Catastrophic case of the total knee arthroplasty dislocation: A case report.

INTRODUCTION AND IMPORTANCE: Arterial injury is extremely rare after total knee arthroplasty. CASE PRESENTATION: We describe a 68-year-old woman with dislocation of total knee arthroplasty after falling from a height. She had a popliteal artery injury and a vascular bypass was performed in delay. The patient died of a second myocardial infarction 3.5 months after her first introduction to our center. CLINICAL DISCUSSION: Due to the prominent risk of vascular injuries after dislocation in TKA patients, we recommend performing vascular evaluations using CT angiography for all patients. CONCLUSION: Any untreated vascular compromise in the setting of TKA dislocation may lead to devastating outcomes such as amputation and death.

Cervicothoracic (C6, C7 & T1) spina bifida occulta - A case report.

INTRODUCTION: Spina bifida (SB), as one of the spine abnormalities, is caused by incomplete closure of the neural tube and generally includes two types: open and closed. This study aims to introduce one of the rare cases of closed SB. CASE PRESENTATION: A 34-year-old male patient was admitted to the hospital with neck pain. Radiographic and computed tomography (CT) imaging revealed bifid spinous processes from C6 to T1 vertebrae, indicative of a rare case of closed SB in the cervicothoracic region. CLINICAL DISCUSSION: Closed SB, while often regarded as benign, can be associated with various pathologies that require follow-up. CONCLUSION: Diagnosing this abnormality is crucial for addressing potential complications that may arise from it.

"Biological Fixation" of Flexor Digitorum Longus: A New Modification of Tendon Transfer for Treatment of Posterior Tibialis Tendon Dysfunction.

Numerous surgical procedures for the treatment of posterior tibialis tendon (PTT) dysfunction have been developed, including tendon transfers, osteotomies, and arthrodesis. Among these methods, foot and ankle surgeons most frequently use flexor digitorum longus (FDL) tendon transfer in conjunction with medial translational osteotomy of the calcaneus. Formerly, some less invasive techniques have been described to reduce surgical-related complications after FDL tendon transfer. Herein, we introduced a new modification of short-stump FDL tendon fixation to the navicular bone and reported the functional outcomes of the current technique in a patient with PTT dysfunction. In the current technique, the FDL tendon was fixed to the navicular bone via a trans-osseous tunnel using a split PTT stump. This method does not require any kind of fixation devices, such as an interference screw or anchor suture.Level of Evidence: V.

Bilateral floating knee injury in a child with down syndrome: A case report.

INTRODUCTION AND IMPORTANCE: Floating knee injury is a rare injury that involves a simultaneous fracture of the femur and tibia. It is more common among young men and is generally caused by high-speed blows. Down syndrome is a chromosomal disorder associated with various musculoskeletal conditions. Children with Down syndrome have generalized ligamentous laxity, joint hypermobility, and hypotonia, leading to musculoskeletal conditions such as atlantoaxial instability, hip instability, and patellar instability. CASE PRESENTATION: A 10-year-old boy with Down syndrome was admitted to the emergency room due to a car accident. Radiographic examinations revealed a diaphyseal fracture of the right femur and a diaphyseal open fracture of the tibia compatible with floating knee injury Type-D, and a physeal fracture of the distal femur (Salter-Harris type 2) and a metaphyseal fracture of the proximal tibia compatible with floating knee injury Type-C. The patient underwent preoperative investigations, including a neck radiograph, cardiology evaluation, pulmonary assessment, and hematologic check. The patient underwent surgery to fix all fractures. CLINICAL DISCUSSION: The necessary investigations were carried out to perform anesthesia and measures before, during, and after the operation. Down syndrome may help the patient recover, especially the ROM, due to various musculoskeletal conditions, such as generalized ligamentous laxity, joint hypermobility, and hypotonia. CONCLUSION: Children with Down syndrome may have various musculoskeletal conditions that can complicate the treatment of other injuries such as floating knee injury. Preoperative investigations should be performed to identify any potential complications.

The clasp and rubber bands technique to close large skin-soft tissue defect: A case report.

This article discusses the use of the skin-stretching technique (SST) to manage large soft tissue defects resulting from various causes. The other surgical techniques for closing such defects, such as pedicle flaps and free tissue flaps, are often associated with significant morbidity and cost. The SST involves progressively stretching soft tissue using an external device to reduce defect size or complete wound coverage. The article describes a simple, inexpensive, and readily available method for managing large wound defects using clasps and rubber bands. The article also highlights the potential complications associated with SST such as skin necrosis, pin site infection, wound dehiscence, infection, and pain. Overall, SST is a promising alternative for the management of large soft tissue defects that are not amenable to direct suturing.

