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1.  Rehabilitation in spinal infection diseases 
Spinal cord infections were the diseases defined by Hypocrite yet the absence of modern medicine and there was not a real protocol in rehabilitation although there were many aspects in surgical treatment options. The patients whether surgically or conservatively treated had a lot of neurological, motor, and sensory disturbances. Our clinic has quite experience from our previous researchs. Unfortunately, serious spinal cord infections are still present in our region. In these patients the basic rehabilitation approaches during early, pre-operation, post-operation period and in the home environment will provide significant contributions to improve the patients’ sensory and motor skills, develop the balance and proriocaption, increase the independence of patients in daily living activities and minimize the assistance of other people. There is limited information in the literature related with the nature of the rehabilitation programmes to be applied for patients with spinal infections. The aim of this review is to share our clinic experience and summarise the publications about spinal infection rehabilitation. There are very few studies about the rehabilitation of spinal infections. There are still not enough studies about planning and performing rehabilitation programs in these patients. Therefore, a comprehensive rehabilitation programme during the hospitalisation and home periods is emphasised in order to provide optimal management and prevent further disability.
PMCID: PMC4303778  PMID: 25621205
Spinal infections; Rehabilitation; Exercises
2.  Hand bone mass in rheumatoid arthritis: A review of the literature 
World Journal of Orthopedics  2015;6(1):106-116.
Rheumatoid arthritis (RA) is a common chronic inflammatory disease and periarticular osteoporosis or osteopenia of the inflamed hand joints is an early feature of RA. Quantitative measurement of hand bone loss may be an outcome measure for the detection of joint destruction and disease progression in early RA. This systematic review examines the published literature reporting hand bone mass in patients with RA, particularly those using the dual X-ray absorptiometry (DXA) methods. The majority of the studies reported that hand bone loss is associated with disease activity, functional status and radiological progression in early RA. Quantitative measurement of hand bone mineral density by DXA may be a useful and practical outcome measure in RA and may be predictive for radiographic progression or functional status in patients with early RA.
PMCID: PMC4303779  PMID: 25621215
Rheumatoid arthritis; Hand bone density; Dual X-ray absorptiometry; Periarticular; Osteoporosis
3.  Current strategies for the restoration of adequate lordosis during lumbar fusion 
World Journal of Orthopedics  2015;6(1):117-126.
Not restoring the adequate lumbar lordosis during lumbar fusion surgery may result in mechanical low back pain, sagittal unbalance and adjacent segment degeneration. The objective of this work is to describe the current strategies and concepts for restoration of adequate lordosis during fusion surgery. Theoretical lordosis can be evaluated from the measurement of the pelvic incidence and from the analysis of spatial organization of the lumbar spine with 2/3 of the lordosis given by the L4-S1 segment and 85% by the L3-S1 segment. Technical aspects involve patient positioning on the operating table, release maneuvers, type of instrumentation used (rod, screw-rod connection, interbody cages), surgical sequence and the overall surgical strategy. Spinal osteotomies may be required in case of fixed kyphotic spine. AP combined surgery is particularly efficient in restoring lordosis at L5-S1 level and should be recommended. Finally, not one but several strategies may be used to achieve the need for restoration of adequate lordosis during fusion surgery.
PMCID: PMC4303780  PMID: 25621216
Lumbar lordosis; Pelvis shape; Pelvis incidence; Spinal fusion; Spine surgery; Sagittal balance
4.  Regeneration of the anterior cruciate ligament: Current strategies in tissue engineering 
World Journal of Orthopedics  2015;6(1):127-136.
Recent advancements in the field of musculoskeletal tissue engineering have raised an increasing interest in the regeneration of the anterior cruciate ligament (ACL). It is the aim of this article to review the current research efforts and highlight promising tissue engineering strategies. The four main components of tissue engineering also apply in several ACL regeneration research efforts. Scaffolds from biological materials, biodegradable polymers and composite materials are used. The main cell sources are mesenchymal stem cells and ACL fibroblasts. In addition, growth factors and mechanical stimuli are applied. So far, the regenerated ACL constructs have been tested in a few animal studies and the results are encouraging. The different strategies, from in vitro ACL regeneration in bioreactor systems to bio-enhanced repair and regeneration, are under constant development. We expect considerable progress in the near future that will result in a realistic option for ACL surgery soon.
