The need for non-technical skills education in orthopedic surgery.

BACKGROUND: The issue of surgical safety has increased significantly over the last few decades. Several studies have established that it is linked to non-technical performance, rather than clinical competencies. Non-technical skills can be blended with technical training in the surgical profession to improve surgeons' abilities and enhance patient care and procedural skills. The main goal of this study was to determine orthopedic surgeons' requirements of non-technical skills, and to identify the most pressing issues. METHODS: We conducted a self-administered online questionnaire survey in this cross-sectional study. The questionnaire was piloted, validated, pretested, and clearly stated the study's purpose. After the pilot, minor wording and questions were clarified before starting the data collection. Orthopedic surgeons from the Middle East and Northern Africa were invited. The questionnaire was based on a five-point Likert scale, the data were analyzed categorically, and variables were summarized as descriptive statistics. RESULTS: Of the 1713 orthopedic surgeons invited, 60% completed the survey (1033 out of 1713). The majority demonstrated a high likelihood of participating in such activities in the future (80.5%). More than half (53%) of them preferred non-technical skills courses to be part of major orthopedic conferences, rather than independent courses. Most (65%) chose them to be face-to-face. Although 97.2% agreed on the importance of these courses, only 27% had attended similar courses in the last three years. Patient safety, infection prevention and control, and communication skills were ranked at the top as topics to be addressed. Moreover, participants indicated they would most likely attend courses on infection prevention and control, patient safety and teamwork, and team management. CONCLUSION: The results highlight the need for non-technical skills training in the region and the general preferences regarding modality and setting. These findings support the high demand from orthopedic surgeons' perspective to develop an educational program on non-technical skills.

Etiology of trauma-related acute compartment syndrome of the forearm: a systematic review.

OBJECTIVES: Acute compartment syndrome (ACS) can be caused by multiple causes that affect people of different ages. It is considered an orthopedic emergency condition that requires immediate diagnosis and surgical intervention to avoid devastating complications and irreversible damages. This systematic review aimed to present the etiology of trauma-related forearm ACS. METHODS: A systematic review was performed on four different databases: Embase, Medline, Cochrane Central Register of Controlled Trials (CENTRAL) and Cochrane Database of systematic review register databases via Ovid, with no restriction on dates (last date was June 30, 2021). It included all the studies containing data about the etiology of trauma-related forearm ACS. RESULTS: A total of 4893 articles were retrieved: 122 met the inclusion criteria, 39 were excluded, 25 were out of scope and 14 had insufficient details. Hence, this review constituted 83 articles and 684 patients. The etiology of ACS causing forearm ACS was classified into three groups: fracture-related, soft tissue injury-related and vascular injury-related. The fracture-related group was the most common group (65.4%), followed by soft tissue injury (30.7%), then vascular injuries (3.9%). Furthermore, supracondylar humerus fractures were the most common cause of fractures related to forearm ACS. Blunt traumas were the most common cause of soft tissue injuries-related forearm ACS, and brachial artery injuries were the most common cause of vascular-related forearm ACS. CONCLUSION: Frequent assessment of patients with the most prevalent etiologies of forearm ACS is recommended for early detection of forearm ACS and to save limbs.

Acute "three-in-one" surgery for the treatment of severe Blount's disease: Surgical technique and report of two cases.

The treatment of Blount's disease has historically remained controversial. All the described techniques for its treatment have their own advantages and disadvantages, and no consensus has been reached on a single surgical approach. The aim of this report is to share the early results of a combination technique in which we have collated three well-known surgical steps in one procedure. This combined procedure is indicated for severe and recurrent cases. Our 'three-in-one' technique combines an intra-epiphyseal plateau elevating osteotomy with a tibial metaphyseal osteotomy and a lateral tibial temporary hemi-epiphysiodesis. We also report initial results of three limbs in two patients who were treated using this technique. The first case was that of an adolescent with severe left Blount's disease (Langenskiold stage IV) and a lateral thrust. The second case was that of bilateral severe infantile Blount's disease (Langenskiold stage V) and the infant had a lateral thrust. All measurements remarkably improved in both patients during the post-surgical assessment. The limb length discrepancy was 0.6 cm in the first case and 0.5 cm in the second. The preoperative internal tibial rotation and lateral thrust were corrected spontaneously. No complications were recorded in either patient. The three-in-one technique is a safe and versatile surgical approach that can be used in severe, refractory, and recurrent cases of open physis. Furthermore, it can potentially solve the problems of lateral thrust and internal tibial rotation. More cases should be studied before we can endorse the safety and effectiveness of this technique.

