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   Table of Contents - Current issue
Coverpage
April-June 2019
Volume 3 | Issue 2
Page Nos. 177-238

Online since Monday, April 1, 2019

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EDITORIAL  

Educational leadership and choice of postgraduate surgical training p. 177
Mohamed Khalid
DOI:10.4103/jmsr.jmsr_73_18  
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REVIEW ARTICLE Top

Surgical versus nonsurgical treatment of distal femur physeal fractures: A systematic review and meta-analysis p. 179
Abduljabbar Alhammoud, Manaf HS Younis, Abdulaziz F Ahmed, Talal Ibrahim
DOI:10.4103/jmsr.jmsr_53_18  
Distal femur physeal fractures can lead to growth disturbance such as premature physeal closure (PPC), leg length discrepancy (LLD), and angular deformity (AD). This study aims to systematically review the literature to assess whether surgical management is associated with a different rate of growth disturbances compared to nonsurgical treatment. We searched several databases from 1966 to 2018 for studies that evaluated surgical versus nonsurgical treatment of distal femur physeal fractures. Descriptive and quantitative data were extracted, and a meta-analysis was performed using a random-effects model to pool odds ratio (OR) for the comparison of PPC, LLD, and AD rate between children undergoing surgical versus nonsurgical treatment. Of the 470 articles identified, 11 case series were eligible, with a total of 527 distal femur physeal fractures. The pooled OR of PPC between surgical and nonsurgical treatments showed no statistically significant difference (OR = 0.30, 95% confidence interval [CI]: 0.30–3.03; I2 = 73.4%, P = 0.01). No significant difference in the rates of LLD (OR = 1.03, 95% CI: 0.36–2.94; I2 = 0%, P= 0.87) and AD (OR = 0.40, 95% CI: 0.10–1.57; I2 = 0%, P = 0.79) was detected between surgical and nonsurgical treatments. Despite the current evidence to date does not support an association between the method of treatment of distal femur physeal fractures and the risks of PPC, LLD, and AD, a significant clinical relevance cannot be carried out. Surgeons can use both treatment methods as dictated case by case.
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ORIGINAL ARTICLES Top

