Reference radiologic measurements for the assessment of tibial pilon fractures

Objectives: The management of pilon fractures is a challenge and the outcome depends on multiple factors, one of which is the quality of reduction. In the literature, there is no assessment of anatomical reduction in pilon fractures. We also lack standard radiological parameters in large patient groups to measure the reduction. The main aim of this analysis was to define normal standard radiological values and identify potential specific types of ankle joint morphology (morphotypes) that might deserve special attention intraoperatively. Methods: We analyzed data of 103 healthy contralateral ankles collected within an observational and prospective multicenter study about tibial pilon fractures. We divided the patients according to their height into two groups, measured 11 radiological parameters, and compared them with each other and the literature. In addition, using cluster analysis, we could identify three morphotypes. Results: There is a statistically significant difference between the two groups in the lengths of three parameters: Mortise width, medial clear space, and length of the lateral malleolus, but not in the angles. The three morphotypes differ only in body mass index and the length of the lateral malleolus. Conclusion: Reference values from the literature are insufficient to assess a reduction after open reduction and internal fixation of tibial pilon fractures because they depend on the height. This does not apply to angles because they are independent of height. For clinical practice, a radiological control of the contralateral healthy ankle gives the best information about the reduction quality and should always be done, especially in normal weight males.

One day versus three days’ antibiotic prophylaxis in joint arthroplasty. A prospective randomized controlled trial

Objectives: The objectives of the study was to compare the effectiveness of 1 day versus 3 days post-operative antibiotic prophylaxis in decreasing surgical site infection (SSI) rate after arthroplasty surgery. Methods: A prospective, randomized controlled trial was conducted over 1 year, in Cairo University Hospitals. The study included adult patients, who were scheduled for arthroplasty. Sixty patients were divided into two groups, 30 patients in each. The first group of patients received cefazolin for 1 day postoperatively (1-day group) and the other group for 3 days postoperatively (3-days group). Patients were randomized using the sealed opaque envelope method. Results: There were 32 females and 28 males. The mean patient age was 52 years (range 20–85 years). Wound infection developed in four cases (one case from the 1-day group and three cases from the 3-days group). All infections occurred within the early post-operative period, and completely resolved after proper management. Correlating the SSI to the type of surgery, operative time, the associated medical co-morbidities, and the duration of antimicrobial prophylaxis was not statistically significant. Conclusion: This study suggests that there is no significant difference in the prevalence of SSI between 1 day and 3 days of antimicrobial prophylaxis after primary joint arthroplasty within the average post-operative follow-up period of 3 months.

Recognizing the better autograft and the factors influencing outcomes of revision anterior cruciate ligament reconstruction

Objectives: The outcome of revision anterior cruciate ligament reconstruction (ACLR) is inferior to that of the primary reconstruction and is influenced by multiple factors. The purpose of this study was to identify the better autograft suited for revision ACLR and to assess the factors influencing the outcome of revision. Methods: A total of 102 patients who underwent revision ACLR were enrolled in this study. The patients were grouped based on the type of autograft used for revision. The mechanism of injury and the cause of the primary ACLR failure, meniscal, and chondral status were noted. All patients’ Tegner Lysholm functional scores were assessed at 2 years of follow-up. Results: Almost 37.3% of the patients underwent revision ACLR with bone-patellar tendon bone, 41.3% with semitendinosus-gracilis, and 21.3% with quadriceps tendon autografts. The mean Tegner-Lysholm score was 85.4 ± 15.8, with the majority achieving good to excellent scores. Chondral defect of Grade 3/4 was associated with an inferior poorer functional outcome (P = 0.03). At a 2-year follow-up, the non-contact mechanism of primary ACLR failure was associated with worse scores compared to the contact mechanism of failure (P = 0.03). On comparison of Lysholm functional score between different autografts using the Kruskal-Wallis test, the p-value was insignificant (P = 0.9). Conclusion: Non-contact mechanism of primary ACLR failure and Grade 3/4 chondral defects was associated with a poorer functional outcome at 2 years post-revision ACLR. The overall functional outcome of revision ACLR was good to excellent in our Middle East Asian population, with no one autograft found to be superior to the other.

