https://abjs.mums.ac.ir/ The Archives of Bone and Joint Surgery en daily 1 Wed, 01 Jul 2026 00:00:00 +0330 Wed, 01 Jul 2026 00:00:00 +0330 https://abjs.mums.ac.ir/article_27954.html Platelet-rich plasma (PRP) has emerged as a cornerstone of regenerative medicine, promising to revolutionize tissue repair across various fields, from orthopedics to aesthetic medicine. However, despite its widespread adoption and hypothetical potential, a persistent gap remains between its biological promise and consistent clinical outcomes. This editorial aims to critically examine the current challenges hindering the standardization and efficacy of PRP therapy and to propose a roadmap for transitioning from empirical use to evidence-based practice. The primary obstacle to PRP’s clinical reliability is the significant heterogeneity in preparation protocols, resulting in products with varying platelet counts, leukocyte concentrations (particularly neutrophils), and growth factor kinetics. This lack of standardization, compounded by methodological limitations in existing literature—such as small sample sizes and the pronounced placebo effect—makes interpreting therapeutic efficacy difficult. Furthermore, regulatory ambiguities and concerns regarding cost-effectiveness in resource-constrained environments pose additional hurdles. While the autologous nature of PRP ensures a high safety profile, the transition from a "one-size-fits-all" approach to a precision-based methodology is urgently needed. To bridge the gap between laboratory potential and real-world clinical results, the field must prioritize rigorous, large-scale clinical trials and standardized classification systems. Research should shift from questioning general efficacy to identifying specific formulations tailored to particular clinical conditions. Moving forward, scientific discipline and evidence-based data must replace commercial hype to ensure that PRP therapy is both ethically sound and clinically predictable. https://abjs.mums.ac.ir/article_27903.html Objectives: Two frequently used surgical interventions for knee joint osteoarthritis include closing wedge high tibial osteotomy (CW-HTO) and opening wedge high tibial osteotomy (OW-HTO). Studies showed that, most to near all cases lead to failure, requiring a total knee arthroplasty (TKA). This systematic review aimed at answering this question: What are the outcomes of TKA following CW-HTO and OW-HTO? Methods: The main electronic databases were searched up to November 2025. Only studies that included comparative arms for both closing-wedge high tibial osteotomy (CW-HTO) and opening-wedge high tibial osteotomy (OW-HTO) were considered for further assessment. The primary outcomes included knee joint function scores, such as the International Knee Society (IKS) score and the Knee Society Score (KSS). A meta-analysis was not feasible because of heterogeneity in the reported data and follow-up periods. The Joanna Briggs Institute (JBI) critical appraisal tool was used to assess the methodological quality of each included study. Results: Of the 6,756 records identified and screened, three comparative clinical studies, including a total of 541 TKA cases, were included in this systematic review. Two studies reported no significant difference in KSS or range of motion after TKA between patients who had previously undergone CW-HTO and those who had undergone OW-HTO. However, one study reported improvements in walking ability in both groups after 80–90 months of follow-up. Post-operative complication rates were comparable between groups (OW-HTO: 12.3% vs. CW-HTO: 8.3%); however, one study noted a significantly higher incidence of specific complications, such as skin necrosis and nerve injury, in the CW-HTO cohort (12% vs. 6%, P<0.05). Intra-operative complications were rare, affecting 2.8% of cases with no significant between-group difference. Conclusion: The limited available evidence precludes definitive conclusions. Current data suggest potential benefits after TKA following either CW-HTO or OW-HTO, including earlier relief of joint loading, shorter recovery time, and improved clinical outcomes, with no significant differences in clinical outcomes and complications between the two HTO techniques. Level of evidence: V https://abjs.mums.ac.ir/article_27947.html Objectives: The use of antibiotic-loaded bone cement (ALBC) is a common strategy for preventing periprosthetic joint infection (PJI) after total knee arthroplasty (TKA); however, its effectiveness remains controversial. This study aimed to provide a clear, evidence-based recommendation regarding the use of ALBC versus plain bone cement (PBC) for the prevention of PJI after TKA. Methods: This systematic review and meta-analysis was conducted in accordance with the PRISMA 2020 reporting guidelines. PubMed, Embase, and Scopus were searched to identify relevant studies evaluating PJI in patients who received ALBC versus PBC. Eligible studies were screened, selected, and assessed for risk of bias using appropriate checklists. Random-effects meta-analyses were performed to calculate odds ratios (ORs) with 95% confidence intervals (CIs). Heterogeneity was assessed using the I² statistic. The effects of antibiotic type and dose were examined through subgroup analyses. Meta-regression was performed to evaluate the effects of age, sex, follow-up duration, and diabetes mellitus on the occurrence of PJI. Results: Eighteen studies including 72,928 TKAs (20,201 in the ALBC group and 52,727 in the PBC group) were included. The overall analysis showed no significant difference in PJI rates between the ALBC and PBC groups (OR, 0.92; 95% CI, 0.67–1.27; p = 0.6). However, cefuroxime-loaded cement was associated with a significantly lower risk of PJI (p = 0.01). In contrast, cement containing gentamicin (p = 0.08), vancomycin (p = 0.3), or tobramycin (p = 0.6) did not show a similar protective effect. Antibiotic dose, age, sex, diabetes mellitus, and follow-up duration did not appear to influence the results. Conclusion: Most ALBC formulations were not associated with a significant reduction in the risk of PJI. Larger, dedicated trials are needed to further evaluate the effect of ALBC on PJI risk in selected patient populations.         Level of evidence: II https://abjs.mums.ac.ir/article_27318.html Objectives: The Patient-Rated Ulnar Nerve Evaluation (PRUNE) is a validated, condition-specific instrument designed to assess symptoms and functional limitations in individuals with ulnar nerve disorders. However, no Persian adaptation has been developed to date. The present study aimed to translate, culturally adapt, and evaluate the psychometric properties of the Persian version of the PRUNE among patients with Cubital Tunnel Syndrome (CuTS). Methods: Following international guidelines, the PRUNE was translated and culturally adapted into Persian. A total of 106 patients with clinically diagnosed Cubital Tunnel Syndrome (CuTS) were enrolled in the study. Internal consistency was evaluated using Cronbach’s alpha, and test–retest reliability was determined with the Intraclass Correlation Coefficient (ICC) over a two-week interval. Construct validity was examined through an exploratory factor analysis (EFA) using principal component extraction and Varimax rotation. Convergent validity was examined by assessing the correlations between PRUNE scores and those of established instruments, including the QuickDASH, DASH, and Visual Analog Scale (VAS). Results: The Persian version of the PRUNE demonstrated excellent internal consistency (Cronbach’s α = 0.889) and strong test–retest reliability (ICC = 0.886). Exploratory factor analysis confirmed a multidimensional factor structure consistent with that of the original instrument. Significant positive correlations were observed between the PRUNE and the QuickDASH (r = 0.768), DASH (r = 0.699), and VAS (r = 0.664), supporting its convergent validity. Conclusion: The Persian version of the PRUNE proved to be a reliable and valid instrument for assessing symptoms and functional limitations in Persian-speaking patients with Cubital Tunnel Syndrome. It can be confidently applied in both clinical practice and research contexts.         Level of evidence: II https://abjs.mums.ac.ir/article_27695.html Objectives: Proximal femoral nails (PFNs) are widely used in managing unstable proximal femur fractures. These implants are designed with fixed femoral neck-shaft angles in different sizes, based on anthropometric studies of the Western population. In this study, we aimed to evaluate the Caput-collum-diaphyseal (CCD) angle in the Iranian population and determine whether any design modification for PFNs is needed for this population.Methods: In this retrospective study, we evaluated patients who underwent hip and pelvic radiography at our hospital between 2015 and 2023. The CCD angles were measured on AP pelvic and hip radiographs. The mean CCD angle of the Iranian population was calculated. Correlation analysis was also conducted to evaluate the CCD angle in different age and sex groups.Results: The CCD angle was evaluated in 1040 patients with a median age of 72 (range 60-99) in this study. The mean CCD angle in the Iranian population was 130.6 ± 5.9 (range: 115.4-149). 117 (11.3%) of the patients had Coxa Vara or Coxa Valga. The CCD angles did not differ significantly between men and women. We observed a significant correlation between the patient’s age and the CCD angle. It was found that 20.35% of our population’s CCD is not covered by the most commonly available Western PFN designs.Conclusion: This study's findings demonstrated that the Iranian population's mean CCD angle is higher than in Western countries. Therefore, future PFN designs should consider the CCD angles of the specific populations.        