Musculoskeletal pain among medical students at two Jordanian universities.

BACKGROUND: Musculoskeletal (MSK) pain is a debilitating multi-perceptual condition afflicting many individuals, especially individuals in the medical profession. OBJECTIVE: To analyze and evaluate the prevalence of musculoskeletal pain among medical students at Jordanian universities during the complete virtual learning process. METHODS: A cross-sectional study of 593 medical students at two Jordanian universities was conducted. A modified Nordic questionnaire was used to assess musculoskeletal pain in three body regions. RESULTS: Five hundred ninety-three students at the two Jordanian universities participated in this study. The prevalence of having MSK pain during the past week in the neck, shoulder, and lower back was 34.6%, 27%, and 41%, respectively; during the past 12 months, it was 61.2%, 45.5%, and 63.1%, respectively. Overall prevalence of having MSK pain was 58.9% in the last week and 78.1% in the past 12 months. 66.8% of students who had psychosomatic symptoms and 62.3% of those with depressive symptoms in the past week had MSK pain. Students who studied 8 hours per day had higher percentages of MSK pain (68.4%) (OR 1.12, 95% CI 0.965-1.312). The average number of hours using a computer per day was significantly associated with MSK pain (p= 0.032). MSK pain during the last week was significantly associated with psychosomatic symptoms (OR 1.842, 95% CI 1.272-2.668, p= 0.001). Family history of MSK pain was significantly related to the presence of the problem in participants (OR 1.732, 95% CI 1.182-2.538, p= 0.005). Gender, depressive symptoms, average hours of computer use per day, and average hours of study at home per day did not show significant relationships with MSK pain over the year. CONCLUSIONS: High prevalence of MSK pain was observed among medical students. Measures to balance in-person and virtual learning should be considered in medical schools to minimize the risk of MSK pain.

Short versus Long-Leg Hip Spica After Closed Reduction in Developmental Dysplasia of the Hip: A Retrospective Comparative Study.

Purpose: Closed reduction (CR) is a standard treatment for developmental dysplasia of the hip (DDH) after failed conservative treatment. After CR, the affected hip is held in the reduced position by a spica cast that typically extends below the knee (long). Above knee (short) spica cast is an alternative technique utilized by some pediatric orthopedic surgeons. We aimed to compare short versus long spica cast after CR in terms of success rate and complications. Methods: Patients who underwent CR with short or long hip spica cast over a 3-year period (2016-2019) were evaluated for the success (sustainability of the reduction) and complications. The acute and long-term success were recorded retrospectively. Acute success was defined as concentric reduction of the hip confirmed by intraoperative arthrogram and immediate postoperative CT scan. Long-term success was defined as maintained reduction at 12 months' post reduction. Results: Forty-seven patients were included in our study. Long spica casts were used in 24 patients and short ones in the remaining 23. The overall acute and long-term success rates were 83% and 66%, respectively. The acute success rate of long spica was 87.5%, while short spica achieved 78.2%. On the long term, the success rate of short spica was higher than long one (73.9% vs 58.3%). Cox regression analysis showed that the type of cast (short vs long spica) was not correlated with acute success (P = 0.405), long-term success (P = 0.263), residual dysplasia (P = 0.405), or avascular necrosis (P = 0.053). Conclusion: CR in DDH is an important line of management in the younger patient population and can save them an invasive open surgery later in life. A short leg spica could represent an easier and likely as successful alternative to the traditional long spica. More prospective future research is needed to validate our observational findings. Level of Evidence: III.

Correlation between plain X-ray measurements and DXA scans, and its possible use as a screening tool for performing DXA scans.

PURPOSE: The purpose of this study is to determine if there is a relationship between radiological parameters measured using a plain X-ray and DXA scan score, and whether a plain X-ray can be used as surrogate imaging modality when DXA scan is not readily available. METHODS: We included all patients who had both a DXA scan and a pelvis X-ray done from 1 January 2013 to 31 December 2017. Bone mineral density had been measured by DXA scanning of the femoral neck and the spine. Osteoporosis was defined by T-score of any site less than -2.5. Cortical thickness indices on the AP radiograph were calculated. RESULTS: Sixty patients were involved in the study and were divided into two groups. Group A had 22 patients who had a T-Score on their DXA Scans ≤-2.5 SD at the femur neck or the spine with median ± SD (-2.5 ± 0.8, -2.8 ± 1.0), respectively. Group B had 38 patients who had a T-score on their DXA Scans of >-2.5 at the femur neck and the spine with median ± SD (-1.2 ± 0.9, -1.3 ± 1.0), respectively, which was significantly higher than the T-score of osteoporotic (group A) patients (P = .000) at both sites of measurement. The cortical thickness index (CTI) was significantly higher (P = .027) in group B mean ± SD (0.56 ± 0.07), compared with (0.51 ± 0.08) that in group A. CONCLUSION: DXA imaging remains the gold standard for diagnosing osteoporosis and we advocate the use of CTI to detect the patients who need DXA screening in places where this modality is not readily available.

