Density functional theory, molecular docking, In vitro and In vivo anti-inflammatory investigation of lapachol isolated from Fernandoaadenophylla.

Medicinal plants are the main source of active chemical constituents responsible for curing or mitigating various ailments. To discover new, safe, and effective drug candidates the isolation and screening of natural products are essential. In the current research work, lapachol was isolated from Fernandoa adenophylla, which was evaluated for anti-inflammatory effect followed by molecular docking. The isolated compound was tested for anti-inflammatory effects using in vitro (HRBC assay) and in vivo (xylene-induced ear edema) experimental models. Various concentrations of lapachol demonstrated anti-inflammatory effects with a percent potential of 77.96 at 100 µM. Different concentrations of Lapachol demonstrated a dose-dependent anti-edematous effect with a maximum percent effect of 77.9 % at a higher dose. The histopathological study revealed that the application of xylene led to a significant increase in ear thickness, along with clear signs of ear edema and infiltration of inflammatory cells, as well as epidermal hyperplasia of the dermis when compared to the control group. However, treatment with the investigated compound showed a significant reduction in ear thickness and pathological differences comparable to those observed in the group treated with diclofenac. Density functional theory calculations are accomplished to gain insight into structural and spectroscopic properties. Geometry optimization, FMO, and MEP analyses are performed. Overall, the molecular docking results indicate that lapachol has potential as a COX inhibitor by binding to the active sites of both COX-1 and COX-2 enzymes.

Effect of anteromedial portal location on femoral tunnel inclination, length, and location in hamstring autograft-based single-bundle anterior cruciate ligament reconstruction: a prospective study.

BACKGROUND: Portal positioning in arthroscopic anterior cruciate ligament reconstruction is critical in facilitating the drilling of the femoral tunnel. However, the traditional approach has limitations. A modified inferior anteromedial portal was developed. Therefore, this study aims to compare the modified and conventional far anteromedial portals for femoral tunnel drilling, assessing factors such as tunnel length, inclination, iatrogenic chondral injury risk, and blowout. MATERIAL AND METHODS: Patients scheduled for hamstring autograft-based anatomical single-bundle arthroscopic anterior cruciate ligament reconstruction were divided into two groups: modified and far anteromedial groups. Primary outcomes include differences in femoral tunnel length intraoperatively, tunnel inclination on anteroposterior radiographs, and exit location on lateral radiographs. Secondary outcomes encompass tunnel-related complications and reconstruction failures. To identify potential risk factors for shorter tunnel lengths and posterior exits, regression analysis was conducted. RESULTS: Tunnel parameters of 234 patients were analyzed. In the modified portal group, femoral tunnel length and inclination were significantly higher, with tunnels exhibiting a more anterior exit position (p < 0.05). A higher body mass index exerted a negative influence on tunnel length and inclination. However, obese patients in the modified portal group had longer tunnels, increased inclination, and a lower risk of posterior exit. Only a few tunnel-related complications were observed in the far anteromedial group. CONCLUSION: The modified portal allowed better control of tunnel length and inclination, ensuring a nonposterior femoral tunnel exit, making it beneficial for obese patients.

Neuroprotective evaluation of diospyrin against drug-induced Alzheimer's disease.

Alzheimer's disease (AD) is a progressive neurodegenerative disease linked to memory impairment. A current investigation was performed to assess the neuroprotective effect of Diospyrin, a novel therapeutic agent, for the curing of Alzheimer's disease. For this purpose, in-vitro acetylcholinesterase (AChE) and butyrylcholinesterase (BChE) inhibitory assays and antioxidant studies were conducted, whereas in-vivo studies involved different behavioral animal models tests such as elevated plus maze (EPM), morris water maze (MWM) and paddling Y-maze test. Results of the in-vitro analysis showed IC50 values of 95 µg/mL for AChE and 110 µg/mL for BChE as compared to the standard drug donepezil (IC50: 95 & 85 µg/mL, respectively). DPPH antioxidant assay showed a maximum of 72.85% inhibition (IC50: 139.74 µg/mL) of DPPH-free radicals at the highest concentration of 1000 µg/mL as compared to the ascorbic acid (IC50: 13.72 µg/mL). Moreover, the in-vivo analysis revealed that diospyrin treatment demonstrated gradual betterment in memory and enhanced motor functionality. On the other hand, the computational analysis also showed that the diospyrin had exceptional binding affinities for both AChE and BChE enzymes. In the net shell, it may be deduced that our compound diospyrin could be a valuable drug candidate in managing neurodegenerative disorders like AD.

