each participant's trunk, scapula and across the arm and one IMU was attached via a self-adhesive strap on the forearm. A single tester simultaneously collected shoulder kinematic data for four shoulder movements: flexion, extension, external rotation, and abduction. Agreement between OMC system and IMU measurements was assessed with Bland-Altman analyses. Secondary analysis included mean biases, root mean square error (RMSE) analysis and Welch's t -test., Results: Bland-Altman limits of agreement (LoA) exceeded the acceptable range of mean difference for 95% of the population (-22.27°, 11.31°). The mean bias showed high levels of agreement within 8° for all four movements. More than 60% of participants demonstrated mean bias less than 10° between methods. Statistically significant differences were found between measurements for abduction (P<0.001) and flexion (P=0.027) but not for extension and external rotation (P≥0.05)., Conclusions: Our study shows preliminary evidence for acceptable accuracy of a commercially available IMU against an OMC system for assessment of shoulder movements by a single tester. The IMU also exhibits similar whole degree of error compared to a standard goniometer with potential for application in remote rehabilitation., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://mhealth.amegroups.com/article/view/10.21037/mhealth-22-7/coif). SRYB and HRBAR report consulting role for XCLR8 Technologies Pte Ltd in an unpaid role as a medical advisor. LY reports full-time employment at XLCR8 Technologies Pte Ltd since 2020 with no financial interests related to the submitted work. LD reports stock ownership of XCLR8 Technologies Pte Ltd with no financial interests related to the submitted work. The other authors have no conflicts of interest to declare., (2022 mHealth. All rights reserved.)

Purpose: Asians have a low venous thromboembolism (VTE) incidence following total knee arthroplasty (TKA). This systematic review and network meta-analysis was conducted to evaluate the best prophylaxis against VTE in Asians following total knee arthroplasty in current literature., Materials and Methods: A systematic search of PubMed, Embase and CINAHL was conducted in adherence with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Prophylaxis types were separated into low-molecular-weight heparin (LMWH), novel oral anti-coagulants (NOAC), mechanical-only prophylaxis (MOP) and no prophylaxis (NP). The primary outcome was VTE incidence, grouped according to diagnosis modality (ultrasound, venography, clinical). The secondary outcome was bleeding incidence, grouped into minor and major bleeding., Results: Fourteen eligible articles, totalling 4259 patients, were pooled with the following significant results: NOACs had lower venography-diagnosed VTE incidence than LMWH (12.77%, p = 0.02) and NP (20.64, p < 0.001). MOP had lower venography-diagnosed VTE incidence than LMWH (23.72%, p < 0.001), NOACs (10.95%, p < 0.001) and NP (31.59%, p < 0.001) but, interestingly, a statistically higher ultrasound-diagnosed VTE incidence than LMWH (6.56%, p = 0.024) and NP (4.88%, p = 0.026). No significant differences were observed between prophylaxis types for symptomatic VTE, pulmonary embolism (PE) or death. LMWH and NOACs had a higher minor bleeding incidence than NP (11.71%, p < 0.001 and 6.33%, p < 0.02, respectively). No significant differences were observed between prophylaxis types for major bleeding incidence., Conclusion: NOACs are a superior form of chemoprophylaxis, compared with LMWH, in reducing venography-diagnosed VTE incidence with no added bleeding incidence. However, routine chemoprophylaxis may not be required as LMWH and NOACs do not appear to reduce symptomatic VTE incidence compared with MOP and NP with an increased minor bleeding incidence. Mechanical prophylaxis in the form of graduated compression stockings or intermittent pneumatic compression should be routinely considered with significantly lower rates of venography-diagnosed VTE compared with NP. On the basis of current evidence, we recommend an individualised approach to select the most appropriate prophylaxis type., (© 2022. The Author(s).)

