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1 Knee Problems Connected with Incorrect Positions of Sitting , Karski Tomasz1*, Karski Jacek2, Karska Klaudia2, Pyrc Jaros?aw3
The pathology of knee and hips in children and adults can be caused by different factors. Disfunction of the hip joint can be connected with dysplasia not properly cured in the childhood, with Perthes disease, with epiphyseolisis capitis femors juvenilis, with trauma and other influences. The knee insufficiency can be connected with incorrect axis of shank or knee-valgus or varus, with flexion contracture or recurvation of the knee, with a pathology of patello-femoral joint and other influence. Since 2012 we have observed “others influences”, among which an “incorrect position of sitting”, which is leading to pathology of the knee-instability and pain syndromes. In the article, we present many cases of such pathology and we are giving the rules of the therapy and prophylaxis. Other influences-incorrect sitting-appear very frequently in our material, but till now such “etiological factors in pathology of the knee” have not been presented in the literature.
2 Non-operative Treatment of Kienbock’s Disease, Systematic Literature Review and Report on Three Cases , Bryce N Clinger1*, Mark S Anderson1, Moheb S Moneim1
Objective: Evaluate patient outcomes after non-operative treatment for Kienbock’s disease. Methods: A systematic review of literature using CINAL, Cochrane and PubMed databases was performed by the authors. Common keywords associated with Kienbock’s disease were searched. Articles were limited to those published less than 40 years ago and those in English. The bibliographies of all relevant results were manually searched for any additional references. Duplicates and paediatric articles were removed and abstracts were reviewed for relevance. Each eligible study was independently reviewed in its entirety by two of the investigators. Three cases with stage II Kienbock’s disease on MRI treated non-operatively are also presented. Results: 15 out of 967 articles met inclusion criteria. Various surgical techniques compared to non-operative treatment. Surgery was largely no better than non-operative treatment with symptom relief. Wrist mobility, grip strength, and activity modification showed non-operative treatment having better long term outcomes. The cases of three patients with stage II disease on MRI treated non-operatively are presented. At follow up, patients reported improved pain and function. One patient demonstrated improved vascularity on repeat MRI. Conclusion: Based on the results of our systematic review along with the successful outcomes of three cases presented by the authors, non-operative treatment of Kienbock’s disease may be more beneficial than previously thought or described regardless of the stage of Kienbock’s disease.
3 The Role of Obesity on Cast Index and Secondary Intervention in Pediatric Forearm Fractures , Kathy M McGurk1*, Ted Samaddar1, William R Barfield1, Robert F Murphy1
Background: Pediatric forearm fractures are common, and the majority are treated with closed reduction and immobilization. Additionally, the incidence of pediatric obesity is rising. Cast index is a useful metric to assess the quality of a cast mold. This study aims to assess the effect of obesity in obtaining an adequate cast index as a predictor for fracture redisplacement and risk for subsequent intervention after a reduction. Methods: A retrospective chart review was conducted over a six-year time period on children with a displaced/unstable forearm fracture that underwent reduction and molded long arm casting with >4 weeks follow-up. The cast index was measured on immediate post-manipulation radiographs. Children were divided into three groups according to body mass index (BMI) percentile for age: Underweight (<5th); Normal BMI (5th-85th); Overweight/obese (≥ 85th). Clinical notes and radiographs were reviewed for loss of reduction and secondary intervention. Results: 84 patients (70% male) qualified for inclusion. Mean age was 7.4 years (Range 3-14 years). Fracture redisplacement and secondary intervention occurred in 8 patients (9.5%). Patient BMI distribution was 5% in the Underweight, 71% in the Normal BMI and 24% in the Overweight/obese groups. The mean cast index in the 8 patients who required a second procedure was significantly higher than those who did not (1.00±0.06 vs 0.83±0.07, P<.001). The mean cast index among the underweight, normal BMI and overweight/obese groups was not statistically different. Obesity was not an independent risk factor for secondary intervention. Regression analysis did not correlate increasing cast index with BMI percentile for age. Conclusion: Cast index continues to be reliable metric for evaluating the quality of the cast mold and loss of subsequent reduction. In this cohort, it does not appear that BMI plays a significant role in hindering the ability to place a well-molded cast. Level of Evidence: Prognostic level IV
4 Assessment of the Piso-Triquetral Kinematics-A Pilot Study Using Dynamic CT , Josipa Petric1*, Roland Deek1, Neil Kruger2, Melanie Amarasooriya3, John White4, Gregory I Bain5
Introduction: The purpose of this study was to use 4D-CT to quantify the motion of the pisiform with relation to the triquetrum, in order to understand the piso-triquetral joint kinematics through active wrist movements. The use of 4D-CT allowed us to explore kinematic concepts objectively in a quantitative real-time manner, and has the advantage of visualisation in 6 degrees of freedom. Materials and Methods: A normal wrist as was imaged through FE and RUD. Surface rendered models were created from individual carpal bones in each wrist position through the motion arc. These bones were tracked during RUD and FE using a registration algorithm. Radio-ulnar and flexion-extension motions of the pisiform and triquetrum, as well as the piso-triquetral distance were graphed against the global wrist motion. Results: In wrist extension, the pisiform and triquetrum undergo more in-plane motion than the movement of the wrist, and are closest together. During flexion, the bones are furthest away from each other and exhibit out-of-plane (radioulnar deviation) motion in opposite directions. There is minimal out-of-plane motion during extension and during radioulnar deviation. During radioulnar deviation, the minimum articular distance between the pisiform and triquetrum changes negligibly. Conclusions: These in vivo findings, although in a single patient, may be used for further characterisation of dynamic wrist pathology.