Molecular docking, DFT studies, and anti-inflammatory evaluation of peshawaraquinone isolated from Fernandoa adenophylla.

In recent years, there has been growing interest in exploring natural compounds with anti-inflammatory properties for potential therapeutic applications. This study focuses on investigating the anti-inflammatory potential of peshawaraquinone (PAQ), a compound isolated from Fernandoa adenophylla, which is known for its local use in pain relief. We aim to evaluate the efficacy of peshawaraquinone in both in vitro and in vivo models and gain insights into its mode of action. In the in vitro Human red blood cell (HRBC) assay, various concentrations of peshawaraquinone were tested for their ability to inhibit the hemolysis of red blood cells, a well-established indicator of anti-inflammatory activity. The results demonstrated a maximum percent inhibition of 79.69 at a concentration of 100 µM, indicating significant anti-inflammatory potential. Furthermore, the in vivo xylene-induced ear edema model was employed to assess the compound's efficacy in reducing inflammation. Xylene was topically applied to the ear to induce edema, and peshawaraquinone was administered to evaluate its inhibitory effects. The findings revealed a substantial 74.19% reduction in ear edema, accompanied by decreased ear thickness and histopathological improvements, such as inhibited cell infiltration and epidermal hyperplasia. To gain further insights into the compound's mechanism of action, density functional theory (DFT) calculations were performed to investigate its spectroscopic characteristics and geometric properties. Additionally, docking studies were conducted on key targets involved in inflammation, including COX-1 and COX-2. In conclusion, this study showcases the significant anti-inflammatory potential of peshawaraquinone, offering promising prospects for its use as a natural anti-inflammatory agent. The results from both in vitro and in vivo models, as well as the mechanistic insights gained from computational analyses, provide a solid basis for further exploration of peshawaraquinone's therapeutic applications.Communicated by Ramaswamy H. Sarma.

Corrigendum to "Fellowship and future career plans for orthopedic trainees: Gender-based differences in influencing factors" [Heliyon 8(9) (September 2022) e10597].

[This corrects the article DOI: 10.1016/j.heliyon.2022.e10597.].

The Perception of Spirituality and Its Assessment among Those with Different Health Statuses in Saudi Arabia.

This study compares the perception of spirituality among individuals with different health statuses. It also describes the spiritual services and religious support in the healthcare system that are recommended by the community. A cross-sectional comparative study was conducted in Riyadh during the year 2021. A face-to-face questionnaire was used to obtain data from seriously ill inpatients (N = 132), chronically ill outpatients (N = 202), and healthy individuals (N = 283), which is an assessment tool designed by the investigators to meet the purpose of the study. This study was conducted in two tertiary hospitals and in the community. Participants were randomly selected using a stratified random sampling technique. The study was performed on 635 participants. A significant number of the participants agreed that the provision of spiritual services has a positive effect on patient condition. The rural population had a higher mean value on limiting the concept of spirituality to religious aspects. There is a clear tendency from all categories toward religious services. The majority of the participants support the provision of psychological services, especially if it is provided by specialized and expert spiritual care providers. The positive perception of participants about spiritual care has been reflected on the tendency toward providing spiritual services. The provision of spiritual care in healthcare systems is expected to be a necessity and not a luxury.

Representation of women in orthopaedic surgery: perception of barriers among undergraduate medical students in Saudi Arabia.