Management of floating arm: a case report.

The floating arm is a rare fracture, and so far there have been few cases reported. The treatment of this type of fracture is challenging and depends on several factors including age, underlying conditions, daily level of activity, fracture pattern, surgeon's experience, and availability of devices. Case presentation: This study report a 59-year-old man with a rare humeral fracture and a severe crush injury of the forearm. There is a paucity of evidence regarding the management of concomitant floating arm and soft tissue injuries in the literature.The patient was managed by minimally invasive plate osteosynthesis (MIPO) and vacuum-assisted closure (VAC) followed by a split-thickness skin graft. Clinical discussion: The concurrent presence of the two pathologies exacerbated the patient's condition and made the management challenging. In this case, the authors have used the MIPO approach to fix both fractures with minimal soft tissue injury. To manage the prominent soft tissue injury, we applied the VAC device. VAC has the advantages of reducing edema, controlling bacterial growth, and promoting granulation tissue formation, leading to faster cellular turnover and healing. Conclusions: In patients with floating arm, especially with concomitant soft tissue damage, the MIPO approach is a safe, minimally invasive, and quick method with minimal bleeding.

Efficacy of Platelet-Rich Plasma for Chronic Lateral Ankle Instability After Modified Broström-Gould surgery: A Randomized, Single-Blinded, Prospective Controlled Trial.

Background: Modified Broström-Gould (MBG) surgery is frequently used for chronic lateral ankle instability (CLAI). However, conventional postoperative management (CPOM) due to prolonged immobilization may have adverse effects on tendons, ligaments, and joints, causing stiffness. This prospective, randomized controlled trial aimed to determine outcomes among patients randomized to receive CPOM plus ultrasonography-guided triple injections of leukocyte-rich platelet-rich plasma (LR-PRP) compared to patients who receive only CPOM after MBG surgery. Methods: The present study included 40 patients with symptomatic CLAI who were candidates for the MBG surgery. The patients were randomized into 2 groups of 20, the control and PRP groups. In the PRP group, patients were injected with 3 doses of LR-PRP solution using ultrasonographic guidance. In the first injection, 2 mL of LR-PRP was injected near the injury site, and in the second and third injections, 4 mL of LR-PRP was injected in the tibiotalar joint. All patients received a short leg splint for 2 weeks, followed by 4 weeks in a walking boot. The primary outcome measure was the visual analog scale (VAS), and the secondary outcome measures were the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scale and ankle total range of motion (total ROM). The assessment was performed at baseline and 3 and 6 months after surgery. Results: The mean VAS and AOFAS scores improved significantly in both groups 6 months after surgery (P < .001). However, the PRP group did not significantly improve in VAS or AOFAS scores compared with the control group. No clinically significant difference was observed between the 2 groups regarding the total ROM scores at month 3. Conclusion: The application of LR-PRP after MBG surgery did not show any superior clinical or functional improvement over CPOM. Level of Evidence: Level II, prospective randomized trial.

Job satisfaction, Career Burnout, and Work-Related Well-Being Prevalence among Orthopedic Surgeons: A Nationwide Study.

Background: Burnout is a well-known consequence of chronic stress. Orthopedic surgery is among the most desired specialty among Iranian medical students. The nature of the job, the income, and the ability to deal with stress can all be stressful factors for orthopedic surgeons. Nonetheless, little is known about how these medical doctors work and live in Iran. The present study aimed to assess job satisfaction, engagement, and burnout among Iranian orthopedists. Methods: A nationwide online survey was conducted in Iran. Job satisfaction, engagement, and burnout were evaluated using the job description index (JDI), Utrecht Work Engagement Scale, and Maslach Burnout Scale. They were also asked some additional questions related to career choice. Results: A total of 456 questionnaires (41% response rate) were retrieved. Overall, 56.8% of the participants experienced burnout. The burnout levels significantly differed based on age, years from graduation, working in public hospitals, operating more than 10 patients in a week, monthly income, having less than two children, and being single (P<0.05). They scored higher on work questions on the present job and jobs in general but lower scores on pay and opportunities for promotion. Conclusion: In a national study of orthopedic surgeons, their primary concern in JDI was "pay and promotion." Burnout was substantially associated with respondents' characteristics, such as younger age and having fewer children. This will lead to impaired performance, increased patient complaints, and the tendency to immigrate.