Role of Arthrodiastasis Using Hinged Monolateral External Fixator Without Soft Tissue Release in Advanced Stage of Legg-Calve-Perthes Disease.

PURPOSE: Presentation with the advanced stage of Legg-Calve-Perthes disease (LCPD) carries a poor prognosis, regardless of the treatment that the patient receives. The aims of this study are to assess the clinical and radiological outcomes of arthrodiastasis in advanced cases of LCPD using a hinged monolateral external fixator without soft tissue release and to raise safety issues regarding its low rate of complications. PATIENTS AND METHODS: Six patients with LCPD who were classified as lateral pillar types B and C and were operated on in our department were included in this retrospective study. Data collected from medical files and X-ray measurements were retrospectively reviewed. RESULTS: A total of six male patients were included in this analysis. The mean age at onset of symptoms was 8.5 years (range 7-10 years). The mean follow-up period was 46 months (range 40-50 months). Five cases were Herring C and one case was Herring B at presentation. The average distraction time was 8 days (range 7-9) and the average duration of external fixator application was 3.1 months (range 2.5-3.5 months). The range of motion of the hip in flexion, abduction and internal rotation were improved postoperatively. Pain score and limping were also improved. At the final follow-up, the mean sphericity deviation score was 10.6. The mean epiphyseal index was improved from 19.3% to 23.8%. In addition, the mean cervical index improved from 99.7% to 89.7% at the last follow-up. Femoral fractures, pin loosening, mechanical failure of the fixator, chondrodiastasis, and hip subluxation were not seen in this group of patients. CONCLUSION: Arthrodiastasis with a hinged monolateral external fixator without soft tissue release improved both the clinical and radiological outcomes in this group of patients.

Safety of the LCP Pediatric Hip Plate in Proximal Femoral Osteotomy in Children with Cerebral Palsy.

PURPOSE: Proximal femoral osteotomy in cerebral palsy patients is a demanding procedure. The fixation of the osteotomy can fail due to the weak osteoporotic bone. The LCP pediatric hip plate with its good grip makes these procedures safe. The aims of the present study are to evaluate the radiological outcome of proximal femoral osteotomy that was fixed with the pediatric LCP in cerebral palsy patients and to raise safety issues regarding its low rate of complications. PATIENTS AND METHODS: Sixteen patients with cerebral palsy who were operated in our department were included in this retrospective study. Data collected from medical charts and X-ray measurements retrospectively reviewed. RESULTS: In total, 16 patients (21 hips), ie, 9 males and 7 females, were included in this analysis. The mean age at the time of the index surgery was 11.9 years (5.9-18.0). The mean follow-up period was 4.78 years (1.5-8.0). Five patients had bilateral hip involvement and 11 had unilateral involvement. All patients had spastic cerebral palsy. The mean values of varus correction and de-rotation were 25° (0°-45°) and 35° (20°-50°), respectively. Neck shaft angle and the Reimer's migration index were significantly improved postoperatively (p<0.01 for both). Seventeen hips showed complete consolidation within 14 weeks of fixation and four hips needed 16 weeks. These four hips were in three patients who were 16 years of age or older. The correlation between age at surgery and the time needed for consolidation was statistically significant (p=0.005). Avascular necrosis, revision surgeries, failure of fixation, acetabular penetration, screw loosening or fracture of the femur were not seen in this study. CONCLUSION: The LCP pediatric hip plate can be used safely in CP patients. The plate provides a strong stable fixation on osteoporotic bone with a low rate of complications.

Relationship between intra-operative hypotension and post-operative complications in traumatic hip surgery.

