Purpose The current study aimed to evaluate how open-wedge high tibial osteotomy (OWHTO) without the release of medial collateral ligament (MCL) changes in vivo intra-articular joint space after the surgery. Methods Patients with varus malalignment of the knee with an indication for OWHTO were included in this study. The intra-articular gap was measured before and 30 min after OWHTO without MCL release using a series of calibrated nerve hooks. The association of post-operative gap size with varus angle, medial proximal tibial angle (MPTA), lateral distal femoral angle (LDFA) and joint line convergence angle (JLCA) was also assessed. Results A total of 42 knees from 38 patients were evaluated. The mean size of the intra-articular gap of the medial compartment was 5.2 ± 1 mm before the osteotomy and 3.1 ± 2.2 mm at 30 min post-osteotomy. The size of the intra-articular gap decreased post-operatively in 30 knees (71.5%), increased in eight knees (19%) and remained the same in the remaining four knees (9.5%). Smaller MPTA and more correction were associated with a decrease in gap size after the osteotomy (p = 0.01 and p = 0.03, respectively). A significant negative correlation was observed between the correction size and the gap size after osteotomy (r = − 0.317, p = 0.04). Conclusion Intra-articular pressure of the medial compartment increases in the majority of cases following OWHTO without MCL release. Until the factors affecting this increased pressure are thoroughly identified, MCL release seems to be a wiser option during OWHTO. Level of evidence III. KeywordsOpen-wedge high tibial osteotomy • Medial collateral ligament • Gap size • Intra-articular pressure Abbreviations MCL Medial collateral ligament OWHTO Open-wedge high tibial osteotomy MPTA Medial proximal tibial angle LDFA Lateral distal femoral angle JLCA Joint line convergence angle * Hooman Yahyazadeh

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Background:The degree of patient's suffering in association with radiological evidence of osteoarthritis (OA) determines the time point of surgery. Thus, a more clear understanding of the association between clinical and radiological symptoms of OA is necessary. Objectives: Here we aim to evaluate how clinical and radiographic symptoms of patients are associated with each other in an Iranian Knee OA population. Methods: In a cross -sectional study, patients with knee OA were recruited. The diagnosis of OA was made using the criteria of American College of Rheumatology (ACR) Classification. Western Ontario & McMaster Universities Osteoarthritis Index (WOMAC) was used as an indicator of self-reported disability. The Kellgren -Lawrence index was used for OA grading.Results: A total of 96 OA patients, including 77 females and 19 males, with a mean age of 53.27 ± 10 years, were included. The OA was graded as I, II, III, and IV in 28, 35, 19, and 14 patients, respectively. The mean WOMAC score was 55.2 ± 20.5, ranging from 6.3 to 100.The WOMAC score was not significantly correlated with the grade of OA (p = 0.1, r = -0.188). When we stratified the patients based on their gender, a strong correlation was observed between WOMAC scores and OA grade in male patients (p < 0.001, r = -0.882), while it was still non -significant in female patients (p = 0.9, r = 0.002). Conclusions: Self -reported disability is associated with radiographic symptoms in male patients with knee OA, but not in females.Hence, the orthopedic surgeons should consider this discrepancy in their decision -making process to decide appropriately about the choice of therapy.Given the role of clinical symptoms in the appropriate selection of OA patients as TKA candidates, a more clear understanding of the association between clinical and radiological symptoms is necessary.

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Background A higher mortality and morbidity rate has been reported in COVID-19 patients undergoing surgery. To reduce the morbidity and mortality rate in COVID-19 patients undergoing orthopedic procedures, we aimed to increase the threshold for surgical planning. Methods In a prospective cohort study, COVID-19 patients who underwent elective or emergent orthopedic surgery in three orthopedic surgery centers from February 2020 to September 2020 were included. In this period, 6751 patients were scheduled for orthopedic surgery. To increase surgical threshold planning, all patients with grade 5 of the American Society of Anesthesiologists (ASA) classification and patients with COVID-19 related moderate to severe pulmonary involvement were identified as high-risk patients and were excluded. Results 35 deaths occurred during the study. The frequency of deaths was significantly higher in patients with COVID-19, 6 (9.4%) than patients without COVID-19, 29 (0. 43%). The average hospitalization stay was 12.8 ± 12.1 days. The odds ratio (OR) for death was significantly higher in patients with COVID-19 than patients without COVID-19. [OR: 8.13, Confidence interval 95% (CI95%) (5.02–11.25), P: 0.001]. Four (6.3%) COVID-19-associated complications were recorded in this series that all were respiratory failure requiring unexpected postoperative ventilation. Twenty surgical complications (31.3%) were recorded. The odds ratio for ICU admission was significantly higher in patients with COVID-19 than patients without COVID-19. [OR: 5.46, CI 95% (2.68–8.68), P: 0.001]. Conclusions An increased threshold for orthopedic surgery is suggested for COVID-19 patients with a mortality rate of 9.3%, which is less than the mortality rate in other studies. Level of evidence III.

III.

Background: Platelet-rich plasma (PRP) is plasma of enriched platelets with high concentration of platelet granules and growth factors. The platelet growth factors have a great potential of wound and connective tissue healing used to treat cartilage lesions and retarding the progression of knee osteoarthritis. Objectives: This study was designed to evaluate PRP injection results in knee osteoarthritis. Patients and Methods:This was a case-series study of 39 patients and all of them had three injections of PRP for the involved knee (every two weeks) and they were followed up at two weeks, two months and six months post-injection of PRP. All included patients filled the WOMAC (western Ontario and Mcmaster universities arthritis index) standardized and translated to our national language and culture. We analyzed the collected scores of before initiation of PRP injections, the second week, the second month and the sixth month after injections into the knees. Results: Thirty-nine patients with a mean age of 55.24 ± 9.27 years (ranged 40 to 83) were evaluated in this study. Six patients (15.4%) were male and 33 patients (84.6%) female. There were significant differences in WOMAC score of patients in two months and six months after injection of PRP compared to before injection. Conclusions: PRP had a great clinical improvement in short-term follow-up for early stages of knee osteoarthritis.

Background: Internal fixation is the standard choice for treatment of posterior cruciate ligament (PCL) avulsion with a large bony fragment. However, it is not without complication. This study investigated PCL avulsions with large bony fragments to determine if conservative management resulted in acceptable outcomes. Methods: In a prospective cohort study, the outcome of conservative management of PCL avulsion with large bony fragment was evaluated in 40 patients. The inclusion criteria were a fracture size of more than 20 mm and a displacement of less than 2 mm. The outcomes were evaluated after 12 mo and included the evaluation knee range of motion and scoring of the modified Lysholm questionnaire and the International Knee Documentation Committee. Knee instability was checked by the drawer test and confirmed by stress radiography. Results: The mean patient age was 36.9±16.1 yr. The mean final knee range of motion (ROM) was 125.6±8.2 degrees. The mean Lysholm score was 92.3±6.1 points. Accordingly, the excellent, good, and fair results were observed in 29 (72.5%), eight (20%), and three (7.5%) patients, respectively. The mean International Knee Documentation Committee score of the patients was 94.2±5.3 points. Postoperative instability was seen in two patients. Nonunion was observed in two other patients. The size of the bony fragment was 30 and 32 mm in patients with nonunion. Conclusions: Conservative management of the PCL avulsion with a large bony fragment could result in acceptable outcome. However, application of this technique needs further characterization, particularly with respect to the size of bony fragment. Level of Evidence: Level II.