Terrible Triad of the Elbow with Ipsilateral Complete Triceps Tearing, Distal Radius and Scaphoid Waist Fracture: A Case Report.

Introduction: The terrible triad of the elbow includes an elbow dislocation or subluxation with coronoid and in combination with radial head fractures. Still, none of them are accompanied by rupture of the triceps tendon. Case Report: The article describes a terrible triad injury in a young patient with an additional triceps rupture. The treatment involved lateral and medial approaches for the repair of various ligaments and fractures, but the elbow remained unstable. A posterior approach was used to repair the triceps rupture. Conclusion: Triceps tendon rupture may be accompanied by dribble triad injuries, highlighting the importance of pre-operative evaluation to select the most appropriate surgical approach. The selection of an optimal surgical approach is crucial for the successful treatment and management of these injuries.

Outcomes of the Modified Stoppa Approach in Acetabular Fracture Management: Incidence of Nerve Injuries.

Objectives: Displaced acetabular fractures are complex injuries that necessitate precise surgical intervention. Obturator nerve injuries occur in approximately 2% of cases. The modified Stoppa approach, offering enhanced exposure of the quadrilateral plate, has gained attraction as an alternative technique for anterior acetabular fractures. However, its proximity to the obturator nerve poses a risk of iatrogenic injury. This study aimed to investigate the incidence of nerve injuries and functional outcomes in patients undergoing the modified Stoppa approach for traumatic acetabular fractures. Methods: This retrospective study involved 86 patients with anterior column fractures, whose data were prospectively collected. The fractures were treated using the modified Stoppa approach. Exclusion criteria were pathological fractures, alternative surgical approaches, prior nerve injuries, hip issues, refusal to participate, or inadequate follow-up. Data collection involved pre-operative imaging, thorough post-operative neurological assessments, and post-operative radiographic evaluation. Functional outcomes were assessed using the Harris Hip Score (HHS). Results: Most patients were male (n=54) with a mean age of 40±17.3 years. Post-operative infection occurred in six cases, with resolution in four through antibiotics and two necessitating device removal. Obturator nerve damage was detected in 14 patients, comprising nine traumatic and five iatrogenic cases. During the follow-up, symptoms improved in all patients, except for the four patients with iatrogenic nerve damage. Conclusion: Traumatic nerve injuries generally heal naturally over time. In contrast, iatrogenic injuries have a less optimistic prognosis, potentially resulting in lasting neurological deficits.

Acellular Fish Skin for Deep Dermal Traumatic Wounds Management; Introducing a Novel Dressing.

The optimal therapy for deep wounds is based on the early debridement of necrotic tissue followed by wound coverage to avoid a systemic inflammatory response and optimize scar-free healing. The outcomes are affected by available resources and underlying patient factors, which cause challenges in wound care and suboptimal outcomes. Here we report a patient with deep dermal injury wounds, who was treated with platelet-rich fibrin (PRF) gel, plasma rich in growth factor (PRGF) gel, and acellular fish skin. Patient's outcomes regarding healing and scar quality were collected objectively and subjectively for one year after the injury. Wounds treated with acellular fish skin demonstrated accelerated wound healing, a significantly higher water-storage capacity, and better pain relief. Furthermore, improved functional and cosmetic outcomes, such as elasticity, skin thickness, and pigmentation, were demonstrated. It seems that, the PRGF gel and PRF in combination with acellular fish skin grafts resulted in the faster healing of wounds and better functional and aesthetic outcomes than split-thickness skin grafts treatment.

Atypical anterior wall fracture extending to anterior inferior iliac spine with preservation of pelvic brim: A case report and literature review.

Key Clinical Message: Anterior acetabular wall fractures that extend into the anterior inferior iliac spine are more likely to be unstable, and more likely to require surgical fixation. Abstract: Conventional acetabular anterior wall fractures originate below the anterior inferior iliac spine (AIIS) level and involve the pelvic brim. Since surgical treatment is preserved for instability and hip incongruency, atypical variation of this fracture usually jeopardizes hip stability. We report on a 33-year-old case of an acetabular anterior wall fracture extending to the anterior inferior iliac spine. He was prepared for the stress test and hip stability checked, that was unstable in extension and external rotation. The joint was exposed with the Smith-Peterson approach. Hip congruency was restored, and the AIIS fragment was stabilized by open reduction. Acetabular anterior wall fracture involving AIIS with preservation of pelvic brim is a rare equivalent of anterior wall fracture that jeopardizes hip stability and should be managed surgically. Anterior approaches are preferred in order to visualize the joint.