Effects of fixation of clavicle fracture using wide-awake local anesthesia no tourniquet (WALANT) technique on intra-operative bleeding volume, surgical duration, and post-operatively visual analog scale (VAS); A case series study.

Clavicle fractures are common fractures with a rate of 2-5 percent among fractures. Mid-shaft fractures of the clavicle are more common than the other sites of the clavicle. Traditionally, surgical fixation of clavicle fractures has been performed under General Anesthesia (GA). The purpose of this study was to assess the effects of WALANT on intraoperative bleeding, pain control during and after surgery, postoperative complications and patients' function. In the current study, 30 patients with clavicle fractures were surgically fixed using the WALANT technique. The obtained results showed that it could be an effective technique for pain control during the operation and also early postoperative period. Moreover, the WALANT technique could be considered safe in patients who are at risk for GA because of medical comorbidities, cervical spine injuries, or other factors that make intubation difficult.

Initial Outcomes of a Novel Modification of Looped Threaded Carpal Tunnel Release Method.

Various surgical techniques are available for the alleviation of symptoms in carpal tunnel syndrome and each of them has its pros and cons. This study was designed and performed to present a novel approach for cutting transverse carpal ligament by the thread looping technique without the use of ultrasonography. The novel modification of looped threaded carpal tunnel release was performed on 10 hands of 10 patients. The disabilities of arm, shoulder, and hand score, visual analog scale, and 2-point discrimination were used for assessing the outcomes. No patients developed pillar pain or scar discomfort after surgery. Complete elimination of paresthesia, pain, and numbness occurred in all patients. There was a significant reduction in the disabilities of arm, shoulder, and hand and visual analog scale scores ( P value<0.05). This technique is safe, available, and effective for carpal tunnel release and minimizes postoperative complications, such as pillar pain, and scar discomfort with avoiding unnecessary injuries to the surrounding soft tissue.

Clinical Outcomes of Double Mini-Plating Compared with a Single Superior Plating in Midshaft Clavicular Fractures: A Randomized Clinical Trial Study.

Background: In the current study, we aimed to assess the clinical outcomes of the double-plating method using 2.7 mm compression plates compared with the single superior 3.5 mm compression plating method in displaced midshaft fractures of the clavicle. Materials and Methods: Thirty patients with midshaft fractures of the clavicle were randomly assigned into two groups. In group A, 15 patients were fixed by a double-plating technique using two 2.7 mm compression plates on the superior and anteroinferior sides of the bone. The fractures in group B were fixed by a superior plating technique using a single 3.5 mm compression plate. Intraoperative bleeding measurement, length of surgical incision, duration of procedure time, and functional scores were assessed post-surgically through one-year follow-ups. Results: There was no significant difference between groups in terms of surgery time. Device failure was not found among all recruited patients. Incision length and device prominence complaint were significantly different between groups (P value = 0.02, P value = 0.03). Mean ± standard deviation intraoperative bleeding rate was 88.67 ± 29.96 milliliter in the double-plating group and 108.67 ± 41.72 milliliter in the other group, which was not different between these two groups (P value = 0.14). There were no signs of non-union either in radiographies or clinically. Conclusion: Double mini-plating of diaphyseal clavicular fractures could result in a smaller surgical incision and a lower rate of prominence without affecting fixation stability and clinical outcomes in comparison with single superior 3.5 mm plates.

Incidence of primary bone sarcomas in Iranian population (2008-2015): A national population-based study.

Background: Epidemiological characteristics of bone sarcomas are variant in different populations, however, there is no previous study on primary bone sarcomas among Iranian population. This study aimed to evaluate the incidence, age, sex distribution, histologic type, and location of malignant bone sarcomas, based on the Iran National Cancer Registry (INCR). Methods: This was a national population-based study using INCR data from March 20, 2008, to March 20, 2015, on patients who were diagnosed with primary bone sarcomas of the appendicular (C-code:40) and axial skeleton (C-code 41), excluding skull and face bones. Primary bone sarcomas were classified according to the International Classification of Diseases for Oncology (ICD-O-3: C40-C41). Results: A total of 4112 patients (59.5% males and 40.5% females) with a mean age of 36 years were included in the study. 60.38% of patients were between 10 to 44 years old. The overall age-standardized incidence rates (ASIR) was 8.23 (males=9.67 and females=6.80) per million person-years. Osteosarcoma chondrosarcoma and Ewing sarcoma were the three main histology subtypes with the ASIR of 2.36, 1.26, and 1.08 per million person-years. Long bones of the lower limb were the most affected area, with the ASIR of 3.18 (95% CI: 3.02-3.33) per million. We found an increasing trend in the incidence of bone sarcomas in Iran from 8.59 in 2007 to 11.37 per million person-year in 2015. Conclusion: This study provided the epidemiological features of bone sarcomas, including the histological type of sarcoma, tumors' location, and patients' age and gender in the Iranian population for the first time.

