Establishing growth charts for proposed body shape and size index of the Pakistani population, using quantile regression approach.

BACKGROUND: Obesity leads to other fatal diseases like diabetes, cardiovascular diseases, depression, and some forms of cancer. Still, the well-known tool to measure obesity is the body mass index. But it usually failed in the measurement of adipose tissues. So, we present a novel anthropometric measure, called body shape and size index which is developed by the combination of major anthropometric determinants: body surface area, body mass index, weight, and height. METHODS: This study is based on cross-sectional data consisting of 7224 individuals that were taken from the city Multan, Punjab, Pakistan. All the individuals, both males, and females, of age 2 years and above were included in the study except the pregnant women. The variables included in this study are gender, area (urban and rural), age (years), weight (kg), and height (meters). Growth charts of quantile regression are used for the inferential analysis of data. Comparison of proposed body shape and size index at different obesity levels has also been made to access the relationship of proposed body shape and size index with obesity. RESULTS: The results show that the proposed body shape and size index has a great association with body surface area, body mass index, weight, height, and age. The proposed body shape and size index has a high negative association with body surface area, moderate negative association with body mass index and weight, and low negative association with height and age. According to growth charts of body shape and size index, after the age of 25 years, body shape and size index curves go upward while it smoothly goes downward at the age of 50 years but decreases in earlier ages. Body shape and size index showed a significant association with body shape and body size (body development) at the same time. CONCLUSION: Body shape and size index is found, generally linear with age, and increased with decreasing body mass index and body surface area. The proposed index has an indirect relationship with obesity. Body shape and size index with low values indicates a high risk of obesity. While, however, body shape and size index with high values indicates a low risk of obesity. Applications of the proposed body shape and size index are also presented in statistical modeling.

Changes Within Clinical Practice After a Randomized Controlled Trial of Knee Arthroscopy for Osteoarthritis.

BACKGROUND: In 2002, Moseley et al published a randomized controlled trial (RCT) that showed no difference between knee arthroscopy and placebo for patients with osteoarthritis (OA). We wanted to assess the impact of the trial on clinical practice in the United States. PURPOSE/HYPOTHESIS: To evaluate changes in knee arthroscopy practice before and after publication of the article by Moseley et al and to assess the effect of this landmark RCT on the behavior of practicing orthopaedic surgeons. We hypothesized that after publication of the Moseley trial, the overall frequency of knee arthroscopy would decrease, that the mean age of patients undergoing knee arthroscopy would decrease, and that the proportion of arthroscopies for a diagnosis of OA would decrease. STUDY DESIGN: Descriptive epidemiology study. METHODS: The State Ambulatory Surgery Database was used to analyze cases from 1998 to 2006, which were classified as meniscus tear, OA, or OA with meniscus tear. Changes in age, surgery rates, and case classification were evaluated before and after Moseley's trial using Student t tests and analysis of variance. RESULTS: After publication of the trial, the number of knee arthroscopies per year increased from 155,057 in 1998 to 172,317 in 2006 (P ≤ .001). Mean patient age increased from 47.6 to 49.2 years (P < .001). Meniscus tears increased from 69.1% to 70.8%, representing approximately 15,500 additional cases per year. OA decreased from 10.6% to 7.2%, representing approximately 4000 fewer cases per year. OA with meniscus tear increased from 20.3% to 22.0%, representing approximately 6400 additional cases per year. CONCLUSION: While overall age and rates of knee arthroscopy increased contrary to our hypothesis, we identified a decrease in rates of knee arthroscopy for OA after publication of the Moseley trial, demonstrating that well-publicized RCTs can influence patterns of clinical practice.

Bicondylar tibial plateau fracture after posterior cruciate ligament reconstruction.