Improved physical disability and nutritional status by bovine colostrum supplementation in adults with traumatic peri-trochanteric femoral fracture: A randomized, controlled, clinical trial.

OBJECTIVES: Patients with femur fracture after surgery are at risk of malnutrition, weight loss, disability, and mobility complications. In the present study the role of colostrum supplementation on physical disability, and some nutritional variables after surgery has been investigated. RESEARCH METHODS & PROCEDURES: Patients were randomly assigned to two groups. The intervention group received 45 g colostrum and the control group received 15 g whey protein daily for 21 days (each containing 12 g of protein). The trend comparison during 30 days of variables including weight, appetite, serum albumin level, hemoglobin and lymphocytes between the two groups was modeled with the generalized estimation equation. Moreover, the trend comparison during 90 days of Oswestry Disability Index (ODI) between the two groups was calculated. RESULTS: The basic characteristics were the same between the two groups (colostrum, n = 46; control, n = 48). Protein intake was the same in both groups during the study period. There was a significant difference in weight gain (ß = 0.32, 95 % CI: 0.09-0.54; P = 0.005) within 30 days after operation between the colostrum and control groups in favor of the increase in the colostrum group. Compared to the control group, patients in the colostrum group had a 0.31 score more appetite (P < 0.001), 0.17 g/dL higher serum albumin level (P = 0.001), 0.5 mg/dL higher hemoglobin level and 440 more blood lymphocytes (P < 0.001) during the 30 days of intervention. Regarding physical function disability, patients in the colostrum group had about 4 ODI scores lower than the control group during the study period. CONCLUSION: Colostrum supplement can increase appetite, hemoglobin, serum albumin level and the number of blood lymphocytes more than the control group. It can also accelerate weight gain and physical performance after surgery.

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.

Two-step sequential management for hip arthroplasty after hip joint gunshot injury: A case report.

Combined fractures of the femoral head and acetabulum due to hip gunshot injuries (GSI) are rare, and there is no preferred treatment option. We present a 35-year-old male patient who sustained a right hip GSI. Delayed THA with a two-step sequential approach is a feasible management in this situation to manage soft tissue and decrease infection rate. At a 1-year follow-up visit, the pain was relieved, and the function improved significantly, and he had no complaints.

Spinopelvic imbalances are associated with worse postoperative functional outcomes in patients undergoing total hip arthroplasty.

PURPOSE: We aimed to investigate the relationship between spinopelvic imbalances and functional disabilities after total hip arthroplasty in an at least two years of follow-up. METHODS: Patients with normal sagittal alignment and normal motion (PI-LL < 10°, APP < 13°, ∆SS > 10°) were defined as control, and patients with any of sagittal alignment or motion abnormalities were defined as case groups. Visual Analog Scale, SF-36, Harris hip score, HOOS-JR, and complications were recorded. RESULTS: The differences of the means of Harris hip score, HOOS-JR, SF-36, and VAS score in the control and case groups were statistically significant. The mean of these parameters in patients with sagittal balanced (PI-LL < 10°) was much better than patients with sagittal unbalanced (PI-LL > 10°). Same results were noted in patients with decreased (∆SS < 10°) and normal spinopelvic motions (∆SS > 10°). CONCLUSION: Our observations indicate that spinopelvic imbalances are associated with worse postoperative functional outcomes in patients undergoing total hip arthroplasty.

Klebsiella pneumoniae and Enterobacter cloacae Induced Septic Arthritis in a Healthy Adolescent: A Rare Case Report.

Septic arthritis (SA) is a joint inflammation that develops secondary to infectious causes. SA in children is associated with a high rate of morbidity and mortality; therefore, it is regarded as an orthopedic emergency. Because SA of the hip joint usually mimics other musculoskeletal diseases, diagnosis remains challenging. Although this lesion usually shows a good outcome, treatment at an inappropriate time, neglect, or inadequate treatment could lead to poor outcomes. We report on the case of a healthy adolescent who complained of episodes of fever and chills, weight loss, pain in his left hip, and limping. After performing necessary workups, two differential diagnoses of tumor and SA were made. The results of Gram stain and culture of the synovial fluid after surgical excision showed Klebsiella pneumoniae and Enterobacter cloacae complex. To the best of our knowledge, this is the first report of SA due to co-infection with K. pneumoniae and E. cloacae in a healthy patient.

Thoracolumbar and Lumbar Posterior Vertebral Resection for the Treatment of Rigid Congenital Spinal Deformities in Pediatric Patients: A Long-Term Follow-up Study.

