Acetabular index as an indicator of Pavlik harness success in grade I developmental dysplasia of the hip: A retrospective study.

Purpose: Some articles have focused on the effectiveness of the Pavlik harness treatment for unstable and dislocated hips, yet data on monitoring its effectiveness with the acetabular index remains elusive. Therefore, this study aimed to assess Pavlik harness effectiveness in infants ≤6 months diagnosed with grade I developmental dysplasia of the hip using acetabular index improvement and identify the possible predictors of successful Pavlik harness treatment. Methods: A retrospective review of infants with grade I acetabular dysplasia treated with a Pavlik harness and monitored with anteroposterior pelvis X-rays at presentation and follow-up. Successful treatment was defined as achieving an acetabular index <30°. Results: A total of 231 infants with acetabular dysplasia were treated with a Pavlik harness. A successful outcome was achieved in 135 infants (58.4%). Younger age, lower initial acetabular index, and patients with unilateral developmental dysplasia of the hip were significant predictors of a successful outcome. An age of 4.5 months or older was found to be the threshold for an unsuccessful result following Pavlik harness treatment, with a sensitivity of 65.2% and specificity of 57.3%. An initial acetabular index of 35.5° was found to be the threshold for an unsuccessful result, with a sensitivity of 83.7% and specificity of 61.5%. Conclusion: Pavlik Harness's success in correcting the acetabular index in acetabular dysplasia patients was related to unilateral cases, a younger age at presentation, and a lower initial acetabular index. The thresholds for unsuccessful treatment were an age of 4.5 months or greater and an acetabular index of 35.5° or higher.

Pediatric and Adolescent Flatfoot: A Questionnaire Based Middle East and North Africa Study.

Background: Flatfoot is commonly seen in the community and is a common cause of concern for parents because it could become symptomatic and lead to decreased quality of life. One of the most used management approaches is foot orthoses, although no clear evidence supports their use. We aimed to study flatfoot symptoms' prevalence, effect on activities of daily living, and the use and effectiveness of orthoses. Methodology: This was a cross-sectional study that included five countries from the Middle East and North Africa region (Jordan, Palestine, Syria, Egypt, and Iraq). Data were collected using an online questionnaire directed toward parents of children aged 0 to 16 from September to December 2020. The demographic factors were expressed as frequencies (percentages) using standard descriptive statistical parameters, and Pearson's chi-square test was used to examine the relationship between study factors. Results: 1256 participants were recruited using this online survey. The majority (29.6%) of children were diagnosed in the age group of 0 to 2. The abnormal appearance of the foot was the most common (78.7%) complaint. Overall, 54.2% of patients were prescribed orthoses, of which 36.8% noticed improvement in flatness and 37.6% reported relief of symptoms. Conclusion: This study demonstrated that most participants have no or minimal symptoms and that there is a mismatch between participants' expectations and the actual effectiveness of orthoses. Taking into consideration that there is no clear evidence to support the corrective effect of orthoses, we recommend that physicians prescribing them adhere more to their proper indications and spend more time and effort counseling and addressing patients' and parents' concerns about this developmental stage.

Treatment of Aneurysmal Bone Cysts by Minimally Invasive Curettage and Allogenic Bone Impaction Grafting: Mid-to Long-term Results.