BACKGROUND AND AIMS: The relationship between intra-operative hypotension and post-operative complications has been recently studied in non-cardiac surgery. Little is known about this relationship in traumatic hip surgery. Our study aimed to investigate this relationship. METHODS: A retrospective study was conducted on patients who underwent surgical correction of traumatic hip fracture between 2010 and 2015. We reviewed the perioperative blood pressure readings and the episodes of intra-operative hypotension. Hypotension was defined as ≥30% decrease in the pre-induction systolic blood pressure sustained for ≥10 min. The relationship between intra-operative hypotension and post-operative complications was evaluated. Post-operative complications were defined as new events or diseases that required post-operative treatment for 48 h. Factors studied included type of anaesthesia, blood transfusion rate, pre-operative comorbidities and delay in surgery. We used the Statistical Package for Social Sciences (SPSS, IBM 25) to perform descriptive and non-parametric statistics. RESULTS: A total of 502 patients underwent various types of traumatic hip surgery during the study period. Intra-operative hypotension developed in 91 patients (18.1%) and 42 patients (8.4%) developed post-operative complications. Significantly more patients with hypotension developed post-operative complications compared to patients with stable vitals (18.7% vs. 6.1; P < 0.001). There was no statistically significant difference in the incidence of post-operative complication in patients receiving general or spinal anaesthesia. Pre-operative comorbidities had no significant relationship with post-operative complications. Intra-operative blood transfusion was related to both intra-operative hypotension and post-operative complications. CONCLUSION: There was an association between intra-operative hypotension and post-operative complications in patients undergoing traumatic hip surgery.

Bifocal Tibial Kaposiform Hemangioendothelioma Responsive to Vincristine Therapy: A Case Report.

BACKGROUND Kaposiform hemangioendothelioma is a rare locally aggressive vascular endothelial-derived spindle cells neoplasm. Herein, we report a rare case of bifocal tibial kaposiform hemangioendothelioma. CASE REPORT A 9-year-old female presented with a 2-year history of pain and swelling in the left leg. The patient had a high plasma level of the D-dimer and fibrinogen. Radiography revealed a centric lytic lesion on the left proximal tibial metaphysis and an eccentric lateral distal tibial metaphyseal. Histopathologic examination of the sample taken from the distal tibia revealed a dense spindle cell tumor with lobular architecture composed of compact spindle cells compressing small slit-like vascular spaces, forming glomeruloid nests. No necrosis was identified. Based on these findings and the positive immunohistochemical staining for CD31, CD34, and D2-40, the patient was diagnosed with kaposiform hemangioendothelioma. Treatment was started by using vincristine chemotherapy, after which the patient developed temporary peroneal neuropathy, which improved over the next 3 months. CONCLUSIONS Bifocal tibial kaposiform hemangioendothelioma lesions are unique in pediatric patients and can be successfully treated with vincristine chemotherapy. In these cases, the treating physician should be aware of peroneal neuropathy as a potential complication of vincristine administration.

Deficiency of lrp4 in zebrafish and human LRP4 mutation induce aberrant activation of Jagged-Notch signaling in fin and limb development.

Low-density lipoprotein receptor-related protein 4 (LRP4) is a multi-functional protein implicated in bone, kidney and neurological diseases including Cenani-Lenz syndactyly (CLS), sclerosteosis, osteoporosis, congenital myasthenic syndrome and myasthenia gravis. Why different LRP4 mutation alleles cause distinct and even contrasting disease phenotypes remain unclear. Herein, we utilized the zebrafish model to search for pathways affected by a deficiency of LRP4. The lrp4 knockdown in zebrafish embryos exhibits cyst formations at fin structures and the caudal vein plexus, malformed pectoral fins, defective bone formation and compromised kidney morphogenesis; which partially phenocopied the human LRP4 mutations and were reminiscent of phenotypes resulting form a perturbed Notch signaling pathway. We discovered that the Lrp4-deficient zebrafish manifested increased Notch outputs in addition to enhanced Wnt signaling, with the expression of Notch ligand jagged1b being significantly elevated at the fin structures. To examine conservatism of signaling mechanisms, the effect of LRP4 missense mutations and siRNA knockdowns, including a novel missense mutation c.1117C > T (p.R373W) of LRP4, were tested in mammalian kidney and osteoblast cells. The results showed that LRP4 suppressed both Wnt/ß-Catenin and Notch signaling pathways, and these activities were perturbed either by LRP4 missense mutations or by a knockdown of LRP4. Our finding underscore that LRP4 is required for limiting Jagged-Notch signaling throughout the fin/limb and kidney development, whose perturbation representing a novel mechanism for LRP4-related diseases. Moreover, our study reveals an evolutionarily conserved relationship between LRP4 and Jagged-Notch signaling, which may shed light on how the Notch signaling is fine-tuned during fin/limb development.

Capillary Hemangioma as an Unusual Cause of Doughnut Sign on Bone Scan.

ABSTRACTS: A 28-year-old woman presented with a mass in her right leg, which, on plain radiograph, appeared as a lytic lesion in the mid-shaft of the tibia with cortical thinning but without periosteal reaction. Tc-MDP 3-phase bone scan demonstrated intense uptake in the periphery of the mass with a photopenic center, the so-called doughnut sign. Histopathology revealed a capillary hemangioma. This case demonstrates that the doughnut sign on bone scan can be caused by capillary hemangioma in addition to other reported bone pathologies, including aneurysmal bone cyst, giant cell tumor, and telangiectatic osteosarcoma.

