Time to Look for Ergonomically Viable Designs of Radiation Protection Aprons and Thyroid Shields in Orthopedic Surgery: A Survey of 416 Orthopedic Surgeons.

Introduction The advent of minimally invasive surgery has increased the use of C-arm among orthopedic surgeons. Their views on the ergonomicity of radiation protection aprons and thyroid shields need elucidation. To investigate, we deliberated a question-based survey. The primary aim of the survey was to find out the percentage of those not using these devices, the prevalence of back pain, and its relationship with the type of radiation protection aprons. Materials and methods This was a cross-sectional survey. A five-section Google Forms survey (Google, Inc., Mountain View, CA) was filled out, and responses from 416 orthopedic surgeons were included. Analysis was carried out using Statistical Package for the Social Sciences (SPSS) version 14.0 (SPSS Inc., Chicago, IL). Results Of the total number of orthopedic surgeons, 36.8% felt that apart from radiation exposure, wearing a radiation protection apron was the biggest problem in C-arm usage. Furthermore, 20.4% wore thyroid shields the majority of the time. The 31-40 years age group was the most comfortable wearing these devices, wore them more often, and suffered more often from back pain (all p<0.01). Conclusion The study concluded that the majority of orthopedic surgeons were not comfortable with the current designs of radiation protection aprons and thyroid shields. Thyroid shields are worn less than aprons. Lead apron weight and thyroid shield ergonomicity were the number one reason for being bare-bodied. Among those who regularly wore aprons, a large proportion suffered from back pain.

Does obesity affect diaphyseal femoral fracture healing treated with intramedullary locking nail?

OBJECTIVES: This study aims to evaluate the effect of obesity on radiological fracture union in diaphyseal femoral fractures (DFFs) treated with intramedullary nailing (IMN). PATIENTS AND METHODS: Between January 2017 and December 2018, a total of 120 patients (101 males, 19 females; mean age: 35.1±3.0 years; range, 18 to 72 years) treated with IMN for closed DFFs were retrospectively analyzed. Data including age, sex, location, weight, height, comorbidities such as diabetes mellitus, hypertension or kidney injury, date of injury, mechanism of injury, type of femoral fractures (AO classification), date of surgery, duration of surgery, IMN length and diameter used, date of radiological fracture union and complications of surgery such as nonunion, delayed union, and infections were recorded. RESULTS: Of the patients, 63 had obesity and 57 did not have obesity. There was a statistically significant difference in fracture configuration among patients with obesity; they sustained type B (p=0.001) and type C (p=0.024), the most severe fracture configuration. The nonunion rate was 45%. Obesity had a significant relationship with fracture nonunion with patients with obesity having the highest number of nonunion rates (n=40, 74.1%) compared to those without obesity (n=14, 25.9%) (p=0.001). Fracture union was observed within the first 180 days in 78.9% of patients without obesity, while it developed in the same time interval in only 38.1% of patients with obesity (p=0.001). CONCLUSION: Fracture union time for the patients with obesity was longer, regardless of the fracture configuration. Obesity strongly affects fracture union time in DFFs treated with an IMN. Obesity should be considered a relative risk in decision-making in the choice of fixation while treating midshaft femoral fractures.

A review of the efficacy of intraarticular hip injection for patients with hip osteoarthritis: To inject or not to inject in hip osteoarthritis?

Hip injection (HI) for osteoarthritis (OA) are in vogue nowadays. Corticosteroids (CSs) and hyaluronic acid (HA) gel are the two most common agents injected into the hip. Off late, platelet-rich plasma (PRP), mesenchymal stem cell (MSC), bone marrow aspirate concentrate (BMAC), local anesthetic (LA) agents, non-steroidal anti-inflammatory drugs (NSAIDs) and their different combinations have also been injected in hips to provide desired pain relief. However, there is a group of clinicians who vary of these injections. A search of the literature was performed on PubMed, Cochrane Library, and DOAJ using the keywords "hip osteoarthritis injection". Data were analyzed and compiled. Intraarticular CSs are effective in providing the desired pain relief in OA hip, but repeated injections should be avoided and the interval between HI and hip arthroplasty must be kept for more than three months. Methylprednisolone or triamcinolone are combined with 1% lidocaine or 0.5% bupivacaine. Chondrotoxic effects of LA is a concern. Although national guidelines do not favor the use of HA for hip OA, numerous publications have favored its usage for a moderate grade of OA. The PRP, MSC, and BMAC are treatment options with great potential; however, currently, the evidence is conflicting on their role in hip OA. There is always a risk of septic arthritis, particularly when aseptic precautions are not followed, and clinicians must vary of this complication.

