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   Table of Contents - Current issue
January-March 2021
Volume 5 | Issue 1
Page Nos. 1-81

Online since Saturday, February 20, 2021

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Legg-Calve-Perthes disease: Impact of prognostic criteria on management plan p. 1
Mohamed M Zamzam
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Artificial intelligence application in bone fracture detection p. 4
Ahmed AlGhaithi, Sultan Al Maskari
The interest of researchers, clinicians, and industry in artificial intelligence (AI) continues to grow, especially with recent deep-learning (DL) advances. Recent published reports have shown the utility of DL for bone fracture diagnosis in the radiological examination. It is important for practicing physicians to recognize the current scope of DL as it may impact the clinical practices in the near future. This article will give an insight to the practicing clinician of the current advances in AI fracture diagnosis by reviewing the current literature on this participant. Electronic databases were searched for relevant articles relating to AI applications in bone fracture detection. We included all published work in PubMed, Medline, and Cross-references, which satisfied the inclusion criteria. The search identified 104 references. Of those, 13 articles were eligible for the analysis. AI advancements in fracture imaging applications can be divided into the categories of fracture detection, classification, segmentation, and noninterpretive tasks. Despite the potential work presented in the literature, there are many challenges in the form of clinical translation and its widespread uses. These challenges range from the proof of safety to clearance from the regulatory agencies.
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Saudi orthopedic society guidelines for treating patients with bone and soft-tissue tumors during the COVID-19 pandemic Highly accessed article p. 10
Wazzan S Al Juhani, Mohammed Ahmed Al Sobeai, Abdullah A Alhamdan, Abdulrahman H Bobseit, Abdullah M Alanzi, Abdullah M Alqaseer, Sabiq O Edrees, Abdulkareem Al Ghamdi, Mahmood F Shaheen, Rajeev Pant, Saleh A Alsulaimani, Osama S Al Shaya, Hasan M Swan, Mahbub A Khan, Ibrahim S Alshaygy, Ali H Alyami, Bashar R Reda, Emad J Alabsi, Majid A Alyamani, Zaki S Alhifzi, Ibrahim O Almoftery, Rayan M AL Arabi, Mohammed AL Tayeb, Fayez F ALsayegh, Ahmed M Khan
Objectives: The corona virus disease 2019 (COVID-19) pandemic has had a global effect and the Saudi Government has reacted aggressively to control the disease. Cancer patients are more susceptible to disease due to reduced immunity and are at higher risk of developing severe disease. In this article, we discuss the recommendations on slowing down the spread and easing the severity of COVID-19 in such patients. Methods: We have outlined guidelines and recommendations to be followed by orthopedic oncology centers in Saudi Arabia. These have been distributed to the Saudi Orthopedic Association-Oncology Chapter (SOA-OC) members for suggestions and recommendations. Results: A review of the literature was performed by searching for articles discussing COVID-19 measures related to cancer patients or patients undergoing surgical interventions during the pandemic. The authors discussed the recommendations and algorithmic pathways that were created to be implemented in orthopedic oncology centers around the country. Recommendations were reviewed by the SOA-OC members, who reached an agreement on application and publication. These recommendations focused on orthopedic cancer patient protection during clinical visits, inpatient, and surgical interventions. In addition, we discussed the recommendations for staff protection, including minimizing patient contact and continuing medical education during the pandemic. Conclusion: The reported algorithms and recommendations could help orthopedic oncology centers protect both their patients and staff from COVID-19 infection. These measures are highly recommended for continuing the treatment offered to orthopedic oncology patients, regardless of their infection status with COVID-19 during the pandemic.
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Variety of hand surgery cases during the COVID-19 pandemic: Experiences from seven countries p. 15
Margareta Arianni, Ahlam Arnaout, Jose R Castro-Obeso, Ali Cavit, Vitale Cilli, Juana Medina, Mohammad A Okhovatpour, Kutay Yilmaz
Objectives: The COVID-19 pandemic has affected the practice of hand surgery in the world. The aim of this study is to learn and describe the variety of operated hand surgery cases between countries during the pandemic. Methods: Eight authors from seven countries collected data of hand surgery patients that they operated on within a 1-month study period. Age, gender, diagnosis, procedure, mechanism of injury, object causing injury, place of injury occurrence, type of anesthesia, and COVID-19 screening were recorded for emergency patients. We also noted the reasons for elective surgeries during the pandemic. Results: A total of 124 operated emergency patients and 19 elective patients from all 8 hand surgeons in 7 countries were reported within the study period. Fractures were found in 33.1% of 124 emergency patients, soft-tissue injuries in 39.5% of patients, combined fracture and soft-tissue injuries in 25% of patients, and infection in 3 patients. The most frequent mechanism of injury was the blunt mechanism (49.2%). Home and workplace injuries were 44.4% and 30.6% of emergency cases, respectively. Turkey presented the highest number of emergency patients (71 patients). Most injuries occurred in workplaces (49.3%) and homes (42.3%), with the predominance of penetrating mechanism of injury (47.9%). Excluding Turkey the other six countries were grouped, home and road injuries were the highest (47.2% and 37.7%, respectively). Elective hand surgeries were performed in only four countries. Implant removal (seven patients) was the most frequently performed. No patient was diagnosed with COVID-19. Conclusions: Hand surgery cases during the pandemic differed between institutions represented in this study, due to differences in restriction policies, demographics, and types of hospital. The surgical resources for possible outbreaks in the future must be prepared accordingly.
