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   Table of Contents - Current issue
July-September 2020
Volume 4 | Issue 3
Page Nos. 115-169

Online since Tuesday, July 7, 2020

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Discharge against medical advice in orthopedic trauma surgery: Ethical considerations and practical tips p. 115
Khalid I Khoshhal, Owais K Khoshhal
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Should bone densitometry define osteoporosis in 2020? A current concepts review of the role of vibrational spectroscopy in the evaluation of bone health p. 118
Mohamed Khalid, Fahim Khan, Musab S Baik, Jinan Fazal
Bone mineral density (BMD) is the most widely used parameter for measuring bone strength. Indeed, the World Health Organization definition of osteoporosis is based solely on the BMD as measured by dual energy X-ray absorptiometry (DEXA). As our understanding of the factors contributing to bone strength has improved in recent years, this might need to be re-visited. In this review, we have outlined the recent advances in our understanding of the structural health of the bone, specifically how whole bone geometry, micro-architecture and tissue properties are all factors that determine bone strength. We have outlined the importance of micro-crack formation and the pathways that could result following micro-crack formation. We have also presented evidence that makes a case for seeking an alternative technique to DEXA that could potentially improve/augment our ability to assess osteoporosis. Vibrational spectroscopic techniques such as Raman spectroscopy and Fourier transform infrared spectroscopy are evolving as important modalities that have the capability to evaluate all the determinants of bone strength qualitatively and quantitatively in a spatially resolved manner that could potentially provide a much more accurate assessment of bone health.
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Elbow dislocation in sports: A narrative review p. 124
Mohammad A Almalki, Mohammed H Alkhudhayri, Ali M Aljomah, Nayef A Alhinti, Abdulmalik F Alhumidani, Mishary A Alassaf, Shaker H Alshehri
The incidence of elbow dislocations in the normal population is approximately 6/100,000; nearly half of these cases are related to sports. Twenty-six percent of elbow dislocations have associated fractures. When all types of sports-related injuries are considered, the elbow is ranked 5th among the most common body parts injured in young athletes. Around 10%–25% of these elbow injuries are dislocations. Majority of these injuries are treated conservatively. Patients are usually fit to resume their normal functions without any significant long-term impairment after treatment. However, in a small number of patients, there is accompanying damage to the anatomical structures within the elbow joint, which aggravates the situation and deserves a more aggressive therapeutic approach and closer follow-up. Proper treatment and rehabilitation should ensure the stability of the elbow and minimize subsequent dislocations. This also prevents known complications that carry significant morbidity, can affect the athlete's performance, and hinder the progression of their careers. In this review, we covered the current literature on sports-related elbow dislocations while highlighting the role of radiology in the proper management of these patients. By reviewing the available literature, we aim to help medical practitioners to better diagnose and treat this injury and prevent its complications.
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Indications of blood transfusion following total knee replacement at a tertiary care center in central Saudi Arabia p. 132
Abdullah A Alturki, Reema S Algufaili, Majed N Alnefaie, Shaden A Almojel, Suliman Alghnam, Ali A Alhandi
Objectives: Total knee replacement (TKR) is an increasingly common procedure worldwide with a continued projected increase in the future. Blood loss following TKR can be relatively high. Globally, the incidence rate of blood transfusion (BT) following TKR has been reported to range between 8% and 18%, whereas a higher estimate reported locally (35%). This study aims to review the indications leading to BT following TKR in a single center. Methods: This is a retrospective study of patients who had BT following primary TKR (171 patients) at a single tertiary center between 2012 and 2016. Patients were categorized into “transfusion indicated” and “transfusion not indicated” groups. Cases were considered indicated if their hemoglobin (Hb) level was ≤8 g/dL, or if there was a drop accompanied by the clinical findings. Patient's demographics, comorbidities, surgery-related data, laboratory findings, blood loss, number of blood units transfused, and their complications were compared between the two groups. Results: Of the study sample, 50 (29.24%) patients were classified as cases without a clear indication for BT. Postoperative Hb was significantly higher in the nonindicated transfusion group (Hb nonindicated 8.54 g/dL, Hb indicated 7.74 g/dL, P < 0.001). Similarly, the body mass index (BMI) was significantly higher in the nonindicated group (BMI nonindicated 35.54, BMI indicated 32.49, P = 0.0123). Conclusion: The number of cases with no clear indication for BT following TKR remains relatively high, enforcing hospital-based policies that require the documentation of rationale for BT might help reduce transfusions with no clear reasoning behind them.
