Adamantinoma of the ulna: A case report and literature review.

INTRODUCTION AND IMPORTANCE: Adamantinomas are rare, low-grade, malignant skeletal tumors accounting for only 0.33-0.48 % of primary malignant bone tumors. CASE PRESENTATION: An 11-year-old boy with adamantinoma of the ulna was treated with en bloc resection, kryptonite bone cement, and plate fixation. The surgery resulted in marked pain relief and good functional recovery. No evidence of recurrence was observed for 5 years postoperatively, and the Musculoskeletal Tumor Society score was 93. CLINICAL DISCUSSION: This case of an 11-year-old previously treated for an aneurysmal bone cyst (ABC) illustrates the complexity of diagnosing adamantinoma, especially in atypical locations like the ulna. The successful use of en bloc resection and synthetic bone graft highlights the importance of accurate diagnosis and advanced surgical methods in achieving favorable outcomes in pediatric orthopedic oncology. CONCLUSION: Ulnar adamantinomas are rare and can be difficult to diagnose. The successful treatment of this tumor, as described in this case report, can help guide the management of similar cases in the future.

Unusual Multiple Recurrences of Soft Tissue Giant Cell Tumors in a Patient Above 60 Years.

Primary giant cell tumors of soft tissues (GCT-ST) are rare neoplasms that share histopathological and immunohistochemical characteristics with osseous giant cell tumors. While GCT-ST generally exhibits a benign progression and can affect individuals of various ages, older patients may face a higher risk of recurrence and aggressive disease progression. In this case report, we present the case of a 63-year-old woman who experienced recurrent GCT-ST nine months after the complete excision of an initially localized tumor. Despite the mainstay treatment of GCT-ST being tumor-free margin surgical excision, this case demonstrates the occurrence of recurrences. The etiology of recurrence in GCT-ST remains unclear, highlighting the need for further studies and careful patient follow-up to prevent potential complications such as lung metastasis or widespread metastasis. Thus, this report aims to raise awareness of these tumors and emphasize the importance of diligent patient follow-up to facilitate early identification and management, thereby preventing potential complications such as lung or widespread metastasis.

Knotless Anchor with FiberTape® for Fixing Pure Distal Patellar Tendon Rupture. A Case Report.

Introduction: The extensor mechanism and patellar tendon (PT) are considered essential components. Adult PT avulsion from the tibial tubercle is uncommon, with little information in the literature. Technical challenges arise during injury management. Knotless anchors have several applications in treating tendon injuries, such as the rotator cuff, distal biceps, and quadriceps tendons but were not used to repair distal PT avulsions. Case Report: A 50-year-old male patient, an active adult, presented to emergency department with significant right knee pain, giving away and limitation of range of motion (ROM) that had started after he sustained direct trauma with a ground-level fall on his knee that morning. Conclusion: In this paper, we report a case and describe a technique to manage a rare presentation of pure distal PT rupture without an avulsion fracture using knotless anchors with FiberTape®, which showed excellent results. To the best of our knowledge, this technique has never been used before in such injury and anatomical location. At 2 years of follow-up, the patient is free of complaints with almost full ROM at the knee and back to his standard daily life activity.

Measurement of Condylar Offset and Posterior Condylar Cartilage Thickness in Normal Knees: An MRI Study From Saudi Arabia.

Background The maximum amount of knee flexion after total knee replacement is largely determined by the knee's posterior condylar offset (PCO). Using magnetic resonance imaging (MRI), this study examined the relationship between PCO and the thickness of the femoral posterior condylar cartilage (PCC) in healthy people. Methodology We reviewed the medical records of 300 skeletally mature patients who did not exhibit symptoms of knee arthritis and had undergone MRI for traumatic soft tissue knee injuries that did not affect the femoral PCC. Results The study cohort consisted of 300 participants, of whom 68.3% (205) were male, and 31.7% (95) were female aged between 18 and 59 years, with a mean age of 31.13 ± 8.83 years. Most participants were under 30 years of age (45.7%), and the mean body mass index was 27.52 ± 5.64 kg/m2. The total medial distance was 28.50 ± 3.11 mm, ranging from 21.20 to 39.80 mm. The medial PCC was 1.71 ± 0.63 mm, ranging from 0.60 to 4.00 mm. The medial bony PCO was 38.40 mm, ranging from 18.80 to 38.40 mm. The total lateral distance was 25.24 ± 3.16 mm, ranging from 13.50 to 34.90 mm. The lateral PCC was 1.48 ± 0.75 mm, ranging from 0.30 to 10.70 mm. Finally, the lateral bony PCO was 23.76 ± 3.19 mm, ranging from 11.99 to 32.8 mm. There was a statistically significant weak positive relationship between the bony lateral PCO and the patients' age in females only (p = 0.016; r = 0.00-0.39). There was a statistically significant mean difference in the total medial distance, medial PCC, and lateral PCC between the two knees (p < 0.05). Conclusions These findings shed light on the factors influencing these parameters, offer insightful information about the associations between particular patient characteristics and knee measurements, and may help guide clinical evaluations and treatment decisions.