Common musculoskeletal disorders in chronic liver disease patients.

Chronic liver disease (CLD) is the commonest ailment affecting the hepatobiliary system. Six significant pathologies related to CLD include hepatic osteodystrophy (HO), increased infection susceptibility, sarcopenia, osteonecrosis of the femoral head (OFH), increased risk of periprosthetic complications and fracture. Hepatic osteodystrophy, which comprises osteopenia, osteoporosis, and osteomalacia, refers to alterations in bone mineral metabolism found in patients with CLD. The HO prevalence ranges from 13 to 95%. Low complement levels, poor opsonization capacity, portosystemic shunting, decreased albumin levels, and impaired reticuloendothelial system make the cirrhotic patients more susceptible to developing infectious diseases. Septic arthritis, osteomyelitis, prosthetic joint infection, and cellulitis were common types of CLD-associated infectious conditions. The incidence of septic arthritis is 1.5 to 2-fold higher in patients with cirrhosis. Sarcopenia, also known as muscle wasting, is one of the frequently overlooked manifestations of CLD. Sarcopenia has been shown to be independent predictor of longer mechanical ventilation, hospital stay, and 12-month mortality of post-transplantation. Alcohol and steroid abuse commonly associated with CLD are the two most important contributory factors for non-traumatic osteonecrosis. However, many studies have identified cirrhosis alone to be an independent cause of atraumatic osteonecrosis. The risk of developing OFH in cirrhosis patients increases by 2.4 folds and the need for total hip arthroplasty increases by 10 folds. Liver disease has been associated with worse outcomes and higher costs after arthroplasty. Cirrhosis is a risk factor for arthroplasty complications and is associated with a prolonged hospital stay, higher costs, readmission rates, and increased mortality after arthroplasty. Greater physician awareness of risk factors associated with musculoskeletal complications of CLD patients would yield earlier interventions, lower healthcare costs, and better overall clinical outcomes for this group of patients.

Preoperative femoral abduction angle correlates with initial postoperative lateral hip pain after transcutaneous osseointegrated prosthetic system (TOPS) in transfemoral amputees.

PURPOSE: To analyse whether a preoperative femoral abduction angle (FAA) correlates with postoperative initial lateral hip pain (LHP) in above-knee amputees (AKA) treated with transcutaneous osseointegrated prosthetic system (TOPS). METHODS: Pre- and postoperative long-leg radiographs of eighteen unilateral AKA (mean age 51.55y ± 12.16) were retrospectively measured. FAA was measured on both sides. Pain intensity of LHP was measured by numeric rating scale (NRS) preoperatively and every week for four weeks from the first day of weight loading. Pearson's r was calculated for correlation. Furthermore, odds ratio for LHP ≥ 5/10 NRS and relative FAA > 13° was calculated. RESULTS: FAA significantly decreased in the postoperative period (pre/post. 15.33° ± 4.22; p < 0.001). Median LHP was 0/10 NRS (min.0, max.3) preoperatively and 4/10 NRS (min.2, max. 7, p < 0.001) postoperatively after first loading. Interestingly, it decreased within four weeks to a median of 0.5/10 NRS (min.0, max. 3) without intervention. A strong correlation was seen on the amputated side between preoperative FAA and LHP after loading (r = 0.835, p < 0.001), as well as the relative FAA to LHP after loading (r = 0.732, p < 0.001) and between the gap of pre- to postoperative FAA and LHP. Odds ratio for LHP ≥ 5/10 and relative FAA > 13° was 6.4 (95%CI = 0.55; 74.89). CONCLUSION: The preoperative FAA strongly correlates with postoperative LHP. Surgeons should be aware of high risk of LHP that can limit prosthetic training. High preoperative FAAs should be realised in the decision meeting of TOPS implantation and pre-rehabilitative reduction of the FAA should be taken into consideration.

Risk factors for dislocation after bipolar hemiarthroplasty: a retrospective case-control study of patients with CT data.

