Research activities and critical appraisal skills among Saudi orthopedic residents.

BACKGROUND: Medical research is a central part of any residency training. In view of the new Saudi orthopedic committee promotion regulation that mandates each resident to participate in a research project, the challenges that stand in the way of completion of substantial research within surgical residency must be investigated. The aim of this study was to assess the practice, attitudes, perception, and limitations associated with research among residents in the Saudi orthopedic program in the central region. METHODS: A cross-sectional study was conducted between June and July 2020 using an online-based survey. The total number of study participants was 128 orthopedic residents out of the 191 residents enrolled in the central region program. Data were analyzed, and descriptive statistics in the form of frequency and percentage were determined, analytical tests were performed with P < 0.05 being statistically significant. RESULTS: Most residents (95 %) participated in a research project during residency. Most projects (53.10 %) were case reports followed by retrospective studies (48.40 %). The majority (79.70 %) did not attend a research methods course during residency. Experience in research differed significantly (P < 0.05) by age, residency year, and center. The mean involvement score was significantly higher among males at 3 (± 1) than among females at 2 (± 0) (P < 0.001). Only 40.60 % have access to orthopedic journals, and the same percentage (40.60 %) knew how to Critique original articles. There was a statistically significant difference in the accessibility score according to the training center. Lack of faculty support and mentorship were the main barriers to medical research at 62.50 and 39.10 %, respectively. A total of 68.80 % reported that funding was not available through their institutes. CONCLUSIONS: In Saudi Arabia, the level of meaningful clinical research and publications by orthopedic residents is still low. The results of this study should be taken into consideration before the implementation of the new promotion criteria in the centers under the umbrella of Saudi orthopedic committee.

High Incidence of Irradiated Cortical Strut Allograft Resorption Following Revision of Femoral Stems.

BACKGROUND: Despite the widespread use of revision total hip arthroplasties using cementless stems and cortical strut allografts, graft resorption has not been explicitly studied. METHODS: Between 2010 and 2018, 40 femoral strut grafts were used in the revision of femoral stems of 36 patients (18 males and 18 females; average age, 51.9 ± 12.9 years). The mean follow-up was 78.9 ± 37.3 months. Failure was defined as revision surgery for any reason and subsidence of greater than 5 mm. RESULTS: The survival rate of the stem without the need for revision at 5 years was 95% (mean graft survival time, 10.8 [95% CI, 9.414-12.234] years). Overall survival with graft resorption as the endpoint was 90% at 5 years (mean graft survival time, 8.8 [95% CI, 7.5-10.2] years). Survival with graft nonunion as the endpoint was 90% at 3 years (mean survival time, 11.7 [95% CI, 10.5-12.8] years). CONCLUSION: The resorption rate increases proportionally to the follow-up duration and can be very severe in a high percentage of cases. Long-term multicenter studies are required to assess the effect of resorption on prosthesis longevity.

Principles of bone and tissue banking in Saudi Arabia: 10-year experience report.

BACKGROUND: The role of bone and tissue banking is well known to meet the ever-growing need of bone and soft tissue allografts. Strict guidelines have been established to ensure high standard and minimize complications related to bone transplantation. METHODS: The Bone Bank in King Faisal Specialist Hospital and Research Centre (KFSH&RC), affiliated with the Saudi Council of Organ Transplantation, was inaugurated in 2010, and it has since been an integral part of the KFSH&RC organ retrieval team. The bank has a very strict regulations which were described. RESULTS: Between January 2010 and January 2020, there were 143 multi-organ donors (mean age: 36 years, range: 24-55 years). The total number of allografts used was 2191 which were utilized in 1047 patients. CONCLUSIONS: In this paper, we present our 10-year experience of administrative structure, donor and recipient testing protocols, allograft retrieval, processing procedures, and the internal audit safety arrangements. The utilization of allografts in various pathologies such as revision joint replacement, spine surgery, and tumor surgery is discussed with our results over a 10-year period.

Long-term follow-up of bilateral hip and knee arthroplasty secondary to ochronotic arthropathy.

