Immunoglobulin A Nephropathy in a Patient With Bilateral Metal-on-Metal Hip Arthroplasty.

Immunoglobulin A (IgA) nephropathy in the presence of a metal-on-metal (MoM) hip arthroplasty is a rare condition that requires close monitoring. A 61-year-old male with bilateral hip osteoarthritis underwent resurfacing hip arthroplasty with MoM articulating surfaces. Prior to his four-year postoperative visit, the patient was diagnosed with IgA nephropathy. During this visit, the patient reported clicking in the left resurfacing hip arthroplasty, and serum metal ions were significantly elevated. Consequently, the patient underwent conversion to bilateral ceramic-on-cross-linked polyethylene total hip arthroplasty, which resulted in the restoration of metal ion levels to normal. This case highlights that IgA nephropathy played a critical role in impeding the clearance of metal ions. Routine metal ion counts are warranted in patients with MoM articulating interfaces and a newly diagnosed nephropathy.

Cobalt ions induce a cellular senescence secretory phenotype in human synovial fibroblast-like cells that may be an early event in the development of adverse local tissue reactions to hip implants.

Objectives: Total hip arthroplasty is a successful procedure for treating advanced osteoarthritis (OA). Metal bearing surfaces remain one of the most widely implanted prosthesis, however approximately 10% of patients develop adverse local tissue reactions (ALTRs), namely lymphocytic predominant soft tissue reaction with or without necrosis and osteolysis resulting in high revision rates. The mechanism(s) for these reactions remains unclear although T lymphocyte mediated type IV hypersensitivity to cobalt (Co) and chromium (Cr) ions have been described. The purpose of this study was to determine the prolonged effects of Co and Cr metal ions on synovial fibroblasts to better understand the impact of the synovial membrane in the development of ALTRs. Methods: Human synovial fibroblast-like cells were isolated from donors undergoing arthroplasty. DNA content and Alamar blue assay were used to determine cellular viability against exposure to Co and Cr. A beta-galactosidase assay was used to determine the development of cellular senescence. Western blotting and RT-qPCR were employed to determine changes in senescent associated secretory factors, signaling and anti-oxidant enzyme expression. A fluorescent assay was used to measure accumulation of hydrogen peroxide. Results: We demonstrate that prolonged cobalt exposure results in a downregulation of the enzyme catalase resulting in cytosolic accumulation of hydrogen peroxide, decreased Akt activity and cellular senescence. Senescent fibroblasts demonstrated upregulation of proinflammatory cytokines IL-1ß and TNFα in addition to the neurotrophic factor NGF. Conclusion: Our results provide evidence that metal ions induce a senescent associated secretory phenotype in synovial fibroblasts that could contribute to the development of adverse local tissue reactions.

Evaluation of the Effectiveness of Canadian Cardiovascular Society Guidelines in Minimizing Cardiac Events After Total Hip Arthroplasty.

INTRODUCTION: The aim of the study was to analyze the Canadian Cardiovascular Society (CCS) guidelines for routine postoperative troponin testing after elective total hip arthroplasty (THA) to reduce the mortality rate resulting from myocardial injury. The purpose of this study was to assess the prognostic relevance of implementing these guidelines to minimize cardiac events in patients undergoing elective THA. METHODS: Patients who underwent THA surgery in 2020 were included in the study. The inclusion criteria were elective THA patients aged ≥ 45 years, while emergency, revision, and simultaneous bilateral THA surgeries were excluded. The patients were categorized into four groups based on the CCS guidelines. RESULTS: The study included 669 patients who had an average age of 67 years. There were forty-three patients (6.4%), who experienced a rise in troponin levels ≥ 30 ng/L and developed myocardial injury after noncardiac surgery (MINS). Among these patients, eight developed cardiac complications, and one experienced a serious cardiac event that resulted in death. Notably, there was a significant increase in the length of hospital stay for patients who received the postoperative screening protocol. CONCLUSION: The implementation of the CCS guidelines for routine postoperative troponin testing in elective THA surgery did not significantly decrease the rate of cardiac events or mortality.