Students' Interest in Orthopedic Surgery in Saudi Arabia.

OBJECTIVES: The demand for orthopedic surgery is expected to increase as the Saudi population grows and ages. Therefore, this study aimed to assess the interest of medical students and interns in orthopedic surgery and the factors that influence their interest. METHODS: This cross-sectional study was conducted using a structured questionnaire adapted from a similar study and modified by the authors. The questionnaire was distributed via email to more than 500 medical students from the second year to the internship year. The questionnaire was designed to assess knowledge, interest, and students' perception of orthopedics. RESULTS: Five hundred and ten responses were obtained; 382 (74.90%) were from women. Gender, family orientation, private practice, and perceptions of orthopedic surgery as a stressful specialty or a specialty in crisis were variables that did not influence participants' perceptions of orthopedic surgery. Further, 13% of participants showed early interest in orthopedic surgery, especially during their third year of medical school. Most of the interested participants recognized that having strong level of knowledge, future academic opportunities, a controllable lifestyle, direct patient care, experience during their clerkship, a high salary, immediate satisfaction, and a prestigious specialty were important aspects that determined their interest in considering a future career in orthopedic surgery. Work preferences that had a significant impact on interest included working with patients not requiring long-term care, working only in the hospital, working outside the hospital, and working only during the day. CONCLUSION: There was no difference between genders in terms of interest in orthopedic surgery. This study might serve as a basis for future research assessing the interest of medical students in orthopedic surgery as well as identifying and managing the barriers that prevent students from pursuing careers as orthopedic surgeons.

Outcome of Surgical Management of Dermatofibrosarcoma Protuberance: A Single-Institution Multidisciplinary Approach.

Introduction: Dermatofibrosarcoma protuberans (DFSP) is a rare, slow-growing, and locally aggressive soft tissue tumor with a high recurrence rate and metastatic potential, even with the proper treatment. Methods: This was a retrospective (case series) study that took place at King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia, to determine the outcomes of and appropriate margin excision for DFSP. All patients who were diagnosed with DFSP from 2016 to 2021 were included. The following variables were assessed: demographics, tumor characteristics, management options, and most importantly, whether patients were managed with an oncology-oriented approach or a non-oncology-oriented approach. Results: There were a total of seventeen patients with DFSP, four of whom had fibrosarcomatous differentiation (FS-DFSP). The majority (N = 13, 76.5%) of the patients were females. The lower extremities and back were the most common locations for DFSP, accounting for 47.1% and 23.5%, respectively. Only two (11.76%) patients had metastatic disease, one of whom had FS-DFSP. The minimum resection margin was 3 cm, and the maximum was 5 cm. Thirteen (76.47%) patients were managed with an oncology-oriented approach (Group I), 23% of whom had post-excision positive margins. However, all patients who were managed with a non-oncology-oriented approach (Group II) had positive margins post-excision. More than three-quarters (76.9%) of group I underwent wide resection. Split-thickness skin grafting and primary closure were the most commonly used reconstruction methods in groups I and II, respectively. The mean planned margins in groups I and II were 3.9 cm and 1.7 cm, respectively. Conclusion: The findings of this study suggest that a planned wide-margin excision with a minimum safe margin of 3-5 cm should be implemented to reduce the recurrence, metastasis, and need for further surgeries in patients with DFSP.

Patient-related risk factors of prosthetic joint infections following total hip and knee arthroplasty at King Abdulaziz Medical City, a 10-year retrospective study.