Level of evidence: III https://abjs.mums.ac.ir/article_27160.html Objectives: Varus knee deformities involving both the tibia and femur can be addressed using proximal tibial osteotomy alone or in combination with femoral osteotomy; however, the outcomes have been inconsistent. Medial opening wedge high tibial osteotomy (MOWHTO) presents a viable alternative for correction. This study aims to evaluate the clinical and functional outcomes of MOWHTO in patients with combined tibial and femoral deformities.Methods: We retrospectively analyzed 30 patients who underwent MOWHTO at Shafa Yahyaiyan Hospital, Iran University of Medical Sciences, between 2015 and 2021. In all cases, the procedure aimed to overcorrect the medial proximal tibial angle (MPTA) to 90 degrees, without addressing the femoral varus deformity. Preoperative and postoperative standing radiographs were used to measure the joint line obliquity angle (JLOA), joint line convergence angle (JLCA), hip-knee-ankle angle (HKA), MPTA, and mechanical lateral distal femoral angle (mLDFA). Functional outcomes were assessed using the Knee Society Score (KSS), Knee Injury and Osteoarthritis Outcome Score (KOOS), and Visual Analog Scale (VAS).Results: The mean age of patients was 32.19 ± 11.63 years, with a mean follow-up duration of 39.38 months. MPTA increased significantly (90.53 ± 1.80 vs. 82.47 ± 3.66; p = 0.001), while the HKA and JLCA decreased significantly (p < 0.05). Functional outcomes, assessed by the KSS, KOOS, and VAS, showed significant improvement (p < 0.05). Although the JLOA increased by approximately 3 degrees postoperatively, this change was not clinically significant.Conclusion: MOWHTO, with overcorrection of the MPTA to 90 degrees, demonstrated excellent short- to mid-term clinical and radiological outcomes. Although the follow-up duration was limited, the findings support the efficacy of MOWHTO in managing combined tibial and femoral deformities in patients with varus knee alignment     Level of evidence: III https://abjs.mums.ac.ir/article_27729.html Objectives: Osteoid osteoma (OO) is one of the most common benign bone tumors and can occur in various skeletal structures. It often presents with symptoms, such as nocturnal pain, which may mimic constitutional conditions, and it is characterized by a distinct radiological appearance that allows for easy differentiation from other lesions. Over the past decade, numerous studies have evaluated the efficacy of both surgical and radiological interventions for treating OO. While several treatment methods are available, each carries distinct advantages and disadvantages. This study aims to report the outcomes of surgical resection for ocular (OO) lesions. Methods: A total of 29 patients were enrolled in this study. Of these, 14 patients chose surgical resection as their primary treatment, while 15 patients opted for radiofrequency (RF) ablation. Three patients who exhibited a lack of response to RF ablation subsequently underwent surgical resection, bringing the total number of patients in the surgery group to 17. This study specifically focused on lesions located in the peritrochanteric region. For lesions that recurred at the same site, whether due to recurrence or lack of response to initial treatment, the same treatment modality used in the first instance was applied. Results: Among the 17 individuals who initially underwent surgical resection, 11 had extracapsular lesions, and 6 had intracapsular lesions. All patients who underwent surgical resection became symptom-free, and no complications were observed during the procedure. Furthermore, all cases that received surgical resection were confirmed through pathological assessment. Additionally, three patients with extracapsular lesions had previously been treated with RF thermoablation but had not fully recovered from their symptoms, necessitating surgical resection. Conclusion: Based on the results, although RF is the first choice of treatment for OO, surgical resection could be a vital and safe option for peritrochanteric OO.         Level of evidence: IV https://abjs.mums.ac.ir/article_27732.html Objectives: This study presents a novel approach to revising failed medial unicompartmental knee arthroplasty into kinematically aligned total knee arthroplasty using an augmented reality (AR) system (NextAR by Medacta International). Traditional methods involve mechanically aligned total knee arthroplasty (TKA), which can be complex and often requires additional components like stems and augments. The proposed technique builds on the caliper-based manual method by integrating AR-based navigation to enhance precision during surgery, particularly in maintaining the patient’s native joint line and soft tissue behavior. The procedure includes preoperative three-dimensional planning and intraoperative adjustments based on real-time data on collateral ligament elongation. This AR-assisted technique aims to reduce the technical challenges associated with unicompartmental knee arthroplasty (UKA) revisions, offering potential benefits for alignment accuracy and soft-tissue management.        Level of evidence: V https://abjs.mums.ac.ir/article_27733.html An 85-year-old female walker dependent presented with a displaced olecranon fracture following a fall. Open reduction and internal fixation (ORIF) using an anatomic olecranon locking plate was performed. Two-week postoperative X-rays revealed fixation failure with persistent fragment displacement and a wide fracture gap. To manage this condition, non-operative management, including sling immobilization for 4 weeks and progressive physical therapy, was pursued with the elbow at 90 degrees flexion. At the 6-month follow-up, the elbow was pain-free with functional range of motion (ROM) being achieved, and functional independence was observed in daily activities including using a walker. This case highlights the potential for successful functional recovery through non-operative management in geriatric patients as an initial treatment or after a failed ORIF, emphasizing the importance of tailoring treatment to patient-specific factors and functional goals over radiographic outcomes.        Level of evidence: V https://abjs.mums.ac.ir/article_26485.html Objectives: Our study was conducted to define the anatomy of the deep motor branch of the ulnar nerve based on known and recognizable landmarks of the hand. We sought to define the approximate location of the nerve along its course to aid surgeons in recognizing potential areas of injury during other procedures involving the hand. Methods: Our study was performed using 10 fresh, frozen, matched cadavers harvested at the level of the distal forearm. The dissections were performed by and under the supervision of four fellowship-trained hand surgeons. The ulnar nerve was identified proximal to the Guyon canal and traced distally. The deep motor branch of the ulnar nerve was then dissected along its deep course until the level of its insertion into the adductor pollicis muscle. Results: The deep motor branch of the ulnar nerve was described along its entire anatomic path in relation to each metacarpal and the carpal tunnel. The nerve sits proximal to the digital palmar crease at the level of the respective metacarpal at a distance of 61mm – 64mm. The nerve was always deep to the flexor tendons and distal to the distal edge of the transverse carpal ligament by an average of 11mm. The nerve was consistently found deep and proximal to the superficial palmar arch. Conclusion: Thorough understanding of the anatomy of the deep motor branch of the ulnar nerve is of critical importance when performing surgeries of the hand. Knowing the nerve’s relative position in relation to identifiable landmarks can aid in preventing injury to the nerve and preserving the critical function of the hand intrinsic musculature. https://abjs.mums.ac.ir/article_26691.html Objectives: The objective of this study was to analyze the differences in social media attention, news attention, readership, and number of citations between open-access and subscription-based randomized control trials (RCTs) examining rotator cuff pathology. We hypothesize that open access articles will have higher attention scores and readership, but closed access subscription-based articles will have higher citation rates. Methods: A PubMed search was conducted to identify RCTs on rotator cuff tears. Using the Altmetric Explorer Database, metrics such as Altmetric Attention score (AAS), news mentions, X mentions, Mendeley readers, and Dimensions citations were extracted. A negative binomial regression adjusted for time since publication was used to compare metrics between open and closed access articles. Results: : Of 218 articles analyzed, 39% were open access, and 61% were closed access. Open access publications had higher costs and significantly higher mean AAS’s (42 ± 190 vs 15 ± 36), news mentions (2.6 ± 17 vs 0.48 ± 4.4), X mentions (45 ± 160 vs 19 ± 33), and Mendeley readers (120 ± 110 vs 87 ± 67) compared to closed access publications (p<0.05). However, the mean dimensions citations between open access vs closed access (29 ± 45 vs 27 ± 27) was not significantly different (p=0.554). Conclusions: Open access articles have higher attention scores while maintaining comparable citation numbers compared to closed access articles. Level of Evidence: Level 3 https://abjs.mums.ac.ir/article_26812.html ABSTARCT: OBJECTIVES : The objectives of the study are to compare the efficacy of external fixator /ligamentotaxis and volar plating in treatment of displaced intra-articular distal end radius fracture by comparing the functional outcome using the Green and O’Brien score and to assess the radiological outcome of displaced intra-articular distal end radius fracture treated with external fixtator /ligamentotaxis and volar plate. METHODS: This randomized study was done from August 2022 to May 2024 at GIMSR Medical College and Hospital on 70 patients. 