Objective: To determine if individuals with chronic ankle instability (CAI) demonstrate altered landing kinematics, muscle activity, and impaired dynamic postural stability during a unilateral jump-landing task., Methods: 21 studies were included from PubMed, MEDLINE, Embase and CINAHL searched on September 26, 2021. Mean differences in joint angles and muscle activity between CAI and controls were analysed as continuous variables and pooled using a random-effects model to obtain standardised mean differences and 95% confidence intervals. Dynamic postural stability measured using time to stabilisation (TTS) was assessed qualitatively., Results: We found greater plantarflexion (pooled SMD = 0.33, 95%CI [0.02,0.65]), reduced knee flexion (pooled SMD = -0.67, 95%CI [-0.97, -0.37]), and reduced hip flexion (pooled SMD = -0.52, 95%CI [-0.96, -0.07]) in CAI after landing. Regarding muscle activity, we observed reduced peroneus longus muscle activation (pooled SMD = -0.77, 95% CI [-1.17, -0.36]) in CAI prior to landing., Conclusion: Our study provides preliminary evidence of altered landing kinematics in the sagittal plane and reduced peroneus muscle activity in CAI during a dynamic jump-landing task. These results may have clinical implications in the development of more effective and targeted rehabilitation programmes for patients with CAI., Competing Interests: Declaration of competing interest The authors declare that there is no conflict of interest., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Background: The introduction of direct oral anticoagulants (DOACs) shows promise for their role as a chemoprophylaxis agent after total knee arthroplasty (TKA) for the prevention of venous thromboembolism (VTE). However, existing studies are largely based on Western populations that do not account for the different risk profiles and lower rates of VTE in Asians. This systematic review and meta-analysis aimed to evaluate the efficacy of DOACs compared with enoxaparin in an Asian-based population study., Methods: The review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. All studies that compared outcomes between enoxaparin and DOACs as VTE prophylaxis after TKA in the Asian population were included., Results: Five studies with 121,153 patients were included. DOACs demonstrated a convincing benefit over enoxaparin in overall VTE prevention (odds ratio [OR] = 0.42, 95% confidence interval [CI]: 0.24-0.74). However, although the OR trended in favor of DOACs for the reduction of deep vein thrombosis events (OR = 0.54, 95% CI: 0.20-1.48) and pulmonary embolism (OR = 0.75, 95% CI: 0.07-8.20), statistical significance was not reached. In terms of bleeding complications, both arms had similar rates of major (0.91% vs 0.20%), clinically relevant nonmajor (3.28% vs 2.94%), and minor bleeding complications (12.8 vs 13.3%). A nonsignificance advantage of enoxaparin over DOACs was revealed in the OR for major bleeding (OR = 3.17; 95% CI: 0.81-12.43), whereas DOACs were favored to reduce risk of clinically relevant nonmajor (OR = 0.82; 95% CI: 0.01-91.51) and minor bleeding (OR = 0.76; 95% CI: 0.11-5.33)., Conclusion: DOACs confer a significantly reduced rate of overall VTE compared with enoxaparin in Asians after TKA. No significant differences in deep vein thrombosis, pulmonary embolism, and rates of bleeding complications exist., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Postoperative X-rays are a key part of management of orthopaedic patients. These X-rays serve to check stability of orthopaedic fixation as well as to ensure that there are no peri-implant fractures and periprosthetic fractures following surgical fixation of fractures and arthroplasty procedures, respectively. Timely accurate interpretation of postoperative X-rays are crucial in guiding weight-bearing status as well as rehabilitation. Therefore, delays in X-ray acquisition may impact initiation of postoperative rehabilitation and overall length of stay negatively. The aim of this project is to optimise acquisition of postoperative X-rays in patients undergoing implant surgery and as a result increase efficiency of deployed healthcare staff. A multidisciplinary team was formed to study the efficacy of a new workflow for patients to undergo X-rays immediately after surgery while en-route to the ward. Pretrial and in-trial delays in acquiring X-rays and total man-hours spent on transport were recorded. These processes were refined and integrated to optimise the new workflow. Compared with the old workflow, delays in obtaining X-rays were significantly reduced from the longest of 20 hours and 40 min to no delays at all. Overall man-hours spent on transport of these patients were reduced by a mean of 12 and 16 min for nurses and porters, respectively. The trial workflow has since been adopted successfully by our institution and since inception has become standard practice, allowing timely review of postoperative X-rays. This has led to increased workforce efficiency as well as timely rehabilitation and discharge of patients., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background Mid-pole patellar fractures are typically fixed with metal implants in the conventional "11-8" tension band construct. However, this technique is fraught with numerous implant-related complications. The aim of this study is to evaluate the union rate following "all-suture" fixation of mid-pole patellar fractures. Methods We retrospectively evaluated a consecutive case series of patients with displaced mid-pole patella fractures treated with "all-suture" fixation in our institution. Fifteen cases were available for this study. The average age was 61.5 years. Clinical and radiological outcomes were evaluated. Union time, complications, and revision rate were recorded. The minimum follow-up was one year. Results There were eight males and seven females, with a mean age of 61.5 ± 13.3 years. Fourteen out of 15 cases (93.3%) achieved radiographic union at 12 weeks postoperatively. The average time to radiographic union was 8.0 ± 2.7 weeks. Five cases (33.3%) had an increase in the fracture gap (>2 mm) at around four to six weeks postoperatively. Four of these cases had an eventual union, whereas one patient had fibrous non-union. There was one case of superficial surgical site infection and one case of infected hematoma. None of the patients required revision surgery. Conclusion "All-suture" fixation of mid-pole transverse patellar fractures is a safe and viable alternative to the conventional "11-8" tension band constructs with metal implants, with good union time, rates, and added benefits of not requiring additional surgery for implant removal., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, Lee et al.)