BACKGROUND: While female participation has improved in several surgical specialties over time globally, no such increase has been observed in orthopaedic surgery over the past decades. The potential barriers to female participation are likely present from the beginning of medical education. Therefore, this study assessed the apparent lag in equal representation among men and women in orthopaedic surgery in the Kingdom of Saudi Arabia. METHODS: This cross-sectional study used a questionnaire survey to investigate medical students' and interns' perceptions of women participating in orthopaedic surgery, their subspeciality preferences, and barriers preventing them from pursuing an orthopaedic career. The responses were analysed to understand general perceptions, gender-based differences, impact of clinical experiential learning, and exposure to orthopaedic surgery. RESULTS: Approximately 565 medical students (49% females, 51% males) participated in the survey. Only 17% of students (11% females, 23% males) considered orthopaedic surgery as their future career option. While 31% of female and 17% of male students disagreed with the concept of female-appropriate orthopaedic subspecialties, most of the remaining male and female students perceived paediatric orthopaedics as a female-appropriate subspecialty. Concerning equal representation of women, gender bias and lack of a strong physique were the most frequently selected barriers by female and male students, respectively. Patient preference for male orthopaedicians, gender discrimination, social and family commitments, and need for physical strength were all perceived as barriers for women in orthopaedics. Overall, clinical experience and orthopaedic exposure did not significantly improve the likelihood of female students in choosing orthopaedic surgery as a career. CONCLUSIONS: The bias against women in orthopaedic careers is prevalent among medical students early in their academic years. Clinical experience and exposure to orthopaedic surgery should be improved to make a significant impact on female participation in orthopaedic careers. Career building efforts in terms of improved career opportunities, career counselling, flexible working hours, social and family related adjustments and implementation of mentorship/research/fellowship programmes for females are needed to reduce gender discrimination and improve female orthopaedic participation. Furthermore, process improvements may yield greater flexibility for women pursuing the challenging field while accommodating other barriers faced by women in orthopaedic surgery.

Incidentally Found Cholecystoduodenal Fistula and an Unusual Case of Gallstone Ileus After Laparoscopic Cholecystectomy.

Gallstone ileus, a rare and potentially fatal complication of cholelithiasis, occurs when gallstones breach the gastrointestinal tract through a fistula, causing an obstruction and potentially leading to severe complications. This case report details the experience of a 44-year-old woman with gallstone ileus stemming from an unnoticed cholecystoduodenal fistula following a routine cholecystectomy. The fistula was only discovered during surgery despite advanced imaging, revealing extensive adhesions. The discovery led to a subtotal cholecystectomy and fistula repair. Postoperatively, complications arose, prompting a computed tomography scan to rule out further issues. However, she later returned with gallstone ileus, necessitating a second operation. This case underscores the importance of thorough intraoperative exploration for biliary enteric fistulas during cholecystectomy, potentially averting the need for subsequent interventions. The case also highlights the diagnostic challenges of gallstone ileus and the significance of clinical suspicion.

Foot Care Prioritization Among Health Care Providers Treating Diabetic Patients in Saudi Arabia: A Survey-Based Study.

BACKGROUND: Diabetic foot disease (DFD) is a significant complication associated with diabetes, characterized by the potential for progressive amputation of specific foot segments or the entire lower limb in the absence of timely identification of infection and intervention. The aim of our research is to evaluate the degree of importance given to foot care by healthcare professionals who are responsible for treating individuals with diabetes in Riyadh, Saudi Arabia. METHODS: This cross-sectional study utilized an online survey previously validated in Australia. The mean foot care prioritization score was used to identify the dummy variable for binary logistic regression analysis, which was used to identify predictors of foot care prioritization. RESULTS: A total of 222 participants were involved in this study. Assessing for the risk of developing foot complications, visually inspecting feet for wounds, and providing or recommending footwear to prevent foot complications were the most commonly reported practices, accounting for 80.60% (n = 178), 76.10% (n = 169), and 75.20% (n = 167), respectively. The most commonly referred patients to a specialist tertiary multi-disciplinary foot care team were patients with ulcers in patients with absent foot pulses, ulcers with ascending cellulitis, and diabetic ulceration, accounting for 73.50% (n = 163), 71.60% (n = 159), and 66.70% (n = 148), respectively. The mean foot care prioritization score for the study participants was 54.1 (standard deviation: 11.7) out of 78 (69.4%), which demonstrates a moderately high level of foot care prioritization. Binary logistic regression analysis identified that healthcare professionals who are aged 35-44 years, those who have 5-10 years of experience, those who work at private hospitals, those who have a higher number of practice clinics per week, and those who have to manage a higher number of patients with diabetes in each clinic were more likely to prioritize foot care in their practices (p < 0.05). CONCLUSION: Our study found that healthcare professionals in Saudi Arabia place a moderate degree of emphasis on foot care. Healthcare professionals falling within the age range of 35-44 years, possessing 5-10 years of experience, employed at private hospitals, overseeing a greater number of practice clinics weekly, and managing a greater number of patients with diabetes per clinic exhibited a greater propensity to prioritize foot care within their respective practices. Policymakers should consider the integration of continuous glucose monitoring technologies, the establishment of standardized foot screening protocols, and the implementation of targeted educational programs for healthcare professionals.