Objective: We sought to determine whether a posterior vertebral resection on congenital deformities of thoracolumbar and lumbar vertebrae leads to more complications and provides less correction. Methods: Twenty-three patients underwent a posterior vertebral resection for a rigid congenital spinal deformity, which included scoliosis (13 patients), kyphoscoliosis (6 patients), and pure kyphosis (4 patients). The surgeries involved removing 1 to 2 vertebrae using multiaxial pedicle screws in all but 2 of the patients. All surgeries were performed under intraoperative spinal cord monitoring. Thoracic curve, lumbar lordosis, focal kyphosis, shift, and sagittal vertical axis were collected at baseline and during the last follow-up (taking place after at least 3 years) and were then statistically analyzed. Results: The major curve correction was about 55% in cases of scoliosis, with focal kyphosis improving from 54.3 ± 19.1 degrees to 21.3 ± 15 degrees. Two patients experienced intraoperative neuromonitoring changes, with data returning to baseline without any surgical intervention. Sensory or motor palsy after the surgery was not reported in patients.Despite improving sagittal or coronal deformities, 8 patients experienced excessive sagittal decompensation during follow-up, 1 of whom underwent revision surgery. Sagittal decompensation was by far the most common complication. Larger kyphoscoliosis or focal kyphosis angles were preoperative risk factors for postoperative sagittal imbalance (P value < 0.05). Conclusions: Using a lumbar or thoracolumbar posterior vertebral resection enables surgeons to correct rigid curves in the pediatric population without major risk to nerve roots. The primary complications would be sagittal decompensation and the likelihood of undercorrection, which requires mindful addressing during the preoperative planning stages.

Is Standing Coronal Long-Leg Alignment View Effective in Predicting the Extent of Medial Soft Tissue Release in Varus Deformity during Total Knee Arthroplasty?

The aim of this study was to assess the predictive value of the femoral intermechanical-anatomical angle (IMA), mechanical lateral distal femoral angle (mLDFA), medial proximal tibia angle (MPTA), femorotibial or varus angle (VA), and joint line convergence angle (CA) in predicting the stage of the medial collateral ligament (MCL) during total knee arthroplasty (TKA) of varus knee. We evaluated 229 patients with osteoarthritic varus knee who underwent primary TKA, prospectively. They were categorized in three groups based on the extent of medial soft tissue release that performed during TKA Group 1, osteophytes removal and release of the deep MCL and posteromedial capsule (stage 1); Group 2, the release of the semimembranosus (stage 2); and Group 3, release of the superficial MCL (stage 3) and/or the pes anserinus (stage 4). We evaluated the preoperative standing coronal hip-knee-ankle alignment view to assessing the possible correlations between the knee angles and extent of soft tissue release. A significant difference was observed between the three groups in terms of preoperative VA, CA, and MPTA by using the Kruskal-Wallis test. The extent of medial release increased with increasing VA and CA as well as decreasing MPTA in preoperative long-leg standing radiographs. Finally, a patient with a preoperative VA larger than 19, CA larger than 6, or MPTA smaller than 81 would need a stage 3 or 4 of MCL release. The overall results showed that the VA and MPTA could be useful in predicting the extent of medial soft tissue release during TKA of varus knee.

Anthropometric Measurements of Distal Femur to Design the Femoral Component of Total Knee Arthroplasty for the Iranian Population.

BACKGROUND: Acquiring knowledge about anatomic and geometric quantities of bones is among the most vital parameters in orthopedic surgery that has a significant effect on the treatment of various disorders and subsequent outcomes. The aim of this study was to obtain anthropometric information for distal femur in order to compare with similar dimensions of prosthesis used in total knee arthroplasty (TKA) surgery and to design more suitable and optimal components. METHODS: Morphological data of distal femur were measured in 132 knees (81 males and 51 females) using magnetic resonance imaging (MRI). The data included anterior-posterior (AP) length, medial-lateral (ML) width, medial AP (MAP), lateral AP (LAP), MAP to LAP distance in the anterior distal femur namely anterior medial lateral (AML) width, medial and lateral condyle width, and intercondylar notch. The aspect ratio (ML/AP) was also calculated and the results were compared with similar dimensions of currently used knee implants. RESULTS: Our data showed that men are significantly larger in all dimensions than women. In the distal femur with similar AP lengths in both sexes, women had a smaller ML width than men (P<0.001). Comparison between the distal femur and studied prostheses showed no high correlation and similarity between the femoral component and femoral condyle prostheses in the resected surface of the bone. CONCLUSION: The results of this study can provide the data needed to design prostheses suitable for the Iranian population.