Iliopectineal line: A valuable radiological reference for spino-pelvic parameters

Objectives: Spinopelvic parameters are crucial to address sagittal spinal imbalance; such measurements require standardized lateral radiographs that include spine and hips, which are neither always available, nor readily feasible intra-operatively. The aim of this study was to describe pelvic radiological reference points that could provide reliable sagittal balance estimates from conventional lumbosacral lateral radiographs. Methods: A descriptive, cross-sectional, radiological-based study was conducted. Readings were taken from institute’s digital radiology library, blinded to personal and clinical data. The correlation was made to conventional pelvic incidence (CPI), conventional pelvic tilt (CPT), and sacral slope (SS), measured for the same patients, and from the same standardized standing radiographs that included femoral heads. Results: Radiological images for 140 adult subjects, with suspected or established spine problems were studied. The average lumbar lordosis (LL) of 3 readers was 47 ± 13 (13–81) with an interclass agreement of 0.9, SS was 41 ± 9 with an interclass agreement of 0.9, CPI was 53 ± 10 with an interclass agreement of 0.8, CPT was 14 ± 8 with an interclass agreement of 0.9, iliopectineal inclination (IPI) of 4 readers was 64 ± 8 with an interclass agreement of 0.7 and iliopectineal tilt (IPT) was 24 ± 8 with an interclass agreement of 0.8 LL was with 6° of CPI and 16° of IPI. The CPI was equal to (CPI = SS + [CPT + 1.2]) and (IPI = SS + [IPT + 0.6]). The IPI was negatively correlated with CPI –0.2 P = 0.006, and IPI was negatively correlated with CPT –0.333 P < 0.001. Conclusion: Iliopectineal line provides reproducible readings, closer values to LL, and addresses the center of mass displacement.

Traumatic injuries in children and youth from Southern Brazil: A cross-sectional study

Objectives: The objective of the study was to identify the prevalence of firearm injuries (FI) and bladed weapon injuries (BWIs) in underage people and their respective outcomes. Methods: Using a retrospective observational design, data were recorded on patients who met the inclusion criteria receiving care in a public hospital between June 30, 2015, and June 30, 2018. Results: Ninety-one medical records were found, 76.9% of patients were males and 23.1% were females. Most injuries were caused by firearms (76%) and the remainder by bladed weapons (24%). The majority of patients were 12–18 years old (92.3%), while 7.7% were 6–12 years old. Male participants were the ones who most needed medical care (77%). Male adolescents in the older age group with injury-associated fractures (P = 0.015 and P = 0.032) accounted for the most common association in the sample, demonstrating greater susceptibility to fractures in these groups. Analysis of detailed location proved that BWIs BWIs were the leading cause of injuries to soft abdominal organs (P = 0.011). Conclusion: The occurrence of FI and BWIs in the pediatric population is significant and can imply death and tragic sequelae. Emergency services need to be prepared to provide care to these victims, particularly males and the 12–18 age range, as these are the most affected groups. Further studies should be conducted on this theme to gain a greater and better understanding of the etiology and repercussions of this type of injury in the lives of young patients.

A population-based assessment of the post-operative complications rates and 30-day mortality associated with lower limb amputations at a tertiary care center in Riyadh, Saudi Arabia

Objectives: There is no consensus on the postoperative 30-day mortality, complication rates, and their risk factors post lower limb amputations (LLA) in the literature, especially in Saudi Arabia. To address this gap, we assessed these three parameters in our patients who underwent LLAs. Methods: We conducted a retrospective cross-sectional study in King Abdulaziz Medical City, Riyadh, Saudi Arabia, between 2015 and 2019. Using non-probability purposive sampling, we targeted 318 adults who underwent LLA at our hospital. The primary outcome variables were postoperative 30-day mortality and complications, such as stump pain, wound infections, hemorrhage, and acute kidney injury. In addition, we collected data on demographics, comorbidities, and clinical course from electronic medical records. Results: We assessed 318 patients (mean age = 65.7 [SD = 0.840] years), most of whom were male patients (68.6%) with endocrine and metabolic disorders (92.1%). Most amputees (87.1%) had peripheral vascular diseases as the main indication for LLA at an above-knee level (62.6%). The 30-day mortality and complication rates were 6.6% and 74%, respectively. Intermediate complications predominated (57%), with stump pain (17.3%) and phantom limb pain (15.4%) being the most common. Thirty-day mortality was significantly associated with some patient characteristics and comorbid kidneys and neurological disorders. The immediate, intermediate, and late complications were significantly related to smoking and several renal, vascular, and respiratory disorders. Conclusion: Calculating the 30-day mortality and complication rates after LLA and mapping the associated risk factors helped identify high-risk patients, deliver better treatment, lower medical costs, and establish protective measures.