Factors Influencing Sports Medicine as a Career Choice Among Orthopaedic Trainees in Saudi Arabia.

Background: Sports medicine is one of the most popular orthopaedic specialties, with more fellowship applicants than in any other subspecialty of orthopaedics. Purpose: To investigate the factors influencing orthopaedic trainees to complete their fellowships and subsequently subspecialize in sports medicine in Saudi Arabia, as well as to compare the motivational factors of trainees planning to pursue sports medicine versus other orthopaedic specialties. Study Design: Cross-sectional study. Methods: An online anonymous questionnaire was distributed to 400 orthopaedic surgical trainees from 44 training centers (residency and fellowship training programs) across Saudi Arabia. The questionnaire identified trainees planning to select sports medicine as their career and the most influential factors affecting their choice; items exploring the influential factors were answered on a 5-point Likert-type scale. A comparison of responses was performed with candidates aiming to pursue other orthopaedic specialties. The chi-square or Fisher exact test was used to compare demographic parameters and the percentage of "agree" and "strongly agree" responses between trainees opting for sports medicine fellowships and those choosing other fellowships. Results: Of the 400 potential participants, 250 orthopaedic trainees (response rate, 63%) completed the survey (201 [80%] male and 49 [20%] female). Sports medicine was the most coveted specialty among trainees, with 70 (28%) participants opting for it as their career choice. The most prominent factors for the decision included disease prognosis and surgical outcomes (90%), personal interest (87%), experience during residency training (83%), type of surgical skills (81%), disease pathology and patient population (77%), expected workload and lifestyle (73%), role model or mentor (70%), and patient volume and variety of cases (67%). Significant differences compared with trainees who preferred other orthopaedic specialties included role model/mentor impact (70% vs 54%), expected rate of income (60% vs 47%), and private sector job opportunities (64% vs 45%) (P = .025, .034, and .020, respectively). Conclusion: Study findings indicated that a significant percentage of orthopaedic trainees in Saudi Arabia choose to specialize in sports medicine. Role model/mentorship, private sector job opportunities, and expected rate of income were the most influential when compared with the motivations of trainees not choosing sports medicine.

Perception and Satisfaction of Undergraduate Medical Students of the Mini Clinical Evaluation Exercise Implementation in Orthopedic Outpatient Setting.

Purpose: The Mini Clinical Evaluation Exercise (mini-CEX) is a brief and direct observational assessment of trainee-patient interactions that helps to assess several clinical domains. There is limited evidence of mini-CEX implementation in orthopedics and undergraduate perceptions toward such an approach. This study investigated the perception of mini-CEX among undergraduate medical students through a questionnaire-based survey in an orthopedic outpatient setting. Patients and Methods: Undergraduate medical students completing their orthopedic clinical posting were invited to participate in an anonymous, self-administered questionnaire written in English to evaluate their perceptions toward mini-CEX implementation in the orthopedic outpatient setting for the 2016-2017 academic session. The questionnaire comprised 28 closed-ended questions with a five-point Likert rating-scale, and five open-ended questions. The survey responses were analyzed for reliability, validity, and quantitative and qualitative analyses. Results: A total of 350 students completed the questionnaire; the questionnaire was proven to be valid and reliable. The closed-ended questions were designed to assess the knowledge of the mini-CEX as an assessment tool. The participants demonstrated a satisfactory understanding of the mini-CEX methodology, purpose, clarity, comprehensiveness, and as a self-assessment tool for undergraduate medical students. Instructor support for the implementation of mini-CEX appeared inadequate and was rated with non-confidence among most students. Most participants appreciated better clinical skills, which was reflected through improvements in clinical exam preparation, the Objective Structured Clinical Examination, and clinical judgment. Conclusion: Undergraduate medical students perceived the mini-CEX as an effective tool for clinical teaching in an outpatient orthopedic setting. However, most students indicated suboptimal instructor involvement in the teaching and assessment process; this raises concerns regarding inadequate direct observation and limited feedback for student performance. Additional measures are needed to ensure high quality clinical encounters, teacher training, integration with other assessment tools, and standardized coverage mini-CEX implementation in orthopedics.

