Prevalence of Intimidation of Medical Students in the Clinical Years by the Staff at a Saudi Arabian University.

BACKGROUND: Intimidation of medical students by the staff appears to be an evolving problem. Our study aimed to determine the prevalence of intimidation among medical students by the staff, identify the types of intimidation that exist, and recognize the barriers that stand in the way of reporting any incident of intimidation. METHODS: A cross-sectional study was conducted among medical students in their clinical and final years at the College of Medicine, Taibah University (TU), Al-Madinah Al-Munawwarah, Saudi Arabia. Students were invited to voluntarily complete an anonymous survey that explored students' exposure to any type of intimidation, including verbal, physical, and sexual abuse, and academic intimidation. RESULTS: A total of 311 medical students participated in our study, with 164 females and 147 males. Of these, 187 (60.1%) students reported having received some sort of intimidation. The most testified type of intimidation was verbal abuse (165, 53.1%). Following that, in order of frequency, were academic intimidation (101, 32.5%), physical intimidation (25, 8.0%), and sexual abuse (13, 4.2%). CONCLUSION: Our study revealed a high rate of intimidation between the staff and medical students at our institution. Verbal abuse was the most popular type of intimidation. Promoting a more positive learning environment for medical students by managing the teacher-student relationship is crucial to improving students' learning outcomes. Medical schools should resist intimidation through strict guidelines.

The Reliability of the Divergence Angle for Evaluating Rotational Implant Positioning in Medial Unicompartmental Knee Replacement.

Background Unicompartmental knee arthroplasty (UKA) is a highly effective surgical procedure used to treat patients with osteoarthritis affecting a single knee compartment. UKA has gained significant popularity, accompanied by an expansion of its surgical indications. This increasing trend can be attributed to the consistently excellent clinical outcomes associated with UKA, which rival those achieved with total knee arthroplasty (TKA). However, despite these advancements, implant rotation malposition remains a prevalent factor contributing to early failure in UKA cases. The aim of this study is to analyze the rotational positioning of femorotibial implants in UKA and to identify an appropriate angle formed by the femoral component and the tibial component using a newly described angle. Methods This was a retrospective study of patients' data of 40 medial UKA cases of 33 patients who were operated on in our hospital between October 1998 and March 2019. The study introduces a new angle called the "divergence angle." This angle is formed between the lateral portion of the femoral component and the lateral part of the tibial component, as measured on a patellofemoral Merchant view at 30 degrees of knee flexion. The divergence angle was evaluated through radiographic assessment by two independent reviewers. Results According to statistical analysis, the divergence angle was highly reliable with both intra- and inter-observer reproducibility. Intra-observer reproducibility was excellent with an intra-class correlation coefficient (ICC) between 0.901 and 0.933 (p < 0.001). The inter-observer reproducibility was excellent with an ICC of 0.92 (p < 0.001). The Gaussian curve confirmed the normal distribution of the divergence angle values with moderate dispersion of values. The majority of the angles of divergence (85%) measured between the femoral and tibial components were less than 10 degrees (n = 34), with a mean angle of 6.3 ± 4.5°. Conclusion The divergence angle between the femoral and tibial components, measured at 30 degrees of knee flexion using the Merchant view, is an easily accessible, reliable, and reproducible method. This technique enables the assessment of the optimal rotational positioning of implants in medial UKA.

Primary Hydatid Cyst of the Thigh: Atypical Location and Perioperative Strategies to Minimize Recurrence After Accidental Cyst Rupture.

This study presents a rare case of hydatid cyst (HC) located in the left thigh, an atypical site for this parasitic infection, which typically affects the liver and lungs. A 22-year-old female presented with a gradually increasing swelling in the anterior aspect of her left thigh over a period of six months. The diagnosis of the thigh HC was established through a combination of imaging techniques, including ultrasonography and magnetic resonance imaging (MRI), and serological tests. The patient underwent surgical removal of the cyst. We also highlight a management strategy for perioperative accidental rupture of the cyst to minimize the risk of dissemination and reduce the likelihood of recurrence. This report emphasizes the need for a careful multidisciplinary approach to ensure effective diagnosis and successful management of HC, particularly when they occur in atypical locations.

The Current State of Undergraduate Trauma and Orthopedics Training in Saudi Arabia: A Survey-Based Study of Sixth-Year Medical Students' and Interns' Learning Experience and Subjective Clinical Competence.