35 patients underwent volar plating and 35 patients underwent external fixation. Functional outcomes were assessed at 3 and 6 months using Cooney modification of Green and O’Brien scores, and radiological outcomes were assessed using Sarmiento radiological score. RESULTS: By 6 months, both groups had comparable functional outcomes. The volar plating group achieved excellent results in 71.4% of cases versus 48.5% in external fixation group. Radiological parameters like palmar tilt, radial shortening, and deviation, showed no significant differences. Complications were similar between groups. Superficial pin tract infections more found to be common in external fixation group and surgical site infections in volar plating group. CONCLUSION: Volar plating provided superior early functional outcomes, especially in grip strength, but both methods show comparable long-term results. Treatment choice should consider patient-specific factors, including bone quality and need for early mobilization. https://abjs.mums.ac.ir/article_26895.html Objective: To investigate the efficacy of drain use and its impact on clinical outcomes and patient satisfaction in bilateral carpal tunnel release (CTR).Methods: In a randomized clinical trial, 41 patients (82 hands) with moderate-to-severe bilateral carpal tunnel syndrome (CTS) underwent open CTR in 2022. One hand was randomly assigned a Penrose drain, while the contralateral hand served as a control. The primary outcome was patient satisfaction at 16 weeks post-surgery, with secondary outcomes including pain (VAS), grip strength, wound healing, and pillar pain, which were assessed at baseline, three days, three weeks, and 16 weeks post-surgery.Results: Wound healing (P=0.85), pain (P=0.48), pulp pinch strength (P=0.73), and pillar pain (P=0.28) showed no significant differences between groups. However, palmar grip strength showed a significant difference in improvement between groups (P=0.028), favoring the non-drain group. Satisfaction was significantly lower with drains (P<0.001), and functional status (BCTQ-FSS) improved more without drains (P<0.001).Conclusion: Drain use in bilateral CTR provides no clinical benefit and reduces patient satisfaction, the primary outcome of this study, suggesting its routine use is unwarranted. https://abjs.mums.ac.ir/article_26974.html Abstract Objective: Osteoporosis is a progressive disease characterized by reduced bone density, which increases the risk of fractures and impairs functionality, particularly in postmenopausal women. Thoracic kyphosis and weakened back extensor muscles further exacerbate these issues, leading to a diminished quality of life (QoL). While exercise therapy is a standard treatment for these patients, dry needling may provide additional benefits. Methods: A single-center, double-blind randomized controlled trial (RCT) will involve 24 postmenopausal women diagnosed with osteoporosis. Participants will be randomly assigned to one of two groups :the dry needling plus exercise group (n=12) or the sham needling plus exercise group (n=12). Both groups will undergo nine sessions over a period of three weeks (three sessions per week). Outcomes will be assessed both before and after the intervention. The Primary outcomes will include back extensor muscle strength, endurance, and thickness, while the secondary outcomes will focus on thoracic kyphosis, lumbar lordosis, FoF, and QoL. Data will be analyzed using SPSS version 22. Results: The study has received ethical approval (IR.TUMS.FNM.REC.1401.194) and is registered in the Iranian Registry of Clinical Trials (IRCT20230315057723N1). Results are expected by mid-2025. Conclusion: This study aims to explore the synergistic effects of dry needling and exercise therapy, potentially improving treatment outcomes for postmenopausal women with osteoporosis, reduce fracture risks, and enhance QoL. https://abjs.mums.ac.ir/article_27018.html Objectives: Trigger finger, or stenosing tenosynovitis, is a common condition of the hand. A wide range of results have been reported on the effectiveness of corticosteroid injections for trigger finger, especially depending upon medical comorbidities. The purpose of this study was to evaluate patients a year after initial injection to determine what percentage needed additional injections, went on to surgery, and/or are still having symptoms of pain and triggering. Methods: Patients who received a corticosteroid injection for trigger finger from 6/4/2019 to 9/26/2019 were included in the study. Patients were contacted by phone one year after the first injection to assess persistent triggering and/or pain, additional injections, and surgical procedures. Previously collected information on the time to initial relief from the initial injection was also included. Results: The percentage of patients not requiring additional intervention was 64.6% (106/164) at one year. Additionally, 32.8% (19/58) of those who failed initial treatment required repeat injection only and 67.2% (39/58) of these patients required surgery. There was no statistically significant difference in the age, sex, diabetes, thyroid disease status, or time to relief after initial injection of patients requiring surgery, additional injection only, or no further intervention at one year. Conclusion: Our success and failure rates after initial corticosteroid injection were comparable to other rates reported in the literature. Contrarily, there was no difference when comparing diabetic or thyroid disorders patients with healthy patients and the need for further intervention at one year post initial injection. We also found that time to pain and triggering resolution after first corticosteroid injection is not predictive of the need for further intervention at one year post initial injection. https://abjs.mums.ac.ir/article_27170.html Objectives: The effective management of patellofemoral pain syndrome (PFPS) remains a significant clinical challenge. While various interventions demonstrate short-term efficacy, long-term outcomes are often suboptimal, potentially owing to a lack of understanding regarding which patient characteristics predict treatment success. This study aimed to identify clinical predictors of successful outcomes following a six-week combined intervention of exercise therapy, patellar taping, and prefabricated orthoses in individuals with PFPS. Methods: Fifty patients (30 females, 20 males; mean age, 29.4 years) diagnosed with PFPS were assessed for demographic, pain-related, biomechanical, and functional variables. Treatment success was defined as a ≥2-point reduction in the visual analog scale (VAS) score of pain during daily activities and a ≥8-point increase in the anterior knee pain scale (AKPS) score postintervention. Results: Logistic regression analysis identified several significant predictors of treatment success. A higher body mass index (BMI) and greater maximum pain intensity at baseline were associated with a lower probability of a successful outcome (OR = 0.427, p = 0.043; OR = 0.317, p = 0.027, respectively). Conversely, higher baseline AKPS scores (indicating better function), greater isometric hip internal rotation strength, hip extensor strength, hip abductor strength, and hip external rotation strength were positively associated with treatment success (ORs ranging from 2.583 to 3.858, all p < 0.05). Furthermore, hamstring shortness negatively impacted treatment outcomes (OR = 0.497, p = 0.034). Conclusions: Study findings suggest that a combination of anthropometric measures, pain and functional status, hip muscle strength, and hamstring length can serve as valuable clinical predictors for identifying individuals with PFPS who are more likely to benefit from a combined physiotherapy approach. The identified predictors may aid clinicians in tailoring treatment strategies and improving long-term outcomes for this challenging patient population. https://abjs.mums.ac.ir/article_27183.html Hemi-hamate arthroplasty (HHA) is a promising technique for reconstructing of the proximal interphalangeal joint (PIPJ), particularly in dorsal fracture-dislocations with loss of the volar articular surface of the middle phalanx. These injuries challenge joint stability and functionality. HHA requires a detailed reconstruction using a graft from the hamate bone to restore the volar articular surface and hunge mechanics. The “shotgun” approach allows hyperextension after collateral ligament release, providing direct visualization and precise graft placement while minimizing postoperative stiffness. This technical note details key steps for visualization and access to the fracture site, facilitating precise graft placement to ensure alignment of the articular surface, minimizing the risk of a mechanical block or stiffness postoperatively. By addressing technical precision often overlooked, this guide serves as a practical resource for surgeons managing complex PIPJ injuries requiring anatomical restoration. Hemi-hamate arthroplasty (HHA); Proximal interphalangeal joint (PIPJ); Shotgun approach; Bone graft; Joint stability. Level V. https://abjs.mums.ac.ir/article_27206.html Proximal humerus fracture and acromioclavicular (AC) joint injuries are common injuries of upper extremity. Preoperative imaging interpretation is important for accurate diagnosis. As our knowledge, this case reports