Fellowship and future career plans for orthopedic trainees: gender-based differences in influencing factors.

Objective: Understanding gender-based preferences and factors influencing fellowship and subspecialty choice might help maximize gender diversity in orthopedic surgery. This study aims to identify the differences between male and female orthopedic trainees' future career plans. It also examines the factors and determinants that influence selection of fellowship specialties in Saudi Arabia. Methods: This cross-sectional multicenter study recruited orthopedic surgical trainees from multiple training centers. The survey was completed by 270 participants; 20 residents were excluded because they were unsure of their future career interests or preferred fellowships in general orthopedic practice. The participants were either postgraduate orthopedic residents or fellows who already enrolled in postgraduate residency and/or fellowship training program. A total of 201 (80% of 250 participants) were male and 49 (20%) were female. Results: The orthopedic subspecialities and fellowship preferences and their influencing factors varied considerably across genders. Pediatric orthopedics and hand and upper extremity were top sub-specialties preferences among women while arthroscopy and sports medicine, arthroplasty, and trauma were the top preferences among men. Women preferred to practice single subspeciality while men preferred to do multiple fellowships and practiced different orthopedic subspecialities. The expected income, private-sector job opportunities, and hospital needs were the most significant factors influencing subspecialty and future career preferences among men while personal interest and social and family commitments were the most influential factors for women. Conclusions: This study addresses the knowledge gap regarding gender-based subspecialty preferences and the factors influencing them. The results can inform strategy development for addressing women's needs and interests in orthopedic surgery as well as the shortages of orthopedic surgeons in some subspecialties. Furthermore, these data may assist directors of training centers in analyzing expected future demands on fellowship training programs and addressing the training gap in all subspecialties and career counseling.

A structured multimodal teaching approach enhancing musculoskeletal physical examination skills among undergraduate medical students.

Current evidence indicates that undergraduate medical students display deficits in musculoskeletal physical examination skills (MPES). While various instructional methods are recommended for teaching clinical skills, effective methods for teaching MPES have not been established. This study compared the effectiveness of a multimodal teaching approach incorporating video-based learning, interactive small-group teaching, hands-on practicing, peer-assisted learning, formative assessment, and constructive feedback with traditional bedside teaching in developing undergraduate orthopedic MPES. Participants were 151 fifth-year medical students divided into two groups. One group received multimodal teaching, and the other received traditional bedside teaching. In both groups, the participants learned how to physically examine the knee and shoulder. The primary outcome was objective structured clinical examination (OSCE) scores, while the secondary outcomes included teaching sessions' total durations, facilitator's demonstration time, participants' practice time, and proportion of students with passing checklist scores and global ratings-based assessments for the two teaching approaches. The multimodal teaching group had significantly higher OSCE scores (checklist scores, global ratings, and passing rates; p = 0.02, 0.02, 0.01, respectively) than the comparison group. Individual OSCE component assessments showed significant improvements in the special musculoskeletal physical examination test. The overall duration and amount of participants' hands-on time were significantly longer for the multimodal than for the traditional bedside teaching group (p = 0.01 and 0.01, respectively), and the facilitator's demonstration time was significantly shorter (p = 0.01). The multimodal learner-centered teaching approach evaluated in this study was effective for teaching MPES. It appeared to maximize learner engagement through enhancing interactions and providing increased time to engage in hands-on practice. This teaching approach improved MPES levels, maximized teaching efficiency for scenarios with limited instruction time and resources, and enhanced competency of undergraduate medical students in performing special musculoskeletal physical examinations compared to traditional bedside teaching.

INTRAOPERATIVE EVALUATION AND LEVEL OF CONTAMINATION DURING TOTAL KNEE ARTHROPLASTY.