PURPOSE: Bipolar hemiarthroplasty has been shown to have a lower rate of dislocation than total hip arthroplasty. However, as the influencing risk factors for bipolar hemiarthroplasty dislocation remain unclear, we aimed to analyse patient and surgeon-specific influencing risk factors for bipolar hemiarthroplasty dislocation. METHODS: We retrospectively analysed patients who were operated between 2012 and 2018 and had dislocated bipolar hemiarthroplasty and matched them to patients without a dislocated bipolar hemiarthroplasty, operated between 2018 and 2019. The study was limited to patients who received either a pre- or postoperative pelvic computed tomography. Besides demographic, morphologic, and physiologic data, we analysed duration of surgery; ASA score; Charlson Comorbidity Index; Almelo Hip Fracture Score; Parker Score; and acetabular morphology angles including acetabular anteversion angle, posterior acetabular sector angle, posterior wall angle, and acetabular roofing. RESULTS: We included nine patients with a dislocated bipolar hemiarthroplasty and 30 with a non-dislocated bipolar hemiarthroplasty. Patient-specific factors prompting a higher risk for dislocated bipolar hemiarthroplasty were longer duration of surgery (min) (115 ± 50 vs. 80 ± 27, p = 0.01); dementia (56% vs. 13%, p < 0.01); smaller posterior acetabular sector angle (°) (96 ± 6 vs. 109 ± 10, p < 0.01); and smaller posterior wall angle (°) (67 ± 6 vs. 77 ± 10, p = 0.02). CONCLUSION: Dementia and insufficient posterior wall angle were associated with higher risk of dislocation in bipolar hemiarthroplasty.

Management of complex femoral nonunion with monorail external fixator: A prospective study.

AIM: To evaluate 30 patients who underwent distraction osteogenesis with monorail external fixator for complex femoral nonunion. METHOD: Complex femoral nonunion includes infective non-union, gap nonunion, and limb-length discrepancy secondary to traumatic bone loss, which needs specialized treatment to ensure the functional integrity of femoral bone. 30 patients, including 28 male and 2 female (aged 22-62 years) patients, underwent surgical debridement followed by bone transport with monorail fixator. The lengthening index, radiographic consolidation index, functional status, bone healing, and various problems, obstacles, and complications encountered during the treatment were assessed. RESULTS: Patients underwent a mean of 2.2 (range 1-4) surgeries before presentation. The mean bone defect after surgical debridement was 5.83 cm (range 2-16 cm). The mean treatment duration was 204.7 days (range 113-543 days). The mean lengthening index was 13.06 days/cm with range from 12 to 16 days/cm. Mean maturation index was 23.51 days/cm with range from 17 to 45.5 days/cm. In our study, bone result was excellent in 17, good in 9, fair in 3, and poor in 1 patient. In our study functional outcome is excellent in 9 [30%], good in 14 [46.67%], fair in 5, and poor in 2 patients. In our study, we encountered 34 problems, 17 obstacles, and 8 complications. CONCLUSION: We concluded that monorail external fixator is an effective treatment option for complex nonunion femoral shaft fracture and its functional outcome is comparable with any other treatment options. Lack of complications and its effectiveness makes monorail external fixator the treatment of choice for complex nonunion femoral shaft.

Osteosclerotic and osteolytic manifestations of hyperparathyroidism in a case of Tc99m SestaMIBI positive parathyroid adenoma.

Primary hyperparathyroidism is the first differential diagnosis when a patient presents with asymptomatic hypercalcemia. The symptoms of hyperparathyroidism can be as grave as skeletal, cardiovascular, and neuropsychological changes. Skeletal manifestations are relatively common, and patient may present with generalized or focal bone pains, fragility fractures, subperiosteal bone resorption, and osteolytic lesions like brown tumors and salt and pepper appearance of the skull. However, focal osteosclerotic lesions of the skull are rare findings in hyperparathyroidism. Only a few cases of associated osteosclerosis are reported in the literature. Here, we report a case of Tc99m SestaMIBI positive parathyroid adenoma with coexisting osteolytic and osteosclerotic skull lesions on Tc99m methylene diphosphonate bone scan.

Application of monorail fixator for femoral gap nonunion.

Difficult femoral nonunion takes account of infective nonunion and aseptic gap nonunion. Limb length discrepancy and nonunion need to be tackled simultaneously. Conventionally Ilizarov ring fixator is in vogue but it has some limitations. To overcome these, monorail fixator is an effective alternative. Persistent good results can be obtained if we can get a perfect anatomical alignment and good regeneration.

An unusual cause of radial nerve palsy.

Neurapraxia frequently occurs following traction injury to the nerve intraoperatively, leading to radial nerve palsy which usually recovers in 5-30 weeks. In our case, we had operated a distal one-third of humeral shaft fracture and fixed it with 4.5 mm limited contact dynamic compression plate. The distal neurovascular status of the limb was assessed postoperatively in the recovery room and was found to be intact and all the sensory-motor functions of the radial nerve were normal. On the second postoperative day, following the suction drain removal and dressing, patient developed immediate radial nerve palsy along with wrist drop. We reviewed the literature and found no obvious cause for the nerve palsy and concluded that it was due to traction injury to the radial nerve while removing the suction drain in negative pressure.

Proximal Femoral Stress Reaction in A Military Recruit - A Treatment Prospect.