PMCID: PMC4303781  PMID: 25621217
Anterior cruciate ligament; Tissue engineering; Orthopedic; Ligament regeneration; Stem cell
5.  Overweight and obesity in hip and knee arthroplasty: Evaluation of 6078 cases 
World Journal of Orthopedics  2015;6(1):137-144.
AIM: To evaluate a possible association between the various levels of obesity and peri-operative charac-teristics of the procedure in patients who underwent endoprosthetic joint replacement in hip and knee joints.
METHODS: We hypothesized that obese patients were treated for later stage of osteoarthritis, that more conservative implants were used, and the intra-and perioperative complications increased for such patients. We evaluated all patients with body mass index (BMI) ≥ 25 who were treated in our institution from January 2011 to September 2013 for a primary total hip arthroplasty (THA) or total knee arthroplasty (TKA). Patients were split up by the levels of obesity according to the classification of the World Health Organization. Average age at the time of primary arthroplasty, preoperative Harris Hip Score (HHS), Hospital for Special Surgery score (HSS), gender, type of implanted prosthesis, and intra-and postoperative complications were evaluated.
RESULTS: Six thousand and seventy-eight patients with a BMI ≥ 25 were treated with a primary THA or TKA. Age decreased significantly (P < 0.001) by increasing obesity in both the THA and TKA. HHS and HSS were at significantly lower levels at the time of treatment in the super-obese population (P < 0.001). Distribution patterns of the type of endoprostheses used changed with an increasing BMI. Peri- and postoperative complications were similar in form and quantity to those of the normal population.
CONCLUSION: Higher BMI leads to endoprosthetic treat-ment in younger age, which is carried out at significantly lower levels of preoperative joint function.
PMCID: PMC4303782  PMID: 25621218
Adiposity; Total knee arthroplasty; Total hip arthroplasty; Obesity; Overweight; Prosthesis
6.  Cost of external fixation vs external fixation then nailing in bone infection 
World Journal of Orthopedics  2015;6(1):145-149.
AIM: To study the cost benefit of external fixation vs external fixation then nailing in treatment of bone infection by segment transfer.
METHODS: Out of 71 patients with infected nonunion tibia treated between 2003 and 2006, 50 patients fitted the inclusion criteria (26 patients were treated by external fixation only, and 24 patients were treated by external fixation early removal after segment transfer and replacement by internal fixation). Cost of inpatient treatment, total cost of inpatient and outpatient treatment till full healing, and the weeks of absence from school or work were calculated and compared between both groups.
RESULTS: The cost of hospital stay and surgery in the group of external fixation only was 22.6 ± 3.3 while the cost of hospital stay and surgery in the group of early external fixation removal and replacement by intramedullary nail was 26.0 ± 3.2. The difference was statistically significant regarding the cost of hospital stay and surgery in favor of the group of external fixation only. The total cost of medical care (surgery, hospital stay, treatment outside the hospital including medications, dressing, physical therapy, outpatient laboratory work, etc.) in group of external fixation only was 63.3 ± 15.1, and total absence from work was 38.6 ± 6.6 wk. While the group of early removal of external fixation and replacement by IM nail, total cost of medical care was 38.3 ± 6.4 and total absence from work or school was 22.7 ± 4.1. The difference was statistically significant regarding the total cost and absence from work in favor of the group of early removal and replacement by IM nail.
CONCLUSION: Early removal of external fixation and replacement by intramedullary nail in treatment of infected nonunion showed more cost effectiveness. Orthopaedic society needs to show the cost effectiveness of different procedures to the community, insurance, and health authorities.
PMCID: PMC4303783  PMID: 25621219
Cost; Fixator; Nailing; Infection
7.  How are those “lost to follow-up” patients really doing? A compliance comparison in arthroplasty patients 
World Journal of Orthopedics  2015;6(1):150-155.
AIM: To determine whether there is a functional difference between patients who actively follow-up in the office (OFU) and those who are non-compliant with office follow-up visits (NFU).
METHODS: We reviewed a consecutive group of 588 patients, who had undergone total joint arthroplasty (TJA), for compliance and functional outcomes at one to two years post-operatively. All patients were given verbal instructions by the primary surgeon to return at one year for routine follow-up visits. Patients that were compliant with the instructions at one year were placed in the OFU cohort, while those who were non-compliant were placed in the NFU cohort. Survey mailings and telephone interviews were utilized to obtain complete follow-up for the cohort. A χ2 test and an unpaired t test were used for comparison of baseline characteristics. Analysis of covariance was used to compare the mean clinical outcomes after controlling for confounding variables.