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Rotational instability of the knee: Injury of anterior cruciate and anterolateral knee ligaments, MRI findings p. 24
Ramón Gonzalez-Pola, Juan G Gómez Mont-Landerreche, Alberto Herrera-Lozano, Ricardo A Torres-Valdés, Alejandro Flores-Carrillo
Objectives: The anterior cruciate ligament (ACL) is a major stabilizing structure of the knee, restraining force of anterior translation, while also preventing excessive tibial medial and lateral rotation. Persistent rotatory knee laxity is increasingly recognized as a common finding after ACL reconstruction. The impact of the anterolateral knee structures is now known to be significant. This study aimed at evaluating patients with the symptoms of knee rotational instability through the use of simple magnetic resonance imaging (MRI) looking for the presence and combined injury of the ACL and anterolateral ligament (ALL). Methods: Descriptive study of 564 MRIs of patients with lesions of the ACL and symptoms of rotational instability, which were retrospectively evaluated in 5 years. The authors assessed the images. The visibility of ALL in T1, T2, and FatSat was evaluated in coronal, axial, and sagittal sections, as well as the presence of lesions. Results: The ALL was visible in a total of 505 MRIs (89.5%) similar to those previously reported in the literature, and its lesion was accompanied in 121 patients with partial ACL injury (23.9%), in 141 with total rupture of ACL (27.8%). Conclusions: The ALL is a dense structure seen by MRI in the coronal plane, similar to that of any other ligament structure, and its lesion was found, in conjunction with an ACL lesion, in 46.4% of the patients with the clinical symptoms of rotational instability, and it can also present itself as an isolated injury.
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Factors associated with fear of re-injury in physically active individuals after an anterior cruciate ligament reconstruction p. 30
Muath Alswat, Osama Khojah, Albara Dabroom, Abdulrhman Alghamdi, Ammar Alshibely, Hussam Algarni, Mohab Almadani, Anas Alswat, Mohammed Alshehri
Objectives: Fear of re-injury is a psychological consequence of an anterior cruciate ligament (ACL) injury. For physically active individuals, fear of re-injury is a frequent cause for not returning to their preinjury physical activity level after ACL reconstruction. The aim of this study is to investigate fear of re-injury, and factors associated with its increase in physically active individuals who had an ACL reconstruction. Methods: A cross-sectional study was conducted in our institute. An online survey was sent to participants. The survey focused on sports participation and included two instruments, the International Knee Documentation Committee (IKDC) and an 11-item version of the Tampa Scale for Kinesiophobia (TSK-11). Results: In total, 103 individuals participated in this study. The mean age was 35 years, males constituted 98% and the mean body mass index (BMI) was 27.8 kg/m2. The mean post-surgery follow-up period was 5.1 years, and around 59.2% of the sample returned to sports. Soccer was the most frequent (73.8%) sport practiced. The mean TSK-11 was 27.9. Age, BMI, concomitant knee injury, time from injury to surgery, follow-up period, and sport type were not correlated with fear of re-injury. However, sports participation frequency, returning to sports, and IKDC scores were significantly correlated with fear of re-injury. Conclusion: Fear of re-injury after an ACL reconstruction is affected by the frequency of sports participation, resuming activity after injury and knee function. Optimizing these factors may improve the psychological outcomes after an ACL reconstruction.