The authors present a report of a bicondylar tibial plateau fracture in an adolescent athlete after posterior cruciate ligament (PCL) reconstruction. The procedure was performed via arthroscopic transtibial PCL reconstruction with quadrupled semi-tendinosus and gracilis autograft. The patient recovered uneventfully postoperatively and was able to participate in high-level sports activity, such as baseball and track, with no limitations, no subjective complaints, and no episodes of instability. He continued to be asymptomatic up to 3.5 years postoperatively. Almost 4 years postoperatively, the patient reinjured the left knee during recreational noncontact football and was seen emergently. Plain radiographs, magnetic resonance image scan, and computed tomography scan at the time of injury showed a bicondylar tibial plateau fracture with intra-articular involvement. Operative intervention was undertaken for open reduction and internal fixation of the bicondylar tibial plateau fracture. A plate was placed along the medial aspect of the tibia with locking and nonlocking screws, and the joint line was restored appropriately. The patient recovered uneventfully and at the most recent follow-up had full active and passive range of motion, had no subjective or objective evidence of instability, and had returned to full activity with no restrictions. The patient had no history of multiple fractures or any medical or pharmacologic history that predisposed him to decreased bone density. This case shows a unique possible complication after transtibial PCL reconstruction in an adolescent patient.

Burnout and its Associated Factors in Medical Students of Lahore, Pakistan.

INTRODUCTION: Burnout is a widely known phenomenon. It is defined as a state of prolonged physical and psychological exhaustion and is experienced virtually by every medical student due to the highly demanding nature of medical education. This study probes into the prevalence and psychosocial determinants of burnout in Pakistani medical students. METHODS: A descriptive, cross-sectional study design and convenience (non-probability) sampling technique were employed in undergraduate medical students from years 1-5. A total of 777 medical students from two medical colleges were included in the study from May-August, 2014. An English version of the Copenhagen Burnout Inventory (CBI) and a series of demographic questions, intermixed with questions from other topics, were included in the questionnaire. Data was analysed by using SPSS ver.21. RESULTS: The majority of students were females and enrolled in the third year of MBBS. Of the medical students involved, 30.6% were found to have high/very high levels of burnout (Kristenson's burnout scoring). Although 38.7% of students said that they did not feel burned out after reading the definition of burnout given in the questionnaire, 35.9% out of these students actually had high levels of burnout according to CBI. According to the multiple regression analysis, burnout in medical students was significantly associated with age, gender, doctor parents, no help or no supportive resources (e.g., from colleagues), lack of time off, lack of belief in what you do, fear of big consequences of failure, family responsibilities, and uncertain future. Perception of teachers lacking leadership skills and doing too much study with little balance was associated with low burnout scores. CONCLUSION: There is a high prevalence of burnout in Pakistani medical students. The present study identifies several factors associated with burnout in Pakistani medical students. Although these factors are a part of daily life of medical students, their identification should prompt the use of effective coping strategies and skills, thus, minimising their burnout levels.

The longitudinal anatomy of the long head of the biceps tendon and implications on tenodesis.

PURPOSE: Regarding biceps tenodesis, there are no evidence-based recommendations for the ideal level at which to cut and stabilize the tendon. The purpose of this study is to provide information referencing the tendon for potential clinical applications during biceps tenodesis. METHODS: Forty-three embalmed shoulder specimens were dissected, and markers were placed at four points along each biceps tendon: (1) proximal border of the bicipital groove, (2) distal border of the bicipital groove, (3) proximal edge of the pectoralis major insertion, and (4) musculotendonous junction. Using the origin as the initial point of reference, measurements were made to the four subsequent sites. The humeral length was recorded by measuring the distance between the greater tuberosity and the lateral epicondyle. RESULTS: Measurements were recorded from the origin of the tendon on the supraglenoid tubercle to each established point along its length, and the mean, minimum, and maximum values (cm) were calculated as follows: origin to the proximal bicipital groove [2.8 (1.9, 4.3)], distal bicipital groove [5.2 (3.8, 7.0)], pectoralis major insertion [8.1 (6.3, 10.4)], and musculotendonous junction [13.8 (7.7, 20.3)], and overall humeral length [29.2 (25.2, 32.7)]. An analysis demonstrated a statistically significant overall increase in tendon length at each anatomic site as the overall humeral length increased (p < 0.05). Utilizing the constant and coefficient data from our regression analysis, a predictive formula was calculated based on humeral length. For example, distance from the origin to each anatomic point was determined by a formula [Tendon length at each anatomic landmark, cm = coefficient (humeral length, cm) + constant] for each respective anatomic landmark along the course of the tendon. CONCLUSION: This work will allow surgeons who prefer tenodesis to more accurately re-approximate the appropriate length-tension relationship of the biceps when tenodesing the tendon in a variety of locations. This benefit will potentially result in the most efficient biceps muscle-tendon function and improve the results of biceps surgery. LEVEL OF EVIDENCE: IV.

