Journal of Orthopaedic Surgery and Research - Latest Comments

Use of Tranexamic acid is a cost effective method in preventing blood loss during and after total knee replacement

Sanjay Meena — 2012-01-10T14:45:23Z

Sir,

I read with interest the article, Use of Tranexamic acid is a cost effective method in preventing blood loss during and after total knee replacement. However , I have some comments for authors and readers:

(1) Intra operative blood loss was not taken in account. So exact amount of blood loss couldn¿t be determined.

(2) Some studies [1] have demonstrated a minimum dosage of 10 mg / kg of TEA, to obtain the desired antihemorrhagic effect. Hence, the authors may have started with lesser amount of dosage so as to minimize the side effects.

(3) Single dose of TEA has also been shown to be equally efficient in controlling blood loss during TKA [2]

(4) Since the mean duration of effect of TXA is around 3 hours a second dose may be administered after this period to prolong the effect over the first 6 h, when most bleeding occurs.[3]

Refrences:

1. Kinzel V, Shakespeare D, Derbyshire D. The effect of aprotinin on blood loss in bilateral total knee arthroplasty. Knee 2005;12:107-11.

2. Ralley FE, Berta D, Binns V, Howard J, Naudie DD. One intraoperative dose of TA for patients having primary hip or knee arthroplasty. Clin Orthop Relat Res. 2010;468:1905-11.

3. M. A. Camarasa1, G. Olle´1, M. Serra-Prat, A. Mart¿´n1, M. Sa´nchez1, P. Rico´s1, A. Pe´rez1 and L. Opisso1. Efficacy of aminocaproic, tranexamic acids in the control of bleeding during total knee replacement: a randomized clinical trial British Journal of Anaesthesia 96 (5): 576¿82 (2006)

Classification and treatment of proximal humerus fractures: inter-observer reliability and agreement across imaging modalities and experience

Raphael Adobor — 2012-01-10T14:44:56Z

Kappa values do not adequately describe agreement properties when comparing two methods. As described by Altman and Blant, agreement should be evaluated using repeatability coefficients. This is well described in the literature but it is a shame very few use it.

Excision arthroplasty elbow : some concerns

Sanjay Meena — 2012-01-10T14:39:17Z

Dear Sir,

We read with great interest the manuscript by Rex et al ¿Inverted V osteotomy excision arthroplasty for bony ankylosed elbows¿ [1]. I must congratulate the authors for this study. However, I would like to draw attention of authors and readers to the following:

1. Nine patients were operated in the study. The primary indication for the procedure is functional restriction of the patients in seven and both functional limitation and pain in two patients. A joint immovable from fibrous ankylosis is distinguished from a joint immovable from bony ankylosis by the fact that, in former, attempts at motion are productive of pain and subsequently of inflammation: therefore, pain on attempted motion excludes bony ankylosis.

2. The authors labelled this procedure as excision arthroplasty but there was nothing excised as such, so it is not an excision arthroplasty in true sense and is simply an osteotomy.

3. There is a risk of buttonholing of the bony spike of apex of osteotomy into biceps and triceps as the patient moves the pseudoelbow joint.

4. Although ulnar nerve was released but no anterior transposition was performed. As full extension is done, there is definite risk of ulnar nerve neuropraxia, as is evident in one case of author¿s series. This may have been prevented if the authors performed anterior transposition of ulnar nerve.

Warm regards and once again congratulations for the research.

Refrences:

1. Rex C, Periyasamy R, Balaji S, C P, Alva S and Reddy S Inverted 'V' osteotomy excision arthroplasty for bony ankylosed elbows. Journal of Orthopaedic Surgery and Research 2011, 6:60 (5 December 2011)

Commitment and Psychological issues

Vinícius Ynoe Moraes — 2010-03-25T03:28:35Z

This is a very interesting paper regarding to post-operative issues after hip resurfacing. It is a fact that not only the surgical technique and surgeon's skills are isolated factors influencing rehabilitation outcomes. We would like to share our data with the authors and other readers. We have delevoped a cross-sectional study regarding to identify - on an orthopedic ward population - which are the patients that would be prone to develop anxiety or depression on the wards. We have found that the patients who were submitted arthroplasties (knee and Hip) were more prone to develop anxious status, as somewhat as pointed by this study, showing that the patients whose had more vigorous mental status were well suceeded on rehabilitation. Comparing this paper data, it is possible that promoting preventative out-of-hospital improvement of mental status, and as a quick intervention an in-ward psychological support would even make our outcomes even better.