Introduction: Despite numerous articles on intraoperative contamination in total knee arthroplasty (TKA) procedures, the available data on tissue contamination are scarce and mainly based on evaluating bacteriological swabs. Methods: Two hundred and forty specimens, divided between bone and soft tissue, were obtained from 40 consecutive unilateral primaries TKAs. The specimens were evaluated for aerobic and anaerobic bacterial growth. Colony-forming units/gram (CFU/g) were calculated on the contaminated specimens to determine the level of contamination. Results: The contamination rate in intraoperative specimens was 15% during TKA. The contamination level had a mean of 10.6 and a median of 5, ranging from 1-70 CFU/g. The most common contaminating organisms in all samples were Staphylococcus aureus (38.9%) and Staphylococcus epidermidis (30.6%). No clinical infections were detected in TKAs in the follow-up period. Conclusion: The contamination rate during TKA is relatively high, despite the practice of standard preventive measures. Contamination levels, measured by CFU/g, are considered low when compared to the infection threshold of 105 reported in the literature. However, contamination should not be underestimated due to the presence of foreign bodies (implants), which are known to significantly lower this threshold. Level of evidence IV; case series .

Introdução: Apesar dos inúmeros artigos sobre a contaminação intraoperatória em procedimentos de artroplastia total do joelho (ATJ), os dados disponíveis sobre a contaminação tecidual são escassos e baseiam-se principalmente na avaliação de swabs bacteriológicos. Métodos: Duzentos e quarenta espécimes, divididos entre ossos e tecidos moles, foram obtidos de 40 ATJ primárias unilaterais consecutivas. Os exemplares foram avaliados quanto ao crescimento bacteriano aeróbio e anaeróbio. As unidades formadoras de colônias/grama (UFC/g) foram calculadas nas amostras contaminadas para determinar o nível de contaminação. Resultados: A taxa de contaminação em espécimes intraoperatórios foi de 15% durante a ATJ. O nível de contaminação teve uma média de 10,6 e uma mediana de 5 variando de 1-70 UFC/g. Os organismos contaminantes mais comuns em todas as amostras foram Staphylococcus aureus (38,9%) e Staphylococcus epidermidis (30,6%). Nenhuma infecção clínica foi detectada nas ATJ durante o período de acompanhamento. Conclusão: A taxa de contaminação durante a ATJ é relativamente alta, apesar da prática de medidas preventivas padrão. Os níveis de contaminação, medidos por UFC/g, são considerados baixos quando comparados ao limiar de infecção de 105, relatado na literatura. No entanto, a contaminação não deve ser negligenciada devido à presença de corpos estranhos (implantes) que são conhecidos por reduzir significativamente esse limiar. Nível de evidência IV; series de casos.

Concurrent Research Around Meniscus: A Bibliometric Analysis and Review of the Top Fifty Cited Papers.

Purpose: The knowledge regarding meniscus has vastly evolved over the past few decades. The meniscus's intact, injured, and repaired status can affect other joint structures, i.e., ligaments, articular surfaces, and overall biomechanics of the knee joint. Due to available evidence's extensiveness, it is challenging to determine the most influential topics and the emerging trends in concurrent meniscus research. This study aims to identify the top fifty cited papers in meniscus research and concurrent knee issues and analyse their characteristics. Methods: A comprehensive search was conducted on the Thompson Reuters Web of Science database to prepare a list of top fifty cited articles that included original articles and review articles concerning meniscus. The included articles were analysed for the source journal, investigating institution, country of the corresponding author, year of publication, total citations, annual citation rate, and a qualitative review. Results: The search strategy resulted in 6768 original articles and 453 review articles. The top fifty cited articles were published from 1969 to 2014 and belonged to 14 journal sources. There were 43 original articles and seven review articles. The average citations per article were 417.4 and the average citations per paper per year were 22.6. Besides the meniscus, a general interest in the clinical assessment scores, anterior cruciate ligament, long-term osteoarthritis, and cartilage was observed. Conclusion: Most of the research concerning meniscus relates to the importance of meniscus preservation, the link between meniscus injuries and concomitant anterior cruciate ligament and chondral injuries, and its role in long-term gonarthrosis. The western countries have contributed the maximum to the top-cited evidence concerning meniscus. The meniscus repair and transplantation techniques have recently gained importance and need further research to qualify for the top-cited evidence.

Undergraduate Medical Students' Perceptions of an Online Audio-Visual-Based Module for Teaching Musculoskeletal Physical Examination Skills.