The prevalence of doping among Saudi athletes: Results from the National Anti-Doping Program.

OBJECTIVES: The abuse of substances banned by anti-doping authorities is a significant problem in sports. Recently, several doping cases have been reported by the media. Additionally, a large number of athletes have been found guilty of using banned substances. Although athletes believe that doping is against the spirit of sports and are aware of its consequences, they continue to use these substances. The consumption of banned substances among Saudi athletes is rising. This study aimed to investigate the abuse of drugs among Saudi athletes. METHODS: A systematic random sampling cross-sectional survey was administered to all 15-45-year-old Saudi male athletes who were registered with Saudi Sports Federations and the General Sports Authority. From 2009 to 2018, 388 doping control officers participated in the National Anti-Doping Program across 460 facilities. The study necessitated 171 city visits for data collection. RESULTS: A total of 6306 samples were tested during the study period. There were 6165 negative and 141 (2.24%) positive samples for doping. We report a doping prevalence of 2.24% among Saudi athletes. During the study period, Saudi athletes from all types of sports were tested positive for doping. The number of positive samples was significantly higher among competing athletes than non-competing athletes. CONCLUSION: Doping is a significant problem in KSA. For safe and fair play by all Saudi athletes, the National Anti-Doping Program should enhance the educational campaigns for all athletes in the country.

Failure of faculty to fail failing medical students: Fiction or an actual erosion of professional standards?

OBJECTIVES: Literature has shown that some assessors assign passing grades to medical students who, in fact, should not have passed. This inability of the faculty to fail underperforming students can jeopardise the reputation of professional programs, be it in the medical field or beyond. Simultaneously, weak students become incompetent physicians and, thus, endanger the community they serve. The impetus for conducting this systematic review was to identify barriers to faculty in failing struggling medical students. METHODS: The databases of MEDLINE, Scopus, Wiley online library, Cochrane library, OVID, Taylor and Francis, CINAHL, Springer link, ProQuest, and ISI Web of knowledge were searched using Medical Subject Headings (MeSH) terms 'Faculty failure' AND 'Failing students' AND 'Failure to fail' OR 'Assessment'. The data were synthesised, and the results were analysed. RESULTS: This search showed a wealth of barriers to faculty contributing to a 'failure to fail' such as their concerns about legal action and an appeals process; the stress of failing students; a lack of knowledge about proper documentation; unavailability of support, resources, and offices for faculty; absence of administrative guidelines; and complex dismissal procedures discouraging the faculty from failing students. CONCLUSION: Institutional faculty development programs and training workshops should facilitate the education of supervisors and assessors for timely evaluation and regular documentation of trainee assessment. The provision of legal advice in cases of appeal and professional support by the resource and support office is emphasised.

The journey of orthopaedic surgery from residency to fellowship: A cross-sectional study in the Gulf Cooperation Council countries.

OBJECTIVES: Becoming an Orthopaedic Surgeon is a challenge worldwide. This study attempted to determine the level of training at which orthopaedic surgery is chosen as a career by residents and graduates of Gulf Cooperation Council (GCC) countries. The reasons for choosing this surgical speciality and barriers faced by residents were also explored. METHODS: In this cross-sectional study, a questionnaire was electronically distributed to all GCC orthopaedic surgery residents. All currently enrolled residents and fellows in orthopaedic surgery programmes in KSA, Oman, Kuwait, and Bahrain were invited. Exclusion criteria included first-year residents and those who had completed their residencies before 2013. RESULTS: A total of 275 out of 569 residents responded, a response rate of 48.33%. More than half of the participants (54.5%) chose orthopaedic surgery during their undergraduate studies. Personal interest ranked number one at 61.09%, while parental pressure was found to be the least important reason (0.36%). The majority (88.0%) agreed that orthopaedic surgery was physically demanding, whereas 33.1% wanted to quit orthopaedic surgery. The interest of residents for future subspecialities was mostly in paediatric orthopaedics and sports medicine, as suggested by 16.4% and 16.0%, respectively. CONCLUSION: This study showed an alarming number of residents who wanted to quit orthopaedic surgery. The challenges residents faced were burnout, lack of time, limited exposure to teaching hospitals, and limited seats for subspeciality training. We recommend increasing the number of orthopaedic surgery subspeciality fellowships, as well as the number of fellowship seats in training programmes. The well-being of orthopaedic surgery residents should also be given consideration.