Although both long and short cephalomedullary devices (CMDs) are used in the treatment of extracapsular hip fractures, the advantages of either option are subject to debate. This study aims to evaluate the differences in clinical outcomes with long versus short CMDs for extracapsular hip fractures. Studies included must have included subjects with at least 1 year of follow-up and reported on at least one of the following outcomes: rate of reoperation; rate of peri-implant fracture; operating time; blood loss; complication rate; length of hospital stay; 1-year mortality. Only articles written in the English language were included in this study. A search was conducted across the databases of Medline, Embase, CENTRAL (Cochrane Central Register of Controlled Trials), CINAHL and Scopus for articles published from the inception of the database to 1 November 2020. Included studies were assessed for their risk of bias using the Risk of Bias Tool (RoB2) and the risk-of-bias in non-randomized studies - of interventions (ROBINS-I) tool. A total of 8460 fractures from 16 studies were included in the analysis, with 3690 fixed with short, and 4770 fixed with long CMDs. A meta-analysis of the results revealed that short CMDs offer peri-operative advantages, while long CMDs could offer longer-term advantages. Limitations of this study include a lack of randomized control trials included in the analysis. In conclusion, when planning for the treatment of extracapsular hip fractures, a patient specific approach may be necessary to make a decision according to the individual risk profile of the patient., (© 2021. The Author(s).)

The burden of knee osteoarthritis (OA) is increasing worldwide. Advanced tibiofemoral joint OA in young patients is particularly a problem with inferior results seen with total knee arthroplasty in this patient population. Knee joint distraction (KJD) has been evaluated recently as a joint preserving procedure for young patients with advanced tibiofemoral osteoarthritis, to delay the need for a primary total knee arthroplasty (TKA). This will decrease the risk for revision TKA later in life. KJD temporarily unloads the knee joint and keeps the tibia and femur separated over a course of 6 weeks. Outcomes of KJD appear promising. Through this article, the authors hope to share from their collective experience as well as the available literature on the basic science, principles of surgery and outcomes of KJD., (© 2021 Delhi Orthopedic Association. All rights reserved.)