RESULTS: Complete follow-up data was collected on 554 of the 588 total patients (93%), with 75.5% of patients assigned to the OFU cohort and 24.5% assigned to the NFU cohort. We found significant differences between the cohorts with the OFU group having a higher mean age (P = 0.026) and a greater proportion of females (P = 0.041). No significant differences were found in either the SF12 or WOMAC scores at baseline or at 12 mo postoperative.
CONCLUSION: Patients who are compliant to routine follow-up visits at one to two years post-operation do not experience better patient reported outcomes than those that are non-compliant. Additionally, after TJA, older women are more likely to be compliant in following surgeon instructions with regard to follow-up office care.
PMCID: PMC4303784  PMID: 25621220
Total joint arthroplasty; Revision joint arthroplasty; Functional outcomes; Patient compliance; Patient follow-up
8.  Triangle tilt and humeral surgery: Meta-analysis of efficacy and functional outcome 
World Journal of Orthopedics  2015;6(1):156-160.
AIM: To systematically review and analyze the overall impact and effectiveness of bony surgical procedures, the triangle tilt and humeral surgery in a comparative manner in permanent obstetric brachial plexus injury (OBPI) patients.
METHODS: We conducted a literature search and identified original full research articles of OBPI patients treated with a secondary bony surgery, particularly addressing the limitation of shoulder abduction and functions. Further, we analyzed and compared the efficacy and the surgical outcomes of 9 humeral surgery papers with 179 patients, and 4 of our secondary bony procedure, the triangle tilt surgical papers with 86 patients.
RESULTS: Seven hundred and thirty-one articles were identified, using the search term “brachial plexus” and obstetric or pediatric (246 articles) or neonatal (219 articles) or congenital (188 articles) or “birth palsy” (121 articles). Further, only a few articles were identified using the bony surgery search, osteotomy “brachial plexus” obstetric (35), “humeral osteotomy” and “brachial plexus” (17), and triangle tilt “brachial plexus” (14). Of all, 12 studies reporting pre- and post- operative or improvement in total Mallet functional score were included in this study. Among these, 9 studies reported the humeral surgery and 4 were triangle tilt surgery. We used modified total Mallet functional score in this analysis. Various studies with humeral surgery showed improvement of 1.4, 2.3, 5.0 and 5.6 total Mallet score, whereas the triangle tilt surgery showed improvement of 5.0, 5.5, 6.0 and 6.2.
CONCLUSION: The triangle tilt surgery improves on what was achieved by humeral osteotomy in the management of shoulder function in OBPI patients.
PMCID: PMC4303785  PMID: 25621221
Meta-Analysis; Triangle tilt surgery; Humeral osteotomy; Obstetric brachial plexus injury; Birth palsy; SHEAR deformity; Shoulder function; Mallet score
9.  Acute complications of spinal cord injuries 
World Journal of Orthopedics  2015;6(1):17-23.
The aim of this paper is to give an overview of acute complications of spinal cord injury (SCI). Along with motor and sensory deficits, instabilities of the cardiovascular, thermoregulatory and broncho-pulmonary system are common after a SCI. Disturbances of the urinary and gastrointestinal systems are typical as well as sexual dysfunction. Frequent complications of cervical and high thoracic SCI are neurogenic shock, bradyarrhythmias, hypotension, ectopic beats, abnormal temperature control and disturbance of sweating, vasodilatation and autonomic dysreflexia. Autonomic dysreflexia is an abrupt, uncontrolled sympathetic response, elicited by stimuli below the level of injury. The symptoms may be mild like skin rash or slight headache, but can cause severe hypertension, cerebral haemorrhage and death. All personnel caring for the patient should be able to recognize the symptoms and be able to intervene promptly. Disturbance of respiratory function are frequent in tetraplegia and a primary cause of both short and long-term morbidity and mortality is pulmonary complications. Due to physical inactivity and altered haemostasis, patients with SCI have a higher risk of venous thromboembolism and pressure ulcers. Spasticity and pain are frequent complications which need to be addressed. The psychological stress associated with SCI may lead to anxiety and depression. Knowledge of possible complications during the acute phase is important because they may be life threatening and/ or may lead to prolonged rehabilitation.