Current practice and preferences to management of equinus in children with ambulatory cerebral palsy: A survey of orthopedic surgeons.

INTRODUCTION: The consensus among orthopedic surgeons on the management of equinus deformity in cerebral palsy (CP) children has not been reported previously despite being a prevalent deformity. The goals of this study were to examine the orthopedic surgeons' current practice regarding the management of equinus deformity in children with ambulatory CP, and analyze variations in current practice between general orthopedic and pediatric orthopedic surgeons. METHODS: We implemented a brief cross-sectional self-reported questionnaire that addressed the areas of clinical examination and decision-making skills of management of equinus deformity in CP children. We targeted a convenience sample of 400 participants. Surgeons that provided complete responses to the questionnaire were 223 with a response rate of 56%, of which 123 (55%) were general orthopedic surgeons, whereas 100 (45%) were pediatric orthopedic surgeons. The target population consisted of orthopedic surgeons who were further sub-classified in accordance with practice age, general versus pediatric, and exposure to children's orthopedics during the last three years of their practice. For analytical statistics, the Chi-Square test and Fisher's exact test were used to examine the relationship between two qualitative variables. RESULTS: The overall clinical practice preferences of all survey participants were unimpressive with discordant survey responses. Pediatric orthopedic surgeons generally demonstrated a statistically significant difference regarding clinical assessment skill items of the survey, in contrast to general orthopedic surgeons. However, we found no differences between pediatric orthopedic and general orthopedic surgeons regarding most of the decision-making/knowledge items. DISCUSSION: Generally, there are insufficient clinical practice trends of both general and pediatric orthopedic surgeons regarding equinus treatment in CP children. This may indicate a knowledge-practice gap with potential risks to CP children undergoing surgery for equinus. There is a need for a more competent exposure to CP in orthopedic surgeons' educational curricula and an updated health referral system.

Medical students' perception of test anxiety triggered by different assessment modalities.

OBJECTIVES: Test anxiety is well known among medical students. However, little is known about test anxiety produced by different components of exam individually. This study aimed to stratify varying levels of test anxiety provoked by each exam modality and to explore the students perceptions about confounding factors. METHODS: A self-administered questionnaire was administered to medical students. The instrument contained four main themes; lifestyle, psychological and specific factors of information needs, learning styles, and perceived difficulty level of each assessment tool. RESULTS: A highest test anxiety score of 5 was ranked for "not scheduling available time" and "insufficient exercise" by 28.8 and 28.3% students, respectively. For "irrational thoughts about exam" and "fear to fail", a highest test anxiety score of 5 was scored by 28.8 and 25.7% students, respectively. The highest total anxiety score of 1255 was recorded for long case exam, followed by 975 for examiner-based objective structured clinical examination. Excessive course load and course not well covered by faculty were thought to be the main confounding factors. CONCLUSIONS: The examiner-based assessment modalities induced high test anxiety. Faculty is urged to cover core contents within stipulated time and to rigorously reform and update existing curricula to prepare relevant course material.

Whole genome SNP genotyping in a family segregating developmental dysplasia of the hip detected runs of homozygosity on chromosomes 15q13.3 and 19p13.2.

Developmental dysplasia of the hip (DDH) is one of the most prevalent developmental orthopedic diseases worldwide. DDH is a spectrum of anatomical abnormalities of the hip joint and is characterized by premature arthritis in later life. Sporadic cases have been reported more frequently; however, some studies have reported families segregating DDH. Studies have suggested that the genetic factors play a significant role in the development of DDH. In order to detect genetic defect underlying DDH, we performed Sanger sequencing of all DDH associated genes, whole genome SNP genotyping and exome sequencing in a Saudi family with four individuals having DDH. Sanger sequencing of all known genes did not identify any pathogenic variant. Genotype data analysis using HomozygosityMapper identified shared homozygous regions on chromosome 15q13.3 and chromosome 19p13.2 flanked by rs17228178-rs1534200 and rs466123-rs2112461, respectively. These data were also analyzed by cnvpartition software for identification of DDH associated copy number variations (CNV). A shared copy number gain of approximately 15 kb on chr6p21.32 (chr6:33 053 906-33 069 893) was discovered in all affected individuals. Partial gain of this region has also been found in unaffected sibling of this family. Exome data did not reveal any candidate sequence variant. Whole genome sequencing is required to identify deep intronic variants in the shared homozygous regions. Identification of genetic variants involved in pathogenesis of DDH may open up interesting perspectives into the function of the gene(s) in hip joint development.