Burnout syndrome among orthopedic surgery residents in Saudi Arabia: A multicenter study p. 184
Khalid A Alsheikh, Faisal A Alhabradi, Faisal F Almalik, Abdulrahman A Alsalim, Faris E Ahmed, Ali A Alhandi
DOI:10.4103/jmsr.jmsr_15_19  
Objective: This study aimed to identify burnout syndrome prevalence among orthopedic surgery residents from different levels in different training centers of Saudi Arabia. Methods: A survey was sent to all orthopedic surgery residents in the Central, Western, and Eastern regions of Saudi Arabia in late September/early October 2018. The Maslach Burnout Inventory for Medical Personnel was used as a data collection tool. A three subscale questionnaire based on emotional exhaustion, depersonalization, and personal accomplishment determined the level of burnout syndrome. High, moderate, or low were the parameters reported after calculating the score of each subscale. Results: A total of 142 out of 301 residents completed the survey (response rate: 47.2%). The majority of the sample (90.1%, n = 128) were male. The sample had a mean of 6 on-call days per month, 2 clinic days per week, 2.3 operation days per week, and slept a mean of 5.5 h per night. More than two-thirds of the sample (68.3%) were not satisfied with their work-life balance. Around one-fifth (21.8%) of residents would not choose orthopedic surgery again as career choice and less than half of them (43%) would not choose medicine again for their graduate-level study. The results indicated that more than 56.3% of the sample scored positive for burnout syndrome. Conclusion: The study demonstrated that more than half of the studied orthopedic surgery residents in Saudi Arabia experienced burnout syndrome, which may have negative consequences for patient care, physician's efficacy, and the health-care system.
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Outcomes in virtual reality knee arthroscopy for residents and attending surgeons p. 189
Claudia Arroyo-Berezowsky, Armando Torres-Gómez, Ranulfo Romo-Rodríguez, José O Ruiz-Speare
DOI:10.4103/jmsr.jmsr_3_19  
Objectives: Arthroscopic surgery is one of the most common procedures in orthopedic surgery. It is prone to simulation training, which has consistently shown improvement in the trainees' motor skills. The objective of this study was to compare the differences in absolute values for virtual reality diagnostic knee arthroscopy with and without a probe for residents and attending surgeons at our hospital. Moreover, quantify the difference in results between an initial and final assessment for all participants. Methods: Eighteen residents and twenty attending orthopedic surgeons completed a sequence of exercises that included a diagnostic knee arthroscopy with and without a probe on the ARTHRO Mentor™ virtual reality simulator. The variables analyzed were as follows: time to complete the task, distance traveled by the arthroscope and the probe, arthroscope and probe roughness, and overall task score. We compared residents' scores with attending surgeons' scores and quantified the difference in all participants' results for the initial and final assessment. Results: There was no statistically significant difference in results between residents and attending surgeons. There was a statistically significant improvement in some variables for the knee diagnostic arthroscopy without a probe for all participants in the final assessment. Conclusions: There were no differences between attending surgeons and residents in the virtual reality knee diagnostic arthroscopy with and without a probe. There was an improvement in some variables for the knee diagnostic arthroscopy without a probe for all the participants. With constant training, anyone can improve their simulation motor skills. External validation studies are necessary.
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Outcome of primary cemented bipolar hemiarthroplasty in older patients with unstable hip fracture: A prospective study p. 196
Ahmed S Elhadi, Ammar H Abdelgadir, Emad M Elbushra, Yasir N Gashi
DOI:10.4103/jmsr.jmsr_54_18  
Objective: Internal fixation as a classical method of treatment for unstable intertrochanteric fractures in older patients has significant complications and failure rate. This raises the need for a method that overcomes these difficulties and gives a better outcome. This study aims to evaluate the outcome of the use of primary cemented bipolar hemiarthroplasty in older patients with unstable intertrochanteric fracture both clinically and functionally. Methods: A prospective case series study conducted from January 2014 to February 2016 including 60 patients (>65-year-old) who were treated by primary cemented bipolar hemiarthroplasty for unstable intertrochanteric fractures (Kyle 3 and 4). Main outcome measurements were clinical and mechanical complications, mortality rate, and functional outcome. Results: Early mobilization was good, that 93.3% of patients started partial weight-bearing on the 1st postoperative day. At the final follow-up (mean 13.66 ± 5.9 months), the general and mechanical complications were few; 1-year mortality rate was 16.7%; the mean Harris Hip score was 91.14 ± 5.7. Conclusions: Primary cemented bipolar hemiarthroplasty offers early, pain-free mobility with minimal complications and good functional outcome in older patients with unstable intertrochanteric fracture.
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Correlation between body mass index and quadruple hamstring autograft size p. 200
Wazzan S Aljuhani, Seba G Alamri, Shomoukh AM Alsharif, Monerah M Annaim
DOI:10.4103/jmsr.jmsr_67_18  
Objectives: Anterior cruciate ligament (ACL) tear is a common sports injury affecting the knee joint in the Middle East and worldwide. Providing an adequate graft is required to prevent revision surgery. This study aims to determine if the body mass index (BMI) can be used as a predictor of the hamstring autograft size. Methods: Data of 48 consecutive patients, who underwent ACL reconstruction using quadruple hamstring autograft technique in the same institute by the same surgeon, were retrospectively reviewed. Skeletally immature patients and those who underwent revision ACL surgeries were excluded. Patients' anthropometric measurements were collected. Quantitative data from the patients' charts were included in the descriptive statistics. Results: The mean age of our cohort was 30.3 ± 6.3 years, with a mean height of 1.7 ± 7.8 m and a mean weight of 81.3 ± 14.6 kg. Mean BMI was 27.8 ± 5, and mean graft size was 7.8 ± 0.5 mm. Results showed that the correlation between the BMI and the autograft size was statistically insignificant. Other variables have no association with the autograft size in the linear regression model. Conclusion: Our study showed no correlation between anthropometric measurements and the autograft size; therefore, these measurements were not able to determine the diameter of the autograft. Further studies looking into thigh diameter and ethnicity and radiological studies with a larger sample size are recommended.