PMCID: PMC4303786  PMID: 25621207
Spinal cord injuries; Autonomic dysreflexia; Cardiovascular disease; Orthostatic hypotension; Bradycardia; Thromboembolism; Respiratory insufficiency
10.  Chronic complications of spinal cord injury 
World Journal of Orthopedics  2015;6(1):24-33.
Spinal cord injury (SCI) is a serious medical condition that causes functional, psychological and socioeconomic disorder. Therefore, patients with SCI experience significant impairments in various aspects of their life. The goals of rehabilitation and other treatment approaches in SCI are to improve functional level, decrease secondary morbidity and enhance health-related quality of life. Acute and long-term secondary medical complications are common in patients with SCI. However, chronic complications especially further negatively impact on patients’ functional independence and quality of life. Therefore, prevention, early diagnosis and treatment of chronic secondary complications in patients with SCI is critical for limiting these complications, improving survival, community participation and health-related quality of life. The management of secondary chronic complications of SCI is also important for SCI specialists, families and caregivers as well as patients. In this paper, we review data about common secondary long-term complications after SCI, including respiratory complications, cardiovascular complications, urinary and bowel complications, spasticity, pain syndromes, pressure ulcers, osteoporosis and bone fractures. The purpose of this review is to provide an overview of risk factors, signs, symptoms, prevention and treatment approaches for secondary long-term complications in patients with SCI.
PMCID: PMC4303787  PMID: 25621208
Spinal cord injury; Chronic complications; Management of complications; Long-term morbidity; Secondary morbidity of spinal cord injury
11.  Current and future surgery strategies for spinal cord injuries 
World Journal of Orthopedics  2015;6(1):34-41.
Spinal cord trauma is a prominent cause of mortality and morbidity. In developed countries a spinal cord injury (SCI) occurs every 16 min. SCI occurs due to tissue destruction, primarily by mechanical and secondarily ischemic. Primary damage occurs at the time of the injury. It cannot be improved. Following the primary injury, secondary harm mechanisms gradually result in neuronal death. One of the prominent causes of secondary harm is energy deficit, emerging from ischemia, whose main cause in the early stage, is impaired perfusion. Due to the advanced techniques in spinal surgery, SCI is still challenging for surgeons. Spinal cord doesn’t have a self-repair property. The main damage occurs at the time of the injury primarily by mechanical factors that cannot be improved. Secondarily mechanisms take part in the following sections. Spinal compression and neurological deficit are two major factors used to decide on surgery. According to advanced imaging techniques the classifications systems for spinal injury has been changed in time. Aim of the surgery is to decompress the spinal channel and to restore the spinal alinement and mobilize the patient as soon as possible. Use of neuroprotective agents as well as methods to achieve cell regeneration in addition to surgery would contribute to the solution.
PMCID: PMC4303788  PMID: 25621209
Spinal cord injury; Surgery; Classification; Mechanism; Management
12.  Current and future medical therapeutic strategies for the functional repair of spinal cord injury 
World Journal of Orthopedics  2015;6(1):42-55.
Spinal cord injury (SCI) leads to social and psychological problems in patients and requires costly treatment and care. In recent years, various pharmacological agents have been tested for acute SCI. Large scale, prospective, randomized, controlled clinical trials have failed to demonstrate marked neurological benefit in contrast to their success in the laboratory. Today, the most important problem is ineffectiveness of nonsurgical treatment choices in human SCI that showed neuroprotective effects in animal studies. Recently, attempted cellular therapy and transplantations are promising. A better understanding of the pathophysiology of SCI started in the early 1980s. Research had been looking at neuroprotection in the 1980s and the first half of 1990s and regeneration studies started in the second half of the 1990s. A number of studies on surgical timing suggest that early surgical intervention is safe and feasible, can improve clinical and neurological outcomes and reduce health care costs, and minimize the secondary damage caused by compression of the spinal cord after trauma. This article reviews current evidence for early surgical decompression and nonsurgical treatment options, including pharmacological and cellular therapy, as the treatment choices for SCI.
PMCID: PMC4303789  PMID: 25621210
Spinal cord injury; Treatment; Pharmacological treatment; Trauma; Cellular treatment; Management
13.  Subtalar arthroscopy: When, why and how 
World Journal of Orthopedics  2015;6(1):56-61.