Background and objective Students frequently complain about the lack of practical skill learning and the poor quality of the medical school curriculum. In light of this, the purpose of this study was to assess the learning experience and subjective clinical competence of final-year medical students and interns in the field of orthopedics in Saudi Arabia (SA). Methods A cross-sectional observational descriptive study utilizing an electronically validated survey was conducted, which included the following six main sections: introduction, demographics, self-assessment of competency regarding certain orthopedic skills, clinical experience in orthopedics, orthopedics curriculum assessment, and choice of future career specialty. Results The total number of participants was 794. Among them, 33% (n=160) and 37.1% (180) had attended no "trauma meetings" or "operating room (OR)" sessions respectively, and only 21.9% (n=106) had attended more than five clinics. Subjective competence in history taking was highest (mean: 8.925 ±1.299) among students who had received more than four weeks of orthopedic rotation and attended more than six clinics. The students who had completed more than four weeks of orthopedic rotation and more than six bedside sessions scored the highest in terms of subjective competence in handling orthopedic patients in primary care settings (mean: 8.014 ±1.931). Conclusion The survey indicates that the amount of orthopedic training provided by institutions varies, with some students receiving less training than recommended. However, longer rotations lead to greater perceived orthopedic competence. Students and interns with more exposure to orthopedics through curriculum and elective rotations demonstrated a greater interest in pursuing orthopedics as a future career.

Spinal Cord Ischemia After Lower Extremity Surgery in Pediatric Osteogenesis Imperfecta With Thoracic Kyphoscoliosis: Tertiary Care Center Experience in Jeddah, Saudi Arabia.

Osteogenesis imperfecta is a rare genetic disorder of type 1 collagen which primarily affects children and leads to recurrent bone fractures. In addition, spinal abnormalities can also occur. We report a case of a 13-year-old male with osteogenesis imperfecta type III, associated with severe femur deformity and thoracic kyphoscoliosis, who developed neurological injury after lower extremity surgery. The patient was in a supine position when general anesthesia was administered. The operation lasted for approximately 250 minutes, and anesthesia for 310 minutes, with an estimated blood loss of 600 cc. Apart from a low mean arterial pressure value (45 mm Hg) intraoperatively, the procedure was uneventful. Early postoperatively, he developed spinal paralysis at the level of T4-T7, and an MRI of the spine demonstrated high signal intensity within the spinal cord from level T3 to T7. Subsequently, he was admitted to the pediatric intensive care unit for further assessment and management. Follow-up revealed recovery of paralysis after 12 months.

Prevalence of musculoskeletal normal variations of the lower limbs in pediatric orthopedic clinic.

OBJECTIVES: To determine the rate of pediatric orthopedic clinic visits attributable to normal musculoskeletal (MSK) variations in children less than 12 years of age; to characterize the etiology and to characterize the etiology and management plan in this group in an attempt to identify areas that could be improved in pediatric orthopedic clinical practice. METHODS: The study was a retrospective evaluation of 2,321 consecutive patients who visited a private pediatric orthopedic specialty clinic in Jeddah, Saudi Arabia between 2011-2016. All consultations were recorded in accordance with the standard protocol  via data record form. RESULTS: We identified 764 (32.9%) patients with normal variation of the lower limbs, age birth to 12 years old. No significant association between gender and normal variation was noticed. The following types of normal variation were registered: 189 (24.7 %) genu varus or valgus, 257 (33.6%) in-toe gait, and 318 (41.6%) flexible flat foot. Seven hundred and thirty-seven (96.5%) cases were normal variations, while only 27 cases (3.5%) were deemed pathological and required further treatment. CONCLUSION: Normal variations represent the most common complaint in pediatric orthopedic private practice. Inappropriate referrals, useless follow-up visits, and excessive investigations were a common practice, overloading the health care system. None of the previous efforts made any notable improvement.

Outcome of Revision Total Hip Arthroplasty in Management of Failed Metal-on-Metal Hip Arthroplasty.