for the first time a simultaneous proximal humerus fracture and AC joint dislocation diagnosed prior surgery. This case report describes a 53-year-old male with combined injury of left acromioclavicular (AC) joint dislocation and proximal humerus fracture following a car accident. The patient underwent open reduction and internal fixation (ORIF) of both injuries. This case highlights the importance of thorough clinical examination and imaging in patients with high-energy trauma to identify concomitant injuries. Early surgical intervention is often necessary for optimal outcomes. This case highlights the importance of recognizing complex upper extremity injuries after trauma and the need for prompt surgical intervention. Keywords: Proximal humerus fracture, AC joint dislocation, open reduction and internal fixation, Level of evidence: IV https://abjs.mums.ac.ir/article_27210.html Introduction Pectoralis major tear is not a common but functionally important injury and there is an increase in cases of pectoralis major injury as shown by recent literature. Reasons for the increase in cases are due to interest in intense sports activities, weightlifting particularly bench pressing and in military personnel. Moreover, the use of anabolic steroids especially in weightlifters also has an association with a tear of the tendon. Males from 20 to 40 years of age are more prone to this injury. Methods We are presenting a retrospective review of prospectively collected data on patients who had pectoralis major tear repairs from January 2020 to January 2024, ensuring a minimum follow-up of one year. Exclusion criteria included revision PMT repair, reconstruction, and concomitant repair of another glenohumeral tendon/ligament. All patients were assessed a minimum of 1 year postoperatively for clinical outcomes, Return to sports and Cosmetic satisfaction and strength satisfaction physical exam, ROM & cosmesis using Bak Criteria. Results All patients were men with an average age of 30 years at the time of injury. The average time from injury to surgical repair was 31 days and the average follow-up was 12 months. Most patients suffered an injury while bench pressing (15/22; 60%) or wrestling (3/20; 15%). The most common intra-operative findings were partial sternal tears (7/22; 31%) followed by complete sternal tears (15/22; 69%). According to the Bak criteria, overall results were excellent in 11 patients (50%), good in 9 (37%), while 3 patients (13%) had a fair result. Cosmetic satisfaction was achieved in 20 out of 22 patients. Seventeen patients returned to sports, averaging 18 weeks (range 7-32 weeks), and return to work averaged 9 weeks (range 5-22 weeks). Outcomes were satisfactory for 18 patients and fair for 4, with no reported steroid use or complications. Conclusions Pectoralis major tear repair produces improved PROs at final follow-up compared to preoperative values. Key Words: Pectoralis Major, Tear, Repair, Outcome, Work, Sports Level of Evidence: Level 4 https://abjs.mums.ac.ir/article_27319.html Constrained modular knee prostheses are a valuable tool in the armament of the revision knee surgeon, affording intra-operative flexibility in the restoration of anatomy, function, and stability in complex knee arthroplasty. However, these prostheses have been reported to increase stress at both modular implant junctions and bone-cement interfaces. In cases of poor femoral condylar fixation or condylar loosening, particularly when not augmented with metaphyseal fixation, stress can concentrate at the femoral condylar-stem junction, leading to loosening of the taper interface, toggling, metallosis, and even implant fracture. Whilst this mode of failure has been reported in other constrained modular knee systems, there are no reported cases of this mode of failure in the METS SMILES Total Knee Replacement to our knowledge. We present six cases of femoral condylar-stem junction failure, including two implant fractures, in six patients who presented to our institute (The Royal National Orthopaedic Hospital NHS Trust, Stanmore, UK). https://abjs.mums.ac.ir/article_27582.html In people with mild hemophilia (PwMH) it is essential to characterize the presence of articular complications to develop approaches to minimize the burden of the disease. To this end, on 5 August 2025 a literature search was conducted in PubMed using the keywords “arthropathy mild hemophilia.” Higher burden of arthropathy among PwMH compared to the general population has been reported. Arthropathy of the ankle in PwMH is frequent, is often disabling, and is due to episodes of bleeding into the ankle joint during childhood. It has been reported that 36.5% of PwMH have arthropathy. Patient age and factor levels are the most important risk factors associated with the development of arthropathy in PwMH. The risk of developing arthropathy increased by 7.9% for each additional year of the minimum factor VIII levels required to prevent total and spontaneous joint bleeds (19.2 IU/dL and 17.7 IU/dL, respectively) age and decreased by 7.7% for each 1 IU/dL increase in clotting factor. The minimum FVIII levels required to prevent total and spontaneous joint bleeds in PwMH have been identified (19.2 IU/dL and 17.7 IU/dL, respectively). The need for more careful monitoring of PwMH is required. Level of evidence: III https://abjs.mums.ac.ir/article_27652.html Arthroscopic Pull-Out Suture vs. Open Screw Fixation for ACL Tibial Avulsion Fractures: A Comparative Study Objective: To compare the clinical outcomes of pull-out suture fixation and open screw fixation, focusing on range of motion (ROM), pain levels, and Lysholm scores at six and twelve months postoperatively. Introduction: Anterior Cruciate Ligament (ACL) tibial avulsion fractures are a significant cause of knee instability. Two common surgical techniques for repair include pull-out suture fixation and open screw fixation. This study aimed to compare the clinical outcomes of these two methods, focusing on range of motion (ROM), pain levels, and Lysholm scores at six and twelve months postoperatively. Methods: We conducted a retrospective cohort study involving 50 patients treated at Shahid Chamran Hospital, Shiraz University of Medical Sciences, between 2020 and 2024. Patients were divided equally into two groups: one treated with pull-out suture fixation and the other with screw fixation. Outcomes assessed at six and twelve months included ROM, pain, and Lysholm scores. Results: Statistically significant improvements in ROM and Lysholm scores were observed in the pull-out suture group compared to the screw fixation group at both follow-up points. However, no significant difference in pain scores was detected between the groups. Conclusion: Pull-out suture fixation demonstrated superior clinical outcomes compared to screw fixation in the treatment of ACL tibial avulsion fractures. These findings may guide surgical decision-making to optimize patient recovery. Keywords: Tibial Spine Avulsion, ACL, ORIF, Pull-out suture, Screw Fixation Level of Evidence: Level III, retrospective cohort study. https://abjs.mums.ac.ir/article_27653.html Background: Limb-salvage procedures in pediatric patients with malignant bone tumors around the knee are surgically challenging due to the need for skeletal growth preservation and long-term functional demands. Hemiarthroplasty has emerged as a potential solution when other reconstruction options are limited or unfeasible. Methods: We present a retrospective case series of three skeletally immature patients (ages 5-7) with high-grade malignant tumors of the distal femur. All underwent wide tumor resection followed by reconstruction using a hemiarthroplasty. Functional outcomes were assessed using the Enneking scoring system. Follow-up ranged from 3 to 5 years. Results: All patients achieved limb preservation with good early functional recovery. The mean Enneking functional score was 23/30 (range, 21-25). Two patients remain disease-free with stable implants at the latest follow-up. One patient experienced pulmonary relapse and died 4 years after surgery. No local recurrences or mechanical implant failures were observed. Conclusion: Hemiarthroplasty is a viable and cost-effective reconstructive option in pediatric patients with distal femoral sarcoma, particularly in settings where expandable endoprostheses are unavailable or contraindicated. Mid-term outcomes demonstrate acceptable oncologic safety and functional results. Larger studies are needed to validate its role as a standard reconstructive technique. Level of evidence: IV. https://abjs.mums.ac.ir/article_27655.html Objectives: Movement-specific reinvestment reflects a tendency to consciously monitor and control movements and may contribute to altered motor behavior in individuals with chronic low back pain (CLBP). This study aimed to translate and culturally adapt the Movement-Specific Reinvestment Scale (MSRS) into Persian and to evaluate the reliability and validity of the Persian version (MSRS-P) in individuals with and without CLBP. Methods: This cross-sectional study included 153 Persian-speaking adults classified into three groups: non-low back pain (non-LBP), CLBP without central sensitization (CS), and CLBP with CS. The MSRS was translated using standardized forward-backward procedures. Internal consistency, test-retest reliability, construct validity, known-groups validity, and factor structure were examined using exploratory and confirmatory factor analyses. Results: The MSRS-P demonstrated acceptable internal consistency (Cronbach’s alpha = 0.83 total score) and good test-retest reliability (ICC[2,1] = 0.81-0.84). Known-groups analyses showed significantly higher MSRS-P