Genetics of clubfoot; recent progress and future perspectives.

Clubfoot or talipes equinovarus (TEV) is an inborn three-dimensional deformity of leg, ankle and foot. It results from structural defects of several tissues of foot and lower leg leading to abnormal positioning of foot and ankle joints. TEV can lead to long-lasting functional disability, malformation and discomfort if left untreated. Substantial progress has been achieved in the management and diagnosis of limb defects; however, not much is known about the molecular players and signalling pathways underlying TEV disorder. The homeostasis and development of the limb depends on the complex interactions between the lateral plate mesoderm cells and outer ectoderm. These complex interactions include HOX signalling and PITX1-TBX4 pathways. The susceptibility to develop TEV is determined by a number of environmental and genetic factors, although the nature and level of interplay between them remains unclear. Familial occurrence and inter and intra phenotypic variability of TEV is well documented. Variants in genes that code for contractile proteins of skeletal myofibers might play a role in the aetiology of TEV but, to date, no strong candidate genes conferring increased risk have emerged, although variants in TBX4, PITX1, HOXA, HOXC and HOXD clusters genes, NAT2 and others have been shown to be associated with TEV. The mechanisms by which variants in these genes confer risk and the nature of the physical and genetic interaction between them remains to be determined. Elucidation of genetic players and cellular pathways underlying TEV will certainly increase our understanding of the pathophysiology of this deformity.

Diagnosis and treatment of developmental dysplasia of the hip: A current practice of paediatric orthopaedic surgeons.

BACKGROUND: Developmental dysplasia of the hip (DDH) is one of the prevalent musculoskeletal conditions in young adults and is a leading cause of hip osteoarthrosis in this age group. The optimum age for surgical intervention when needed is not well established in the literature and the lack of management guidelines and standard practice of DDH leads to different practices worldwide. This study aims to investigate the current practice of paediatric orthopaedic surgeons in diagnosing and treating DDH worldwide and identify points of agreement and disagreement. METHODS: A cross-sectional study utilizing an online questionnaire was designed to examine the different points of view and current practice of paediatric orthopaedic surgeons worldwide regarding DDH diagnosis and treatment. RESULTS: Ninety-one surgeons responded, with an overall response of 45.5%. The vast majority of respondents use ultrasonography in children less than 3 months of age and pelvic radiography in over 3 months to diagnose DDH. Pavlik harness is the most popular DDH treatment for children younger than 6 months. For older children, closed reduction with hip spica cast is the most preferable treatment. The maximum duration of first-line treatment has a broad range. The treatment of bilateral DDH varies widely among surgeons. CONCLUSION: This study shows clearly that paediatric orthopaedic surgeons do not agree on the diagnosis and treatment protocol of DDH, hence different approaches to this common disease are practised. The lack of an international guideline should motivate paediatric orthopaedic surgeons to discuss and formulate a uniform and evidence-based protocol for the diagnosis and treatment of DDH.

Exome sequencing identified rare variants in genes HSPG2 and ATP2B4 in a family segregating developmental dysplasia of the hip.