Fixator-Assisted Nailing for Managing Slipped Capital Femoral Epiphysis Sequelae: A Novel Technique: A Case Report.

CASE: An 18-year-old man with a slipped capital femoral epiphysis treated within in situ screw fixation 5 years earlier presented to our clinic with hip pain, limping, and limited range of motion (ROM) of the left hip. Fixator-assisted nailing (FAN) accompanied by double femoral osteotomies was performed to treat the proximal femoral deformity. At follow-up, the patient had regained full ROM and acceptable alignment of the left lower limb. CONCLUSION: The FAN approach effectively manages proximal femoral deformities in select patients. It requires careful analysis of the deformity, meticulous preoperative planning, and surgeons familiar with both intramedullary nailing and external fixation techniques.

Assessment of serum vitamin D levels in surgical adolescent idiopathic scoliosis patients.

BACKGROUND: The mechanism behind idiopathic scoliosis and its progression is not fully understood. Vitamin D insufficiency is known to play a role in the progression and/or occurrence of a variety of bone diseases. In this study, we aimed to estimate the prevalence of vitamin D insufficiency among patients with adolescent idiopathic scoliosis. Additionally, we aimed to calculate the differences in serum vitamin D levels, Cobb angles, spinal bone mass densities, and serum alkaline phosphatase levels between the sexes in the sample and to assess the possibility of a correlation between any of these factors. METHODS: Demographic details, vitamin D levels, Cobb angle, spinal bone mass density, and alkaline phosphatase were collected from the records of 67 patients who were eligible for corrective surgery. These values were compared to normal levels and between the sexes within the study. RESULTS: Of the 67 patients, 54 (80.6%) were female. The mean serum vitamin D level was 37.86 ± 26 nmol/L, and levels below normal were found in 92.5% of the patients. Statistical analysis showed significant differences (p = 0.002) in serum alkaline phosphatase levels between the sexes. No correlation was found between vitamin D levels and the Cobb angles, spinal and bilateral femoral neck bone mass densities, and serum alkaline phosphatase levels. CONCLUSIONS: Most adolescent idiopathic scoliosis patients had insufficient serum vitamin D levels and also suffered from low bone mineral density at an early age.

Hypertrophied reversed palmaris longus muscle (pseudotumor) of the forearm causing median nerve compression: a case report.

BACKGROUND: The palmaris longus muscle is considered one of the most anatomically variable muscles in the human body. Localized swelling of the forearm due to hypertrophy of the palmaris longus muscle is rare. CASE PRESENTATION: Here, we report a rare case of a 24-year-old Arab man who presented with a painful mass on his forearm with symptoms of median nerve compression. A full radiological assessment was performed, and he was treated conservatively. CONCLUSION: This case confirmed that a hypertrophied palmaris longus muscle can be the cause of swelling on the forearm and should always be considered in the differential diagnosis. With this report, we aimed to increase awareness regarding the unusual variations of palmaris longus muscle and the importance of using radiological investigations to establish a diagnosis.

Simultaneous bilateral single-stage combined open reduction and pelvic osteotomy for the treatment of developmental dysplasia of the hip.

Children older than 18 months with developmental dysplasia of the hip (DDH) for the first time or who do not respond to closed treatment require open reduction with/without acetabuloplasty. We determined whether open reduction and pelvic acetabuloplasty using the Pemberton or Dega technique for both hips simultaneously was well tolerated and offered better outcomes. A total of 140 hips of 70 patients with bilateral DDH were identified. All patients were diagnosed after they started walking. Patients were treated with bilateral single-stage open reduction with acetabuloplasty using the Pemberton or Dega procedure. All patients were prospectively followed up between 2007 and 2018. Results were considered satisfactory if the acetabular index was <24°. Hemoglobin levels were evaluated in all patients. At the final follow-up, the results were evaluated radiologically and clinically based on the modified Severin's classification and modified McKay criteria, respectively. The mean age at surgery was 20.3 months (range, 16-24). The mean operative time was 228 minutes. The mean postoperative hemoglobin level was 90.5 g/L (range, 61-122; SD, ±13.4). The mean differences between the preoperative and postoperative acetabular index values for both hips were 22.36° (SD, ±6.69°) and 22.64° (SD, ±6.69°) for the right and left hips, respectively. Open reduction with pelvic acetabuloplasty using the Pemberton or Dega technique simultaneously in both hips was well tolerated, cost-effective, had excellent outcomes, and posed no additional risk to patients with DDH younger than 24 months.