scores in participants with CLBP and CS compared with non-LBP controls and CLBP without CS. Moderate correlations between MSRS-P scores and measures of disability and anxiety were observed in individuals with CLBP without CS, whereas these associations were weaker in those with CLBP and CS. Factor analyses supported a two-factor structure reflecting Conscious Motor Processing and Movement Self-Consciousness. Conclusion: The MSRS-P is a reliable and valid instrument for assessing movement-specific reinvestment in Persian-speaking individuals with CLBP. The scale may be useful for identifying patients with heightened conscious motor control tendencies, particularly in those with central sensitization. https://abjs.mums.ac.ir/article_27696.html Title of paper: New Onset Urological Complication In Pelvic Fractures: Predictors Of bladder Injury, Urethral Injury, Urinary Retention And Urinary Incontinence Following Pelvic FracturesObjectives: This study aims to identify the incidence of urological complications named bladder injury, urethral injury, urinary retention and urinary incontinence following pelvic fractures and examine the patient’s age, sex, fracture type and mechanism of injury as possible predictors.Methods: A retrospective cohort study that was conducted in two general hospitals and included patients who had pelvic ring fractures between January 2021 and March 2024. Data were gathered using the patients’ files and database.Results: 45 patients were included. With regards to complications, 2(4.4%) of the patients experienced urethral injury, 4(8.9%) had bladder injury, 6(13.3%) suffered from urinary incontinence, and 2(4.4%) experienced urinary retention. Regarding the examined predictors, both age and sex did not show a statistically significant value. Regarding the young-burgess classification, APC III injuries were particularly associated with 1 urethral injury, 3 bladder injuries, and 2 urinary retention cases. Patients with APC III injuries had increased probability to sustain bladder injuries (OR- 14.649, p = 0.057). In terms of the mechanism of injury named road traffic accident, fall from height, injury with heavy object and fall from stairs, road traffic accidents were the most common accounting for 51.1% of the cases. However, fall from stairs was identified as the only MOI that showed a statistically significant value in relation to urethral injuries.Conclusion: This study shows a significant association between APC III pelvic fractures and bladder injuries and urinary retention. The results show that the type of fracture and its mechanism of injury play more significant roles in predicting urogenital complications, compared to factors like age and gender. Early diagnostic interventions and management strategies based on these factors are essential in improving patient outcomes. Although the study provides valuable insights, further research with larger sample size is needed to develop predictive models for more effective management. Keywords: Pelvic fracture, urinary retention, urinary incontinence, urethral injury, bladder injuryLevel of evidence: III https://abjs.mums.ac.ir/article_27697.html Objectives: This study aimed to examine physician referral preferences between neurosurgeons and orthopedic spine surgeons across the Middle East and to identify factors influencing these decisions.Methods: A multinational, cross-sectional, web-based survey was distributed between September 2023 and June 2025 to actively practicing physicians in the Middle East. The survey instrument captured demographic characteristics, access to dedicated spine centers, perceptions regarding specialty-specific training, and referral preferences for a range of spinal pathologies. Statistical analyses were performed using chi-square tests and Fisher’s exact tests, as appropriate.Results: A total of 861 valid responses were analyzed. Overall, 52% of physicians preferred referring patients to neurosurgeons for long-term spinal care. Referral preferences varied significantly by condition: radiculopathy and spinal tumors were predominantly referred to neurosurgeons (P < 0.001), while spinal fractures, deformities, and fusion/disc replacement procedures were referred to orthopedic surgeons (P < 0.001). Access to a comprehensive spine institute significantly influenced referral patterns, with balanced preferences observed among physicians with access and a neurosurgical bias among those without (P = 0.019).Conclusion: In this large regional survey, referral decisions for spine care in the Middle East were shaped by specialty perceptions, access to multidisciplinary centers, and clinical context. Despite varying opinions on training equivalence, neurosurgeons and orthopedic surgeons were both recognized as capable providers for spine patients. Expanding integrated spine care models may help reduce referral bias and promote condition-specific, patient-centered referral decisions. https://abjs.mums.ac.ir/article_27698.html Objectives: Chondroblastoma (CB) is a rare, benign but locally aggressive bone tumor. Although the proximal humerus is a common site of involvement, limited data exist regarding its behavior and optimal management. In this study, we report a retrospective series of 26 patients with proximal humerus CB and discuss their management. Patients & Methods: This retrospective study reviewed 26 cases of histologically confirmed proximal humerus CB treated between 1986 and 2022. Patients underwent either extended curettage (for stage 1 & 2) or en bloc resection (for stage 3). Functional outcomes were assessed using the Musculoskeletal Tumor Society (MSTS) score. Results: The cohort consisted of 20 males and six females, with a mean age of 16.5 years. The mean follow-up was 11.4 ± 7.9 years. Most lesions were stage 2 (n = 20, 77%). The recurrence rate was 34.6% (n = 9), occurring only in stage 1 and 2 lesions treated with curettage. No recurrences were observed in stage 3 lesions treated with en bloc resection. The average MSTS score was 29.3 ± 0.8 for curettage and 23.7 ± 0.6 for en bloc resection. Complications included restricted active shoulder motion in three patients who were managed with en bloc resection and superficial infection in one who underwent curettage. Conclusion: Extended curettage for stage 2 chondroblastoma of the proximal humerus carries a high risk of local recurrence. En bloc resection appeared to reduce recurrence in our small cohort, though functional outcomes in this group were lower. Given the limited number of patients treated with en bloc resection, these findings should be interpreted with caution. https://abjs.mums.ac.ir/article_27713.html Objectives: This study evaluates the accuracy and readability of ChatGPT in foot and ankle surgery, particularly for fractures at the metadiaphysis of the 5th metatarsal (Jones fractures). Given that ChatGPT has over 180.5 million monthly users since May 2024, evaluating its efficacy as a patient education tool is essential. Methods: Nine frequently asked questions regarding Jones fractures were posed to ChatGPT 3.5 and 4o on June 28, 2024. Two senior authors scored the responses as “excellent response not requiring clarification” (1), “satisfactory requiring minimal clarification” (2), “satisfactory requiring moderate clarification” (3), or “unsatisfactory requiring substantial clarification” (4). Flesch Reading Ease score and Flesch-Kincaid Grade Level were used to assess length and readability. Results: The mean rating for ChatGPT 3.5 responses was 2.89 ± 0.78 compared to 1.78 ± 0.83 for ChatGPT 4o (P=0.0133), with lower scores corresponding to better quality responses. Flesch Reading Ease averaged 43.7 for ChatGPT 3.5 and 49.06 for 4o (P=0.0918), both correlating with a college reading level. Flesch-Kincaid Grade Level was an average of 11.19 and 9.27 for ChatGPT 3.5 and 4o, respectively (P=0.0214). Conclusion: ChatGPT 4o demonstrated better accuracy than 3.5, with improvements in Flesch Reading Ease and Flesch-Kincaid Grade Level, though both need further enhancement in readability. https://abjs.mums.ac.ir/article_27714.html Title: Concussion Trends In United States Youth Soccer Following The 2015 Heading Ban Objectives: This study aims to identify if rates of soccer-related concussions presenting to US emergency departments (EDs) among youth ages 13 and below decreased after the January 2016 US Soccer heading guidelines implementation. The secondary aim of this study was to assess overall rates of concussions from 2010-2023 in this age group. Methods: This descriptive epidemiological study used the National Electronic Injury Surveillance System (NEISS) to queried and identify concussions associated with soccer that presented to US EDs from 2010-2023 among ages 0-13 years. The outputs were analyzed by sex and year. Incidence rates (IR) were calculated 100,000 person-years. Regression analyses and chi-square tests determined significance. Results: From 2010-2023, a total of 52,856 concussions (IR: 6.93) associated with youth soccer were identified. Yearly concussions did not vary significantly. From 2016-2023, 30,021 concussions (IR: 6.89) were identified. There was no significant trend in concussion incidence was identified. Males accounted for 56.6% (IR: 7.57) and females 43.4% (IR: 6.08). Incidence varied significantly by sex. Conclusion: Since the US Soccer Concussion Initiative implementation in 2016, there has been no significant decrease in soccer-related ED presentations for concussions among the 0–13-year-old age group. Prohibiting heading may not be as effective as previously suspected in decreasing rates of concussion in youth soccer. Key Terms: Traumatic Brain Injury, Concussion, Soccer, Sports, Youth