BACKGROUND: Total joint arthroplasty (TJA) can be associated with the development of periprosthetic joint infection (PJI). It is necessary to determine the modifiable and non-modifiable risk factors of PJI to provide optimum healthcare to TJA candidates. METHODS: This single-center retrospective review investigated 1198 patients who underwent TJA from 2012 to 2022. The data analysis comprised two stages. The first stage was a descriptive analysis, while the second stage was a bivariate analysis. The sociodemographic data, medical history, operative details, and presence of PJI postoperatively were evaluated. RESULTS: The study sample consisted of 1198 patients who underwent TJA. The mean patient age was 63 years. Among the patients, only 1.3% had PJI. No comorbidity was significantly related to PJI. General anesthesia was used in almost 21% of the patients and was significantly associated with a higher risk of infection (p = 0.049). An increased operative time was also significantly related to PJI (p = 0.012). Conversely, tranexamic acid (TXA) administration was a protective factor against PJI (p = 0.017). CONCLUSION: Although PJI is not a common complication of TJA, multiple risk factors such as general anesthesia and prolonged operative time play a significant role in its development. In contrast, TXA administration is thought to reduce the risk of PJI effectively.

Etiologies of Orthopedic Implant Removal Among Patients Who Underwent Orthopedic Fixation Surgeries in King Abdulaziz Medical City.

BACKGROUND: Hardware removal surgeries are considerably common. However, the justifications for these surgeries are debatable. The indications may vary from pain, surgical site infection, or failure of osteosynthesis. Additionally, the surgery can be performed without medical indication. Following these surgeries, many complications can occur. Therefore, surgeons and patients should be aware of the appropriate indications and have realistic expectations of the risks and benefits of implant removal. METHODS: This was a retrospective chart review study. We included all patients aged 17-86 years who underwent hardware removal surgery in the orthopedic surgery department of King Abdulaziz Medical City, Riyadh, Saudi Arabia, from 2010 to 2019. All relevant data, such as demographic characteristics, location and type of hardware, indication for hardware removal, duration between insertion and removal, and complications after removal were recorded and analyzed. RESULTS: A total of 244 medical records were reviewed with a mean patient age of 34 years. Out of the total, 190 patients (77.9%) were male. The femur was the most common location of hardware removal, in 50 cases (20.58%). Plates and screws were the most common type of implants (40.2%). Most patients underwent hardware implantation because of fractures (89.3%). In total, 119 patients (48.8%) had the hardware removed electively. Only 29 patients (12%) reported postoperative complications; 190 patients (77.9%) were advised by their surgeon against hardware removal. CONCLUSION: Hardware removal procedures are commonly performed worldwide for various reasons, including infection, pain, and loosening. In this study, we have outlined the reasons for implant removal, the locations, complications, and the rationale behind this surgery. We have provided a new decision-making assessment, aimed at the general population and surgeons alike, that will help patients better comprehend the complications and risks associated with this elective surgery.

Lateral epicondyle to the joint line distance is a precise landmark for determination of an accurate knee joint line: an observational retrospective study.

PURPOSE: To assess a quantitative and reproducible association between the position of the knee joint line and recognizable anatomical landmarks around it in order to help in restoring joint line in arthroplasty cases. METHODS: Magnetic resonance imaging (MRI) of 130 normal knees were investigated. Anatomical measurements of the knee joint distances on the obtained planes were performed manually by distance measurements using a ruler tool, followed by 6 anatomical bony landmarks determination about the knee to identify the joint line which included the joint line, medial epicondyle, lateral epicondyle, medial flare, lateral flare, and proximal tibiofibular joint. The entire process was examined twice by two independent fellowship trained musculoskeletal radiologists, with a 2-week interval between the first and second sets of readings. RESULTS: The lateral epicondyle to the joint line of the knee (LEJL) could be a reliable landmark for accurate distance measurements for the knee joint line level, with an absolute distance of 24.4 ± 2.8 mm. The analysis showed that the femorotibial ratio between the LEJL and proximal tibiofibular joint (PTFJ) was 1.0 (LEJL/PTFJJL = 1.0 ± 0.1), confirming the location of the knee joint at the midpoint between the lateral epicondyle and PTFJ, revealing two identifiable landmarks. CONCLUSIONS: LEJL is the most precise landmark for determination of an accurate knee joint line because the knee is located at the midline between the lateral epicondyle and PTFJ. These reproducible quantitative relationships can be widely employed in various imaging modalities to help restore the knee JL in arthroplasty surgeries.