Student opinions on orthopedic residency selection, education, and work hours.

Other articles have been written about resident selection, musculoskeletal education, work hours, and call coverage, but none has described orthopedic applicants' opinions on these issues. We conducted a study to gain insight into applicants' attitudes about issues relevant to the specialty. We distributed a survey to 53 applicants interviewing for an orthopedic residency. The survey used both a multiple-choice format and a Likert scale ranging from 1 (strongly disagree or least important) to 5 (strongly agree or most important). Respondents rated the adequacy of musculoskeletal education in medical school a mean standard deviation (SD) of 2.00 (0.8) on the Likert scale. Ranking the factors most valuable to an orthopedic surgery application, they rated United States Medical Licensing Examination (USMLE) Step 1 board examination scores a mean (SD) of 4.26 (0.9). In addition, of the 53 respondents, 46 (87%) anticipated working as a resident more than 80 hours per week, and 36 (68%) anticipated working as an attending 60 to 70 hours per week or less. Respondents also agreed that they should receive compensation for call coverage. Therefore, students agreed that medical school education is insufficient, rated USMLE scores the most important application factor, anticipated working more than 80 hours per week, and agreed that call coverage should be compensated.

Complications and re-operations after Bristow-Latarjet shoulder stabilization: a systematic review.

BACKGROUND: Various methods of bony stabilization, including modifications of Bristow and Latarjet procedures, are considered gold-standard treatment for recurrent anterior shoulder instability but are associated with unique complications and risk of reoperation. The purpose of this study was to identify the prevalence of these complications. We hypothesized that the Bristow-Latarjet procedure would be a successful technique for treatment of shoulder instability but associated with a risk of recurrent postoperative instability, reoperation, and other complications. METHODS: A systematic review of multiple medical databases included studies reporting outcomes with complication and reoperation rates following original or modified versions of the Bristow or Latarjet shoulder stabilization surgeries. RESULTS: Forty-five studies were analyzed (1,904 shoulders) (all Level IV evidence). Most subjects were male (82%). The dominant shoulder was the operative shoulder in 64% of cases. Mean subject age was 25.8 years. Mean clinical follow-up was 6.8 years. Ninety percent of surgeries were done open; 9.3% were all-arthroscopic. Total complication rate was 30%. Recurrent anterior dislocation and subluxation rates were 2.9% and 5.8%, respectively. When reported, most dislocations occurred within the first year postoperatively (73%). Nearly 7% of patients required an unplanned reoperation following surgery. CONCLUSION: Osseous stabilization shoulder surgery using original or modified Bristow and Latarjet procedures has a 30% complication rate. Rates of recurrent dislocation and reoperation were 2.9% and 7%, respectively. Mild loss of external rotation is common. Reoperation rates were lower following all-arthroscopic techniques. There was a greater loss of postoperative external rotation with all-arthroscopic surgery.

Bone impaction grafting of the lateral femoral condyle in a pediatric patient.