Effect of tourniquet use on total blood loss following total knee arthroplasty

Objectives: Blood loss during total knee arthroplasty (TKA) can be a concern. Therefore, a tourniquet (TQ) is commonly used during the procedure to minimize this risk. However, the use of a TQ in TKA continues to be a matter of debate among orthopedic surgeons and is related to its advantages and disadvantages. We retrospectively evaluated the impact of applying the TQ on total blood loss following TKA in 276 patients. Methods: Patients were categorized into two groups: TQ and non- TQ. Demographics, surgical time, pre- and post-operative hemoglobin levels, number of blood units transfused, and rate of venous thromboembolism (VTE) were compared between the groups. The mean age of the study population was 62.8 ± 7.2 years, and 76.4% of patients were females. The TQ group consisted of 159 patients, whereas the non-TQ group consisted of 117 patients. Results: The two groups were homogenous, and there was no statistically significant difference in age or gender distribution between the two groups. The results showed no significant difference in total blood loss, need for blood transfusion, or VTE rate postoperatively when using a TQ. Female gender was identified to be a significant predictor of a decrease in post-operative hemoglobin. Conclusion: We found that the use of the TQ had no effect on total blood loss following primary TKA. Female gender was a predictor of increased blood loss in both groups. It is essential that surgeons performing arthroplasty balance the risks and benefits of using a TQ during TKA.

Knowledge, attitude, and practice of primary care physicians about developmental dysplasia of the hip in a tertiary referral hospital in Riyadh, Saudi Arabia

Objectives: The aim of the study was to determine the current knowledge, attitude, and practice of developmental dysplasia of the hip (DDH) management among primary care physicians (PCP) in Saudi Arabia. Methods: A cross-sectional study on PCP from a single health-care system in Riyadh, Saudi Arabia, was conducted using a survey questionnaire to evaluate the medical knowledge, attitude, and current practice in the clinics, including diagnosis and screening skills. Results: Sixty-five PCPs participated in the survey, 32 (49.2%) were general practitioners and 33 (50.8%) were fellows and consultants. Only six physicians (9.2%) had formal training on DDH management. Twenty respondents (30.8%) had poor knowledge, while 45 (69.2%) had sufficient knowledge of DDH. Most of the respondents believed in the importance of asking about risk factors, the presence of DDH screening protocols and community awareness, and 89.2% of the respondents believed they need to go for further training about DDH. Fifty-nine respondents (90.8%) would refer a DDH case to an orthopedic surgeon when there are positive findings by a radiograph or ultrasound. Forty-two (64.6%) never examined the hip for DDH, and 30 (46.2%) never referred a DDH case. Conclusion: Knowledge of DDH among our PCP directly involved in the screening and management of DDH is sufficient. However, there is a discordance between knowledge to attitude and practice.

Carpal boss: An uncommon cause of dorsal wrist mass and chronic pain in children. A case report

Pain referred to the wrist joint, is a common affection among the pediatric and adolescent population, either due to acute injury or chronic stress. Even though the most common cause of a wrist mass associated with chronic pain in this patient population is a ganglion cyst, other pathologies should also be considered. We report an uncommon case of a 10-year-old girl with a carpal boss that was treated with surgery after non-operative measures failed to achieve symptom resolution. The diagnosis was established based on clinical examination and imaging findings. Although rare in the skeletally immature population, carpal boss should be considered as a differential diagnosis in a pediatric-adolescent patient with a dorsal wrist mass and chronic pain. The purpose of the present study was to describe the presentation and anatomical findings in our patient, that differ from the cases reported to date, as well as to review treatment options of this condition in the pediatric population.