Bone cement spacer: a novel technique for treating a complicated case of developmental dysplasia of the hip with an injured acetabulum: Case report with 7-year follow-up.

RATIONALE: Developmental dysplasia of the hip (DDH) has an incidence of 5 per 1000 newborns and its management depends on various factors. We present a rare case of DDH with soft tissue obliteration and a bony prominence in the center of the acetabulum after failed open reduction and acetabuloplasty. PATIENT CONCERNS: A 20-month-old girl presented to our clinic with right hip stiffness after undergoing open reduction and acetabuloplasty at another hospital. DIAGNOSES: The diagnosis of DDH was made using a computed tomography scan that revealed a right hip dislocation with soft tissue obliteration and a bony prominence in the center of the acetabulum. INTERVENTIONS: We used a novel technique for treating the rare presentation of complicated DDH with massive soft tissue obliteration and bony prominence in the center of the acetabulum after failed open reduction and acetabuloplasty. The right hip was surgically explored. The acetabulum was deepened and resurfaced. Bone cement was applied over the acetabulum to prevent future ankylosis. OUTCOMES: At the follow-up 7 years after the last surgery, the patient had regained full range of motion and a properly reduced right hip with optimal acetabular coverage on radiographs. LESSONS: Care must be taken in any patient with DDH who presents with hip redislocation after open reduction. If deepening and resurfacing of the acetabulum are required, bone cement could be used as a temporary spacer for 8 weeks; this was key in treating our patient.

Assessing public awareness of clubfoot and knowledge about the importance of early childhood treatment: a cross-sectional survey.

BACKGROUND: Clubfoot is a treatable abnormality that can be managed with early intervention. However, there is a lack of public knowledge regarding clubfoot, which can delay treatment. This study aimed to assess the public awareness of clubfoot and knowledge regarding the importance of treatment in early childhood. METHODS: This cross-sectional survey spanned 6 months, from June through November 2018, and involved persons living in Saudi Arabia. To collect data on public awareness of clubfoot risk factors, treatment, and prognosis, a questionnaire was developed by orthopedic experts and disseminated online. The target population included people of both genders and all age groups from the general population, regardless of their knowledge of someone with clubfoot. RESULTS: By the end of the study period, 746 participants completed the online survey. In total, 520 of the respondents (69.7%) had never heard about clubfoot syndrome. Among the participants, 5.4% had a child with clubfoot syndrome and 4.6% were aware of clubfoot because they had an affected child. The top resource accessed by respondents for obtaining knowledge about clubfoot was social media channels (38.4%), followed by obtaining knowledge from relatives and friends (19.9%). The most reported perceived cause of clubfoot was hereditary and genetic disorders (58.4%), followed by neurological disorders (39.9%). CONCLUSIONS: Results show that there is low public knowledge of clubfoot which may be attributed to a lack of awareness campaigns. We recommend increasing awareness regarding clubfoot through social media platforms and public campaigns in key locations, such as malls, as this may encourage people to seek early treatment. This is important because early management of clubfoot is less invasive and with regular follow-up, leads to better patient outcomes.

Assessment of perceptions, knowledge, and attitudes of parents regarding children's schoolbags and related musculoskeletal health.