Avascular necrosis of the femoral condyle is an uncommon but serious sequela in patients who have received chemotherapy or corticosteroid treatment. The optimal treatment of avascular necrosis of the femoral condyles in pediatric patients is not well established. Nonoperative management has had limited long-term success, and many of the surgical procedures available for adults, including core decompression, osteotomy, and femur resurfacing, are undesirable in skeletally immature patients with open physes.This article describes a case of a 7-year-old girl with acute lymphocytic leukemia who developed avascular necrosis of the lateral femoral condyle that was treated with bone impaction grafting. The patient experienced right knee pain and swelling shortly after the initiation of chemotherapy. The radiological studies obtained showed subchondral collapse of the lateral femoral condyle. After a course of nonoperative management failed to improve symptoms, she underwent bone impaction allografting of the lateral femoral condyle using a physis-sparing approach. More than 5 years postoperatively, she has achieved excellent clinical results. Postoperative imaging of the knee has also confirmed good integration of the bone graft, an open physis, and preservation of the articular surface. This technique is a relatively less invasive surgical procedure for the treatment of avascular necrosis of the femoral condyle in a pediatric patient.

Adolescent Segond fracture with an intact anterior cruciate ligament.

Segond fractures, or avulsion fractures of the proximal lateral tibial plateau, have been well documented and studied since their original description in 1878. Segond fractures have a widely recognized pathognomonic association with anterior cruciate ligament (ACL) injuries and often prompt orthopedic surgeons to consider reconstruction following radiographic and clinical evaluation. Adolescent patients are particularly vulnerable to these fractures due to the relative weakness of their physeal growth plates compared with the strength of their accompanying ligamentous structures. This article describes a case of a 13-year-old boy who sustained a Segond fracture that was not coupled with an ACL avulsion or tear. The patient sustained a twisting injury to his knee. He presented to the emergency room with an effusion and radiographic findings consistent with a Segond fracture. On follow-up examination 1 week after injury, the ACL was intact. The patient was followed for 5 months of conservative treatment. At final follow-up, the patient had reestablished his previous level of activity. This article describes the history, physical examination, and radiographic findings necessary to care for patients who present with a Segond fracture. Although considered pathognomonic for an associated ACL injury, this article describes a Segond fracture that occurred in isolation.

A complex injury of the distal ulnar physis: a case report and brief review of the literature.

Physeal fractures of the distal forearm are common injuries in children and adolescents. However, Salter-Harris type III and type IV fractures of the distal ulnar epiphysis are often high-energy injuries that require open reduction for restoration of anatomical alignment. These injuries are uncommon and there are few descriptions of them in the contemporary literature. Here we report the case of a 13-year-old boy with a type IV distal ulna fracture not diagnosed with standard radiography. After closed manipulation, an incompletely reduced physis was suspected on the basis of fluoroscopic imaging and comparison radiographs of the contralateral wrist. Computed tomography showed a large, displaced physeal fragment. The patient underwent open reduction and internal fixation. Thorough radiographic assessment should be conducted when there is a high suspicion for these fracture patterns. Appropriate diagnosis can lead to expedient reduction and expectant management of sequelae associated with these injuries.

Three-in-one nerve block with different concentrations of bupivacaine in total knee arthroplasty: randomized, placebo-controlled, double-blind trial.

Pain after total knee arthroplasty may be severe and lead to adverse outcomes. Using 2 concentrations of bupivacaine, we investigated 3-in-1 nerve block's effect on pain control, narcotic use, sedation, and patient satisfaction. One hundred five patients undergoing unilateral total knee arthroplasty were randomized into 3 groups: low-dose or high-dose bupivacaine or placebo. Ninety-nine patients completed the study. Three-in-1 nerve block reduced patient-controlled opioid analgesia usage and improved pain relief in the early postoperative period but had little effect beyond postoperative day 1. There were no significant differences among groups with respect to nausea or sedation. Patients in each group exhibited high overall satisfaction. Low-dose bupivacaine was superior to high-dose bupivacaine for pain relief, narcotic consumption, and patient satisfaction in the early postoperative period.

Vascular injury involving proximal medial-to-lateral oblique locking screw insertion in tibial intramedullary nailing.