Warm regards, and once again congratulations for the research.

Dr. Vinícius Ynoe de Moraes, M.D.

References:

de Moraes VY, Jorge MR, Faloppa F, Belloti JC. Anxiety and depression in Brazilian orthopaedics inpatients: a cross sectional study with clinical sample comparison. J Clin Psychol Med Settings. 2010 Mar;17(1):31-7.

Long-term follow-up on the use of vascularized fibular graft for the treatment of congenital pseudarthrosis of the tibia

mahmoud el-rosasy — 2008-11-02T03:25:26Z

Dear Sir:

I read with interest this article, however, I have some comments for the authors and readers:

(1) The authors described a well known technique of fibular transposition to bridge the tibial defect [1]. This technique would burn the bridges in case it failed where the limb would loose the fibular support and renders following reconstructive procedures difficult and may even urge the surgeon to recommend amputation rather than reconstruction. The current literature does not support the primary use of this technique except in certain cases of extensive bone loss and soft tissue fibrosis.

(2) From the analysis of the results in this study; the leg length discrepancy (LLD) was more than 5 cm. in four cases, the valgus ankle deformity more than 20 degrees in four cases and ankle pain in three cases. This unacceptably high complications rate in only eight cases does not justify the conclusion to recommend using this procedure primarily in cases of CPT. On the other hand the authors did not clarify how a patient with 15.7 cm. could function with such a limb.

(3) The main aim of limb reconstruction is to provide the patient with a limb to carry him rather than carrying it. In which cases the recommendation of amputation and prosthetic fitting would be much better from a functional standpoint.

(4) the authors described the fibular transposition without any trial to stabilize the ankle joint which in my opinion is the main reason for valgus deformity and instability of the ankle and late arthritis and pain.

(5) I strongly caution the readers against using the described technique in preference to the well documented techniques with predictably good bony and functional outcomes e.g. Ilizarov technique combined with intramedullary rod and bone grafting [2, 3].

REFERENCES:

(1) Huntington TW. VI. Case of Bone Transference: Use of a Segment of Fibula to Supply a Defect in the Tibia. Ann Surg. 1905;41(2):249-51.

(2) El-Rosasy MA, Paley D, Herzenburg JE (2007) Congenital Pseudarthrosis of the Tibia. In: Rozbruch RS, Ilizarov S (eds) Limb lengthening and reconstruction surgery. Informa Healthcare USA, New York, pp 485–493

(3) Paley D, Catagni M, Argnani F, Prevot J, Bell D, Armstrong P. Treatment of congenital pseudoarthrosis of the tibia using the Ilizarov technique. Clin Orthop. 1992;280:81–93

Congratulations for a wonderful study and reasoning.

SUHAIL AFZAL — 2008-11-02T03:23:10Z

I really enjoyed reading this article,Femoral tunnel placement in anterior cruciate ligament reconstruction: rationale of the two incision technique. The authors have discussed a very important aspect of the anterior cruciate ligament reconstruction. I full agreee with them regarding the concept of the anatomic placement of the tunnel and the dirction of action of the graft through single incision. I feel that there two incision technique should be followed to address the lacunae of the single incision technique.

I sincerely applaud the authors for this study.

Some comments on hypertext journals

Myles Clough — 2006-10-25T09:14:34Z

The foundation of another open source journal in orthopaedics is very welcome.

It is to be hoped that the editorial group will consider and encourage the adoption of some of the advantages of hypertext over text. The most important of these is that the work can be presented in layers rather than as a continuity - which is only needed when one reads from beginning to end of a piece of paper. Most of us read only specific parts of an article; constructing it in layers allows the reader to choose the level of detail he/she wishes to read. For example, the 'top' layer would be the abstract with links to more detailed layers. Some of these layers might correspond to the traditional introduction/methods/results/discussion sections but there might be yet deeper layers describing, for example, the exact operative method with a further link to the manufacturer's manual or perhaps a video. Similarly, in the results section there should be nothing to stop authors from posting (elsewhere) a database of their results and Xrays and encouraging the readers to visit it via a link.

The traditional structure of an article evolved to suit the needs of paper journals. The rising generation of orthopaedic surgeons is familiar with the use of hypertext so there is every reason to believe that e-journals will prompt a new evolution and I hope your journal will promote it.

J.F.M.Clough MD FRCSC

Clinical Instructor, Department of Orthopaedics, University of British Columbia

Past President, Internet Society of Orthopaedic Surgery and Trauma