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Flatfoot among school-age children in Almadinah Almunawwarah: Prevalence and risk factors p. 204
Abdullah M Alsuhaymi, Faisal F Almohammadi, Osama A Alharbi, Ahmed H Alawfi, Meyasser M Olfat, Omar A Alhazmi, Khalid I Khoshhal
DOI:10.4103/jmsr.jmsr_89_18  
Objectives: Children with flatfoot are more vulnerable to have foot pain, foot injury, stress fractures, knee pain, and poor exercise performance. Some children may not experience any of these symptoms and the only predominant complaint would be foot pain. Flatfoot is considered a health issue that was not studied well in Saudi Arabia. The study aims to determine flatfoot prevalence among school-age children 7–14 years in Almadinah Almunawwarah and to know the effect of age, gender, and body mass index on the prevalence of flatfoot. Furthermore, a secondary aim is to find if there is a relationship between flatfoot and postactivity foot pain and participation in sports. Methods: This is a cross-sectional analytic study conducted on children aged 7–14 years living in Almadinah Almunawwarah, Saudi Arabia. Flatfoot was diagnosed using Staheli's Plantar Index. Binary logistics regression was used to predict the likelihood effect of sociodemographic data among children with flatfoot. Results: A total of 403 children had been voluntarily recruited in this study. Boys were 193 (47.9%) while 210 (52.1%) were girls. The prevalence of flatfoot was 29.5% (119), 96.6% of them were flexible flatfeet and a relatively very low incidence (3.4%) of rigid flatfeet. Age has a significant relationship on the prevalence of flatfoot (P = 0.050) where 7–8-year-old group was rated highest among other age groups in the prevalence of flatfoot. Conclusion: We found 29.5% of the children had flatfoot in the study sample. This prevalence is still high in comparison to developed countries. Furthermore, this study found a significant association between age and flatfoot in children.
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High-Resolution ultrasound of knee osteoarthritis in a Southwest Nigerian population: Our experience p. 209
Samuel O Oyamakinde, Bolanle O Ibitoye, Oluwadare Esan, Olusola C Famurewa, Adeniyi S Aderibigbe
DOI:10.4103/jmsr.jmsr_47_18  
Objective: High-resolution musculoskeletal ultrasound (MSKUS) is more sensitive than conventional radiography (CR) in evaluating early knee osteoarthritis (OA). The aim of this study is to determine the US findings in knee OA and also to compare these with CR, which is the gold standard. Methods: One hundred and twenty patients with primary knee OA and 120 controls were examined. They all had knee US. CR included weight-bearing anterioposterior and lateral knee radiographs. Kellgren and Lawrence (K–L) grades were assessed, and tibiofemoral joint space width was measured. Data were analyzed using SPSS Version 20. Results: Two hundred and fifteen knees had OA. US findings were tibial osteophytes (67.4%), femoral osteophytes (66.5%), effusion (61.4%), synovitis (46%), medial meniscal protrusion (38.2%), Baker's cysts (34.4%), and lateral meniscal protrusion (27.5%). US detected femoral osteophytes in 13 knees that were not detected in CR. CR detected femoral osteophytes in 12 knees, which US could not. Agreement between US and CR was 74% (P < 0.001). US detected tibial osteophytes in 10 knees which CR film could not. CR detected tibial osteophytes in 9 knees, which the US could not. Agreement between US and CR was 80% (P < 0.001). Sensitivity and specificity of US in detecting femoral and tibial osteophytes were 91.6% and 82.2% for the femur and 93.8% and 85.9% for the tibia, respectively. Student's t-test showed a significant difference (P < 0.001) between femoral condylar thickness in OA patients and controls. Conclusion: MSKUS complements CR in evaluating knee OA.
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Factors that influence orthopedic surgeons when choosing their subspecialty in Saudi Arabia p. 216
Khalid A Bakarman, Kholoud O Al Zain, Nawaf A Alotaibi, Ahmed A Aldakhil, Abdullatif M Alhassan
DOI:10.4103/jmsr.jmsr_56_18  
Objectives: The objectives of this study were to highlight the factors that influence orthopedic trainees in Saudi Arabia to choose their subspecialties and to determine the most desired residents' subspecialty and the percentage of residents who are planning to pursue a fellowship program. Methods: We formatted an online questionnaire using a Likert-type scale. The survey contained 21 questions. The study was conducted in multiple cities in Saudi Arabia. The survey was distributed to orthopedic surgeons. We used WhatsApp Messenger, which is the most popular texting application in Saudi Arabia and the most guaranteed method to ensure that more participants would answer the survey. The survey was closed after 4 weeks for data analysis. Results: The number of surgeons included in this study was 108 out of 175 contacted, including residents, fellows, and consultants. Overall, personal interest in a specialty and a patient's prognosis were the most influential factors that motivated surgeons to choose their careers, while lack of competition was the least important factor. For the 37 (90.2%) residents who chose to continue their training, pediatric orthopedics (26.8%) and foot and ankle surgery (14.6%) were the most desired subspecialties whereas sports medicine (7.3%) and oncology (0%) were the least. The female doctors represented 5.6% among orthopedic surgeons included in our study. Conclusion: Orthopedic residents must be guided to the subspecialties needed in their communities as the fact that general orthopedics is disappearing very soon from clinical practice in tertiary care hospitals in big cities of Saudi Arabia.
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CASE REPORTS Top