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Prevalence of burnout of residents in oman medical specialty board: A cross-sectional study in Oman p. 136
Abdulrahman A Al Subhi, Hassan A Al Lawati, Mohamed O Shafiq, Sheikha S Al Kindi, Marwa A Al Subhi, Ahmed S Al Jahwari
Objective: Burnout is a state of physical and emotional exhaustion and a sense of low personal accomplishment. Our aim was to study the prevalence of burnout among all residents of Oman Medical Specialty Board (OMSB), to increase awareness of burnout among trainers and trainees not only within Oman but also in other countries with similar residency programs. This would help residency directors to increase the performance of their residents. Methods: This is a cross-sectional study with residents of OMSB involved in 17 training programs from April 2018 to April 2019. The residents were invited to answer a validated burnout questionnaire (Maslach Burnout Inventory). Only exclusion criteria were programs with at least three residents. Results: A total of 343 of 555 residents (61.8% of the total OMSB residents) participated in the study. The response rate was 100% of those who got the survey. The overall burnout rate was 16.6%. From postgraduate years (PGY) 1–5, there was a sudden spike of burnout at PGY 2 and PGY 5 at 17.6% and 25%, respectively. Emergency residents had the highest incidence of burnout at 46.2%. Burnouts among surgical, medical, and diagnostic specialties were 13.9%, 19.0%, and 12.8%, respectively. Chi-squared test showed no significant association between burnout and marital status, gender, or number of children at 0.18, 0.88, and 0.55, respectively. The percentage of residents who reported emotional exhaustion was 61.2%, while the highest percentage of depersonalization was 42.6%. Conclusion: Emergency medicine program burnout is alarming. PGY 2 and 5 show higher burnout. The overall burnout in OMSB is low.
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Incidence and predictors of 30-day postoperative complications following musculoskeletal tumor surgery p. 141
Wazzan Aljuhani, Mutlaq Almutlaq, Abdulrahman Alomar, Khalid Alanazi, Abdullah S Al-Thani, Taif Alqahtani
Objectives: Surgical intervention remains one of the best curative approaches in musculoskeletal (MSK) tumors. However, postoperative complications remain an issue, especially within the first 30-day postoperatively. Hence, the main objective of this study is to estimate the incidence and to identify the predictive factors of 30-day complications following MSK tumor surgery (MTS). Methods: This is a retrospective, descriptive study of 85 patients who had undergone MTS between 2016 and 2019 in our institution. The included patients were those who had MTS caused by a malignant tumor or giant cell tumor. Results: Twenty-eight patients (33%) had a complication during the first 30 days following surgery. The most common complication was surgical site infection in 64% (n = 18 / 28) followed by venous thromboembolism in 11% (n = 3 / 28) and then death in 7% of the patients (n = 2 / 28). Complications were distributed equally among genders. The complication rate was 36% in bone tumor surgeries (n = 22 / 61) and 21% in soft tissue tumor surgeries (n = 4 / 24). Ewing's sarcoma patients had the highest complication rate among bone tumors (36%, n = 8 / 22). Lower extremities' surgeries had the highest complication rate (35%, n = 18 / 51). Furthermore, 80% of the patients with a cardiovascular condition other than hypertension developed a complication (n = 4 / 5, P = 0.0322). Conclusion: One-third of the patients who underwent MTS developed a complication within a 30-day duration. The diagnosis of Ewing's sarcoma, surgery of lower extremities, and preexisting cardiovascular conditions was linked to a higher complication rate.
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Factors affecting the outcome in the correction of angular deformities around the knee using extraperiosteal tension band plate: A local experience p. 146
Munzir I. A. Gaboura, Kabiruddine Kazi, AlShahid A Abak, Mohamed AlRumaih, Adel AlKenani
Objectives: The aim of this study is to reflect on our local experience with extraperiosteal tension band plate around the knee and the factors that affect the outcome. Methods: This is a retrospective review of 21 patients (34 limbs) and involving 35 segments gathered and treated during a period from 2007 to 2018 by a single surgeon employing a standardized technique. The inclusion criteria were all patients with coronal plane deformities around the knee with an open physis, regardless of pathological background. Patients who had previous or concurrent surgeries for the same problem were excluded from the study. Patients' age and body mass index were recorded. Mechanical axis deviation (MAD) distance, tibio-femoral (T-F) angle, mechanical lateral distal femoral angle, and mechanical medial proximal tibia angle were measured from a standing anteroposterior radiograph. Results: The average age was 6.5 years, and the mean duration of treatment was 13.6 months, with “sick physis” requiring longer durations. The mean rate of correction of T-F angle was 1.5°/month. The MAD distance improved at an average rate of 2.4 mm/month. The distal femur physis improved at a rate of 0.69°/month, while the proximal tibia physis improved at a rate of 0.58°/month. Conclusion: The severity of preoperative deformity influenced the rate of correction, and this is further influenced by the pathological background and physis treated, femora faster than tibiae. Patients with more than 3 years of growth remaining showed faster correction.