Reasons for operation cancellations at a teaching hospital: prioritizing areas of improvement.

PURPOSE: To report rates of and reasons for operation cancellation, and to prioritize areas of improvement. METHODS: Retrospective data were extracted from the monthly reports of cancelled listed operations. Data on 14 theatres were collected by the office of quality assurance at Jordan University Hospital from August 2012 to April 2016. Rates and reasons for operation cancellation were investigated. A Pareto chart was constructed to identify the reasons of highest priority. RESULTS: During the period of study, 6,431 cases (9.31%) were cancelled out of 69,066 listed cases. Patient no-shows accounted for 62.52% of cancellations. A Pareto analysis showed that around 80% of the known reasons for cancellation after admission were due to a lack of surgical theatre time (30%), incomplete preoperative assessment (21%), upper respiratory tract infection (19%), and high blood pressure (13%). CONCLUSION: This study identified the most common reasons for operation cancellation at a teaching hospital. Potential avoidable root causes and recommended interventions were suggested accordingly. Future research, available resources, hospital policies, and strategic measures directed to tackle these reasons should take priority.

ANESTHESIA FOR CHARCOT-MARIE-TOOTH DISEASE: CASE REPORT.

Charcot-Marie-Tooth disease comprises a group of disorders characterized by progressive muscle weakness and wasting. Reviewing the anaesthetic literature produced conflicting reports about the best anaesthetic options for patients with CMTD; as they are at increased risk of prolonged response to muscle relaxants, malignant hyperthermia and risks of regional anaesthesia. We present a case of the successful use of total intravenous anaesthesia with dexmedetomidine and propofol combined with caudal block using bupivacaine mixed with dexmedetomidine without any complications, for a 17 year old male patient with Charcot Marie-Tooth disease who underwent a lower limb orthopedic surgery.

Late-presenting developmental dysplasia of the hip in Jordanian males. A retrospective hospital based study.

OBJECTIVES: To describe the pattern of developmental dysplasia of the hip (DDH) in late presenting Jordanian male patients and identify the risk factors and associated findings. METHODS: This is a retrospective study of 1145 male patients who attended the Pediatric Orthopedic Clinic for a DDH check up. This study was carried out in the Orthopedic Section, Special Surgery Department, Faculty of Medicine, The University of Jordan, Amman, Jordan between March 2011 and October 2014. Data was collected from medical records, and x-ray measurements were evaluated.  RESULTS: Of the 1145 male patients, 43 (3.75%) with 70 involved hips were diagnosed with late- presenting DDH. Being a first-born baby resulted in 41.9% increased risk for DDH. Cesarian delivery was significantly associated with an increased risk of hip dislocation (p=0.004) while normal delivery was significantly associated with acetabular dysplasia (p=0.004). No predictable risk factors were found in 44.2% patients with DDH. Bilateral cases were more common than unilateral cases: (26 [60.5%] versus 17 [39.5%]). Limited abduction was a constant finding in all dislocated hips (p less than 0.001). Associated conditions, such as club foot and congenital muscular torticollis were not observed.   CONCLUSION: Cesarian section is a significant risk for dislocated hips while normal delivery is significantly associated with acetabular dysplasia. Bilateral DDH is more common than the unilateral. Club foot and torticollis were not observed in this series.

The influence of aging on the association between adiposity and bone mineral density in Jordanian postmenopausal women.

The objective of this study was to assess the relative association between body weight, body mass index (BMI), lean mass (LM) and fat mass (FM), and bone mineral density (BMD) in a group of Jordanian postmenopausal women and investigate if this possible association changes with age. A total of 3256 patients had dual-energy X-ray absorptiometry (DXA) scan in the period from January 2009 till January 2012 at the Radiology and Nuclear Medicine Department of Jordan University Hospital. Only 584 women met the selection criteria. Age has been recorded, and patients were divided into subgroups according to age. Body weight and height were measured, and BMI was calculated. Body composition (LM, FM, percentage of android fat, and percentage of gynoid fat) was assessed by DXA. BMD of the lumbar spine (L1-L4) and femoral neck was measured by DXA. Weight, BMI, FM, LM, percentage of android fat, and percentage of gynoid fat were positively correlated to BMD at both lumbar spine and femoral neck. However, this correlation disappeared at the age of 70 yr at lumbar spine and 75 yr at femoral neck. This study suggests that both FM and LM are important determinants of BMD in Jordanian postmenopausal women, and this correlation disappears after the age of 70 yr at lumbar spine and 75 yr at femoral neck.