Elastic stable intramedullary nailing as a treatment option for comminuted proximal humeral shaft fractures in adults: A report of two cases and a review of the literature p. 221
Abdulmuhsen N Alshammari, Mohammad A Altayeb, Eilaf M Alnazer
DOI:10.4103/jmsr.jmsr_46_18  
Despite the success of nonoperative treatment in the majority of adult-comminuted proximal third humeral shaft fractures, surgical intervention is preferable in selected cases in order to avoid specific potential disadvantages associated with nonoperative treatment, including shoulder and elbow stiffness, poor compliance, and nonunion. Elastic stable intramedullary nailing (ESIN) is commonly used in the treatment of children's long-bone fractures and is known to achieve a high union rate with minimal complications. The literature review of the use of percutaneous ESIN treatment of comminuted proximal third humeral shaft fractures reveals that while it is not a common procedure, it can still produce favorable results with limited complications. This paper evaluates the use of ESIN in two patients with comminuted proximal third humeral shaft fractures. The patients were aged 56 and 72 and both had experienced comminuted proximal third humeral shaft fractures. In this report, the management of these cases is presented, along with a review of other studies, which used ESIN in the treatment of humeral shaft fractures in adults.
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Anterior transolecranon fracture-dislocation of the elbow in a 4-year-old child p. 228
Alejandro Miravete-Galvez, Jacobo Saleme-Cruz, Pedro Jorba-Elguero, Alejandro Dabaghi-Richer
DOI:10.4103/jmsr.jmsr_60_18  
Anterior elbow dislocation is a rare entity in the pediatric population, with only case reports or small series of cases found in the literature. Because of its extremely rare occurrence, there are low to nonexisting guidelines available for the correct and standardized treatment of this pathology. We present the case of a 4-year-old male who fell from a standing height, the exact mechanism of injury is unknown, and who sustained an anterior transolecranon fracture-dislocation of the left elbow. We performed a closed reduction of the fracture-dislocation, and fixation was made with one percutaneous 1.6-mm Kirschner wire, entering through the tip of the olecranon and anchoring the anterior cortex of the ulna. A posterior fiberglass elbow splint was placed for 1 week and changed to a fiberglass cast for 3 additional weeks. Five weeks after removing the fiberglass cast, the child's elbow motion was from 15° to 120°, with full pronation/supination, recovering full elbow motion at approximately 6 months. This case represents an extremely uncommon injury pattern, presenting as a potentially serious fracture-dislocation of the elbow; our results are a reminder of the importance of avoiding aggressive treatment modalities in young children, even in the presence of severely displaced articular injuries.
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A Case of proximal humeral physeal separation in a newborn: Is internal fixation justified? p. 231
John F Amen, Khalid Nabil Youssef
DOI:10.4103/jmsr.jmsr_49_18  
We aim to investigate the clinical and radiologic outcome of conservative management in a newborn with proximal humeral physeal separation (PHPS) on the intermediate term. PHPS is rare and occur typically in newborns. In general, the prognosis is satisfactory. The largest series of PHPS in neonates used routine open reduction and internal fixation for management. We treated a newborn girl with a severe PHPS conservatively with excellent intermediate-term results. The remodeling potential of the proximal humerus in neonates allows for conservative treatment. Closed reduction or operative fixation is not routinely justified. Based on the results of this case and the current literature, we caution against the potential hazards of overtreatment in such patients.
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LETTER TO THE EDITOR Top

Intracapsular osteochondroma of the humeral head in a skeletally mature patient: A rare cause for restriction in the range of movement p. 235
Reddy Ravikanth, Kanagasabai Kamalasekar
DOI:10.4103/jmsr.jmsr_80_18  
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RADIOLOGY QUIZ Top

Acute knee trauma after anterior cruciate ligament reconstruction p. 237
Nizar A Al-Nakshab
DOI:10.4103/jmsr.jmsr_61_18  
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