BACKGROUND: Developmental dysplasia of the hip (DDH) is a common pathological condition of the musculoskeletal system in infants which results in a congenital and developmental malformation of the hip joint. DDH is a spectrum of pathologies affecting the infant hip ranging from asymptomatic subtle radiographic signs through mild instability to frank dislocations with acetabular dysplasia. A Saudi family with three affected individuals with DDH was identified and genetic analysis was performed to detect the possible genetic defect(s) underlying DDH in the affected members of the family. METHODS: We performed whole genome genotyping using Illumina HumanOmni 2.5 M array and whole exome sequencing (WES) using Nextera Rapid capture kit and Illumina NextSeq500 instrument in four individuals of a family with DDH. RESULTS: SNP data analysis did not identify any runs of homozygosity and copy number variations. Identity-by-descent (IBD) analysis on whole genome genotyping data identified a shared haplotypes on chromosome 1 in affected individuals. An analysis of the WES data identified rare heterozygous variants in HSPG2 and ATP2B4 genes in the affected individuals. Multiple prediction software predicted that the variants identified are damaging. Moreover, in silico analysis showed that HSPG2 regulates ATP2B4 expression using a variety of transcription factors. CONCLUSION: Our results indicate that there might be a functional epistatic interaction between HSPG2 and ATP2B4, and DDH in the family studied is due to a combined effect of both variants. These variants are also present in the asymptomatic mother suggesting that the variants in HSPG2 and ATP2B4 are incompletely penetrant. This study provides the first evidence of digenic inheritance of DDH in a family and extends the spectrum of genetic heterogeneity in this human disorder.

Exam anxiety in the undergraduate medical students of Taibah University.

BACKGROUND AND OBJECTIVES: Assessment is perceived to create highly stressful environment among medical students. Several studies have reported exam-related anxiety symptoms but the contributing factors seem to differ across institutions. This study aimed to determine the prevalence of exam anxiety, gender differences and the variables that moderate exam anxiety among students of a Saudi medical school. METHODS: A cross-section study was done on 5th year medical students by administering a 12-statement self-administered questionnaire. The degree of exam anxiety was gauged by a visual analog scale. RESULTS: Of 125 students, 111 responded (response rate 89%). About 65% students experienced exam anxiety due to various reasons. Studying all night before exam (28 students; 25.2%) and extensive course load (26 students; 23.4%) were the major confounding factors. Female students experienced more stress due to extensive course load as compared with male students (p = .00). CONCLUSIONS: The data about the identified risk factors for exam anxiety can help medical educators to deeply understand the reasons for exam anxiety. There is a need to reassess the amount of study material in undergraduate medical curricula and students need to organize their time management skills to cope with exam anxiety.

Low bone mineral density among young healthy adult Saudi women. Prevalence and associated factors in the age group of 20 to 36 years.

OBJECTIVES: To screen for low bone mineral density among young adult Saudi women using quantitative ultrasound (QUS) and exploring the high risk groups. Methods: A cross-sectional study was performed on 279, 20-36 years old female students and employees of Taibah University, Al Madinah Al Munawwarah, Kingdom of Saudi Arabia between January and May 2014. The study included bone status assessed using QUS, a structured self-reported questionnaire, anthropometric measurements, and evaluation of bone markers of bone metabolism. Results: The prevalence of low bone mineral density was 9%. Serum osteocalcin was found significantly higher in candidates with low bone mineral density, 20.67 ng/ml versus 10.7 ng/ml, and it was negatively correlated with T-scores. At any given point in time the exposed subjects to low calcium intake and inadequate sun exposure in the population were 11 times and 3 times more likely to have low bone mineral density, (adjusted odds ratio [OR], 11.0; 95%confidence interval [CI]=3.16, 38.34; p=0.001) and (adjusted OR, 3.32, 95%CI=1.27, 8.66, p less than 0.01). Conclusion: Early detection screening programs for low bone mineral density are needed in Saudi Arabia as it affects young Saudi women specially the high-risk group that includes young women with insufficient calcium intake and insufficient sun exposure. Serum osteocalcin as a biomarker for screening for low bone mineral density could be introduced.

Multiple Concomitant Injuries in One Upper Extremity: A Case Report.

BACKGROUND: This report is about unusual multiple upper extremity concomitant injuries in an adult after a fall from a height. To the best of our knowledge this is the first reported case of concomitant ipsilateral occurrence of multiple common injuries, uncommonly occurring together in a single traumatic episode. CASE REPORT: A 36-year-old right-handed man fell through a skylight to the floor about 4 meters below. He presented with multiple concomitant injuries in his right upper extremity: elbow dislocation with radial head fracture associated with distal radius, ulnar styloid, and scaphoid fractures. CONCLUSIONS: The probable mechanism of injury along with the surgical treatment of these previously undescribed injuries is discussed to emphasize the need to clinically examine the whole upper extremity in severe injuries. The awareness of such an association for early recognition is paramount for excellent clinical results.