Purpose: This study aims to compare the efficacy of a dual therapy of Platelet-Rich Plasma (PRP) and Hyaluronic Acid (HA) compared with PRP-alone therapy in the treatment of knee osteoarthritis (KOA)., Methods: PubMed, Embase, CINAHL, SCOPUS, Cochrane Library, grey literature and bibliographic references were searched from inception to January 2021. Only randomized controlled trials (RCTs) and retrospective cohort studies comparing the effect of PRP and HA versus PRP-alone therapy for KOA were included. Literature retrieval and data extraction were conducted by three independent reviewers. Pooled analysis of Visual Analogue Scale (VAS), Western Ontario and McMaster Universities Arthritis Index (WOMAC), International Knee Documentation Committee (IKDC) scores and adverse events were conducted., Results: Ten studies (7 RCTs, 3 cohort studies) involving 983 patients were covered. Dual PRP and HA therapy resulted in significant reduction in VAS compared to PRP-alone therapy at 4-6 weeks (P < 0.00001) and 12 months (P < 0.00001). Dual therapy resulted in better WOMAC score improvement at 3 (P = 0.02), 6 (P = 0.05) and 12 months (P < 0.0001) compared to PRP-alone therapy. The IKDC score for dual therapy was also higher at 6 months compared to PRP-alone therapy (P = 0.007). Regarding adverse events, dual therapy was generally safer than PRP-alone therapy (P = 0.02)., Conclusion: While there is a paucity of large high-quality Level I studies, current best evidence suggests that dual therapy with PRP and HA for KOA may be effective at providing pain relief and improvement in function up to 1 year following administration., Level of Evidence: II., (© 2021. The Author(s).)

Purpose: Previous investigations suggested that femoral side-to-side differences were located in the upper femur anatomy. However, little is known about the asymmetry between distal femur and patella. The degree of bony asymmetry in the patellofemoral joint was evaluated using pairs of CT-scans with emphasis on morphometric measurements and risk factors relevant to patellofemoral disorders., Methods: Patellofemoral morphometric parameters and anatomical risk factors were analyzed from 345 pairs of CT scans to evaluate side-to-side differences for each patient. All measurements were automatized using previously published algorithm-calculated bone landmarks. We analyzed asymmetry based on absolute differences (AD) and percentage asymmetry (AS%). Significant asymmetry was defined as AS% > 10%., Results: Patellar height was found to be highly symmetric (mean AD 0.1 for both Insall-Salvatti and Caton-Deschamps methods, AS% 8% and 9%, respectively). Patellar and femoral morphometric parameters were found highly symmetric, except for the trochlear groove depth. Substantial asymmetry was reported in two patellofemoral risk factors: the lateral trochlear inclination (mean AD 2°, AS% 16%) and the tibial tuberosity-trochlear groove distance (1 mm, 116%). Patellar and femoral morphometric asymmetries were independent of demographics, including age, gender, height, weight and ethnicity., Conclusion: Patellar height was found to be highly symmetric and is, therefore, a reasonable index for contralateral templating. While very few patellofemoral morphometric parameters and anatomical risk factors were asymmetric, the mean differences were clinically negligible and independent of demographics., Level of Evidence: III., (© 2021. European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA).)

Knee osteoarthritis (OA) is the most common joint disorder worldwide. In particular, primary knee OA often presents with a varus malalignment. This increases the loads going through the medial compartment resulting in cartilage degeneration and symptomatic arthritis. High tibial osteotomy (HTO) is the workhorse surgical procedure for treating medial knee OA. When performed precisely in the hands of an experienced surgeon, HTO can delay or avoid knee arthroplasty. Of note, outcomes of knee arthroplasty are at best unpredictable in patients of younger age. Hence, there is a growing need for joint preservation procedures for younger patients presenting with knee OA, of which HTO is one. Through this article, the authors of whom all are joint preservation surgeons with a special interest in osteotomy hope to share from their experience as well as the available literature on the indications, perioperative planning, surgical technique, outcomes as well as pearls and pitfalls of HTO., (© 2021 Delhi Orthopedic Association. All rights reserved.)

