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   Table of Contents - Current issue
Coverpage
October-December 2019
Volume 3 | Issue 4
Page Nos. 317-377

Online since Wednesday, November 13, 2019

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EDITORIAL  

To fix or not to fix? p. 317
Nicolas Lutz
DOI:10.4103/jmsr.jmsr_56_19  
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REVIEW ARTICLE Top

Osteoporosis in children: Possible risk factors and role of antioxidants p. 319
Salah A Sheweita, Awad S Al Samghan, Owais K Khoshhal
DOI:10.4103/jmsr.jmsr_40_19  
Osteoporosis is well recognized in children as a consequence of several factors. Therefore, the present review sheds light on the role of diabetes mellitus (DM), malabsorption, glucocorticoids, nutrition, free radicals, and oxidative stress in the induction of osteoporosis. It may also provide valuable information regarding the early detection of osteoporosis to improve not only the bone health of schoolchildren but also their general quality of life. Measurement of bone mineral density (BMD) does not capture all the risk factors of bone fractures and/or osteoporosis. Therefore, bone resorption and formation markers such as osteoprotegerin; prolidase; osteocalcin; bone alkaline phosphatase and Vitamin D; parathyroid hormones; and macroelements such as calcium, phosphorus, and magnesium should be measured beside BMD in the plasma of school-aged children. Moreover, endocrine abnormalities, high levels of free radicals, and induction of oxidative stress showed an adverse effect on the skeleton and cause osteoporosis. It has been found that there is a strong correlation between osteoporosis and DM, malnutrition, and glucocorticoids in both pediatric and adult patients. Inhibition of antioxidant enzyme activities, such as superoxide dismutase, catalase, and glutathione peroxidase, was found to increase the production of reactive oxygen species by osteoclasts. Therefore, oxidative stress and other factors are important mediators of bone loss and also osteoporosis. Furthermore, antioxidants should be provided to maintain bone integrity because a deficiency of antioxidant vitamins has been found in the osteoporotic children.
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ORIGINAL ARTICLES Top