Magnetic Resonance Imaging Assessment of Hip Abductor after Total Hip Arthroplasty Using a Direct Lateral Approach.

BACKGROUND: Surgical techniques and rehabilitations after total hip arthroplasty (THA) play a significant role in the improvement of pain and limping. This study aimed to assess hip abductor muscle's diameter and its strength after 6 months postoperative THA performed by Hardinge approach. METHODS: After obtaining the patients' demographic characteristics, the preoperative values of patients' hip abductor muscle diameter were measured using magnetic resonance imaging, and were compared with postoperative values 6 months later. Moreover, the hip abductor muscle's strength was assessed using the Trendelenburg test. RESULTS: A total of 88 patients participated in this study with a mean age of 47.3±1.574 years. It should be noted that 55.7% of the participants were male. Muscle diameter decreased from a mean value of 27.07±7.485 preoperative to mean value of 25.64±7.353 mm postoperative (P<0.001). Moreover, the degrees of Trendelenburg test (i.e., mild or severe) decreased after surgery (P<0.001). There was no significant difference between the frequencies of different grades of limping according to the studied variables. CONCLUSION: A decrease was observed in gluteus medius muscle diameter, and the Trendelenburg test results were improved in this study. Moreover, the difference between pre- and postoperative gluteus medius muscle diameters were measured using MRI. It can be concluded that MRI is not an appropriate diagnostic tool for the assessment of abductor strength after THA in the 6-month postoperative visit. Accordingly, it is suggested to evaluate muscle strength before and after each surgery to schedule the following treatment protocol required for each patient.

An uncommon presentation of hepatic hydatid cyst leading to biliary cirrhosis and portal hypertension.

Hydatid disease is an ongoing issue in endemic areas. Hydatid cysts can be seen in any organ but, liver is one of the most common involved organs. Cystobiliary communication as an overwhelming complication of hepatic hydatid cysts can contribute to the obstructive jaundice, cholangitis, sepsis and even biliary cirrhosis if left untreated. The patient we are trying to present is a 61-year-old farmer who presented with obstructive jaundice, multiple common bile duct stones and biliary cirrhosis attributed to a long-lasting untreated hepatic hydatid cyst. Portal hypertension is introduced to be an uncommon presentation of hydatid cyst. Extrinsic compression of the porta hepatis and obstruction of inferior vena cava are amongst major causes of hydatidosis leading up to portal hypertension as reported in the literature. Portal hypertension in the presented case is proposed to emerge from long-lasting cystobiliary communication ending in biliary cirrhosis.

Correlation of Anthropometric Measurements of Proximal Tibia in Iranian Knees with Size of Current Tibial Implants.

BACKGROUND: The results of clinical studies have reported that Asian knee anatomical aspects are smaller than those of the Caucasian population. The purpose of this study was to investigate the morphometry of the proximal tibia in the standard resected surface of total knee arthroplasty (TKA). METHODS: In this descriptive study, the anthropometric data of the proximal tibia were measured in 132 knees (80 males and 52 females) using magnetic resonance imaging in 2015. The collected data included anteroposterior (AP) length, mediolateral (ML) width, medial AP, lateral AP, and aspect ratio (ML/AP). The medial and lateral AP distance to bone center was calculated for symmetry analysis. The morphometric data were also compared with the same dimensions of four current tibial implants. RESULTS: The mean age of the subjects was 38.26±11.45 year (age range: 20-60 years). The mean AP length and mean ML width in the resected surface of the bone, as well as the mean aspect ratio (ML/AP) of tibial bone in all the subjects, were 46.53±4.05 mm, 73.36±6.86 mm, and 1.58±0.11, respectively. The mean values of medial and lateral AP distance up to bone center were 13.40±6.17 and 17.09±6.83 mm, respectively, indicating asymmetric proximal tibia in the study population. CONCLUSION: The measurements of anatomic shapes and dimensions of the proximal tibia revealed that women have smaller dimensions than their male counterparts. Prostheses with smaller AP size tended to be undersized and larger AP size had a tendency towards overhang in the mediolateral dimension. The data and obtained results of this study can be used as guidance on designing tibial implant components suitable for TKA in the Iranian population.

Prospect of mesenchymal stem cells in therapy of osteoporosis: A review.