OBJECTIVE: Recurrence is the main hinderance in treatment of aneurysmal bone cysts (ABCs). Therefore, several treatment modalities and adjuvant therapies have been proposed. In this study, we aim to evaluate the long-term effectiveness of percutaneous curettage and allogenic bone grafting as a new, minimally invasive modality in treating ABCs. METHODS: We performed a retrospective review of the medical records of patients diagnosed with primary ABCs at a university hospital over a 10-year period (2000-2010). We selected all patients who were diagnosed with primary ABC in the extremities and pelvis, treated with the same surgical procedure, and were followed for at least 2 years postoperatively. All patients underwent the same procedure of percutaneous curettage and impaction of allogenic pulverized fine bone fragments (harvested from locally stored femoral heads) mixed with autologous bone marrow aspirate from the iliac bone. We reported patient's characteristics (age and gender), site and size of the lesion, presenting symptoms, Capanna classification, follow-up duration, and post-operative complications. Assessment of cyst healing was based on the appearance on radiographs according to the modified Neer classification. RESULTS: Nineteen patients were included in this study; 10 patients were males and nine were females. The mean age was 9.6 years (range 3-15). The location of the lesions was as follows: femur (eight), tibia (four), pelvis (four), proximal humerus (one), distal radius (one), and calcaneus (one). The most common presenting symptom was pain in the involved area. Pathological fracture was the presenting feature in two patients. The mean follow-up duration was 6.4 years (range 2-18). The earliest radiological sign of incorporation of the allograft was seen at 3 months after surgery. All patients showed bone remodeling and radiographic resolution (classified as either A or B on the modified Neer classification) of their cystic lesions within 6 months. No local recurrence, infection, or pathological fractures occurred during the follow-up period. CONCLUSION: Percutaneous curettage and impaction of allogenic bone graft mixed with autogenic bone marrow aspirate is an efficient, minimally invasive, reproducible, and affordable procedure for the treatment of primary ABCs.

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.

The Effect of a Single Intravenous Corticosteroid Administration on Pain after Knee Arthroscopy: A Prospective, Double-Blind, Non-Randomized Controlled Clinical Trial.

BACKGROUND: Knee arthroscopy is a standard surgical procedure that is nowadays widely performed as day-case surgery. The aim of the study was to observe the effect of a single dose of intravenous corticosteroid on pain after undergoing knee arthroscopy for non-bony procedures. METHODS: A prospective, double-blind study design was adopted. Patients undergoing knee arthroscopy for non-bony procedures were prospectively assigned into two equal groups: control (those who were not given steroids) and treatment (those who were given eight milligrams of dexamethasone intravenously 15 min prior to the inflation of the tourniquet). The pain was assessed pre-operatively on admission and on the first post-operative day during the morning round in five different movements using a visual analogue scale (VAS). RESULTS: A total of 60 patients were included in the study. There was no significant difference in the pre-and post-operatively scores between both groups. The treatment group experienced a significant reduction in post-operative morphine requirements, with 80% of patients who did not receive dexamethasone requiring post-operative morphine compared to only 53.3% of patients who did (p = 0.027). CONCLUSIONS: Pre-operative intravenous administration of a single dose of dexamethasone may decrease opioid requirements for adequate pain control after knee arthroscopy.

Lower Limb Reconstruction Using Tibial Strut Autograft after Resection of Primary Malignant Bone Tumors in Skeletally Immature Patients.

BACKGROUND: Reconstruction of large bone defects in skeletally immature patients remains a surgical challenge. We report the long-term clinical outcomes of a novel surgical technique for lower limb reconstruction using the tibia as a strut autograft following resection of primary malignant bone tumors in skeletally immature patients. METHODS: We retrospectively reviewed the medical records of six patients diagnosed with lower limb primary bone sarcoma. All patients underwent tumor resection and reconstruction using tibial strut autograft. The radiological and clinical outcomes including complications at the recipient and donor sites were assessed. RESULTS: The mean age at presentation was ten years (range 6-15 years). Two cases had osteosarcoma and four had Ewing sarcoma. The mean length of the resected tumor and tibial autografts were 20.83 and 19.33 cm respectively. Union at both ends was achieved in five grafts while one graft achieved union only at the distal end. The mean time for union of the proximal and distal junctions was 4 and 8.8 months respectively. The mean follow-up period was 8.4 years (range 14 months-20 years). One patient developed a foot drop, and three patients underwent subsequent joint arthrodesis (2 knees and 1 ankle). The mean musculoskeletal tumor society functional score was 80.8%. Two patients had clinically significant leg-length discrepancy that needs further lengthening procedure. Four patients survived with no evidence of disease and two patients died due to their primary oncologic disease. All donor sites regenerated, with the earliest signs of new bone formation at (2-4) weeks post-operatively. CONCLUSION: Reconstruction using non-vascularized tibia strut autograft after resection of primary malignant lower limb bone tumors can be a viable alternative method for reconstructing large bone defects in the immature skeleton.