Alkaptonuria is a rare metabolic disorder caused by the deficiency of homogentisic acid oxidase enzyme, which is responsible for eliminating homogentisic acid from the body through the renal system. Excessive accumulation of homogentisic acid leads to ochronosis and ochronotic arthritis. Owing to the rarity of the disease, long-term functional outcomes of joint replacements of the hips and knees in ochronosis arthropathy are unconfirmed, and only a limited number of case reports are available on this. We present a case of a 45-year-old man with ochronosis and advanced osteoarthritis of both the hips and knees. He underwent bilateral hip and knee replacements as staged procedures. At a follow-up of more than 12 years, the man had full mobility with no loosening of implants.

Noncemented Total Hip Arthroplasty in Sickle-Cell Disease: Long-Term Results.

BACKGROUND: Avascular necrosis of the femoral head is a well-known sequela of sickle-cell disease (SCD) requiring a surgical intervention that comes with technical challenges. METHODS: Uncemented hip arthroplasty for avascular necrosis of the femoral head due to SCD was carried out for 101 patients (133 hips) between 2000 and 2012. The duration of follow-up ranged from 5 to 17 years (mean, 14.59 years). All patients received a noncemented femoral stem and a noncemented acetabular shell. RESULTS: After surgery, all patients showed improvement in their hip scores for pain, range of motion, and function. The 10-year survivorship was 98%. There were 6 intraoperative fractures of the proximal femur (4.5%), 4 superficial and 5 deep infections (6.77%), 1 aseptic shell failure (0.75%), and 1 aseptic femoral stem failure (0.75%). Brooker grade IV heterotopic ossification developed in 5 hips (3.76%). CONCLUSION: Hip arthroplasty in SCD is now a safe and effective procedure when the high rate of complications associated with this disease is given full consideration. With careful preoperative and postoperative planning, a highly successful outcome can be achieved. Noncemented shells and noncemented stems have shown durable long-term results.

Simultaneous bilateral total hip arthroplasty in Morquio syndrome.

A 16-year-old girl who had Morquio syndrome presented with severe bilateral hip pain and limited mobility because of bilateral hip osteoarthritis and fixed flexion deformities. She was wheelchair bound for the previous 6 months. Cervical spine flexion-extension views showed mild subluxation (<3 mm), and there was thoracolumbar spine kyphosis. Magnetic resonance imaging of the cervical and thoracolumbar spine showed hypoplasia of the odontoid and vertebral bodies, but no spinal cord compression. Bilateral cemented total hip arthroplasty was performed through a posterior approach under general anesthesia with fiberoptic intubation. The femoral canals accepted a small-diameter stem, the right femoral head was used as a graft for superior right acetabular deficiency, and low-profile all-polyethylene acetabular cups were implanted. Follow-up at 15 years after surgery showed that the patient was fully ambulatory without pain or supports, and radiographs showed no loosening. In summary, total hip arthroplasty at a young age may be necessary in patients who have Morquio syndrome because of severe arthritis and soft tissue contractures. Extensive preoperative evaluation that includes imaging of the entire spine is mandatory because of the risk of developing spinal cord compression.

Freeze Dried Proximal Femoral Allografts in Revision of Femoral Stems.

BACKGROUND: Femoral bone deficiency is a challenging problem in revision femoral arthroplasty in younger patients. We evaluated outcomes of revision femoral arthroplasty using a freeze-dried allograft prosthetic composite (APC). METHODS: This was a retrospective review of 16 patients (12 men and 4 women) who had unilateral proximal femoral deficiencies (Paprosky type III B, 13 patients; type IV, 3 patients) revised with freeze-dried APC. Follow-up at mean 7 years included assessment with Merle D'Aubigné score and radiographs. RESULTS: At follow-up, the average hip score was improved for pain, function, and range of motion. The 5-year graft survival was 87%, and the estimated median survival was 8.8 years. There were 3 patients who walked without support, 10 patients who walked unlimited distance with a cane, 2 patients who walked with 2 crutches, and 1 patient who walked with a walker. Radiographs showed nonunion at the graft-host junction in 3 hips (19%), but only 1 patient was symptomatic. Asymptomatic trochanteric nonunion was observed in 4 hips (25%). There was moderate graft resorption in 2 patients at 9 years after surgery and mild graft resorption in 1 graft at 7 years. There was subsidence of <2 cm in 2 patients and 3.5 cm in 1 patient. CONCLUSION: The present study showed acceptable results in treatment of major femoral deficiencies using freeze-dried APC in younger patients. Freeze-dried APC may be a useful for revision femoral arthroplasty.