Osteoporosis is a systemic skeletal disease associated with reduced bone strong point that results in raised fracture risk, with decreased bone strength, leading to reduced bone mineral density and poor bone quality. It is the most common in older females but some men are also at high risk. Although considered as a predictable result of aging, it is can be avoidable and treatable. The existing treatment of osteoporosis mainly contains antiresorptive and anabolic agents. In spite of these improvements, concerns around unusual side-effects of antiresorptive drugs, and the lack of perfect confirmation in maintenance of their long-standing effectiveness is bring about many patients not receiving these drugs. Over the years, the stem cell-based therapy has attained substantial clinical consideration because of its potential to treat numerous diseases. The stem cell therapy has been recommended as a probable therapeutic approach for patients with osteoporosis. Even though the concept of stem cell-based therapy for osteoporosis has caught substantial attention, no clinical trial has been published on humans. The cell studies based on osteoporosis are primarily focused on osteoclastic activity and bone resorption procedures. Earlier, it was on osteoblastogenesis and in recent times, on the differentiation probable of mesenchymal stem cells. In this review, we have summarized the therapeutic role of stem cell-based strategy in osteoporosis.

The Outcomes of Pilon Fracture Treatment: Primary Open Reduction and Internal Fixation Versus Two-stage Approach.

BACKGROUND: Pilon fracture is one of the challenging injuries in orthopedic surgery. Associated soft tissue injury is an important factor in choosing treatment options. Two major methods of treatment are considered as one-stage open reduction internal fixation (ORIF) and two-stage treatment (primary external fixation and secondary ORIF). The latter is most accepted in literature. In the current study, we compared the results of these two methods. METHODS: In a retrospective study, 41 patients were assigned to two groups containing one-stage primary ORIF (21 patients) group, and two-stage group included external fixation and secondary ORIF (20 patients). The rate of infection (superficial or deep infection, osteomyelitis), malunion, nonunion, duration of hospital stay, neurovascular injury, pain intensity, and patients' satisfaction with AOFAS score, were compared between the two groups. RESULTS: There was no significant difference between the two groups in measured variables except hospital stay which was significantly longer for the two-stage group. CONCLUSION: Based on our findings, we recommend using one stage ORIF for a patient with Pilon fractures type C and Tscherne 1, 2 if the patient is planned to be operated on during the first 24 hours after the injury.

Measurement of Posterior Tibial Slope Using Magnetic Resonance Imaging.

BACKGROUND: Posterior tibial slope (PTS) is an important factor in the knee joint biomechanics and one of the bone features, which affects knee joint stability. Posterior tibial slope has impact on flexion gap, knee joint stability and posterior femoral rollback that are related to wide range of knee motion. During high tibial osteotomy and total knee arthroplasty (TKA) surgery, proper retaining the mechanical and anatomical axis is important. The aim of this study was to evaluate the value of posterior tibial slope in medial and lateral compartments of tibial plateau and to assess the relationship among the slope with age, gender and other variables of tibial plateau surface. METHODS: This descriptive study was conducted on 132 healthy knees (80 males and 52 females) with a mean age of 38.26±11.45 (20-60 years) at Imam Reza hospital in Mashhad, Iran. All patients, selected and enrolled for MRI in this study, were admitted for knee pain with uncertain clinical history. According to initial physical knee examinations the study subjects were reported healthy. RESULTS: The mean posterior tibial slope was 7.78± 2.48 degrees in the medial compartment and 6.85± 2.24 degrees in lateral compartment. No significant correlation was found between age and gender with posterior tibial slope (P≥0.05), but there was significant relationship among PTS with mediolateral width, plateau area and medial plateau. CONCLUSION: Comparison of different studies revealed that the PTS value in our study is different from other communities, which can be associated with genetic and racial factors. The results of our study are useful to PTS reconstruction in surgeries.

First Carpometacarpal Joint Dislocation and Review of Literatures.

Dislocation of the first carpometacarpal (CMC) is a rare occurrence. Treatment of this dislocation varies from closed reduction and casting to ligament repair. Neglected dislocation or incomplete reduction of the 1(st) CMC cause chronic instability and painful arthritis, muscle imbalance and decreased grip force. In our study 6 patients is evaluated that were visited in less than 24 hours from their injury. All were primarily reduced and except one patient later injured ligament were repaired. All patient after 6 months had normal range of motion without pain and they had not any complaint. Stability at the 1(st) CMC joint is dependent on static and dynamic forces. However, dislocation of the 1(st) CMC occur rare, but important function of the thumb specially in gripping and grasping makes it a significant problem. Injured ligament should repair for increased stability of 1(st) CMC joint, because neglected dislocation or incomplete reduction cause chronic instability and painful arthritis.