This study aims to find out if routine preoperative group crossmatch and postoperative check hemoglobin for total knee arthroplasty (TKA) patients is necessary. A retrospective analysis was performed on patients who underwent unilateral TKAs for osteoarthritis from January 1, 2004 to December 31, 2014. The main outcome measures were postoperative hemoglobin levels and transfusion requirements. Patients' demographics, comorbidities, laboratory results, and surgical details were analyzed. A total of 955 TKAs were included in this study (males = 207, females = 748; mean age = 66.1 years, standard deviation [SD] = 7.7). A total of 79 (8.27%) cases required postoperative blood transfusion, and the crossmatch-transfusion ratio was 17.5. Significant predictors for postoperative transfusion included lower preoperative hemoglobin levels ( p  < 0.001) and advanced age ( p  < 0.001). Receiver operating characteristic (ROC) curve and Youden's Index analyses identified the preoperative hemoglobin cut-off value for females to be 12.1 g/dL (relative risk (RR): 5.65, p  < 0.001) in predicting postoperative blood transfusion requirement, and 12.4 g/dL (RR: 11.71, p  < 0.001) for males. For age, the identified cut-off value was 68 years (RR: 3.18, p  < 0.001). The largest decline in hemoglobin levels was noted on postoperative day (POD) 3 (31.8%), and smallest on POD 1 (18.8%). The postoperative transfusion requirements in TKA are low and do not justify routine perioperative blood investigations. However, these investigations should be reserved for patients with the identified risk factors, in particular advancing age (68 years and above) and lower preoperative hemoglobin (below or equal to 12.1 and 12.4 g/dL for females and males, respectively). In the event that postoperative hemoglobin level needs to be checked, it should be performed beyond the first POD., Competing Interests: None declared., (Thieme. All rights reserved.)

Purpose: To qualitatively evaluate the current evidence reporting outcomes of intra-articular injection of orthobiologics in patients undergoing high tibial osteotomy (HTO) for osteoarthritis of the knee., Methods: A systematic search methodology of the PUBMED, EMBASE, and CINAHL databases was conducted in July 2021. The search workflow was in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The following inclusion criteria were adopted: clinical trials of any level of evidence, reporting outcomes following intra-articular injection of orthobiologics during high tibial osteotomy for knee osteoarthritis, with a minimum number of 10 patients treated. Duplicate data, studies on implanted orthobiologics and articles not written in English were excluded from this review., Results: Eight studies were included in this review, with a total of 585 patients. Outcomes were discussed based on the types of orthobiologics used: (i) Platelet-Rich Plasma (PRP), (ii) Bone Marrow Aspirate Concentrate (BMAC), and (iii) Injected Mesenchymal Stem Cells (MSCs). Two studies utilised PRP, 4 studies utilised BMAC and 4 studies utilised injected MSCs.. Three studies provided Level II evidence and five studies provided Level III evidence. Statistically significant improvements in outcomes were documented in multiple trials, with few patients experiencing adverse events., Conclusion: Intra-articular injection of orthobiologics in patients undergoing HTO is safe and effective with good outcomes reported. Due to the lack of high-level evidence, further research is required before this can be considered standard of care., Level of Evidence: III., (© 2021. The Author(s).)

Patients undergoing prolonged surgery in a lithotomy position may develop acute lower limb compartment syndrome in the absence of trauma or pre-existing vascular disease, otherwise known as well-leg compartment syndrome (WLCS). Early recognition and management would prevent the potential, lethal complications associated with this condition. We present a case of a 55-year-old gentleman who developed bilateral WLCS after prolonged abdominoperineal resection of his pelvic liposarcoma., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, Lee et al.)