Introduction: Video-based learning has gained prominence in medical education and, more recently, in musculoskeletal teaching. This study investigated medical students' perceptions of the effectiveness of online video-based learning for musculoskeletal physical examination skills. Methods: For one academic year, undergraduate medical students were instructed online through video-based learning before bedside teaching about the physical examination of knee and shoulder joints. At the end of the course, the students participated in a survey to assess their perceptions of the online video-based learning module using a pre-validated questionnaire. The questionnaire consisted of closed-ended and open-ended questions. The closed-ended question responses were assessed using a Likert scale; the open-ended responses were analyzed qualitatively. Results: In total, 242 out of 310 students who participated in the online video-based learning responded to the survey. Most students found the teaching approach to be satisfactory and preferable to traditional teaching methods. However, they also felt that these modules could not replace hands-on practice. The most helpful aspects of the training modules were a better understanding of the specific tests, technique, and sequence of administering the physical examination. Perceived limitations included the inadequately addressed theoretical basis of the physical examination and the special tests, the need for more time to explain clinical anatomy, and the practical implications of the positive special tests. Conclusion: Undergraduate medical students perceive VBL as helpful for MPES learning. The positive aspects of the VBL approach in teaching MPES are that it is comprehensive, easily accessible, offers standardized teaching, save times, and it includes demonstrations of special tests, examination techniques, and the sequence and organization of the clinical examination. The main perceived limitations were lack of content regarding clinical reasoning and the anatomical basis of the clinical tests.

Trends in the pursuit of multiple orthopedic surgery fellowships among orthopedic trainees in Saudi Arabia.

BACKGROUND: The increase in the enrollment of orthopedic surgery residents in multiple fellowship programs has gained considerable interest. Different factors may determine the specialty and number of fellowships trainees enroll in. This study aimed to elucidate these factors and determinants among orthopedic trainees. METHODS: This is a descriptive cross-sectional study, which was conducted among orthopedic surgical trainees (residency and fellowship training programs) in Saudi Arabia, between March 2021 and May 2021. The data were obtained through an online anonymous questionnaire aiming to clarify the most influential factors that determine the number of fellowships trainees choose, as well as to compare the choice of single fellowships with those of multiple ones. RESULTS: Two hundred and fifty orthopedic trainees (201 (80%) males and 49 (20%) females) completed the survey. Among them, 216 (86%) and 34 (14%) were residents and fellows, respectively, and 81% (n = 203) of the trainees preferred multiple fellowship training, and 22% (n = 47) preferred a single fellowship specialty. Notably, the male trainees preferred multiple fellowships to a single one (85% vs. 62%, p-value = 0.001), while the female trainees preferred single fellowships to multiple ones (38% vs. 15%, p-value = 0.001). The expected rate of income (17% vs. 9%), job opportunities in the private sector (17% vs. 9%), and availability and guarantee of jobs (33% vs. 23%) were the most significant factors that influenced the choices of the participants toward enrolling in multiple fellowships (p-values = 0.001, 0.001, and 0.004, respectively). CONCLUSIONS: The study demonstrated that most of the orthopedic trainees in Saudi Arabia prefer the pursuits of multiple fellowship programs. Further, the female trainees preferred single fellowships, whereas the male ones preferred multiple fellowships. The main influencing factors for pursuing multiple fellowships were determined to be private job opportunities, financial gains, and job guarantees.

Hamstring graft diameter above 7 mm has a lower risk of failure following anterior cruciate ligament reconstruction.

PURPOSE: Multi-stranded hamstring-tendon autografts have been widely used for anterior cruciate ligament reconstruction (ACLR) surgeries. Recently, smaller diameter hamstring autografts have been linked with the risk of failure or graft rupture. However, there is limited evidence concerning the optimal diameter of the hamstring autografts for ACLR. The current systematic review and meta-analysis analysed the association of ACLR failure with the diameter of hamstring autografts. METHODS: A systematic search of three major scientific databases (Pubmed, EMBASE, and Cochrane library) was conducted to identify studies that presented ACLR failure-related outcomes with different diameters of hamstring autografts. The pooled data from the included studies were analysed to investigate the association between ACLR failure and the cut-off diameters of 6, 7, 8, and 9 mm. Subgroup analyses based on the level of evidence and follow-up duration were also performed at each cut-off diameter. RESULTS: Of the 2282 studies screened, 16 reported failure rates with hamstring autografts of different diameters, 15 of which were included in the meta-analysis. A graft diameter ≥ 7 mm was associated with significantly lower ACLR failure rates than a graft diameter < 7 mm (p = 0.005), based on pooled data of 19,799 cases. Age < 20 years and higher physical activity were associated with significantly higher ACLR failure rates. CONCLUSION: The current systematic review suggests that the hamstring graft diameter for ACLR should be more than 7 mm considering the significantly higher failure rates with graft diameters less than 7 mm. LEVEL OF EVIDENCE: Level IV.