Publish or Perish mantra in the medical field: A systematic review of the reasons, consequences and remedies.

OBJECTIVES: Generally, academic promotions, job retention, job mobility, and professional development of a medical faculty members are judged primarily by the growth in publication outputs. Universities and research institutions are more likely to recruit and promote those academics carrying voluminous résumés with larger number of published articles. This review elaborates the causes and consequences of the pressure to publish and the ways and means to cope with this paradigm. METHODS: In 2015, database of Abstracts of Reviews of Effects, LISTA (EBSCO), Medline and Oxford University Library were searched for the English language full-text articles published during 2000-2015, by using MeSH terms "pressure to publish", "urge to publish", "research ethics", "plagiarism", "article retraction", "medical field". This search was further refined by selecting the articles in terms of relevancy and contents. RESULTS: This research showed that some universities offer generous grants to researchers with a high h-index and with more publications in elite journals, which promise an enhanced prospect of citations and elevation in the scientific rankings of the funding institutions. This generates an involuntary obsession to publish with the primary intention to obtain promotions, high scientific rankings, and improved job security. This compelling pressure to publish results in widespread publication of non-significant research with a high index of plagiarism that eventually leads to an increased frequency of retractions. CONCLUSION: Research centers and academic institutions have an obligation to train their academics in sound scientific writing and to apprise them of the publication ethics and the grave consequences of plagiarism and research misconduct.

Botulinum neurotoxin-A in idiopathic chondrolysis: a report of two cases.

Two cases of idiopathic chondrolysis were treated by botulinum neurotoxin-A injections, with a favorable outcome. The treatment consisted of botulinum neurotoxin-A injections, followed by an intensive rehabilitation program. No surgery was needed. Both patients were symptom-free and showed an extremely satisfactory range of motion. Radiographs indicated reconstitution of the joint space in both cases. We believe that botulinum neurotoxin-A injections combined with an intensive rehabilitation program may be considered a new potential management modality and is worth attempting and studying when one considers the results of previously published reports.

Learning styles of medical students at Taibah University: Trends and implications.

BACKGROUND: Understanding the learning styles of medical students can drive the institutions to adapt instructional materials to enhance students' learning of knowledge and skills. This study explored the learning styles of undergraduate medical students, comparing gender variations in terms of their significant preferences. MATERIALS AND METHODS: A cross-sectional observational study was performed in 2012-2013, incorporating 1(st)-5(th) year undergraduate medical students of Taibah University. The instrument used was a Learning Style Questionnaire, with four learning styles (activist, reflector, theorist and pragmatist) and 40 items. RESULTS: Of 450 students, 384 responded (response rate; 85%). No single learning style predominated; 96 (25%) reflectors, 78 (20%) theorists, 68 (17%) pragmatists, and 37 (9%) activists. Combined reflector and theorist was the predominant dual learning style in 27 (7%) students. Among genders, theorist style had a significant result (P = 0.071) indicating that theorists varied among genders due to their different opinions. Learning style preferences of theorists and pragmatists also showed a significant result (P = 0.000 each), depicting that both genders had unique preferences. Males had fewer variations of preferences, when compared with females who showed a significant difference of opinions (P < 0.05). CONCLUSION: The students in the study preferred diverse learning styles, which were unevenly distributed, reflectors being the most common and activists as the least common. The results reflect the need to promote self-directed learning and modifications of instructional strategies, with expectant tilt in the students' learning styles towards activists and pragmatists.

The closed wedge counter shift osteotomy for the correction of post-traumatic cubitus varus.

A variety of osteotomies have been proposed to correct post-traumatic cubitus varus deformity. Each one of them has advantages and disadvantages or limitations. A new technique for correcting post-traumatic cubitus varus with closed wedge counter shift osteotomy of the distal humerus is described and the preliminary results in six cases are reported. Five patients showed excellent results and one patient showed good result. We believe that the described technique is an alternative to the other procedures for the treatment of post-traumatic cubitus varus with minimal internal rotation and hyperextension deformities. It has the advantages of being a simple, safe, inherently stable, technically sound procedure, and yields an excellent cosmetic outcome.