Osteoarthritis (OA) is a global health issue with myriad pathophysiological factors and is one of the most common causes of chronic disability in adults due to pain and altered joint function.The end stage of OA develops from a destructive inflammatory cycle, driven by the pro-inflammatory cytokines interleukin-1β (IL-1β) and tumour necrosis factor alpha (TNFα).Owing to the less predictable results of total knee arthroplasty (TKA) in younger patients presenting with knee OA, there has been a surge in research evaluating less invasive biological treatment options, one of which is autologous protein solution (APS).APS is an autologous blood derivative obtained by using a proprietary device, made of APS separator, which isolates white blood cells (WBCs) and platelets in a small volume of plasma, and APS concentrator, which further concentrates platelets, WBCs and plasma proteins, resulting in a concentrated solution with high levels of growth factors including the anti-inflammatory mediators against IL-1β and TNFα.A single intraarticular injection of APS appears to be a promising solution for treatment of early-stage OA from current evidence, the majority of which comes from preclinical studies.More clinical studies are needed before APS can be widely accepted as a treatment modality for OA. Cite this article: EFORT Open Rev 2021;6:716-726. DOI: 10.1302/2058-5241.6.200040., Competing Interests: ICMJE Conflict of interest statement: The authors declare no conflict of interest relevant to this work., (© 2021 The author(s).)

Background  An important surgical landmark in the distal radius is the watershed line. The watershed line is a landmark for the positioning of volar locking plates (VLP) in the distal radius. Inconsistencies remain in the literature as to the presence and dimensions of landmarks in this compact area. We studied the detailed anatomy and dimensions of the distal radius with reference to bony anatomy around the watershed line, with special attention to the area between the pronator quadratus (PQ) and radial styloid. Materials and Methods  The distal radius regions of 31 cadavers (23 right sided and 8 left sided) were dissected and studied. The heights at the junction of the scaphoid and lunate fossa, at the radial styloid, at the midpoint in between, and the widths of the PQ line, scaphoid, and lunate fossa were measured. The angle subtended by the pronator fossa and the radial styloid was also recorded. Results  The mean heights at the junction of the scaphoid and lunate fossa, radial styloid, and midpoint in between were 5.1, 15.7, and 8.2 mm, respectively. The widths of the PQ line, scaphoid, and lunate fossa were 27, 19.4, and 10.6 mm, respectively. The mean angulation between the pronator fossa and the radial styloid was 128.9 degrees. Conclusion  The area between the PQ and watershed line comprises a narrow area of bone which tapers to a point at its medial extent largely below the lunate fossa, thus it can hardly contain any implant proximal to the lunate fossa. The anterior orientation of this area and the concave anatomy of the articular surface mean careful screw direction is imperative to avoid inadvertent joint penetration. An angulation exists between the pronator fossa and the radial styloid, below the scaphoid fossa., Competing Interests: Conflict of Interest None declared., (Thieme. All rights reserved.)

Purpose: To evaluate clinical outcomes after intraosseous injection for knee osteoarthritis systematically with available clinical evidence., Methods: A systematic search methodology of the PUBMED, EMBASE, and CINAHL databases was conducted in November 2020. The search workflow was in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The following inclusion criteria were adopted: clinical trials of any level of evidence, reporting clinical outcomes following intraosseous injections of bone substitutes or biologic agents, and mesenchymal stem cells or platelet-rich plasma into the knee as treatment modalities for osteoarthritis. Duplicate data and articles not written in English were excluded from this review., Results: Six studies were identified and included in this review, with a total of 167 patients. Two studies used subchondroplasty CaP injections, while 4 studies used intraosseous injections of platelet-rich plasma. Two studies provided Level II evidence, 2 studies provided Level III evidence, and a further 2 provided Level IV evidence. Five out of 6 studies reported data using the visual analog scale, 4 studies used the Knee Injury and Osteoarthritis Outcome Score, while 3 studies used the Western Ontario and McMaster Universities Osteoarthritis Index. Clinical improvements in pain and functionality were documented in all trials, with only a few patients experiencing adverse events., Conclusion: Intraosseous injections for knee osteoarthritis are safe and effective. However, multiple pertinent variables such as safety, cost of treatment, and performance against placebos and other treatment modalities require further evaluation before intraosseous injections can be considered as standard treatment for patients presenting with osteoarthritis of the knee., (© 2021 by the Arthroscopy Association of North America. Published by Elsevier Inc.)