INTRODUCTION: Stress fractures occur in individuals in whom repetitive strenuous muscle and tendon force act on bone; that have not adapted to such forces. Under a constant load, osteoclast resorption and osteoblastic reconstruction of bone are in equilibrium, resulting in normal remodeling. If loading increases, additional bone resorption occurs. Increased osteoclastic activity at sites of stress may cause local weakening and predispose to micro damage. If allowed to progress, such micro fractures may progress to complete fractures. CASE REPORT: A 30-year-old man presented with right thigh pain for 3 days without any history of significant trauma. He was a military recruit with history of running 5 miles a day for last 12 years and was running 20 miles a day for last 5 days before he developed pain. Examination revealed pain to palpation along the proximal medial and lateral right thigh. Range of motion was painful and limited. Radiograph of right hip showed fracture line in intertrochanteric region of femur. CONCLUSION: Here we have reported a case of stress fracture of proximal femur in intertrochanteric region which to our knowledge has not been reported in the literature so far. This fracture is important to recognize early as there are high chances of displacement resulting in increased risk of complications. We suggest immediate anatomical reduction and stable internal fixation to prevent complications and early mobilization to decrease the morbidity.

Role of nonoperative treatment in managing degenerative tears of the medial meniscus posterior root.

BACKGROUND: Tears of the medial meniscus posterior root can lead to progressive arthritis, and its management has no consensus. The aim of our study was to evaluate the effect of supervised exercise therapy on patients with medial meniscus posterior root tears. MATERIALS AND METHODS: Between January 2005 and May 2007, 37 patients with this tear verified by magnetic resonance imaging (MRI) and osteoarthritis grade 1-2 by radiographic examination were treated by a short course of analgesics daily for up to 6 weeks and then as required during follow-up, as well as a 12-week supervised exercise program followed by a home exercise program. Final analysis was performed for 33 patients, average age 55.8 (range 50-62) years and average follow-up of 35 (range 26-49) months. Patients were followed up at 3, 6, and 12 months and yearly thereafter using the Lysholm Knee Scoring Scale, Tegner Activity Scale (TAS), and visual analog scale (VAS). The analysis was performed using one-way analysis of variance (ANOVA) and Pearson's correlation coefficient to determine the relationship between Lysholm score and body mass index (BMI). RESULTS: Patients showed an improvement in Lysholm score, TAS, and VAS, which reached maximum in 6 months and later was accompanied by a decline. However, scores at the final follow-up were significantly better than the pretherapy scores. There was also a progression in arthritis as per Kellgren and Lawrence radiographic classification from median 1 preintervention to median 2 at the final follow-up. A correlation between BMI and Lysholm scores was seen (r = 0.47). CONCLUSION: Supervised physical therapy with a short course of analgesics followed by a home-based program results in symptomatic and functional improvement over a short-term follow-up; however, osteoarthritis progression continues and is related to BMI.

We need a break: Bisphosphonates.

Bone is a dynamic tissue. It remodels, thereby maintaining serum calcium, repairing micro damage and maintaining strength. A reduction in the strength of bone leads to osteoporosis that may manifest clinically as low energy vertebral and non-vertebral fractures. The bone strength, in turn, is determined by its material, structural properties and on its remodeling potential. Commonly, osteoporosis is objectively evaluated by 'T' and 'Z' scores and these are the indicators of bone density as determined by Dexa scan; these scores correlate inversely with the fracture risk. Quite often, we forget that Dexa scan results are not the only factors determining bone strength and the association between bone density and bone strength is not fixed, and is exemplified by the example of "osteopetrosis". The same issue is happening with the prolonged use of bisphosphonates (BP's).

Scurvy: An unusual presentation of cerebral palsy.

Scurvy is caused by prolonged severe dietary deficiency of ascorbic acid, in which the breakdown of intercellular cement substances leads to capillary hemorrhages and defective growth of fibroblasts, osteoblasts and odontoblasts, resulting in impaired synthesis of collagen, osteoid and dentine. It is characterized by hemorrhagic gingivitis, subperiosteal hemorrhages, perifollicular hemorrhages, and frequently petechial hemorrhages (especially on the feet). People with abnormal dietary habits, mental illness or physical disability are prone to develop this disease. Epiphyseal separation is known to occur in scurvy but is rarely seen now. Epiphyseal separation from the metaphysis is always through the zone of calcified cartilage, known as "scorbutic lattice", which in the radiographs is represented as "the white line of Frenkel". We report a case of multiple epiphyseal separations in a cerebral palsy child because of vitamin C deficiency. The child was treated with splintage of extremity and nutritional supplementation. All physeal separation healed completely without any deformity.