Level of Evidence: III https://abjs.mums.ac.ir/article_27715.html Objectives: To compare the effects of Virtual Reality (VR)-based exercises and routine physical therapy on pain, kinesiophobia, and functional abilities in patients with Non-Specific Chronic Low Back Pain (NSCLBP). Methods: Twenty-eight participants aged 20 to 55 were included and randomly assigned to two groups, ensuring single blinding. Both groups received routine physical therapy, which included transcutaneous electrical nerve stimulation (TENS), ultrasound therapy, and infrared light, along with identical exercise programs. The intervention group also engaged in additional exercises using VR technology. Participants had been experiencing NSCLBP for three months or longer. Results: The intervention group showed significant improvements in pain(P=0.001), disability index, quality of life (QoL) (P=0.004), range of motion (ROM) in flexion and extension (P=0,008, P=0.002), and both left and right sided balance (P=0.001, P=0.013) compared to the control group. However, no significant differences were observed in the Tampa Scale of Kinesiophobia (P=0.148) and strength in flexion and extension (P=0.370, P=0.09). Conclusion: VR-based therapeutic exercises significantly improved pain, disability, quality of life, and balance in NSCLBP patients compared to routine physical therapy interventions. Keywords: Kinesiophobia, low back pain, Virtual Reality, physical therapy modalities, wearable electronic devices. Level of Evidence: Level I https://abjs.mums.ac.ir/article_27726.html Intramedullary interlocking nailing is widely used for extra-articular distal tibial fractures, yet outcome interpretation depends on consistent definitions and transparent reporting. Purpose: To provide a critical appraisal of Dake et al.’s cohort study on IMN for EADTFs. Main Points: We call for an explicit, standardized definition of “distal” (distance from the tibial plafond and/or AO/OTA classification), clearer reporting of outcome assessment timing, and incorporation of validated patient-reported measures beyond AOFAS/OMAS to capture late sequelae, including anterior knee pain. We also encourage detailed perioperative protocols (weight-bearing progression, rehabilitation pathway, surgical approach, and open-fracture wound care) to improve reproducibility and clinical translation. https://abjs.mums.ac.ir/article_27727.html Two of the four articles published after September 2020 were systematic reviews. The first systematic review found that concentrations of TXA beyond 20 mg/mL were cytotoxic to chondrocytes, tenocytes, synoviocytes and periosteum-derived cells. The other systematic review suggested that the utilization of TXA in ACLR diminished the need for joint aspiration, articular bleeding, drain output, and knee inflammation in the postoperative period. The other two articles were clinical studies. One of them contemplated IA-TXA as a potentially efficacious and relatively safe option to diminish postoperative bleeding and pain in ACLR individuals. The other clinical study found that IA-TXA was efficacious in diminishing postoperative bleeding and early postoperative pain in individuals who underwent arthroscopic synovectomy of PVNS. Given the scarcity of well-designed studies on the long-term impact of IA-TXA on chondrocytes, we cannot know whether IA-TXA is harmful in the long-term, although it certainly appears to be beneficial in the short-term following some arthroscopic knee procedures (diminish postoperative bleeding and pain in ACLR and PVNS individuals). It is clear that very little progress has been made in the last five years and that well-designed, long-term studies will be needed to determine whether IA-TXA is harmful to chondrocytes in arthroscopic knee surgery. https://abjs.mums.ac.ir/article_27767.html Objectives: To compare two groups of patients undergoing hip surgery for DDH (those who received TXA pre- and per-operatively with those who did not) with respect to the amount and percentage of blood loss and the need for blood transfusion in a prospective cohort study. Methods: The study was a comparative, prospective cohort study. The participants were children with DDH who required surgical treatment, including bone (pelvic and femoral) osteotomies. They were divided into two groups: Group 1 consisted of patients who didn’t receive TXA (control group), while Group 2 consisted of those who received it (experimental group). Results: One hundred and two cases (51 in each group) were included in the current study. Group 1 did not differ statistically from Group 2 in mean age, sex, grade of DDH, mean number of osteotomies, mean blood loss, mean percentage of blood loss, or mean odds of blood transfusion. The amount and rate of blood loss showed a weak positive correlation with patient age and sex, but this association was not statistically significant. Their correlations with DDH grade, number of osteotomies, and odds of blood transfusion were also positive, but statistically significant. Conclusion: There was no statistically significant difference between those who didn’t receive and those who received tranexamic acid in reducing the amount and percentage of blood loss, and odds of blood transfusion in children who underwent DDH surgery with bone osteotomies. https://abjs.mums.ac.ir/article_27768.html Purpose: Flipped meniscus tears (FMTs) are a distinct subtype of medial meniscal injury, characterized by displaced fragments lodged in the meniscotibial or meniscofemoral recess. Though MRI is key for diagnosis, subtle findings often hinder early detection. Bone marrow edema (BME), commonly seen in intra-articular trauma, has been proposed as a potential marker. This study evaluates whether BME on MRI can help predict FMTs compared to other medial meniscal tear patterns. Methods: We retrospectively reviewed 430 patients who underwent knee arthroscopy for symptomatic medial meniscus tears from 2013 to 2024 at a single academic institution. Exclusion criteria included advanced osteoarthritis, significant cartilage damage, and concomitant cruciate injuries. MRI findings, including presence and location of BME, were analyzed. Tears were classified as FMT or non-FMT and further categorized by acuity (acute vs. chronic) and mechanism (traumatic vs. atraumatic). Chi-square and Pearson correlation analyses assessed associations. Results: Of the 430 knees, 74 (17.2%) had FMTs, and 132 (30.7%) demonstrated BME. No significant associations were found between FMTs and BME presence (p = 0.441), or between BME and tear acuity (p = 0.480) or mechanism (p = 1.0). Although BME was more common in acute FMTs than chronic ones, this was not statistically significant (p = 0.308). Conclusion: BME was not significantly associated with FMTs, traumatic mechanisms, or tear acuity. Its absence should not exclude consideration of an FMT. Careful evaluation of tear morphology remains essential, regardless of BME. https://abjs.mums.ac.ir/article_27769.html Objectives: This study aimed to evaluate the effectiveness of a combination of glucosamine–chondroitin, chitosan, and phytoestrogen with paracetamol on biochemical (sIL-6R, IL-10, COMP) and clinical (VAS, WOMAC) outcomes in postmenopausal women with knee osteoarthritis. Methods: This was an uncontrolled, single-arm pre-post study that assessed the effects of two weeks of administration of a combination of glucosamine-chondroitin, chitosan, and phytoestrogen with paracetamol on biochemical and clinical outcomes in 30 postmenopausal women with knee OA. The synovial fluid biomarkers measured were sIL-6R, IL-10, and COMP. Assessment of pain and function used the VAS and WOMAC. Nonparametric analysis and parametric analysis were used accordingly as per the distribution of data. Results: The COMP level showed a significant reduction after intervention, from 124.13 ± 59.33 ng/mL to 87.20 ± 30.98 (P < 0.01), reflecting a decline in the rate of cartilage degradation. sIL-6R decreased from 66.33 (69.17) to 46.33 (68.33) ng/mL (P = 0.36), while IL-10 increased from 20.4 (41.50) to 34.4 (39.00) ng/mL (P = 0.07), indicating anti-inflammatory behavior. Clinically, VAS pain scores improved from 6.65 ± 0.69 to 6.38 ± 0.66 (P < 0.01), and WOMAC scores improved from 56.07 ± 3.43 to 52.17 ± 2.99 (P < 0.01). Conclusion: Glucosamine-chondroitin, chitosan, and phytoestrogen in combination with paracetamol was associated with significant improvement in pain and function, and favorable biomarker modulation, in postmenopausal women with knee OA. This combination may provide complementary biochemical and clinical benefits. https://abjs.mums.ac.ir/article_27814.html Pectoralis major tendon (PMT) ruptures are increasingly seen in athletes, particularly weightlifters, often requiring surgical repair to restore function. Current surgical techniques may be limited by poor tendon quality or significant retraction. We present a novel approach combining unicortical button fixation with DX Reinforcement Matrix augmentation in a competitive weightlifter with a complete PMT rupture and contralateral pectoralis dysfunction. Intraoperatively, the tendon was augmented with a DX Matrix and fixed using a unicortical button to restore the anatomic footprint and reduce repair tension. The patient underwent structured rehabilitation and returned to full activity within six months. MRI at 12 months showed intact tendon healing at the anatomical footprint without graft failure or retraction. The Oxford Shoulder Score was 48 at six months, indicating high patient satisfaction. This technique is designed to provide a biomechanically robust and biologically supportive solution for complex PMT repairs and may improve outcomes, particularly