Technique of subtalar arthroscopy is rapidly evolving. Increasing number of traditional open procedures for the subtalar joint can now be done arthroscopically. It is hoped that less wound complications, faster rehabilitation and better cosmetic outcomes can be achieved with this minimally invasive technique.
PMCID: PMC4303790  PMID: 25621211
Subtalar arthroscopy; Subtalar stiffness; Arthrodesis; Calcaneofibular impingement; Tarsal canal
14.  Diabetic foot syndrome: Immune-inflammatory features as possible cardiovascular markers in diabetes 
World Journal of Orthopedics  2015;6(1):62-76.
Diabetic foot ulcerations have been extensively reported as vascular complications of diabetes mellitus associated with a high degree of morbidity and mortality. Diabetic foot syndrome (DFS), as defined by the World Health Organization, is an “ulceration of the foot (distally from the ankle and including the ankle) associated with neuropathy and different grades of ischemia and infection”. Pathogenic events able to cause diabetic foot ulcers are multifactorial. Among the commonest causes of this pathogenic pathway it’s possible to consider peripheral neuropathy, foot deformity, abnormal foot pressures, abnormal joint mobility, trauma, peripheral artery disease. Several studies reported how diabetic patients show a higher mortality rate compared to patients without diabetes and in particular these studies under filled how cardiovascular mortality and morbidity is 2-4 times higher among patients affected by type 2 diabetes mellitus. This higher degree of cardiovascular morbidity has been explained as due to the observed higher prevalence of major cardiovascular risk factor, of asymptomatic findings of cardiovascular diseases, and of prevalence and incidence of cardiovascular and cerebrovascular events in diabetic patients with foot complications. In diabetes a fundamental pathogenic pathway of most of vascular complications has been reported as linked to a complex interplay of inflammatory, metabolic and procoagulant variables. These pathogenetic aspects have a direct interplay with an insulin resistance, subsequent obesity, diabetes, hypertension, prothrombotic state and blood lipid disorder. Involvement of inflammatory markers such as IL-6 plasma levels and resistin in diabetic subjects as reported by Tuttolomondo et al confirmed the pathogenetic issue of the a “adipo-vascular” axis that may contribute to cardiovascular risk in patients with type 2 diabetes. This “adipo-vascular axis” in patients with type 2 diabetes has been reported as characterized by lower plasma levels of adiponectin and higher plasma levels of interleukin-6 thus linking foot ulcers pathogenesis to microvascular and inflammatory events. The purpose of this review is to highlight the immune inflammatory features of DFS and its possible role as a marker of cardiovascular risk in diabetes patients and to focus the management of major complications related to diabetes such as infections and peripheral arteriopathy.
PMCID: PMC4303791  PMID: 25621212
Diabetic foot syndrome; Inflammation; Cytokines; Cardiovascular risk; Marker
15.  Biotribology of artificial hip joints 
World Journal of Orthopedics  2015;6(1):77-94.
Hip arthroplasty can be considered one of the major successes of orthopedic surgery, with more than 350000 replacements performed every year in the United States with a constantly increasing rate. The main limitations to the lifespan of these devices are due to tribological aspects, in particular the wear of mating surfaces, which implies a loss of matter and modification of surface geometry. However, wear is a complex phenomenon, also involving lubrication and friction. The present paper deals with the tribological performance of hip implants and is organized in to three main sections. Firstly, the basic elements of tribology are presented, from contact mechanics of ball-in-socket joints to ultra high molecular weight polyethylene wear laws. Some fundamental equations are also reported, with the aim of providing the reader with some simple tools for tribological investigations. In the second section, the focus moves to artificial hip joints, defining materials and geometrical properties and discussing their friction, lubrication and wear characteristics. In particular, the features of different couplings, from metal-on-plastic to metal-on-metal and ceramic-on-ceramic, are discussed as well as the role of the head radius and clearance. How friction, lubrication and wear are interconnected and most of all how they are specific for each loading and kinematic condition is highlighted. Thus, the significant differences in patients and their lifestyles account for the high dispersion of clinical data. Furthermore, such consideration has raised a new discussion on the most suitable in vitro tests for hip implants as simplified gait cycles can be too far from effective implant working conditions. In the third section, the trends of hip implants in the years from 2003 to 2012 provided by the National Joint Registry of England, Wales and Northern Ireland are summarized and commented on in a discussion.