Intraoperative evaluation and level of contamination during total knee arthroplasty / Avaliação e nível de contaminação intra-operatória durante a artroplastia total do joelho

ABSTRACT Introduction: Despite numerous articles on intraoperative contamination in total knee arthroplasty (TKA) procedures, the available data on tissue contamination are scarce and mainly based on evaluating bacteriological swabs. Methods: Two hundred and forty specimens, divided between bone and soft tissue, were obtained from 40 consecutive unilateral primaries TKAs. The specimens were evaluated for aerobic and anaerobic bacterial growth. Colony-forming units/gram (CFU/g) were calculated on the contaminated specimens to determine the level of contamination. Results: The contamination rate in intraoperative specimens was 15% during TKA. The contamination level had a mean of 10.6 and a median of 5, ranging from 1-70 CFU/g. The most common contaminating organisms in all samples were Staphylococcus aureus (38.9%) and Staphylococcus epidermidis (30.6%). No clinical infections were detected in TKAs in the follow-up period. Conclusion: The contamination rate during TKA is relatively high, despite the practice of standard preventive measures. Contamination levels, measured by CFU/g, are considered low when compared to the infection threshold of 105 reported in the literature. However, contamination should not be underestimated due to the presence of foreign bodies (implants), which are known to significantly lower this threshold. Level of evidence IV; case series .

RESUMO Introdução: Apesar dos inúmeros artigos sobre a contaminação intraoperatória em procedimentos de artroplastia total do joelho (ATJ), os dados disponíveis sobre a contaminação tecidual são escassos e baseiam-se principalmente na avaliação de swabs bacteriológicos. Métodos: Duzentos e quarenta espécimes, divididos entre ossos e tecidos moles, foram obtidos de 40 ATJ primárias unilaterais consecutivas. Os exemplares foram avaliados quanto ao crescimento bacteriano aeróbio e anaeróbio. As unidades formadoras de colônias/grama (UFC/g) foram calculadas nas amostras contaminadas para determinar o nível de contaminação. Resultados: A taxa de contaminação em espécimes intraoperatórios foi de 15% durante a ATJ. O nível de contaminação teve uma média de 10,6 e uma mediana de 5 variando de 1-70 UFC/g. Os organismos contaminantes mais comuns em todas as amostras foram Staphylococcus aureus (38,9%) e Staphylococcus epidermidis (30,6%). Nenhuma infecção clínica foi detectada nas ATJ durante o período de acompanhamento. Conclusão: A taxa de contaminação durante a ATJ é relativamente alta, apesar da prática de medidas preventivas padrão. Os níveis de contaminação, medidos por UFC/g, são considerados baixos quando comparados ao limiar de infecção de 105, relatado na literatura. No entanto, a contaminação não deve ser negligenciada devido à presença de corpos estranhos (implantes) que são conhecidos por reduzir significativamente esse limiar. Nível de evidência IV; series de casos.

Novel type of medial meniscus ramp lesion: a case report and surgical technique.

Meniscal ramp lesions have been reported in 9-24% of patients who underwent anterior cruciate ligament reconstruction (ACLR). We report a rare type of double medial meniscus ramp lesion in in a 26-year-old male soccer player who presented with persistent knee instability and an inability to return to sports after a successful ACLR due to unaddressed and untreated ramp lesions. To the best of our knowledge, this is the first reported case of a double ramp lesion, with tears occurring in two separate locations: one tear at the meniscosynovial junction and associated with meniscotibial ligament disruption; and a second, more posteriorly located at the meniscocapsular junction and associated with meniscocapsular attachment disruption. It was found to be very unstable upon arthroscopic assessment and was clinically associated with persistent knee instability even after ACLR, thus necessitating surgical repair to restore knee kinematics.