Revision of type III and type IVB acetabular defects with Burch-Schneider anti-Protrusio cages.

Extensive bone loss in severe acetabular deficiencies can make repair with acetabular shells impossible. We retrospectively analyzed mid-term to long-term results of acetabular revision with Burch-Schneider reinforcement cages in 33 hips in patients with a mean age of 59.03years after a mean follow-up period of 6.19years. Under the American Academy of Orthopaedic Surgeons classification, 9 patients had type III acetabular bone defects and 24 had type IVB. Merle D'Aubigné scores improved by a mean of 9.3 points. The prosthesis failure rate was 15.1%, the series complication rate was 21.2%, and the mean survivorship was 11.57years. The Burch-Schneider cage is useful for reconstruction in massive acetabular deficiency, but complication rates are high and long-term mechanical failure is a concern.

Neurofibromatosis induced hip arthritis. An unusual presentation.

PATIENT: Male, 43 FINAL DIAGNOSIS: Neurofibromatosis Symptoms: Hip pain Medication: - Clinical Procedure: - Specialty: Orthopedics and Traumatology. OBJECTIVE: Rare disease. BACKGROUND: Neurofibromatosis type 1 is a disease known for orthopedic manifestations such as spine deformities, congenital pseudarthrosis of the tibia and other bony dysplasias; joint dislocations are rare. Joint arthritis caused by neurofibromatosis, with a stable hip, has never been reported in the English literature before. CASE REPORT: A 43-year-old man diagnosed with neurofibromatosis type 1 (NF-1) presented with hip pain of 5 years duration, with no history of trauma and no clinical or radiological signs of dislocation. He had classical clinical and radiological signs of hip arthritis, with acetabular erosions and femoral head arthritis. The patient was treated with total hip arthroplasty metal-on-metal (MoM). CONCLUSIONS: Hip arthritis alone without subluxation or dislocation due to NF-1 is an extremely rare presentation. This is the first reported presentation and provisional treatment with total hip arthroplasty.

A rare presentation of an intraosseous lipoma in the proximal femur.

PATIENT: Female, 32 FINAL DIAGNOSIS: Intraosseous lipoma Symptoms: Swelling of the thigh Medication: - Clinical Procedure: Excision of the mass Specialty: Surgery. OBJECTIVE: Rare disease. BACKGROUND: Intraosseous lipomas happen to be one of rarest benign soft tissue tumors with only a little known about its etiology and pathophysiology. A pubmed search using key word "Intraosseous lipoma". Came back with 165 results. All the sizes and presentations were reviewed and compared with the case we are presenting. We are reporting a 15×20 cm intraosseous lipoma. CASE REPORT: 32-year-old lady with a large intraosseous lipoma in the proximal thigh. The largest reported in English literature. CONCLUSIONS: A intraosseous lesion with this size could still be benign even if its lager than 5 cm. Keeping in mind that with a lesion this size malignancy should always be ruled out.

Rapunzel syndrome and gastric perforation.

Rapunzel syndrome complicated with gastric perforation is a very rare presentation of trichobezoar. Trichobezoar is an uncommon condition affecting predominantly females. It has non-specific clinical presentation, a wide range of complications, and, if not treated appropriately, carries significant mortality. Traditional treatment of trichobezoar is surgical, though, attempts have been made to excise endoscopically, dissolve chemically or fragment using extracorporeal shock waves. We report a case of a very large trichobezoar occupying most of the stomach and duodenum complicated with gastric perforation, and summarise the literature regarding trichobezoar aetiology, diagnostic difficulties, and management.

Total hip arthroplasty in chronic unreduced hip fracture-dislocation.