BACKGROUND: Heavy schoolbags and their adverse musculoskeletal effects are a cause of great concern. Parents' awareness and knowledge about this are crucial to prevent such health problems. Thus, this study aimed to assess parents' perceptions, knowledge, and attitudes regarding children's schoolbags and related musculoskeletal health. METHODS: A cross-sectional study was conducted targeting parents with children of school age. In January 2015, a self-administered, validated questionnaire was distributed to all participants, consisting of questions about their awareness, knowledge, and attitude regarding the negative effects of carrying inappropriate schoolbags on children's musculoskeletal health. RESULT: A total of 616 parents (284 fathers and 332 mothers) completed the questionnaire (response rate of 100%). A total of 247 (87.3%) fathers and 301 (90.9%) mothers knew that carrying heavy schoolbags produces back problems. However, only 105 (36.9%) fathers and 107 (37.6%) mothers knew that incorrect schoolbag weight and inadequate way to carry it may impede the normal alignment and growth of the spine. Only 107 (37.6%) fathers and 96 (28.9%) mothers knew the ideal weight of the schoolbag, while 49.6% of fathers and 42.8% of mothers did not check their children's schoolbags for unnecessary contents. CONCLUSION: Awareness of parents about the consequences of heavy schoolbags and correct use is still limited and suboptimal. Educational sessions for parents and awareness campaigns may help to reduce the prevalence of musculoskeletal health problems among children.

Nonsyndromic Massive Tarsal and Tarsometatarsal Coalitions in a Young Female.

Tarsal coalition is an abnormal connection between 2 or more tarsal bones, with the most common sites being between the talus and the calcaneus and between the navicular and the calcaneus. The occurrence of multiple and massive tarsal coalitions is rare. We describe a rare case of nonsyndromic bilateral tarsal coalition involving most of the tarsal bones and extending to the metatarsal bones in a 4-year-old female. The condition was not painful and did not affect her gait. The main concern was the abnormal shape of her feet. Tarsal coalition can occur as an isolated anomaly or in association with other congenital disorders, usually presenting around the age of 12 years. The coexistence of nonsyndromic bilateral multiple tarsal coalitions is seldom reported. Regardless of the presentation, treatment is not indicated in cases of asymptomatic tarsal coalition. Our patient had a unique presentation of tarsal coalition, involving both the tarsal and tarsometatarsal bones. To our knowledge, this is the first report of this type of presentation.

The relationship between femoral neck fracture in adult and avascular necrosis and nonunion: A retrospective study.

BACKGROUND: One of the most serious sequelae of femoral neck fractures (FNFs) is avascular necrosis (AVN), and this complication translates to significant morbidity and mortality. This study was conducted to determine the relationship between the etiologies and management of FNFs at our institution and the development of AVN or nonunion. MATERIALS AND METHODS: This study was a retrospective medical chart review of all adult patients admitted and managed for FNF. RESULTS: There were a total of 69 FNF patients reviewed. FNF was caused by a fall in 37 patients (53.6%), a road traffic accident in 16 (23.2%), motorcycle and motorbike accidents in 8 (11.6%), and heavy exercise in 8 (11.6%). Twenty-four patients (34.8%) had fixation within 24 h of injury, and 45 (65.2%) went more than 24 h before fixation. The mean RUSH score at 6 months was 21.4 ±â€¯5.1. There were 4 patients (5.8%) with a collapsed FNF and 4 patients (5.8%) had a nonunion FNF. AVN was documented in 12 patients (17.4%). Of the 12 patients who had AVN, 8 (66.7%) received fixation within 24 h from the time of the injury, whereas only 4 (33.3%) received fixation more than 24 h after the injury. There was a significant negative correlation between the time of fixation and AVN. CONCLUSION: We report a 17.4% incidence of AVN over 10 years in patients managed with FNF. AVN was found to be significantly correlated with the mode of injury (fall and RTA among younger male patients).

Assessment of the efficacy of SERI osteotomy for hallux valgus correction.