Successful Reconstruction of Proximal Phalanx Condylar Fracture in an Athlete Using Auto-Osteochondral Graft from the Base of Fifth Metacarpus: A Case Report and Review of Literature.

Intra-articular fractures of the proximal phalanx head, especially with the condylar defect, are relatively rare but challenging for surgical treatment. Although several surgical procedures are available to reconstruct articular cartilage defects, the optimal method is unclear. This study reports a successful osteochondral reconstruction of proximal phalanx condylar defect in an athlete using the articular portion of the fifth metacarpal base.

Wide-awake local anesthesia for open rotator cuff repair: A case report.

INTRODUCTION AND IMPORTANCE: Improper treatment of rotator cuff tear might result in progression of tear and deterioration of patient function. The rotator cuff tear can be managed conservatively in most cases however surgical treatment is inevitable in persistent patients. PRESENTATION OF CASE: A 45-year-old woman presented to our clinic with shoulder pain and restricted range of motion following a fall from a height three months before the current presentation. Due to the lack of favorable response to conservative treatment and the fact that rotator cuff rupture was traumatic, she became a candidate for rotator cuff repair surgery. Due to financial issues and the patient's refusal of undergoing general anesthesia we considered the WALANT technique. Prior to surgery, we explained the whole procedure to the patient, referring to its pros and cons. CLINICAL DISCUSSION: The WALANT procedure is a relatively recent technique that has become widespread in orthopedic surgery in the past decade. The advantages of the WALANT technique are that it is simple, feasible, and safe and that the analgesic is adequate during the operation and for the first few hours afterward (5). Concerns with this method include patient discomfort and pain during surgery, which can be managed by educating the patient and minute-by-minute explanation during the procedure. CONCLUSION: We advocate open rotator cuff repair with the WALANT approach as an effective, cost-saving, safe, simple, and quick alternative to general and regional anesthesia for certain patients or with limited anesthetic resources. LEVEL OF EVIDENCE: V.

Electric shock sign after digital nerve injury; report of a case and review of literature.

INTRODUCTION AND IMPORTANCE: Digital nerve lacerations are rationally common, especially following penetrating injuries. The majority of patients suffer from numbness as the main complaint. However, electric shock pain is a rare manifestation of partial nerve injury. CASE PRESENTATION: A 65-year-old woman with partial digital nerve injury and an electric shock sign due to a 1 cm laceration on the volar side of the proximal phalanx three weeks earlier. The surgical exploration revealed a neuroma-like mass in the digital nerve; however, the continuity of the nerve was grossly intact. CLINICAL DISCUSSION: Due to the superficiality of digital nerves, penetrating nerve injuries are rationally common in this area. Laceration of the digital nerve could lead to loss of sensation, clumsiness, and even loss of function. Gradually, neuroma formation would add a local pain and electric shock sign to the mentioned symptoms. CONCLUSION: Electric shock sign is characteristic for partial digital nerve injury with unknown mechanism. It seems the symptoms would be progressive and more complicated with neuroma formation. LEVEL OF EVIDENCE: V.

Orthopedic Trauma During Pregnancy; a Narrative Review.

Introduction: Blunt traumas, like road accidents and falls, are common causes of injuries to pregnant women, and the major risk factors are young age and low socioeconomic level. Due to physiological and anatomical changes specific to pregnancy, such as changes in blood pressure and hemoglobin drop, trauma management involves certain complexities. Physical trauma is estimated to cause at least 1 complication in every 12 pregnancies. This study aims to evaluate orthopedic trauma during pregnancy and appreciate the different approaches to circumvent the resultant challenges. Methods: We reviewed 55 articles, published on orthopedic trauma during pregnancy between 2011 and 2021. The articles were identified by searching PubMed, google-scholar, Scopus, and Science-Direct. We utilized the search terms: fall in pregnancy, traumas in pregnancy, motor vehicle accident/crash in pregnancy, blunt trauma in pregnancy, pregnant trauma patient, penetrating injury during pregnancy, assault, interpersonal violence in pregnancy, and mortality and pregnancy. Results: According to available reports, after stabilizing the pregnant patient, diagnostic procedures, including radiography, and even gadolinium-based techniques when needed, can be performed to examine extensive trauma. In contrast to elective orthopedic surgery, emergency orthopedic surgeries, including reduction of open fractures, should be performed promptly. Conclusion: Based on our investigation, pregnant women with orthopedic injuries that are severe, or even seemingly less severe, experience significantly increased adverse pregnancy outcomes, which include preterm birth, placental abruption, poor infant condition at birth, infant death, and even maternal death.