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Assessment of knowledge and awareness regarding radiation safety and fluoroscopy use among orthopedic surgeons in Saudi Arabia p. 35
Hashem A Bukhary, Amaal M Aldosari, Abaad S Althagafi
Objectives: Orthopedic surgeons are heavy fluoroscopy users, which is one of the primary sources of ionizing radiation. Therefore, risks from exposure to these radiations need to be appraised. This study aimed to estimate orthopedic surgeons' knowledge and awareness in Saudi Arabia regarding radiation safety and fluoroscopy use. Methods: This cross-sectional study was conducted from May to August 2020. A total of 150 replies were received from various cities in Saudi Arabia to an 18-item questionnaire. It covered frequency of radiation exposure, safety measures used, and training for radiation safety and fluoroscopy use. Results: The study showed a broad unfortunate negative-associated trend in surgeons' knowledge, with the training of radiation safety and fluoroscopy use, especially for eye and hand-related safety precautions. However, 61% of male surgeons and 48.6% of female surgeons were significantly worried about diseases caused by radiation exposure. Conclusion: This study revealed that most orthopedic surgeons in Saudi Arabia have a limited background on ionizing radiation risks and safe fluoroscopy use. Awareness of radiation safety is required for the well-being of orthopedic surgeons.
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Evaluation of radiation exposure from X-ray imaging among scoliotic patients at a tertiary care hospital p. 41
Faisal Konbaz, Ali A Alhandi, Ibrahim A Almohini, Abdulaziz K Almubarak, Nawaf Alamri, Hadeel S Ghazal
Objectives: The radiographs were reported to cause a potential risk of cancer resulting from multiple spinal radiographs' cumulative radiation. Based on the spine's anatomic location, covering a large body area and its proximity to radiosensitive organs, the radiation dose required is relatively higher than annual background radiation ~2.4 millisievert (mSv)/year. The aim of the study was to estimate the radiation doses from imaging in scoliotic patients at a tertiary care hospital. Methods: The study design was a retrospective cohort study where the charts of scoliotic patients aged 12 years and older were reviewed between 2008 and 2017. Evaluation of the spinal imaging was commenced at the time of diagnosis, where the patients were initially seen in the orthopedic clinic with a follow-up period of 2 years. The estimated radiation dose was measured according to the average effective dose by mSv. Results: The total sample size was 140 patients, and the mean age was 19.3 years. Idiopathic scoliosis was the main subtype with 116 patients (82.6%). The average of total spine X-ray films was 5.2. The average cumulative effective radiation dose was estimated at 22.13 mSv. The initial management type was found to have a significant linear effect (P < 0.0001) on the cumulative effective radiation dose. Conclusions: The cumulative radiation dose is markedly elevated in comparison to the reported numbers in the literature (yearly average dose = 2.17–15.07 mSv). Ultra-low-dose radiation may need to be used instead of standard radiographs to reduce radiation risk.
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Epidemiology of surgically treated pelvis and acetabulum fractures in a Level-1 trauma centre in Oman p. 46
Salim S Al Habsi, Asad H Al Busaidi, Soubhik Ghosh, Marwan Shahin, Jatinder S Luthra
Objective: The purpose of this study is to analyze the epidemiological characteristics of operated pelvic and acetabular fractures at our institution and to compare them with epidemiological data from different parts of the world. Methods: This is a retrospective study of trauma data at Khoula Hospital from January 2010 to December 2016. Epidemiological data including age, gender, mode of trauma, presence of injuries, fracture classification, surgical approach, and associated complications were analyzed. Results: A total of 209 patients with a diagnosis of pelvis and acetabular fracture were included in this study. Young age group (mean: 35) and male gender (68%) were predominately affected. The main leading cause of the injury was road traffic accidents (96%). There were a total of 179 (86%) acetabular fractures and 30 (14%) pelvic fractures. Fracture of the posterior wall of the acetabulum was the most common pattern (39%), followed by transverse fracture (27%). Anterior–posterior compression type was clearly the most common type of pelvis fracture (40%). Six patients had postoperative sciatic nerve palsy, five patients had venous thromboembolism, and nine patients had wound infection. Conclusion: The great majority of the patients were victims of road traffic accidents, male, and young adults. The posterior wall fracture was the most common pattern, as shown in other studies as well. However, we identified some epidemiological differences in comparison with some studies from some other parts of the world. These include a higher contribution of road traffic accidents as a mode of injury and a high female-to-male ratio.