in high-demand individuals. Further evaluation in larger cohorts is needed. https://abjs.mums.ac.ir/article_27815.html Objectives: Bone-patellar tendon-bone (BPTB) autograft remains a frequently utilized technique for anterior cruciate ligament reconstruction (ACLR) due to its biomechanical properties, but is consistently associated with a high incidence of postoperative anterior knee pain (AKP). This study aims to assess the intensity of AKP in patients who underwent ACLR using the BPTB method. Methods: We retrospectively reviewed the patients who underwent anatomical arthroscopic ACLR with BPTB autograft from 2016 to 2021 in our orthopedic medicine center. Outcome measures included range of motion (ROM), presence and location of pain and discomfort, along with completion of the Lysholm, International Knee Documentation Committee (IKDC), and Visual Analog Scale (VAS) questionnaires by all patients. Results: AKP was reported by 11.5% of patients, with only 6.8% experiencing severe pain during kneeling. Mild or greater kneeling pain was reported by 38.8%, while 61.1% reported no kneeling pain. Mean VAS pain score was low (1.6/10), and functional scores were favorable (Lysholm 91.9 ± 11.2; IKDC 85.2 ± 15.0). Notably, AKP intensity and kneeling pain decreased significantly over time (P=0.004 and P=0.05, respectively). Older age correlated with lower IKDC scores (P=0.015). ROM was preserved in 92.5% of patients, with no patellar fractures observed. Conclusion: Although AKP remains a notable complication following ACLR with BPTB autograft, its prevalence and severity are relatively low in this cohort, and symptoms tend to improve with time. These findings support the continued use of BPTB grafts, particularly when early stability and return to high-level activities are prioritized. Careful surgical technique and rehabilitation focusing on full knee extension may mitigate AKP risk. https://abjs.mums.ac.ir/article_27846.html Introduction: Multifocal osteosarcoma (MFOS) is an aggressive presentation of osteosarcoma characterized by multiple skeletal lesions without visceral metastasis. Despite decades of clinical recognition, its biological basis, classification, and optimal management remain poorly defined, particularly regarding distinctions between synchronous and metachronous disease. Hypothesis: Synchronous and metachronous MFOS differ in pathogenesis, imaging characteristics, clinical behavior, treatment feasibility, and prognosis. Methods: A narrative review of the literature was conducted using PubMed, Scopus, and Google Scholar. Studies addressing the definition, classification systems, pathogenesis, imaging characteristics, treatment approaches, and outcomes of MFOS were identified and synthesized, with particular emphasis on differences between synchronous and metachronous forms. Results: MFOS accounts for approximately 1.5% of osteosarcoma cases. Synchronous MFOS typically presents with widespread sclerotic lesions, limited surgical options, and poor survival. In contrast, metachronous MFOS more closely resembles conventional osteosarcoma, is more often amenable to surgical resection, and demonstrates comparatively improved outcomes. Genetic predisposition syndromes and microenvironmental factors appear to play contributory roles in selected cases. However, no definitive molecular markers currently exist to distinguish true multicentric disease from early skeletal metastasis. Conclusion: MFOS remains a diagnostically and therapeutically challenging condition with distinct clinical and prognostic differences between synchronous and metachronous forms. Improved molecular characterization and collaborative research efforts are needed to refine classification, guide treatment strategies, and improve outcomes in this rare and aggressive disease. https://abjs.mums.ac.ir/article_27847.html Objectives: Alcohol use disorder (AUD) has been associated with post-surgical complications, but previous studies were limited by national, single-database sources. The purpose of this study was to characterize differences in complications of matched cohorts of patients with versus without AUD undergoing primary total knee arthroplasty (TKA) and to evaluate the effect of AUD-associated comorbidities on the hazard of post-operative complications. Methods: A total of 6,634 patients were extracted from the TriNetX global database for patients undergoing primary TKA from 2015 to 2025. Univariate analysis was performed to examine the relationship between AUD and postoperative complications. A subgroup analysis was performed using the TKA/AUD cohort with surgical complications compared to AUD patients without surgical complications. Cox proportional hazards modeling evaluated the impact of comorbidities and pre-operative labs on the hazard of post-operative complications. Results: Patients with AUD had a significantly higher risk of acute renal failure, respiratory failure, delirium, transfusion, joint infection, wound dehiscence, superficial skin and soft tissue infection, infection following procedure, periprosthetic fracture around knee joint, and revision arthroplasty. The cohort of TKA/AUD patients with surgical complications had a significantly higher percentage of diabetes, tobacco use, essential hypertension, depression, anxiety, bipolar disorder, and atrial fibrillation than the cohort without surgical complications. These patients also had significantly lower pre-operative hemoglobin, albumin, ALT, and higher INR than patients without complications. The Cox proportional hazards model showed a significantly increased hazard of post-operative complications for hypertension, hemoglobin of 6 – 10 g/dL, and albumin of 2.5 – 3 g/dL in a cohort of patients with AUD. Conclusion: AUD has a significant effect on both medical and surgical complications following primary TKA at 30 days, 90 days, 1 year, and 5 years post-operatively. Certain pre-operative labs can predict the hazard of post-operative complications. This data supports a multidisciplinary approach to optimize care for high-risk individuals. https://abjs.mums.ac.ir/article_27933.html In their review on antibiotic-impregnated cement spacers, Shahpari et al. present an internally contradictory account of how cement mixing technique affects antibiotic elution. They correctly state that porosity increases elution and that hand mixing produces a more porous cement with intact antibiotic crystals, yet conclude that hand mixing decreases the overall elution rate. This conclusion conflates inconsistent elution with reduced elution. Inhomogeneous distribution in hand-mixed cement may produce non-uniform release kinetics, but the increased porosity raises the overall elution rate, whereas vacuum mixing lowers porosity and reduces release while improving mechanical strength. Multiple in vitro studies and systematic reviews confirm that hand mixing increases antibiotic elution relative to vacuum mixing. We propose a corrected statement and highlight the clinical relevance for surgeons selecting a mixing technique when preparing antibiotic-loaded spacers for two-stage revision arthroplasty. https://abjs.mums.ac.ir/article_27934.html Objective: This study aimed to evaluate the associations between magnetic resonance imaging (MRI) findings of the anterolateral ligament (ALL) and clinical variables in patients undergoing anterior cruciate ligament (ACL) reconstruction. By focusing on ALL injuries, we aim to elucidate their imaging manifestations and their relationships with patient demographics and clinical variables. Methods: This retrospective study was conducted across three orthopedic surgical centers in Mashhad, focusing on patients with clinically confirmed ACL tears scheduled for reconstruction surgery between January and August 2024. MRI scans were interpreted by two or three experienced radiologists using a 1.5 Tesla MRI machine. Statistical analysis was performed to assess associations between MRI-detected ALL injuries and clinical variables. Results: Eighty-three patients were included in the study, with a mean age of 29 years; the majority were male (90.6%). MRI revealed ALL injuries in 34 patients (41%), while 45 patients (54.2%) showed no detectable ALL injuries. Four cases could not be classified. Furthermore, 41.7% of the patients had both confirmed ACL and ALL injuries. The high-grade pivot shift test yielded positive results in 54.2% of the patients. Medial meniscus injuries were found in 53% of the patients, whereas lateral meniscus injuries were noted in 13.3%. Joint effusion was present in 60.2% of the cases. A significant association was observed between MRI-detected effusion and ALL injury (P-value = 0.035), and a strong correlation was noted between a positive pivot shift test and ALL injury (P-value < 0.001). No significant associations were found between ALL injury and age, sex, or the anterior drawer test. Conclusion: This study suggests a significant association between ALL injuries and both MRI-detected effusion and positive pivot shift test results in patients undergoing ACL reconstruction. Although a trend toward association with PCL buckling was observed, further research with larger sample sizes is warranted to confirm this finding. https://abjs.mums.ac.ir/article_27938.html Objectives: The population most severely affected by poliomyelitis as children in the 1950’s have now reached the age where anatomic or reverse total shoulder arthroplasty (aTSA, rTSA) is frequently considered for degenerative disease. To date, only three series comprising 14 cases of post-polio patients have been published, illustrating a need for further understanding of outcomes in this population. Methods: A retrospective study was