Pilot Study of Additive Effect of "Offloading Ilizarov Frame" To Reduce "Reverse Sural Flap" Surgery Complications: A Clinical Trial.

Background: A reverse sural flap is an available surgical technique because it provides robust axial blood circulation to flaps with a substantially larger surface area. We aimed to assess Ilizarov frames outcome after reverse sural flaps among patients with traumatic injuries to the distal portion of the leg. Methods: Patients with traumatic distal injury of leg in Shoha-e Tajrish Hospital in 2022-2021 were recruited and treated with reverse sural flaps. Interventional group was followed by Ilizarov frames application (group A). For the second group, just conventional dressings and proper positioning were done after surgery (group B). Between the two groups, the duration of surgery, the degree of flap swelling, the time from surgery to discharge and flap failure, surgical site infection, deep vein thrombosis (DVT), and other complications were compared using SPSS 25 software. Results: Of 26 recruited patients, twenty consented to participate in this study. The average time from initial injury to reconstruction surgery, the mean duration of surgery, the mean time from surgery to discharge and the degree of swelling of the flap was compared between these two groups. The results showed better outcome in Ilizarov group, but the flap swelling grade was the only statistically significant factor between groups (P value= 0.03). Conclusions: The use of "offloading Ilizarov frames" to protect reverse sural flaps resulted in a considerable reduction in the flap swelling. It is a safe, quick, easy, and effective technique.

The Effect of COVID-19 Pandemic on the Characteristics of Pediatric Supracondylar Fracture: A Retrospective Cohort Study.

Background: Environmental factors play a key role in the occurrence of pediatric supracondylar humerus (SH) fracture which has been widely affected by the COVID-19 pandemic and the measures taken to curb its spread. In this study, we aim to investigate the ultimate impact coronavirus pandemic has had on SH fractures in children. Materials and Methods: This retrospective cohort study compares SH fractures which occurred during the pandemic with their prepandemic counterpart in a pediatric trauma public hospital. Patient's data, submitted from February to July 2020 and 2019, were collected and divided into two groups based on fractures' time of occurrence, i.e., during or before the pandemic. Results: There was no significant difference in terms of gender, type of fracture, injury location, and time of admission during a day between the aforementioned groups. However, in the pandemic group, patients were transferred to the operating room significantly quicker (odds ratio; 2.13 vs. 0.607, P = 0.01) and the surgery duration was shorter (40.17 ± 12.28 min vs. 49.11 ± 15.48 min, P = 0.011). It was found that the location of injury (home, school, etc.) varied between the two groups (P = 0.01) and the proportion of domestic injuries during the pandemic grew significantly (53.6% vs. 19.8%). Conclusion: Although the incidence of pediatric SH fractures has decreased due to the closure of schools and sports clubs during the pandemic, domestic occurrence of the same fracture type has grown disproportionately. To prevent this trend, pediatric centers should educate parents on child safety measures and fracture risks during the lockdown.

Osteochondral autograft transfer (mosaicplasty) for treatment of patients with osteochondral lesions of talus.

PURPOSE: Osteochondral lesion of talus (OLT) is one of the common causes of ankle pain. This disorder is common in young athletes after ankle injury. There are various therapeutic options. One of the options is mosaic plasticizer. The purpose of this study was to investigate the effect of mosaicplasty on improvement of symptoms of patients with osteochondral lesions of talus. METHODS: Nineteen patients with osteochondral lesions of talus participated in this study, who were treated with mosaicplasty. Before and after treatment, pain (visual analogue scale), function (American Orthopaedic Foot and Ankle Society), range of motion and radiographic signs were evaluated. RESULTS: The results of this study showed that mosaicplasty could significantly reduce pain, increase function and improve radiographic symptoms. The range of motion increased after treatment, which was not significant. CONCLUSION: We can confirm the effect of mosaicplasty on the improvement of patients with osteochondral lesions of the ankle, suggesting it as a treatment option.