We treated 15 patients with chronic unreduced hip fracture-dislocations at our hospital; all patients sustained the fracture-dislocations in motor vehicle accidents. All presented to our institution more than 6 months after initial treatment at their local hospitals with uncontained femoral heads; all underwent 1-stage total hip arthroplasty with bone grafting. These patients were monitored for a mean of 71.5 months (range, 36-96 months). All patients had significantly decreased pain, increased function, and increased range-of-motion scores using the Merle d'Aubigné scoring system. All grafts showed radiographic evidence of union. There were 2 dislocations, 1 transient peroneal nerve palsy, and 1 superficial infection. Total hip arthroplasty is effective for relieving pain and restoring function in chronic unreduced hip fracture-dislocations.

Comparison of bone grafts for posterior spinal fusion in adolescent idiopathic scoliosis.

STUDY DESIGN: A retrospective comparison of three different types of bone grafts for posterior spinal fusion in adolescent idiopathic scoliosis. OBJECTIVE: To determine the efficacy of bone marrow and demineralized bone matrix as a bone graft substitute for spinal fusion. SUMMARY OF BACKGROUND DATA: Several reports have documented a high morbidity associated with harvesting autologous iliac crest bone graft (ICBG) for spinal fusion. Composite bone graft consisting of demineralized bone matrix and aspirated bone marrow may reduce the morbidity and still retain the osteoinductive properties of iliac crest autograft. METHODS: Three different bone grafting techniques were used by a single surgeon in 88 consecutive patients who had posterior spinal fusion for adolescent idiopathic scoliosis. Segmental instrumentation with dual-rod fixation was used in all cases. Selection of type of graft was determined historically by the time when the operations were performed. Autologous ICBG was used in Group A, freeze-dried corticocancellous allograft in Group B, and composite graft of autologous bone marrow and demineralized bone matrix in Group C. Seventy-seven patients were reviewed, with a minimum of 2 years' follow-up (mean, 3 years 7 months; range, 2 years-9 years 5 months). Radiographs were assessed for pseudarthrosis and loss of correction of 10 degrees or more. Loss of 10 degrees of correction has been previously identified as an indicator of potential pseudarthrosis or fusion instability. Both of these criteria were used to compare success of fusion. RESULTS: Failure caused by pseudarthroses was seen in two patients (2.6%), one in Group A and one in Group B. Eleven patients lost greater than 10 degrees of correction, but only one demonstrated pseudarthroses. The 13 patients with pseudarthroses or loss of correction constitute the failure group for purposes of graft assessment. The failure rate was 12.5% in Group A (ICBG), 28% in Group B (freeze-dried corticocancellous allograft), and 11.1% in Group C (composite graft of autologous bone marrow and demineralized bone matrix). Eliminating patients with crankshaft phenomenon did not substantially change the results. There was no morbidity associated with bone marrow aspiration. CONCLUSIONS: Fusion rates were comparable for GroupA (ICBG) and Group C (composite graft of autologous bone marrow and demineralized bone matrix). The composite graft is our preferred graft for fusions in adolescent idiopathic scoliosis.

Medical management of osteoid osteoma.

OBJECTIVE: To see if the results of managing osteoid osteoma with medical treatment alone is comparable to those after surgery or other ablative therapy. DESIGN: A case series. SETTING: A tertiary care centre. PATIENTS: Eleven patients with osteoid osteoma treated over a 5-year period. The condition was diagnosed from a typical history, patient age, standard radiography, computed tomography, bone scanning, complete blood count and measurement of the erythrocyte sedimentation rate. INTERVENTIONS: Continued medical treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) for 6 months after pain ceased. Surgery was done only in those who refused or could not tolerate medical treatment. MAIN RESULTS: Medical treatment successfully controlled the pain in all patients. Two patients decided to undergo surgery because of intolerance to the NSAIDS. In 7 patients the symptoms resolved after a mean time of 2.5 years. Two patients were still taking NSAIDS 5 years from the time of diagnosis. CONCLUSIONS: The natural history of osteoid osteoma is self-limited so patients should be offered nonoperative treatment, reserving ablative treatment for those who are unable or unwilling to take NSAIDs until their symptoms resolve.