Single bone forearm reconstruction of proximal ulna metastatic lesion: A case report.

INTRODUCTION AND IMPORTANCE: Colorectal cancer rarely metastasizes to the bones, and if so, metastasis usually occurs in the axial skeleton. We encountered a rare case of a metastatic lesion to the right ulna arising from colonic adenocarcinoma that was treated by resection of the proximal ulna and radial neck-to-humerus trochlea transposition to salvage the limb. CASE PRESENTATION: A 60-year-old man previously diagnosed with colonic adenocarcinoma presented with a single bony metastatic lesion in the right proximal ulna and was referred to our clinic for assessment. After five sessions of systemic therapy, the lesion continued to grow, causing diffuse swelling and loss of elbow range of motion. Local x-rays revealed extensive destruction of the proximal ulna and soft tissue component, with subluxation of the radial head. Magnetic resonance imaging showed an extensive lesion involving the proximal half of the ulna and a large soft tissue component. After restaging, only this metastatic lesion was found. Amputation was offered to the patient for wide margin resection, but the patient refused; therefore, we performed resection of the proximal ulna, debulking of soft tissue, and radial neck-to-humerus trochlea transposition to salvage the limb. CLINICAL DISCUSSION: Due to the rarity of the location, no clinical standard exists regarding the surgical treatment. Radial neck-to-humerus trochlea transposition is a valid surgical reconstruction technique to salvage the limb and preserve the hand function. CONCLUSION: Radial neck-to-humerus trochlea transposition is an alternative elbow reconstruction technique after proximal ulna resection in cases where other options are not ideal or contraindicated. Long-term studies are recommended to assess different surgical options for treating and reconstructing proximal ulnar tumors.

The efficacy of vancomycin powder in total knee arthroplasty: A single-center study.

OBJECTIVES: To assess the efficacy of vancomycin powder (VP) in total knee arthroplasty (TKA). METHODS: The study design was retrospective cohort. All patients who underwent primary TKA for osteoarthritis between January 1, 2018, and March 1, 2020, in King Abdulaziz Medical City, Riyadh, Saudi Arabia were included (n=98). Of the total participants, 48 participants in the experimental group matched with 48 participants in the control group were included in the final study sample. Numerical variables are reported as means, standard deviations, and standard errors. The hypothesis was tested using the Chi-square test and independent t-test. RESULTS: In comparison to the control group, intraoperative vancomycin powder (VP) did not decrease surgical site infection risk in the experimental group (p=0.31). CONCLUSION: We found no significant differences in the infection rates following primary TKA when using VP.

The effect of gender, age, and body mass index on the medial and lateral posterior tibial slopes: a magnetic resonance imaging study.

BACKGROUND: The posterior tibial slope (PTS) is crucial in knee joint stability and in maintaining the natural movement of the knee. An increase in the PTS is associated with various knee pathologic conditions, such as anterior cruciate ligament (ACL) injury and anterior tibial translation (ATT). In the present study, we aimed to establish native medial and lateral PTS values for adult Saudis and to identify any association between PTS and gender, age, and body mass index (BMI). MATERIALS AND METHODS: A total of 285 consecutive, normal, magnetic resonance imaging (MRI) studies of the knee were included in the study. The PTS was measured using the proximal anatomical axis of the tibia. The Kruskal-Wallis test was used to compare the medial and lateral PTS angles between age groups. The difference between the medial and lateral posterior tibial slopes was assessed using the Wilcoxon signed-rank test. The Mann-Whitney U test was performed to compare the medial and lateral PTS angles between men and women. Age, gender, and BMI were analyzed by multivariate linear regression to determine whether they positively predict the medial and lateral PTS angles. RESULTS: The mean physiological medial PTS was 5.86 ± 3.0° and 6.61 ± 3.32°, and the lateral PTS was 4.41 ± 3.35° and 4.63 ± 2.85° in men and women, respectively. This difference showed no statistically significant gender dimorphism (p > 0.05). The medial PTS was significantly larger than the lateral PTS (p < 0.0001). There was no statistically significant difference in the medial and lateral PTS angles between age groups (p > 0.05). Higher BMI was significantly associated with a steeper medial PTS (p = 0.001). CONCLUSIONS: This study provided native values for medial and lateral PTS angles in Saudis, which can assist surgeons in maintaining normal knee PTS during surgery. The PTS was not influenced by age. The medial PTS was significantly larger than the lateral PTS in men and women. The PTS showed no significant gender dimorphism. BMI was significantly associated with the medial PTS.