PMCID: PMC4303792  PMID: 25621213
Arthroplasty; Replacement; Hip; Biotribology; Wear; Lubrication; Friction
16.  Rehabilitation of spinal cord injuries 
Spinal cord injury (SCI) is the injury of the spinal cord from the foramen magnum to the cauda equina which occurs as a result of compulsion, incision or contusion. The most common causes of SCI in the world are traffic accidents, gunshot injuries, knife injuries, falls and sports injuries. There is a strong relationship between functional status and whether the injury is complete or not complete, as well as the level of the injury. The results of SCI bring not only damage to independence and physical function, but also include many complications from the injury. Neurogenic bladder and bowel, urinary tract infections, pressure ulcers, orthostatic hypotension, fractures, deep vein thrombosis, spasticity, autonomic dysreflexia, pulmonary and cardiovascular problems, and depressive disorders are frequent complications after SCI. SCI leads to serious disability in the patient resulting in the loss of work, which brings psychosocial and economic problems. The treatment and rehabilitation period is long, expensive and exhausting in SCI. Whether complete or incomplete, SCI rehabilitation is a long process that requires patience and motivation of the patient and relatives. Early rehabilitation is important to prevent joint contractures and the loss of muscle strength, conservation of bone density, and to ensure normal functioning of the respiratory and digestive system. An interdisciplinary approach is essential in rehabilitation in SCI, as in the other types of rehabilitation. The team is led by a physiatrist and consists of the patients’ family, physiotherapist, occupational therapist, dietician, psychologist, speech therapist, social worker and other consultant specialists as necessary.
PMCID: PMC4303793  PMID: 25621206
Spinal cord; Injury; Tetraplegia; Paraplegia; Rehabilitation
17.  Cytokines as biochemical markers for knee osteoarthritis 
World Journal of Orthopedics  2015;6(1):95-105.
Osteoarthritis (OA) is a debilitating degenerative joint disease particularly affecting weightbearing joints within the body, principally the hips and knees. Current radiographic techniques are insufficient to show biochemical changes within joint tissue which can occur many years before symptoms become apparent. The need for better diagnostic and prognostic tools is heightened with the prevalence of OA set to increase in aging and obese populations. As inflammation is increasingly being considered an important part of OAs pathophysiology, cytokines are being assessed as possible candidates for biochemical markers. Cytokines, both pro- and anti-inflammatory, as well as angiogenic and chemotactic, have in recent years been studied for relevant characteristics. Biochemical markers show promise in determination of the severity of disease in addition to monitoring of the efficacy and safety of disease-modifying OA drugs, with the potential to act as diagnostic and prognostic tools. Currently, the diagnostic power of interleukin (IL)-6 and the relationship to disease burden of IL-1β, IL-15, tumor necrosis factor-α, and vascular endothelial growth factor make these the best candidates for assessment. Grouping appropriate cytokine markers together and assessing them collectively alongside other bone and cartilage degradation products will yield a more statistically powerful tool in research and clinical applications, and additionally aid in distinguishing between OA and a number of other diseases in which cytokines are known to have an involvement. Further large scale studies are needed to assess the validity and efficacy of current biomarkers, and to discover other potential biomarker candidates.
PMCID: PMC4303794  PMID: 25621214
Biomarker; Cytokines; Interleukin; Knee osteoarthritis
18.  Arthroscopic treatment options for irreparable rotator cuff tears of the shoulder 
World Journal of Orthopedics  2014;5(5):557-565.
The management of patients with irreparable rotator cuff tears remains a challenge for orthopaedic surgeons with the final treatment option in many algorithms being either a reverse shoulder arthroplasty or a tendon transfer. The long term results of these procedures are however still widely debated, especially in younger patients. A variety of arthroscopic treatment options have been proposed for patients with an irreparable rotator cuff tear without the presence of arthritis of the glenohumeral joint. These include a simple debridement with or without a biceps tenotomy, partial rotator cuff repair with or without an interval slide, tuberplasty, graft interposition of the rotator cuff, suprascapular nerve ablation, superior capsule reconstruction and insertion of a biodegradable spacer (Inspace) to depress the humeral head. These options should be considered as part of the treatment algorithm in patients with an irreparable rotator cuff and could be used as either as an interim procedure, delaying the need for more invasive surgery in the physiologically young and active, or as potential definitive procedures in the medically unfit. The aim of this review is to highlight and summarise arthroscopic procedures and the results thereof currently utilised in the management of these challenging patients.