Usefulness of immersive virtual reality simulation during femoral nail application in an orthopedic fracture skills course p. 326
Claudia Arroyo-Berezowsky, Pedro Jorba-Elguero, Marco A Altamirano-Cruz, Jimena Quinzaños-Fresnedo
DOI:10.4103/jmsr.jmsr_78_19  
Objectives: There is an increasing number of complex and varied surgical techniques and implants in orthopedic trauma. As the paradigm shift in orthopedic surgical education is turning to competency-based curricula and technology is becoming more affordable, new immersive virtual reality (IVR) simulation systems are emerging. The main objective of this study was to evaluate the utility of IVR simulation for learning a complex surgical technique; the application of a Trochanteric Femoral Nail Advanced (TFNA™). Methods: Ten residents participated in the evaluation of the application of TFNA™ in a Synbone® model during an advanced fractures treatment course. Five of them had a previous practice session using a VR simulator to learn the technique. All of them applied a TFNA™ during the course and were then asked to repeat it. Time to completion and the number of steps completed by each group were compared between both groups. Results: The VR group took 25.84 min to complete (standard deviation [SD] 6.14) and the control group 31.6 min to complete (SD 19.3). There was no statistically significant difference between both groups, but there was a tendency for the VR group to complete more steps and finish earlier than the control group (P = 0.554). Conclusion: IVR simulation could be a more accessible way to provide a safe environment where participants can learn a new surgical technique. It is important to develop proficiency-based progressive training programs with specific educational goals that incorporate simulation and emerging technology as a tool. Larger, randomized, internal and external validation studies are needed.
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The influence of initial cartilage damages in pilon fractures on the development of osteoarthritis and functional outcomes: A prospective multicentre case series p. 334
Christoph Sommer, Maio S Chen, Kathrin Espinoza, Alexander Joeris, Daniela Voegtli, Karl Stoffel
DOI:10.4103/jmsr.jmsr_60_19  
Objectives: Pilon fractures have a long-term negative impact on patients. Both initial cartilage damages (CDs) and osteoarthritis (OA) have been suggested to influence outcomes, but direct clinical evidence has been lacking. This study aims to investigate the association of initial CDs, OA occurrence, and functional outcomes. Methods: This is a prospective multicentre observational case series with a 2-year follow-up (FU). Initial CDs were evaluated intraoperatively in 116 enrolled patients; the postoperative OA was evaluated using FU radiographs. Functional outcomes were assessed using the Foot and Ankle Ability Measure (FAAM) for the activity of daily living (ADL) and sports activities (Sports). Change of FAAM scores over time was analyzed using mixed-effects model. Results: The 2-year loss-to-FU rate was 44.0%. Initial CDs on weight-bearing talus were statistically significantly associated with OA development (1-year, P < 0.001 and 2-year, P= 0.018) and poor functional outcomes (2-year ADL, P= 0.012 and 2-year Sports, P= 0.001). The existence of OA was statistically significantly associated with lower 1-year ADL scores (P = 0.018), 1-year Sports scores (P = 0.023), and 2-year Sports scores (P = 0.023). Patients with “good” reduction had higher outcome scores compared to patients with “satisfactory” reduction. Conclusions: In patients with well-reduced pilon fractures, initial CDs were associated with early/mid-term OA development and worse functional outcomes. OA occurrence was associated with worse functional outcomes. Current results need confirmation with a larger cohort.
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Influence of time to surgery and pin fixation (lateral or crossed) on Flynn's criteria in Gartland type II and III supracondylar fracture: A retrospective study on 129 patients p. 342
Lucas Moratelli, Henrique Matias Santarosa, Angela Yuka Katayama, William Dias Belangero
DOI:10.4103/jmsr.jmsr_57_19  
Objectives: There is a lack of consensus about the ideal pin configuration (lateral vs. crossed) and time to surgery regarding supracondylar fractures. We aim in this study to evaluate the influence of pin configuration and time to surgery on the outcome, using the Flynn criteria. Methods: Retrospective study of all children with supracondylar humerus fracture (SCF) Gartland types II and III treated in a single center from 2007 to 2017. Outcomes were classified as satisfactory or unsatisfactory according to Flynn's criteria at 6 weeks after surgery. Demographic, clinical, and surgical characteristics, as well as complications, were analyzed. Inferential analysis was performed by Pearson's correlation coefficient or Fisher's exact test for categorical variables when indicated. Results: One hundred and twenty-nine patients met the inclusion criteria. Mean patient age was 6.3 ± 2.5 years old, and 59.7% were males. Gartland type III fractures accounted for 57.4% of cases. Satisfactory outcomes occurred in 60.5% during this period. There was no difference in outcomes between the type of fixation and time to surgery. All cases of iatrogenic ulnar nerve injury occurred with crossed pin configuration. Conclusion: Lateral or cross fixation and time to surgery do not influence functional outcomes after surgical treatment of SCF in children, but lateral fixation decrease the risk of ulnar nerve injury.
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Return to full military activities post anterior cruciate ligament reconstruction p. 346
Hilal S Al Housni, Ahmed K Al Ghaithi, Ahmed H Al Shukaili, Faisal M Al Abri, Said S Al Kalbani
DOI:10.4103/jmsr.jmsr_61_19  
Objectives: Armed forces represent a physically active population who engage in regular exercises, recreational sports, and physical training that place them at high risk of injury to an anterior cruciate ligament (ACL). Considering the high occupational demand, uniformed military personnel (UMP) are encouraged to have a surgical reconstruction of a ruptured ACL to resume their military activities. The aim of this study was to assess the outcomes of a full return to duties in the armed forces after primary ACL reconstruction. Methods: A single-institution, retrospective review through the analysis of surgical record data and phone interviews of UMP who underwent primary ACL reconstruction during a 5-year period was conducted. Measured endpoints were the rate of return to full military duties as well as knee function (measured by the Lysholm score). Results: The total number of UMP who underwent ACL reconstruction included in the study was 137 with a minimum follow-up of 1 year. All patients were males. The mean age was 30.2 (minimum 22, maximum 44) years. Isolated ACL injury was found in 30.7%, whereas 69.3% were associated with a meniscus injury. The majority of the surgeries were done within 5 years of the injury (92%). The mean postoperative Lysholm functional score was 90.22. Seventy-five percent of the service members returned to full military activity. Conclusions: The overall majority of UMP returned to full military duties with excellent functional Lysholm score that shows the effectiveness of ACL reconstruction in this active population.
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Bone mineral density among postmenopausal Saudi women in Riyadh city – A primary care level cross-sectional survey p. 350
Mahmoud A Mahmoud
DOI:10.4103/jmsr.jmsr_76_19  
Objectives: This study aimed to estimate the prevalence of osteopenia and osteoporosis and to identify the associated risk factors among postmenopausal Saudi women. Methods: A community-based cross-sectional study was conducted included 501 menopausal women from 15 primary health-care centers randomly selected to be representative of various sectors of Riyadh City and three shopping malls located in Riyadh. A tested questionnaire was used to collect information about the related risk factor. Bone mineral density (BMD) of the calcaneus bone was measured using an ultrasound bone densitometer, and serum Vitamin D was measured using an autoanalyzer. BMD was classified into different categories, according to the World Health Organization classification. Descriptive statistics and logistic regression performed. Results: Mean + standard deviation age was 57.7 + 6.2 years with a range of 44–81. The prevalence of low BMD in the current study (osteopenia and osteoporosis) was 18% and 6%, respectively. The age (odds ratio [OR] = 1.07, 95% confidence interval [CI]: 1.01–1.13) and waist–hip ratio (OR = 0.94, 95% CI: 0.90–0.99) were significantly independent associated with osteopenia; also age (OR = 1.16, 95% CI: 1.09–1.24) and joint pain history (OR = 6.08, 95% CI: 2.01–18.3) were significantly independent associated with osteoporosis; and age (OR 1.08, 95% CI: 1.04–1.11) and joint pain history (1.99, 1.05–3.79) were significantly independent associated with low BMD status. Conclusions: The prevalence of low BMD among postmenopausal women was found to be lower than that reported by other studies in Saudi Arabia. Age was the crucial factor associated with Low BMD status. Further community-based studies are required to assess the community prevalence of low BMD and implement strategies to reduce the burden of its related consequences.
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SURGICAL TECHNIQUE Top