Competing Interests: There is no conflict of interests to be declared.

Medial opening wedge high tibial osteotomy (OW-HTO) is an excellent surgical option for patients with varus knee osteoarthritis. This article presents a technique of performing a minimally invasive OW-HTO using a patient-specific cutting guide (PSCG). Preoperative 3-dimensional planning with computed tomography imaging is essential. The correction parameters, the final plate position, as well as the 3-dimensional position of the hinge as well as wedge are verified preoperatively before the PSCG is produced. After exposure with an oblique incision over the posteromedial tibia, the hamstring tendons are released for later re-attachment and the medial collateral ligament is released slightly. The PSCG is then used to perform the OW-HTO with protection of the posterior neurovascular structures by a retractor placed posterior to the medial collateral ligament. The final fixation of the osteotomy is achieved with a low-profile locking plate and a femoral head allograft wedge., (© 2020 by the Arthroscopy Association of North America. Published by Elsevier.)

Medial opening-wedge high tibial osteotomy (OW-HTO) is an excellent surgical option for patients with varus knee osteoarthritis. Medial collateral ligament (MCL) release and posterior neurovascular structure protection during OW-HTO are steps that often induce stress and nervousness during surgery, especially for surgeons in the earlier stages of their learning curve. While is it well-known that the MCL should be released during OW-HTO, the standard retraction techniques pose challenges in visualization and instrument placement in the surgical field. We present our technique, which illustrates an alternative method to manage the MCL and safely protect the neurovascular structures using a second and more posterior surgical window during OW-HTO., (© 2020 by the Arthroscopy Association of North America. Published by Elsevier.)

Background: There is poor correlation between functional outcomes and patient satisfaction following total knee arthroplasty (TKA). We asked if early post-operative scores at 6 months or the pre- to post-operative change in scores are predictive of patient satisfaction 2 years after TKA., Methods: We conducted a retrospective review of prospectively collected registry data of 4359 TKAs performed at a single institution. At 6 months and 2 years, the Knee Society Score (KSS), Oxford Knee Score (OKS), and Short-Form 36 scores were assessed. A satisfaction questionnaire was also completed. Logistic regression was used to generate receiver-operating characteristic (ROC) curves to assess the ability of each scoring system in predicting satisfaction at 2 years., Results: At 2 years, 91.1% of patients were satisfied. For the absolute post-operative OKS at 6 months, an AUC of 0.762 (95% CI 0.736-0.788) and a threshold of ≤ 21.5 points (or ≥ 38.5 points on the new scale) were obtained. For the KSS knee score, an AUC of 0.704 (95% CI 0.674-0.734) and a threshold of ≥ 80.5 points were identified. The OKS performed significantly better than the KSS knee score (p = 0.03) and the other post-operative scores (p < 0.001). When analysing the change in scores pre-operatively to 6 months, the AUC was < 0.7 for all scales., Conclusions: Early post-operative scores, specifically the OKS and KSS knee score, can predict patient satisfaction at 2 years after TKA with good accuracy. The threshold values offer surgeons an additional tool to identify patients at risk of dissatisfaction at 2 years, enabling them to intervene earlier to ensure good patient satisfaction., Level of Evidence: III, retrospective cohort study.

We tested the tensile strength of the proximal juncture of tendon grafts with Pulvertaft tendon repairs in 18 cadaveric digital flexor tendons. These tendons were divided into three groups of six: single, two, or three weaves. Each of the interlacing weaves was secured with eight anchoring sutures. The specimens were loaded in a biomechanical tester until failure. The ultimate tensile strength did not show any significant differences across all three groups with statistical power of 0.77. The mean tendon elongation before repair failure showed significant difference at 10 mm (standard deviation (SD) 2), 16 mm (SD 3), and 15 mm (SD 3), respectively. All specimens failed by intra-tendinous pull-out of the weaves. We conclude that the two-weave Pulvertaft construct demonstrated comparable tensile strength to three weaves and tendon elongation was similar when two or three weaves were used.