PMCID: PMC4133462  PMID: 25405083
Irreparable; Arthroscopy; Rotator cuff; Repair; Massive
19.  Utility of arthroscopic guided synovial biopsy in understanding synovial tissue pathology in health and disease states 
World Journal of Orthopedics  2014;5(5):566-573.
The synovium is the soft tissue lining diarthrodial joints, tendon sheaths and bursae and is composed of intimal and subintimal layers. The intimal layer is composed of type A cells (macrophages) and type B cells (fibroblasts); in health, the subintima has few inflammatory cells. The synovium performs several homeostatic functions and is the primary target in several inflammatory arthritides. Inflammatory states are characterised by thickening of the synovial lining, macrophage recruitment and fibroblast proliferation, and an influx of inflammatory cells including lymphocytes, monocytes and plasma cells. Of the various methods employed to perform synovial biopsies arthroscopic techniques are considered the “gold standard”, and have an established safety record. Synovial biopsy has been of critical importance in understanding disease pathogenesis and has provided insight into mechanisms of action of targeted therapies by way of direct evidence about events in the synovial tissue in various arthritides. It has been very useful as a research tool for proof of concept studies to assess efficacy and mechanisms of new therapies, provide tissue for in vitro studies, proteomics and microarrays and allow evaluation for biomarkers that may help predict response to therapy and identify new targets for drug development. It also has diagnostic value in the evaluation of neoplastic or granulomatous disease or infection when synovial fluid analysis is non-contributory.
PMCID: PMC4133463  PMID: 25405084
Synovium; Synovial biopsy; Arthroscopy; Inflammatory arthritis; Synovial pathology
20.  Power Doppler ultrasonographic assessment of the ankle in patients with inflammatory rheumatic diseases 
World Journal of Orthopedics  2014;5(5):574-584.
Ankle involvement is frequent in patients with inflammatory rheumatic diseases, but accurate evaluation by physical examination is often difficult because of the complex anatomical structures of the ankle. Over the last decade, ultrasound (US) has become a practical imaging tool for the assessment of articular and periarticular pathologies, including joint synovitis, tenosynovitis, and enthesitis in rheumatic diseases. Progress in power Doppler (PD) technology has enabled evaluation of the strength of ongoing inflammation. PDUS is very useful for identifying the location and kind of pathologies in rheumatic ankles as well as for distinguishing between inflammatory processes and degenerative changes or between active inflammation and residual damage. The aim of this paper is to illustrate the US assessment of ankle lesions in patients with inflammatory rheumatic diseases, including rheumatoid arthritis, spondyloarthritis, and systemic lupus erythematosus, focusing on the utility of PDUS.
PMCID: PMC4133464  PMID: 25405085
Ankle; Power Doppler; Ultrasound; Rheumatoid arthritis; Psoriatic arthritis; Spondyloarthritis; Tenosynovitis; Enthesitis
21.  Worldwide spread of the Ponseti method for clubfoot 
World Journal of Orthopedics  2014;5(5):585-590.
The Ponseti method has become the gold standard for the treatment of idiopathic clubfoot. Its safety and efficacy has been demonstrated extensively in the literature, leading to increased use around the world over the last two decades. This has been demonstrated by the increase in Ponseti related PubMed publications from many countries. We found evidence of Ponseti activity in 113 of 193 United Nations members. The contribution of many organizations which provide resources to healthcare practitioners in low and middle income countries, as well as Ponseti champions and modern communication technology, have helped to spread the Ponseti method around the world. Despite this, there are many countries where the Ponseti method is not being used, as well as many large countries in which the extent of activity is unknown. With its low rate of complication, low cost, and high effectiveness, this method has unlimited potential to treat clubfoot in both developed and undeveloped countries. Our listing of countries who have not yet shown presence of Ponseti activity will help non-governmental organizations to target those countries which still need the most help.
PMCID: PMC4133465  PMID: 25405086
Ponseti; Clubfoot; World; Organization; Children
22.  Survival outcomes of cemented compared to uncemented stems in primary total hip replacement 
World Journal of Orthopedics  2014;5(5):591-596.