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Orthopedic surgeons' knowledge, attitude, and practice in view of COVID-19 in Saudi Arabia: A cross-sectional study p. 51
Abdullah Y AlMarshad, Ghazal M Binsultan, Malik A Alshayban, Noura Alhusseini, Omar Alrifai, Thamer S Alhussainan, Anwar M Al-Rabiah, Omar A Al-Mohrej
Objectives: The aim of this study is to evaluate the levels of knowledge, attitude, and practice among orthopedic surgeons toward COVID-19 in Saudi Arabia. Methods: This was an observational analytical, online-based survey. Data were collected in April 2020 using a structured validated self-administered questionnaire, which was composed of four sections: Sociodemographic, knowledge, attitude, and practice sections. It was distributed using the WhatsApp application. Results: The respondents to the questionnaire were 84 orthopedic surgeons, with a response rate of 64%, as 130 surgeons have been contacted, 4 participants were excluded as they were not fit to our inclusion criteria. The majority of the respondents (73; 91.3%), were male and 58 (72.5%) were from Riyadh. Regarding their level of expertise, nearly half of them (42.5%) were junior residents. The majority showed good knowledge about the symptoms and high-risk patients for COVID-19, 73 (91.2%) and 78 (97.5%), respectively. Regarding their attitudes, 40 (50%) declared that COVID-19 widespread has negatively affected their mental and emotional well-being. Moreover, 68 (85%) of them were feeling anxious about going home and infecting their family members after being in contact with patients and colleagues. Conclusion: Most of the participants showed good knowledge, attitude, and practice toward COVID-19. There is a relaxed attitude with some surgeons regarding wearing personal protective gear, despite the knowledge, awareness, and resources. More educational programs for orthopedic surgeons should be implemented to flatten the curve and take control of the outbreak.
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Ipsilateral shoulder and elbow dislocation: Camel bite-related injury p. 57
Yaser A Alshabi, Ibrahim M Alhumaidi, Faisal K Albouq, Fatimah A Mohammed Aziz, Mohammad A Khalil
Ipsilateral dislocation of the shoulder and elbow joints is a quite rare injury. Due to its rare presentation, one of the two-dislocation diagnoses can be delayed or even missed. We present a unique case of camel-bite injury, resulting in ipsilateral shoulder and elbow fracture dislocation with open ulna shaft fracture that has not been reported in the English literature before. Camel-bites injuries should be taken seriously as it can result in severe, devastating open injuries. The gripped extremity should raise the suspicion of multiple injuries, so careful assessment of the entire extremity should be carried out. Moreover, proper surgical and medical management can prevent unpleasant outcomes.
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Giant cell tumor in the proximal phalanges of the hand: A report of two cases treated with a nonbiological construct p. 62
Mohammad A Altayeb, Mahmood F Shaheen, Salim M Abduljawad, Rajeev Pant
Giant cell tumor of bone (GCT-B) accounts for approximately 5% of all primary bone tumors and 20% of all benign bone tumors. Its occurrence in the hand is rare, accounting for <2% of cases. In the Rizzoli study covering the 50 years between 1947 and 1997, of the 900 patients with GCT-B, only 8 (0.9%) had GCT in the small bones of the hand and no phalangeal lesions were observed. A five-decade review of GCT of bone from the Mayo Clinic came up with just five cases of GCT in the phalanges (and 13 overall in the small bones of the hand). Our experience at the King Faisal Specialist Hospital covered the period between 1985 and 2020. During these 35 years, we saw 350 patients with GCT-B, of whom only 2 (<1%) patients presented with phalangeal lesions. Both patients were treated by excision of the involved phalanx and nonbiological reconstruction using a Kirschner wire and cement spacer. A literature review and management options for this rare presentation site in GCT-B are discussed.
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Excellent outcome with modified thompson quadricepsplasty for knee extension contracture: Case report and review of the literature p. 67
Sarmad Rashed K. Sulaiman
The daily life routine activities require a good range of knee motion, losing that after femur fracture is a common problem that can be triggered by extension contracture, flexion contracture, or combined contractures. This case report is about a 19-year-old male with unremarkable medical history who suffered from extension contracture with no flexion following a wrongly applied plate for distal femur fracture, which was treated successfully surgically by modified Thompson's quadricepsplasty after 21 months from the initial injury. The final outcome was no extension lag and 120° active flection. The aim of reporting this case was to increase the awareness about the modified Thompson's quadricepsplasty, which is an excellent solution to the debilitating extension contracture complication and present a review of the literature of this procedure. The aim of the literature review is to evaluate the correlation and the influence of the patient's age, the interval to quadricepsplasty after the initial trauma, preoperative knee range of motion, surgical approach, and the postoperative care on the outcome of Thompson's quadricepsplasty and its modifications for the treatment of posttraumatic knee contractures besides that, to answer the question: Is Thompson's quadricepsplasty an excellent procedure to treat knee extension contracture?
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Editorial review on: Excellent outcome with modified thompson quadricepsplasty for knee extension contracture: Case report and review of the literature p. 75
Sultan D Shobaki
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A speck of a bone p. 77
Ganesh S Dharmshaktu
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Book Review: In the Corridors of Academic Leadership by Gary Sayed (California State University Dominguez Hills, 2020) p. 79
Gary Sayed
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Erratum: Indications of blood transfusion following total knee replacement at a tertiary care center in central Saudi Arabia p. 81

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