performed of all patients with poliomyelitis undergoing aTSA or rTSA between March 2011 and September 2023. Follow-up was collected, as well as post-polio symptoms, range of motion, VAS pain, and revision status at final follow-up. Results: Ten patients (11 shoulders, 3 aTSA, 8 rTSA) were evaluated at an average follow-up of 4.7 (range: 2-13) years. Pre-operatively, polio deficits involved the lower extremities (N = 8), upper extremities (N = 2), and spine (N = 1). At final follow-up, only 1 patient experienced a complication (instability). Postoperative range of motion significantly improved in all planes. Finally, VAS pain scores significantly decreased from 7.0 to 1.2 postoperatively (p=0.02). Conclusion: In shoulder arthroplasty in post-polio patients, low complication rates were observed with improvement in both pain and function. Reverse total shoulder arthroplasty, in particular, appears effective in poliomyelitis patients. https://abjs.mums.ac.ir/article_27940.html The aim of this article has been to analyze what the literature says about outpatient revision total knee arthroplasty (rTKA) in order to determine whether it is currently a worthwhile intervention. Although existing publications on outpatient rTKA claim that it is a safe and effective procedure, their authors also state that proper patient selection is essential. However, none of these publications clearly states how this selection should be made. In addition, all authors agree that more well-designed studies with a high degree of evidence are needed in order to be able to say with scientific certainty that rTKA can be considered a good idea. One study has tried to foretell appropriate outpatient candidates following rTKA utilizing machine learning [random forest (RF) model]. It was found that the ten essential factors favoring outpatient rTKa in the RF model were operating time, anesthesia type, age, BMI (body mass index), American Society of Anesthesiologists (ASA) grade, race, history of diabetes, rTKA type, sex, and smoking status. Therefore, prospective, randomized controlled trials are required. Level of evidence: III https://abjs.mums.ac.ir/article_27996.html Background: The Merle d'Aubigné-Postel (MDP) score is a widely used patient-reported outcome measure (PROM) for assessing hip function, encompassing domains of pain, walking ability, and mobility. Despite its global application, a validated Persian version has been unavailable. This study aimed to translate, culturally adapt, and evaluate the reliability and validity of the Persian MDP score for use in Persian-speaking patients undergoing total hip arthroplasty (THA). Methods: Following Guillemin's guidelines, the MDP score was translated into Persian through forward and backward translations, expert review, and pretesting with 20 patients to ensure cultural relevance and clarity. The adapted tool was then validated in 103 Persian-speaking patients post-THA with a minimum follow-up of one year, assessing internal consistency (Cronbach's alpha), test-retest reliability (intraclass correlation coefficient [ICC]), construct validity (correlation with Harris Hip Score [HHS]), criterion validity (correlation with HHS and Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC]), and content validity (floor and ceiling effects). Inter-rater reliability was assessed among three orthopedic residents for the mobility component. Results: The Persian MDP demonstrated high internal consistency (α = 0.74) and excellent test-retest reliability (ICC = 0.95; 95% CI: 0.91-0.98). Inter-rater reliability for the mobility component was excellent (ICC = 0.89; 95% CI: 0.82-0.94). Construct validity was supported by strong domain-specific correlations (e.g., MDP pain vs. HHS pain: r = 0.73; 95% CI: 0.62-0.81). Criterion validity was confirmed by robust correlations with WOMAC (r = 0.745; 95% CI: 0.65-0.82) and HHS (r = 0.753; 95% CI: 0.66-0.83). Content validity showed a minimal floor effect (0%) and acceptable ceiling effect (14.5%). Conclusion: The Persian MDP score is a valid and reliable tool for assessing outcomes after THA in Persian speakers. Its simplicity and strong psychometric properties support its use in both clinical practice and research. However, the ceiling effect warrants consideration in populations with excellent outcomes. https://abjs.mums.ac.ir/article_28024.html Objectives: This systematic review investigates the impact of vitamin D supplementation on postoperative outcomes following total knee and hip arthroplasty, considering its role in musculoskeletal health and the high prevalence of vitamin D deficiency among arthroplasty patients. Methods: A comprehensive search of PubMed, Scopus, Embase, and Web of Science was conducted up to April 2026. Eligible studies were randomized clinical trials evaluating vitamin D supplementation in patients undergoing total knee or hip arthroplasty. Two reviewers independently screened studies, extracted data, and assessed quality using the Cochrane RoB-2. A qualitative synthesis was performed because of substantial methodological heterogeneity. Results: Five randomized controlled trials involving 519 patients were included. Higher-dose and oral regimens produced greater increases in serum 25(OH)D, including higher postoperative concentrations with 2000 vs 800 IU at 24 months (45.5 vs 37.1 ng/mL) and with oral vs intramuscular 600,000 IU at postoperative day 14. However, most studies found no significant between-group differences in functional measures, pain scores, complications, and clinical outcomes. One study showed significantly greater muscle strength in the supplementation group, including hip abductor strength (P = 0.03) and knee extensor strength (P = 0.01). Conclusion: Vitamin D supplementation appears to improve perioperative vitamin D status, particularly with higher-dose and oral regimens, but current evidence for consistent benefit on broader postoperative functional and clinical outcomes after joint arthroplasty remains limited and mixed. Level of Evidence: Level II Keywords: Vitamin D, total knee arthroplasty, total hip arthroplasty, supplementation https://abjs.mums.ac.ir/article_28025.html Objectives: Perioperative anxiety and depression are common after major orthopaedic surgery and can impair recovery. Ketamine and esketamine have rapid psychotropic effects, but their effectiveness for postoperative mood symptoms in orthopaedic patients is uncertain. We systematically reviewed randomized evidence on these drugs for postoperative anxiety, depression, and side effects. Methods: PubMed, Embase, and Cochrane were searched for randomized controlled trials enrolling adults undergoing major orthopaedic procedures. Eligible studies compared ketamine or esketamine administered pre-, intra-, or postoperatively with placebo or no ketamine-class drug. Primary outcomes were postoperative anxiety or depression measured using validated scales. Secondary outcomes were drug-related adverse effects. Results: Nine randomized controlled trials were included, with follow-up ranging from 24 hours to 12 months. Five trials assessed postoperative anxiety using validated scales; four reported significantly lower anxiety scores with ketamine/esketamine at early postoperative time points, whereas one trial using a single preoperative ketamine dose reported no significant anxiolytic effect. Perioperative ketamine/esketamine may be associated with lower early postoperative anxiety and depressive symptom scores in selected orthopaedic populations. Regarding adverse effects, ketamine/esketamine did not appear to increase the incidence of common adverse events. Conclusions: Perioperative ketamine/esketamine appears to improve early postoperative anxiety and depressive symptoms in orthopaedic patients, without increasing postoperative nausea/vomiting and dizziness. Further standardized trials are needed before firm conclusions can be drawn. Keywords: ketamine, orthopaedic, anxiety, depression, perioperative Level of evidence: Level II. https://abjs.mums.ac.ir/article_28026.html Objectives: The objective of this study was to assess the functional, satisfaction, and quality of life of patients before and after total hip arthroplasty (THA) for different types of dysplastic hips. Methods: This single-group clinical trial included patients with hip dysplasia who underwent THA at Imam Reza and Ghaem hospitals in Mashhad, Iran, from 2018 to 2022. Data collected for each patient included surgical descriptions, pain levels assessed using the visual analog scale (VAS), scores from the hip dysfunction and osteoarthritis outcome score (HOOS), Harris hip scores (HHS) questionnaires, quality of life (QOL), leg length discrepancy (LLD), and abductor muscle strength measured before and at least two years after surgery. Statistical significance was determined using a P-value of less than 0.05. Results: The study included 43 dysplastic hips, with eight (18.60%) male and 35 (81.40%) female, and a mean age of 28.43 ± 10 years. Functional response to THA was significantly better in the before than after surgery (mean score improvements: HHS 31.1 versus 24.6 (P < 0.001), HOOS 61.4 versus 47.2 (P < 0.001), VAS 22.3 versus 16.5 (P = 0.003), QOL 18.4 versus 8.4 (P < 0.001)), and LLD 18.4 versus 8.4 (P < 0.001)). However, there was no significant relationship between the preoperative and postoperative complication rates (P> 0.05). Conclusions: The assessment of THA outcomes in patients with DDH demonstrated that this procedure, irrespective of the surgical approach, instrument, and type of osteotomy used for shortening, resulted in enhanced function, increased patient satisfaction, and improved quality of life, while concurrently reducing pain.