Total hip replacement (THR) is a successful and reliable operation for both relieving pain and improving function in patients who are disabled with end stage arthritis. The ageing population is predicted to significantly increase the requirement for THR in patients who have a higher functional demand than those of the past. Uncemented THR was introduced to improve the long term results and in particular the results in younger, higher functioning patients. There has been controversy about the value of uncemented compared to cemented THR although there has been a world-wide trend towards uncemented fixation. Uncemented acetabular fixation has gained wide acceptance, as seen in the increasing number of hybrid THR in joint registries, but there remains debate about the best mode of femoral fixation. In this article we review the history and current world-wide registry data, with an in-depth analysis of the New Zealand Joint Registry, to determine the results of uncemented femoral fixation in an attempt to provide an evidence-based answer as to the value of this form of fixation.
PMCID: PMC4133466  PMID: 25405087
Primary total hip replacement; Femoral fixation; Cemented; Uncemented; Joint replacement registry; Implamt survival
23.  Degenerative meniscus: Pathogenesis, diagnosis, and treatment options 
World Journal of Orthopedics  2014;5(5):597-602.
The symptomatic degenerative meniscus continues to be a source of discomfort for a significant number of patients. With vascular penetration of less than one-third of the adult meniscus, healing potential in the setting of chronic degeneration remains low. Continued hoop and shear stresses upon the degenerative meniscus results in gross failure, often in the form of complex tears in the posterior horn and midbody. Patient history and physical examination are critical to determine the true source of pain, particularly with the significant incidence of simultaneous articular pathology. Joint line tenderness, a positive McMurray test, and mechanical catching or locking can be highly suggestive of a meniscal source of knee pain and dysfunction. Radiographs and magnetic resonance imaging are frequently utilized to examine for osteoarthritis and to verify the presence of meniscal tears, in addition to ruling out other sources of pain. Non-operative therapy focused on non-steroidal anti-inflammatory drugs and physical therapy may be able to provide pain relief as well as improve mechanical function of the knee joint. For patients refractory to conservative therapy, arthroscopic partial meniscectomy can provide short-term gains regarding pain relief, especially when combined with an effective, regular physiotherapy program. Patients with clear mechanical symptoms and meniscal pathology may benefit from arthroscopic partial meniscectomy, but surgery is not a guaranteed success, especially with concomitant articular pathology. Ultimately, the long-term outcomes of either treatment arm provide similar results for most patients. Further study is needed regarding the short and long-term outcomes regarding conservative and surgical therapy, with a particular focus on the economic impact of treatment as well.
PMCID: PMC4133467  PMID: 25405088
Meniscus; Degenerative joint disease; Meniscal tear; Osteoarthritis; Arthroscopy
24.  Flap reconstruction of the knee: A review of current concepts and a proposed algorithm 
World Journal of Orthopedics  2014;5(5):603-613.
A literature search focusing on flap knee reconstruction revealed much controversy regarding the optimal management of around the knee defects. Muscle flaps are the preferred option, mainly in infected wounds. Perforator flaps have recently been introduced in knee coverage with significant advantages due to low donor morbidity and long pedicles with wide arc of rotation. In the case of free flap the choice of recipient vessels is the key point to the reconstruction. Taking the published experience into account, a reconstructive algorithm is proposed according to the size and location of the wound, the presence of infection and/or 3-dimensional defect.
PMCID: PMC4133468  PMID: 25405089
Knee reconstruction; Local flap; Pedicled flap; Free flap; Recipient vessels
25.  Management bone loss of the proximal femur in revision hip arthroplasty: Update on reconstructive options 
World Journal of Orthopedics  2014;5(5):614-622.
The number of revision total hip arthroplasties is expected to rise as the indications for arthroplasty will expand due to the aging population. The prevalence of extensive proximal femoral bone loss is expected to increase subsequently. The etiology of bone loss from the proximal femur after total hip arthroplasty is multifactorial. Stress shielding, massive osteolysis, extensive loosening and history of multiple surgeries consist the most common etiologies. Reconstruction of extensive bone loss of the proximal femur during a revision hip arthroplasty is a major challenge for even the most experienced orthopaedic surgeon. The amount of femoral bone loss and the bone quality of the remaining metaphyseal and diaphyseal bone dictate the selection of appropriate reconstructive option. These include the use of impaction allografting, distal press-fit fixation, allograft-prosthesis composites and tumor megaprostheses. This review article is a concise review of the current literature and provides an algorithmic approach for reconstruction of different types of proximal femoral bone defects.
PMCID: PMC4133469  PMID: 25405090
Arthroplasty; Proximal; Femur; Reconstruction; Bone loss

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