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Evaluation of surgical site infections and their incidence in patients after total knee arthroplasty at a tertiary care hospital in Riyadh, Saudi Arabia p. 152
Khalid A Alsheikh, Karam M Basham, Rand N Alazaz, Feras M Alsulaiman, Ahmed T Alrasheed, Mohammed A Benmeakel, Abdulaziz K Almubarak, Ali A Alhandi
Objectives: Superficial surgical site infections (SSI) are a well-documented complication after total knee arthroplasty (TKA). The main objective of this research was to investigate the incidence of SSIs in patients who underwent a TKA and whether it is correlated with comorbidities, length of stay, and postoperative care. This will provide valuable insight into local infection rates as there is a lack of literature in this area. Methods: This is a retrospective chart review at a tertiary care hospital in Riyadh, Saudi Arabia. All patients from January 2016 to December 2018 undergoing TKA were included. We excluded patients with a history of infection, Tumor, or cases where surgical intervention was needed due to deeper infection. Data were collected for patients' demographic variables, length of hospital stay, comorbidities, site of infection, and then assessed whether it affects the rate of SSI in TKA. Results: A total of 735 had TKA. Of these, 558 patients (75.9%) were females . The most prevalent comorbidity was obesity (80.3%), followed by hypertension (63.3%). A rate of 1.5% (11 cases) of SSIs was found with no correlation to the length of hospital stay, comorbidities, and site of infection. Methicillin-sensitive Staphylococcus aureus and methicillin-resistant S. aureus were the most common organisms found in cultures. Conclusion: This study shows comparable incidence rates of SSIs following TKA to the published literature. It provides important regional data about the rate of SSIs, common organisms, and patient variables to aid future research.
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Wagner technique for the treatment of recurrent femoral neck active unicameral bone cyst in a child: Expanding the indications p. 156
Wazzan S Aljuhani, Abdullah M Alqaseer, Salma A Alobaidi, Fatimah A Mohammed Aziz, Abdulmuhsen N Alshammari
Unicameral bone cysts (UBCs) are common benign bone tumors in skeletally immature individuals. UBCs are considered active when found in close proximity to the growing physis. An active UBC of the femoral neck raises unique management challenges. This is due to its location in an area known to be high risk for complications if fractured, such as avascular necrosis and varus malunion. Transfixing the femoral neck physis while aiming to stabilize the fracture poses a risk of growth arrest. This risk is minimized when employing smooth Kirschner wires. Here, we present the case of a 5-year-old male with a recurrent active UBC in the left femoral neck complicated with a pathological fracture in which stabilization was achieved utilizing the Wagner technique of multiple Kirschner wires. To our knowledge, this technique has not been described in the treatment of such pathology.
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A rare developmental anomaly of the upper limb: Case of ulnar dimelia p. 160
Majed N Alosaimi, Adnan T Samman, Muath M Alswat, Khalid W Alsaggaf
Ulnar dimelia is a rare developmental anomaly, which is characterized by the duplication of ulna, absence of radius, and polydactyly. We report a case of a 5-year-old male child who was referred to our care with an extension deformity of the right elbow, loss of pronation and supination of the forearm, and flexion deformity with radial deviation of the ipsilateral wrist. Initially, we aimed to provide flexion of the elbow to improve his elbow function. The flexion was restricted to <10°. Intraoperatively, the posterior release of the capsule and the resection of the proximal part of the preaxial ulna allowed us to achieve 90° elbow flexion. A unique anatomic variation was a duplicate ulnar nerve on the lateral aspect, which was smaller than the normal ulnar nerve in the medial anatomical location. With three cases only being reported in Saudi Arabia and around 70 worldwide, each case is to be managed individually with a careful management plan.
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Isolated anterior dislocation of the elbow in an adolescent p. 163
Mohammed L S Alotaibi, Fareed F Alfaya
Although elbow dislocation is the most common dislocation in children, anterior elbow dislocation is considered to be rare. When it occurs rarely as an isolated elbow dislocation with no associated fractures. This report is about a case of isolated elbow dislocation with a rare mechanism of injury. A 14-year-old girl presented to the emergency department with an acute closed injury to her right elbow after her arm got caught and twisted in a washing machine. There was no associated neurovascular injury. A trial of closed reduction failed, so open surgical reduction was performed to avoid growth plate injury or fracture. Urgent open reduction was successful with a good outcome. Anterior elbow dislocation without fracture is a very rare injury and can occur with a vigorous twisting mechanism. Proper management is important to regain normal function. The aim of reporting this case is to emphasize that a rare isolated anterior elbow dislocation can occur by a twisting injury and an open reduction may be needed if a gentle closed reduction could not reduce it, to avoid growth plate injury in a skeletally immature patient.
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Orthopedic trainees' perspective on coronavirus disease 2019 p. 166
Abdullah Y Almarshad, Atheer M Alghamdi
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Precision oncology innovation: Sarcoma as an example p. 167
Ali A Mustafa
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Case of ankle pain p. 168
Nizar A Al-Nakshabandi
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