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.

Long-Term Outcomes of the Knee and Hip Arthroplasties in Patients with Alkaptonuria.

Alkaptonuria is a rare autosomal recessive metabolic disorder. It is characterized by the accumulation of homogentisic acid in the body due to a lack of enzymes that degrade it. Over time, it results in joint degeneration and eventually leads to ochronosis. Ochronosis refers to bluish-black discoloration of connective and other tissues within the body. In this study, we present 5 distinct cases diagnosed with alkaptonuria. They have undergone 8 total joint replacement surgeries (4 hips and 4 knees) within 8 years (2010-2018). All patients had an excellent outcome over several years. The follow-up period ranged from 2 to 10 years. Although none of the presented cases had intraoperative or postoperative adverse sequelae, we must take care when dealing with patients with ochronotic arthropathy. They carry a higher risk of complications than other patients with osteoarthritis disease. These complications include fractures due to fragile bone quality, muscle or tendon rupture, joint instability, and anesthesia-related complications. Total joint arthroplasty is a valid and safe option in the management of hip and knee ochronotic arthropathy.

Determining the risk of acute kidney injury in patients who underwent total joint replacement: A retrospective study.

OBJECTIVES: Total joint replacement (TJR) is a commonly performed procedure worldwide, and postoperative acute kidney injury (AKI) is one of the complications that determine the overall prognosis in various surgical settings. We aimed to identify the risk of AKI after TJR (primary and revision) and determine the factors associated with postoperative AKI. METHODS: We performed a retrospective study of 1068 patients (>18 years) who underwent TJR between 2014 and 2019 at a tertiary medical center. Patients' demographic, clinical, and laboratory data were reviewed. RESULTS: A total of 1068 patients were included in this study [mean age, 60.5 ± 13 years; 260 men (24.3%); 808 women (75.7%)]. A total of 962 patients (90.1%) underwent primary joint replacement (PJR) and 106 underwent joint revision (9.9%). Sixty-six patients (6.2%) had postoperative AKI. Primary total hip replacement patients had a lower risk of AKI than patients with other types of TJR (3.0%; p = 0.024). The factors associated with AKI (adjusting for known confounders) included male gender [adjusted odds ratio (AOR): 1.751; 95% confidence interval (CI): 1.01-3.03; p = 0.046], diabetes mellitus (DM) [AOR: 2.806; 95% CI: 1.687-5.023; p ≤ 0.001], hypertension (HTN) [AOR: 1.751; 95% CI: 1.159-3.442; p = 0.013], and the use of vancomycin as a prophylactic antibiotic [AOR: 1.691; 95% CI: 1.1-2.913; p = 0.050]. Chronic kidney disease (CKD) [AOR: 1.00; 95% CI: 0.432-2.27; p = 0.981] was not found to be a significant risk factor. CONCLUSION: In this study, the risk of preoperative AKI in patients who underwent TJR was 6.2%. Male gender, preoperative comorbidities such as DM and HTN, and preoperative use of vancomycin were associated with increased risk of postoperative AKI.

Association between mobile phone use and neck pain in university students: A cross-sectional study using numeric rating scale for evaluation of neck pain.