A Complication-Based Comparison Between the Posterior and Direct Lateral Approaches to Total Hip Arthroplasty: A Single-Center Experience.

Introduction Many approaches to performing total hip arthroplasty (THA) exist, primarily due to an insufficient amount of research that would favor one approach over the other. This study aimed to compare the risk of nerve injury, dislocation, Trendelenburg gait, and stem malposition between the direct lateral and posterior approaches to THA. Methods The study was a retrospective cohort study, and it was conducted in King Abdulaziz Medical City. It was directed toward adult patients who underwent THA from November 1, 2003, to November 1, 2018. All figures were obtained through the BESTCare system (ezCareTech, Saudi Arabia). Categorical variables were presented as frequencies and proportions. Quantitative variables were measured as mean and standard deviation. Fisher's exact test was used to compare the risk of complications between the two approaches. Results The posterior approach displayed a greater risk of stem malposition (p< 0.001) when compared with the direct lateral approach. However, neither approach showed a higher risk of dislocation, nerve injury, or Trendelenburg gait. Conclusions A higher risk of stem malposition was observed in the posterior approach, and there were no remarkable variances between the two approaches in the risk of dislocation, nerve injury, and Trendelenburg gait. Until more meticulous nationwide studies are available to provide evidence that would favor an approach over the other, the choice of surgical approach for THA remains to depend on the patient's characteristics and the surgeon's prior experience. Regardless of the approach, preoperative, intraoperative, and postoperative factors that increase the risk of complications should also be identified and addressed adequately.

Primary bone sarcomas in KSA: A Saudi tumor registry review.

OBJECTIVES: The geographical incidence of tumours is usually influenced by the environment, race, and culture. This study aimed to report the incidence and differences in tumour type, site of origin, and mortality across gender, regions, age, and the different characteristics of tumour types. METHODS: This retrospective cohort study included all patients diagnosed with primary bone sarcomas from January 1, 2013, to December 31, 2017. Frequencies and percentages were generated for categorical variables. Means and standard deviations were calculated for quantitative variables. A chi-squared test was used to detect differences among categorical variables. Student-t, ANOVA, and Tukey tests were used to detect differences among quantitative variables. Lastly, we calculated the incidence of each tumour type. RESULTS: Of 451 patients, 248 (55%) had osteosarcomas; 160 (35.5%) had Ewing's sarcoma, and 43 (9.5%) had chondrosarcoma. The incidence was 1.56 cases per 1,000,000 per year for osteosarcoma, 0.95 cases per 1,000,000 per year for Ewing's sarcoma, and 0.27 cases per million per year for chondrosarcoma. The three-year survival rate was 82.30%. Significant differences in tumour type, origin site, and three-year survival across age and gender were detected. Similarly, significant differences were also noted in origin site, grade, basis of diagnosis, and lateralisation across tumour types. CONCLUSIONS: In our study, the observed bone sarcoma incidence rates were lower than the ones reported worldwide. Understanding the pattern of tumour behaviour in the region will help develop a risk and response-based treatment plan for early decision-making.

Variability of the Posterior Tibial Slope in Saudis: A Radiographic Study.

Aim The present study aimed to establish the normal range of the posterior tibial slope (PTS) angle in the Saudi adult population and to identify whether there was an association between the angle and gender or age. Materials and methods A total of 524 normal knee radiographs of 410 patients aged 18-85 years were included in the study. The PTS was measured using the anterior tibial cortex method. Data were matched with gender and age for statistical analysis. Results  The mean physiological PTS angle was 13.6 ± 3.4˚ (range: 3.8-23.9˚). Age and gender did not influence the PTS value (P >0.05). The two-way analysis of variance (ANOVA) test showed no interaction effect between age and gender on the PTS (P >0.05). Conclusions This study provided a reference range for the normal PTS among Saudis, which can assist in decision-making during different knee procedures. The PTS value did not significantly differ between male and female subjects, and there was no significant association between the PTS angle and age.