BACKGROUND: This is a retrospective review of the functional outcomes and complications of revision total hip arthroplasty (THA) of failed metal-on-metal (MoM) hip arthroplasty. METHODS: A total of 20 revision THAs were performed in 19 patients. Of them, 2 cases were failed hip resurfacing, and 18 cases were failed (MoM) THA. The mean age at revision (THA) was 59.35 years (standard deviation [SD] 9.83). RESULTS: The mean follow-up was 45 months (SD 13.98). The indications of revision were aseptic loosening of acetabular component without adverse local tissue reaction (ALTR; 10 hips), aseptic loosening of the acetabular and femoral components without ALTR (1 hip), painful hip associated with ALTR (6 hips), iliopsoas impingement associated with a large-diameter femoral head or malpositioned acetabular component (3 hips). The acetabular components were revised in 18 hips using Trabecular Metal Modular cups. The femoral components were revised in 3 hips. A constrained acetabular liner was used in 5 hips. The Harris hip score significantly improved from 48.4 (SD 12.98) to 83.25 (SD 10.08). There were 2 complications (1 foot drop and 1 superficial infection) and 1 failure (recurrent dislocation) that required revision to a constrained liner. CONCLUSION: Early results of revision THA of failed MoM hip arthroplasty showed improvement in pain and functional outcome. No case of failed bone ingrowth was noted with the use of Trabecular Metal Modular cups. Extensive soft tissue and abductor muscles dysfunctions were common. A constrained acetabular component with repair of the hip abductors might be beneficial.

Pediatric aneurysmal bone cyst in the ischial region.

Aneurysmal bone cyst (ABC) is an expanding osteolytic lesion. ABC represents 1% of all primary benign bone tumors, whereby 4-12% occur in the pelvis. The etiology of this disease remains vague. Aneurysmal bone cyst can exist either as primary bone lesion (70%) or as secondary lesion arising from another bone disorder (30%). Moreover, pelvic ABCs are characterized by their large size and high vascularity. We present a rare pediatric case with ABC involving the ischial region. A 5-year-old girl presented with left pelvic pain and limping for the past 6 months. Initial imaging showed an expansile lesion in the left ischium, and computed tomography guided biopsy showed giant cells in histopathology study with no evidence of metastasis. The patient underwent intraoperative frozen section followed by extensive intra-lesional bone excision. Bone curettage was pursued along with bone grafting. The case was successfully managed without postoperative complications after the 6-month follow-up period.

Sawbones laboratory in orthopedic surgical training.

Sawbones are artificial bones designed to simulate the bone architecture, as well as the bone's physical properties. The incorporation of sawbones simulation laboratories in many orthopedic training programs has provided the residents with flexibility in learning and scheduling that align with their working hour limitations. This review paper deliberates the organization of sawbones simulation in orthopedic surgical training to enhance trainee's future learning. In addition, it explores the implications of sawbones simulation in orthopedic surgical teaching and evaluation. It scrutinizes the suitability of practicing on sawbones at the simulation laboratory to improve orthopedic trainee's learning. This will be followed with recommendations for future enhancement of sawbones simulation-based learning in orthopedic surgical training.

Promising Mid-term Results With a Cup-cage Construct for Large Acetabular Defects and Pelvic Discontinuity.

BACKGROUND: Restoring normal anatomy and achieving stable fixation of the acetabular component can be especially challenging when the surgeon must deal with severe acetabular defects and/or pelvic discontinuity. The cup-cage (CC) construct, where an ilioischial cage is cemented within a biologically fixed porous metal cup, has emerged as an excellent option to treat such challenges. QUESTIONS/PURPOSES: We sought to determine (1) mid-term Kaplan-Meier survival; (2) clinical outcomes based on Merle d'Aubigné-Postel scores; (3) radiological outcomes based primarily on construct migration; and (4) the complication rate for a series of 67 CC procedures performed at our institution. METHODS: All hip revision procedures between January 2003 and March 2012 where a CC was used (with the exception of tumor cases or acute fracture; four total cases) that had a minimum 2-year followup and that had been seen within the last 2 years were included in this retrospective review. Acetabular bone loss and presence of pelvic discontinuity were assessed according to the Gross classification. Sixty-seven CC procedures with an average followup of 74 months (range, 24-135 months; SD, 34.3) months were identified; 26 of 67 (39%) were Gross Type IV and 41 of 67 (61%) were Gross Type V (pelvic discontinuity). Postoperative clinical and radiological evaluation was done annually. Merle d'Aubigné-Postel scores were recorded and all radiographs were compared with the 6-week postoperative radiographs to evaluate for radiographic loosening or migration. Failure was defined as revision surgery for any cause, including infection. RESULTS: The 5-year Kaplan-Meier survival rate with revision for any cause representing failure was 93% (95% confidence interval [CI], 83.1-97.4), and the 10-year survival rate was 85% (95% CI, 67.2-93.8). The Merle d'Aubigné-Postel score improved significantly from a mean of 6 preoperatively to 13 postoperatively (p < 0.001). Four CC had nonprogressive radiological migration of the ischial flange and they remain stable. CONCLUSIONS: We believe that the CC construct is a suitable choice to treat chronic pelvic discontinuity; it also remains a reliable option for the treatment of severe acetabular bone defects if stable fixation cannot be obtained through the use of a trabecular metal cup with or without augments. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Reliability of 3 Different Arthroscopic Classifications for Chondral Damage of the Acetabulum.