Orthopaedic surgeons have reported increased neurologic complications with the employment of next-generation tibial nail fixation with variable proximal and distal locking options. However, vascular injury due to oblique screw placement has not been documented. We describe a case in which a medial-to-lateral oblique locking screw led to significant vascular injury. The judicious use of these screws and their relative contribution to fracture stability should be carefully considered for individual cases. Additionally, drill penetration through the far tibial cortex may not be obvious and utilizing oscillation or reverse drilling techniques may be of benefit. Lastly, the forward thrust of the popliteal artery with the use of a positioning bump in the popliteal fossa may place the vascular structure at increased risk of injury. Employing means to avoid these injuries and minimize risks in pertinent patients is of utmost importance.

Human growth hormone and the development of osteochondritis dissecans lesions.

No single etiology regarding the cause of osteochondritis dissecans (OCD) lesions is unanimously accepted. This report documents a novel case of multiple OCD lesions affecting the left knee and a solitary defect of the right elbow in a patient with acquired human growth hormone (hGH) deficiency and supplementation. hGH deficiency and hormone replacement may be related to the development of OCD lesions.

A late vascular complication due to component migration after revision total hip arthroplasty.

Although vascular injuries associated with primary and revision total hip arthroplasty are infrequent, these complications can have devastating effects that can lead to morbidity and even mortality. No previous reports have described embolic distal limb ischemia secondary to a failed and migrated acetabular implant in discontinuity with the pelvis. We present a novel case in which a screw from a failed and migrated acetabular cage construct led to injury of the superficial femoral artery. While awaiting the construction of a custom prosthesis, the patient developed thromboembolism leading to distal extremity ischemia. The patient was treated with thrombolytic therapy, anticoagulation, removal of the offending hardware, forefoot amputation, and later hip reconstruction. Recognition of the risks associated with failed and migrated components may prevent this complication in the future.

A rare anesthetic complication involving central line access during lumbar spine surgery: a case report and review.

STUDY DESIGN: A case report describing a rare perioperative complication involving the intrathoracic placement of a central venous catheter during spine surgery leading to hemodynamic instability. OBJECTIVE: To review the efficacy of central line use in perioperative spine patients and to describe the diagnosis, emergent treatment, and postoperative care of a unique case of intrathoracic extravasation of propofol. SUMMARY OF BACKGROUND DATA: Although placement of central line access is a safe procedure, complications can occur. A case in which a venous catheter delivering propofol into the thorax has never been documented. METHODS: A 48-year-old woman presented for revision spine surgery, and a central line was placed. After placement of spinal instrumentation, she became hemodynamically unstable secondary to mediastinal compression caused by pressure from intraoperative propofol and fluid insufflation. RESULTS: A chest tube was placed, and with aggressive pulmonary toilet and physical therapy, she did well and was discharged without noted symptoms. CONCLUSION: The efficacy of central line use should be carefully considered in perioperative spine surgery, and in patients with significant risk factors, placement of central venous access should be radiographically confirmed.

Solitary osteochondroma of the proximal femur and femoral acetabular impingement.

Although osteochondromas can be present within the context of multiple hereditary exostosis, these tumors are overwhelmingly found as isolated lesions. Increased exostotic load associated with multiple hereditary exostosis can lead to limb-length discrepancy, increased femoral anteversion, valgus angulation, and acetabular dysplasia. Despite these observations, the relationship of more common isolated exostoses near the proximal femur and their role in femoral acetabular impingement has never been depicted. Although solitary osteochondromas have been linked with bursal inflammation and pain, compression on neurovascular structures, and malignant degeneration, they have not previously been associated with femoral acetabular impingement. This article presents a novel case of a proximal femoral osteochondroma of the greater trochanter leading to the development and associated symptoms and radiographic findings consistent with hip impingement. A 24-year-old man presented with groin and lower extremity pain thought to be due to an exostosis of the proximal femur. Following surgical excision and persistence of anterior groin pain, the patient was found to display a presentation and radiographic findings consistent with femoral acetabular impingement. He successfully underwent a hip arthroscopy, femoroacetabular osteochondroplasty, and labral repair. Postoperatively, his symptoms improved significantly, and he returned to normal activity. The presence of a proximal femoral exostosis can be associated with the development of femoral acetabular impingement. Awareness of this relationship may lead to a better understanding of patient symptoms and expectations associated with treatment.