BACKGROUND: SERI (Simple, Effective, Rapid, and Inexpensive) osteotomy is an accepted minimally invasive distal first metatarsal osteotomy performed to correct hallux valgus (HV). In the absence of reports of efficacy of the SERI technique in the Middle East, we studied 1-year outcomes of SERI osteotomy performed at our hospital in Saudi Arabia. METHODS: We reviewed the medical charts of patients aged 20 to 60 years who underwent SERI osteotomy for HV between August 2013 and September 2016 and identified 29 patients, 2 (6.9%) men and 27 (93.1%) women, who met the criteria for inclusion in the study. Patients' clinical and operative characteristics were examined, their pre- and postoperative (1-year) radiographic measurements were compared, and the occurrence of any postoperative complication/event was noted. RESULT: Patients' mean age was 34.9 ± 13.6 years. Six patients (20.7%) were treated for severe HV. Mean operation time was 11.1 ± 2.3 min. Four patients (13.8%) reported postoperative pain. No revision surgery was done. Congruency of the hallux metatarsophalangeal joint increased significantly, documented in only 4 patients (13.8%) preoperatively but in 17 (58.6%) at 1 year. The mean hallux valgus angle (HVA), intermetatarsal angle (IMA), and distal metatarsal articular angle (DMAA) were significantly decreased at 1 year. The HVA normalized in 20 patients (69.0%), the IMA normalized in 25 patients (86.2%), but the DMAA normalized in only 4 patients (13.8%). The number of patients with sesamoid subluxation decreased from 29 (100%) to 13 (44.8%). CONCLUSION: Our study data indicate that SERI osteotomy reliably reduces a wide spectrum of HV deformities and it is a safe procedure with very minimal complications. TRIAL REGISTRATION: This study is registered in ClinicalTrials.gov under the following reference number: NCT03669900 .

Solitary hydatid cyst in the forearm: A case report.

INTRODUCTION: Hydatid cyst is a parasitic disease caused by Echinococcus that is mostly found in the Mediterranean and Gulf States regions. Hydatid cysts usually arise in the liver and lungs but rarely occur in the forearm. PRESENTATION OF CASE: In this report, we present a rare case of a solitary intramuscular forearm hydatid cyst in a 32-year-old woman. The cyst exhibited positive radiological findings and was treated surgically, leading to a complete resolution of the patient's symptoms with no history of recurrence. DISCUSSION: This case was unique because although the patient presented in her fourth decade of life and lived in a Gulf country, the hydatid cyst was in a solitary and unusual location and had been present for one year. It had all positive findings in a radiological investigation without any signs of systemic illness. Additionally, the cyst was attached to the median nerve and a complete excision was performed without affecting the nerve. CONCLUSION: By reporting this rare case of a solitary intramuscular forearm hydatid cyst, we aim to increase the awareness of unusual sites for the appearance of hydatid cysts.

Posterior dislocation of a constrained total knee arthroplasty: A case report.

INTRODUCTION: Dislocation of the knee after primary total knee arthroplasty is rare in a posterior stabilized knee and extremely rare in a constrained total knee arthroplasty. Constrained total knee prostheses are used for severe knee deformities and to provide stable and mobile knees. PRESENTATION OF CASE: In this case, we describe a dislocation of a primary constrained total knee arthroplasty using the Genesis II (Smith & Nephew, Memphis Tennessee, USA) prosthesis. Without any significant trauma, the constrained insert dislocated fifteen months after surgery and revision surgery with a bigger insert was needed. Surgical error may have been the cause of dislocation, but we were unable to establish a clear reason behind this dislocation. DISCUSSION: Knee dislocation after TKA is rare but easily overlooked and can lead to serious complications and permanent disability. This system should provide stable and mobile knees to correct collateral ligament laxity. CONCLUSION: Here, we report the first case, to our knowledge, of dislocation with a constrained prosthesis without any history of trauma.

Bilateral pulmonary embolism after arthroscopic anterior cruciate ligament reconstruction: A case report.