PURPOSE: To report the interobserver and intraobserver reliability of 3 chondral damage classifications used to assess articular cartilage damage during hip arthroscopy. METHODS: A prospective multicenter study was performed during April and May 2013. Inclusion criteria were all patients who underwent hip arthroscopy for femoroacetabular impingement (FAI) and had evidence of chondral damage at the time of surgery. Intra-articular recordings were obtained during the operation in a standardized way. These recordings were obtained from 2 different hospitals in 2 countries by 3 different surgeons. Four fellowship-trained orthopaedic surgeons, with at least 2 years postfellowship experience in hip arthroscopy, independently analyzed the recordings 2 times in randomized order and 4 months apart. They classified the lesions according to the Outerbridge, Beck, and Haddad classifications of chondral damage. The values obtained were used for interobserver and intraobserver analysis. Percentage of agreement and weighted Cohen κ values were calculated. RESULTS: Absolute agreement between observers was present in 12.5% of the cases for the Outerbridge classification, in 20% of the cases for the Beck classification, and in 40% of the cases for the Haddad classification. For interobserver reliability, the average weighted Cohen κ values were 0.28 (95% confidence interval [CI], 0.16 to 0.39), 0.33 (95% CI, 0.24 to 0.41), and 0.47 (95% CI, 0.42 to 0.51) for the Outerbridge, Beck, and Haddad classification systems, respectively. For intraobserver reliability, the mean Cohen κ values were 0.62, 0.63, and 0.68 for the Outerbridge, Beck, and Haddad classification systems, respectively. CONCLUSIONS: In our series, the Haddad classification had the best interobserver reliability. There was no difference in the intraobserver reliability among the 3 classifications studied. LEVEL OF EVIDENCE: Level III, diagnostic study of nonconsecutive patients (without consistently applied reference gold standard).

Consistency of reported outcomes after arthroscopic management of femoroacetabular impingement.

PURPOSE: The purpose of this systematic review is to evaluate the consistency of the reporting of clinical and radiographic outcomes after arthroscopic management of femoroacetabular impingement (FAI). METHODS: Two databases (Medline and EMBASE) were screened for clinical studies involving the arthroscopic management of FAI. A full-text review of eligible studies was conducted, and the references were searched. Inclusion and exclusion criteria were applied to the searched studies, and a quality assessment was completed for included studies. RESULTS: We identified 29 eligible studies involving 2,816 patients. There was a lack of consensus with regard to reported outcomes (clinical and radiographic) after arthroscopic treatment of FAI. Clinical outcomes reported include the Harris Hip Score (45%) and the Non-Arthritic Hip Scale (28%), range of motion (34%), pain scores (24%), and patient satisfaction (28%). The most commonly reported radiographic outcomes included the alpha angle (38%), head-neck offset (14%), and degenerative changes (21%). CONCLUSIONS: There is significant variation in reported clinical and radiographic outcomes after arthroscopic treatment of FAI. This study highlights the need for consistent outcome reporting after arthroscopic FAI surgery. LEVEL OF EVIDENCE: Level IV, systematic review of Level II, III, and IV studies.

Meta-analysis of navigation vs conventional total knee arthroplasty.

Navigated total knee arthroplasty (TKA) is promoted as a means to improve limb and prosthesis alignment. This study involved a systematic review and meta-analysis for all randomized controlled trials in the literature from 1986 to 2009 comparing alignment outcomes between navigated and conventional TKA. Alignment outcomes were pooled using a random-effects model, and heterogeneity was explored. Twenty-three randomized controlled trials were identified comparing navigated vs conventional TKA involving 2541 patients. Patients who underwent navigated TKA had a significantly lower risk of implant malalignment at more than 3° as well as more than 2°. In addition, the risk of malalignment was reduced for the coronal plane tibial and femoral components as well as femoral and tibial slope. This meta-analysis demonstrates that navigated TKA provides significant improvement in prosthesis alignment.