OBJECTIVE: Mobile phones are reliable devices for communication and entertainment. However, their utilization for prolonged periods in flexed neck position is linked to neck and shoulders pain. The main purpose of this study is to investigate the association between neck pain and the duration of device use, taking into consideration gender, age, and the most frequent position in which students use their devices. SUBJECTS AND METHODS: Based on a self-administered online questionnaire, we filled 500 questionnaires between February 15th, 2017 and March 18th, 2017. The study sample included healthy students from health care faculties regardless of their age, gender, or handedness. RESULTS: Analysis of the predictors for pain severity showed that age (p = 0.04) and duration of use (p = 0.001) were significantly associated with the severity of neck pain, while only the duration of use was significantly associated with pain duration (p = 0.036). Subjects were divided into two groups according to the pain score, 75.8% had pain severity equal or less than 4/10 and 24.2% had pain severity more than 4/10. Of those with pain severity >4, 5.8% of students sought medical help at the emergency department and 12.4% visited clinics, compared to only 0.3% seeking medical advice at an emergency department and 4.2% visiting clinics in the group with pain severity of ≤4 (p<0.001). Regarding the use of analgesia in the two groups, 44.6% of subjects with pain severity of >4 used analgesia, compared to only 12.1% in subjects with pain severity of ≤4 (p< 0.001). CONCLUSION: This study demonstrates a significant positive correlation between the duration of mobile phone use and the duration and severity of neck pain. Furthermore, the increased severity of neck pain places a huge burden on the healthcare system.

Superior Extension of Upper Instrumented Vertebrae in Distraction-based Surgery: A Surrogate for Clinically Significant Proximal Junctional Kyphosis.

BACKGROUND: Proximal junctional kyphosis (PJK) is a reported complication of distraction-based growth-friendly surgery for early-onset scoliosis (EOS). A potential consequence of PJK is revision surgery with superior extension of the upper instrument vertebrae (UIV). The purpose of this study was to determine the risk of radiographic and clinically significant PJK during growth-friendly surgery. METHODS: This is a retrospective review of children treated with distraction-based growth-friendly surgeries from two EOS registries with minimum two-year follow-up. PJK is defined as clinically significant in this study if surgery with superior extension of the UIV was performed. RESULTS: Of 419 total patients, there was a 20% risk of developing clinically significant PJK (24% rib vs. 15% spine-based anchors, p = .03). These patients had a mean preoperative age of 5.6 years (5.2-year rib vs. 6.0-year spine, p < .001), scoliosis of 73° (69° rib vs. 77° spine, p < .001), and kyphosis of 51° (47° rib vs. 56° spine, p < .01). Regression analysis demonstrated that these differences in age, scoliosis, and kyphosis between anchor type did not account for a significant proportion of the measured variance. CONCLUSIONS: There was a 20% risk of developing clinically significant PJK, with a slightly higher risk for patients treated with rib-based proximal anchors (24%) than for those patients treated with spine-based proximal anchors (15%). LEVEL OF EVIDENCE: Level III.

Intra-articular injection of expanded autologous bone marrow mesenchymal cells in moderate and severe knee osteoarthritis is safe: a phase I/II study.

BACKGROUND: Knee osteoarthritis (KOA) is a major health problem especially in the aging population. There is a need for safe treatment that restores the cartilage and reduces the symptoms. The use of stem cells is emerging as a possible option for the moderate and severe cases. This study aimed at testing the safety of autologous bone marrow mesenchymal stem cells (BM-MSCs) expanded in vitro when given intra-articularly to patients with stage II and III KOA. As a secondary end point, the study tested the ability of these cells to relieve symptoms and restore the knee cartilage in these patients as judged by normalized knee injury and Osteoarthritis Outcome Score (KOOS) and by magnetic resonance imaging (MRI). METHODS: Thirteen patients with a mean age of 50 years suffering from KOA stages II and III were given two doses of BM-MSCs 1 month apart totaling 61 × 106 ± 0.6 × 106 by intra-articular injection in a phase I prospective clinical trial. Each patient was followed for a minimum of 24 months for any adverse events and for clinical outcome using normalized KOOS. Cartilage thickness was assessed by quantitative MRI T2 at 12 months of follow-up. RESULTS: No severe adverse events were reported up to 24 months follow-up. Normalized KOOS improved significantly. Mean knee cartilage thickness measured by MRI improved significantly. CONCLUSION: BM-MSCs given intra-articularly are safe in knee osteoarthrosis. Despite the limited number of patients in this study, the procedure described significantly improved the KOOS and knee cartilage thickness, indicating that they may enhance the functional outcome as well as the structural component. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02118519.