INTRODUCTION: Venous thromboembolism is a serious complication in orthopedic surgery. It is very common in major surgery, such as total hip arthroplasty. However, few reports have described the incidence of pulmonary embolism and its associated risk factors following less invasive surgery, such as arthroscopic knee surgery. PRESENTATION OF CASE: We describe a rare presentation of a young man with bilateral pulmonary embolism of the main pulmonary arteries following arthroscopic anterior cruciate ligament reconstruction. DISCUSSION: The present patient is different from other similar cases in that he was an active healthy man without any risk factors for the development of thrombosis. Despite this, he experienced a bilateral pulmonary embolism one week after knee arthroscopy. CONCLUSION: Although anterior cruciate ligament reconstruction is a common and safe procedure performed on a daily basis, unexpected complications may occur. One of these is venous thromboembolism which may be fatal.

Bizarre calcaneal spur: A case report.

INTRODUCTION: A calcaneal spur, also known as enthesophyte, is an abnormal bone outgrowth at the inferior part of the calcaneus, which is the most common site of bony spur occurrence. Although there is consensus that a calcaneal spur is a common cause of heel pain, approximately 20% of calcaneal spurs are asymptomatic and its pathology remains not fully understood. PRESENTATION OF CASE: In this report, we present a rare case of a very large and bizarre calcaneal spur in a young adult man. The calcaneal spur was painful, which affected his foot function and was associated with plantar fasciitis. The spur length was measured in the radiograph and exhibited the longest calcaneal spur reported in the literature. The patient was treated conservatively, and he fully recovered his foot function. DISCUSSION: This case was unique because although the patient presented with an extremely large unilateral calcaneal spur, he was young and did not have any chronic disease; hence, he was treated conservatively. The pain subsided and he regained full function of his foot. This case questions the association between calcaneal spur length and plantar fasciitis symptoms. CONCLUSION: This case confirms that the length of calcaneal spurs, even extremely long ones, is not associated with the pathology of plantar fasciitis and that surgical treatment is not necessary.

A forgotten retained drain inside a knee for 10 years: A case report.

INTRODUCTION: Surgical drains are inserted into the wound after an arthroscopic knee procedure mainly to decrease fluid collection after the operation. The use of postoperative surgical drains remains controversial. CASE PRESENTATION: This report presents a rare case of a forgotten retained drain that was accidentally found inside a knee 10 years after an arthroscopic procedure. The drain was removed without any complications. DISCUSSION: A retained and broken drain during removal is a very rare and preventable complication that can be stressful for both the patient and surgeon. Most of the literature supports that retained drains in the soft tissues do not affect long-term outcomes, but if the drain fragment is in the intra-articular area, it might cause complications. Furthermore, there are several preventive measures to avoid retained surgical drains. CONCLUSION: By reporting this case of a forgotten drain retained inside a knee for approximately 10 years, we aim to illustrate the potential risk of leaving a drain inside the joint following an arthroscopic procedure. Furthermore, we advise that surgeons maintain a high index of suspicion for iatrogenic complications when a patient continues to complain about unexplained pain at the surgical site.

Scapular osteochondroma with winging: A case report.

INTRODUCTION: Osteochondroma, a type of cartilaginous tumour, is the most common benign tumour affecting the bone. These tumours usually arise around the knee, proximal humerus, and pelvis, but very rarely occur at the scapula. Osteochondromas are usually asymptomatic and uncomplicated, but must be treated by surgical resection. PRESENTATION OF CASE: In this report, we present a rare case of a symptomatic scapular osteochondroma associated with scapular winging in a 30-year-old man. This tumour exhibited positive radiological findings and was treated surgically, leading to a complete resolution of the patient's symptoms with no history of recurrence. DISCUSSION: This case was unique because although the patient presented in his fourth decade of life, he had not noticed any signs indicative of lesional growth during adolescence and the maturation process. Additionally, this case was symptomatic and involved an unusual site. CONCLUSION: By reporting this rare case of a ventral-side scapular osteochondroma that presented with scapular winging, we aim to increase the awareness of the unusual manifestations of osteochondroma, particularly atypical sites, signs, and symptoms. Furthermore, we have described the surgical treatment of this case in detail to assist other surgeons who face similar cases.