Tibialis anterior muscle herniation repaired with trevira tube: A surgical technique and review of literature p. 357
Hatim A Al Rehaili, Abdullah M Al Ghamdi, Wazzan S Al Juhani
DOI:10.4103/jmsr.jmsr_55_19  
Muscle herniation is an outpouching of the muscle tissue through the fascia covering it. Although it is considered a rare condition, some reports had been published with the concern of misdiagnosis. Lower limbs are considered the most common area of muscle herniation and tibialis anterior muscle is the commonest. Patients usually seek medical advice for pain, cosmetic purposes, or even a worrisome swelling. It can be constitutional in origin or acquired secondary to trauma. Clinical diagnosis is the mainstay for muscle herniation confirmed by imaging (magnetic resonance imaging and ultrasound). The majority are asymptomatic and surgical treatment is reserved for the symptomatic patients using a variety of methods. In our report, we present a case of traumatic tibialis anterior muscle herniation, repaired with trevira tube (polyethylene mesh graft). The patient was satisfied during 9 months of follow-up without immediate nor late complications.
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CASE REPORTS Top

Sternoclavicular joint septic arthritis and osteomyelitis p. 363
Ali M Al Ahmari, Ibrahim M Alanis
DOI:10.4103/jmsr.jmsr_25_19  
Septic arthritis is an emergency condition in orthopedics because any delay in diagnosis and treatment can lead to the development of osteomyelitis and permanent damage to the bones and articulating surfaces. Septic arthritis of the sternoclavicular joint (SCJ) is an especially unusual infection and can be associated with serious complications such as osteomyelitis, chest wall abscess, and mediastinitis. Early diagnosis and prompt management are keys for avoiding the development of untoward complications. The aim of this report is to present our management of a case with no well-known cause for the presence of infection in SCJ and to compare the findings to the literature. This case report describes the course of a patient with medical comorbidities (hypertension, ischemic heart disease, and diabetes mellitus) who was managed surgically for SCJ septic arthritis.
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Short-oblique lumbar spine fracture in ankylosing spondylitis patient p. 367
Sami I AlEissa, Faisal S Konbaz, Fahad H AlHelal, Majed S Abalkhail, Turki S AlMugren
DOI:10.4103/jmsr.jmsr_53_19  
Ankylosing spondylitis (AS) is a chronic inflammatory joint disease that mainly causes fusion of the intervertebral discs and facet joints by involving the axial skeleton that typically leads to kyphotic bamboo spine. Demineralization of vertebral bodies in AS raises the risk of spinal fracture even after a simple trauma. During the progression of the disease, the spine becomes more prone to injury, even after minor trauma. Patients with AS have a higher fracture risk during their lifetime by four times compared to the normal population. A 61-year-old male, a known case of AS, came to the emergency room complaining of back pain. His neurological examination was normal, and the images showed transverse/oblique fracture involving L2 vertebral body associated with small retropulsed fragments and bone debris. Posterior spinal fixation and fusion with a bone graft from T10 to S1 was decided to stabilize the fracture. On the 2nd postoperative day, the radiograph showed good alignment and fixation. One-year follow up showed a normal neurological exam with a stable and fused spine. In this case, we present a rare lumbar spine fracture orientation in a patient with AS, with a good outcome with 1-year follow-up. Up to our knowledge, this is the first report to presenting a short-oblique fracture in a patient with AS disease.
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Symptomatic osteochondroma in the ventral aspect of the scapula in a child with hereditary multiple exostoses p. 370
Bander S Alrashedan, Sudhir K Chowdhary, Jameel Mahmoud, Omar M Hamza
DOI:10.4103/jmsr.jmsr_68_19  
Osteochondroma is the most common bone tumor. It mainly affects the proximal humerus, tibia, and distal femur. It rarely affects the scapula, especially in the ventral aspect and when it does, winging of the scapula can occur, and can lead to a painful range of motion of the shoulder with a snapping sensation and secondary ribs erosion. Hereditary multiple exostoses (HME) is an autosomal dominant disorder causing multiple osteochondromas mainly in the metaphysis of long bones and it rarely affects the scapula. We present an uncommon presentation in a 7-year-old male with HME who presented with a superolateral ventral large osteochondroma measuring 8 cm × 5.5 cm that caused left scapular winging and left shoulder pain with a secondary ribs deformity. The patient was successfully treated surgically through a direct approach and was followed for 18 months and showed a satisfactory outcome with the regression of the ribs deformity.
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LETTER TO THE EDITOR Top

Virtual reality and orthopedic surgical training p. 374
Saeed A Althani
DOI:10.4103/jmsr.jmsr_99_19  
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RADIOLOGY QUIZ Top

Case of shoulder pain p. 376
Nizar Abdulaziz Al-Nakshabandi
DOI:10.4103/jmsr.jmsr_18_19  
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