5 Four-Dimensional CT Assessment of the Transverse Carpal Ligament Attachments-A Pilot Study , Roland Deek1*, Josipa Petric1, Neil Kruger2, Melanie Amarasooriya3, John White4, Gregory I Bain5
Introduction: The wrist is a complex joint, and static imaging techniques may not capture subtle kinematic abnormalities. Four-dimensional (4D) CT presents an alternative method of assessing the dynamic movement of the Transverse Carpal Ligament (TCL). The TCL is important in carpal stability, grip strength, and as a component of the flexor pulley system. The purpose of this study is to determine the dynamic displacement of the TCL attachment points in-vivo through wrist Flexion-Extension (FE) and Radio-Ulnar (RUD) deviation using 4D CT. Materials and Methods: A normal wrist as was imaged through FE and RUD. Surface rendered models were created from individual carpal bones in each wrist position through the motion arc using 4D CT scans. These bones were tracked using a registration algorithm, and their translations were graphed against the global wrist motion. Results: During wrist flexion, all TCL attachment points moved proximally and volarly. There was minimal displacement of the attachments in the radioulnar plane. During wrist ulnar to radial deviation, the radial attachment points moved proximally and ulnar attachment points distally. In the radioulnar plane, all attachment points moved radially, except scaphoid, which translated ulnarly. The scapho-pisiform distance showed marked shortening in wrist radial deviation. Conclusions: This study demonstrates that 4D-CT can be effectively utilized to assess TCL kinematics in-vivo. The TCL is a dynamic structure with distinct movements in all three planes, dependent on the wrist’s direction of movement.
6 Metformin and Bone Metabolism , Jun Li1*
Metformin is a member of biguanide antidiabetic drugs which has been widely used for treatment of Type 2 Diabetes Mellitus (T2DM) over 40 years. Bone is a highly dynamic tissue and its homeostasis mainly depends on the balance between bone resorption and bone formation through regulation of osteoblasts and osteoclasts. Recent studies showed that metformin has beneficial effects in maintaining bone metabolism [1,2]. Intriguingly, it has been reported that metformin has no effect on glucose levels in nondiabetic individuals [3,4]. These evidences suggested that metformin might be a considerable medication option for treatment of bone loss or prevention of fracture in patients with T2DM. However, its mechanism of action is becoming complicated and not fully understood according to recent emerged data. The aim of this review was to elaborate the potential signalling pathways of metformin on regulation of bone metabolism.
7 Adductor Canal Block vs Intra-articular Catheter in Total Knee Arthroplasty: A Double Blinded Randomized Clinical Trial , Sheldon Moniz1*, Samuel Duff1, Christopher W Jones1, Alex Swann1, Matthew Harper1, Piers J Yates1
Aims: Approximately half of patients undergoing Total Knee Arthroplasty (TKA) experience severe perioperative pain. The ideal analgesic regimen for perioperative pain control in patients undergoing TKA is yet to be determined. Methods: A prospective, double-blinded, randomised clinical trial was performed, comparing adductor canal blocks versus intra-articular pain catheters in 100 patients undergoing unilateral total knee replacement by a single surgeon. All other analgesic aspects of the perioperative care were kept standard. Patients underwent an identical surgical approach and all received an Attune TKA (Depuy etc). Post-operative pain levels, Range of Movement (ROM) and opioid equivalent breakthrough analgesia were recorded. All assessors were blinded to group allocation. In addition patients completed WOMAC and Oxford knee scores. Southampton wound score was used to detect adverse outcomes. Results: There were no differences in baseline demographics between the groups preoperative Visual Analogue Pain Score (VAS), Oxford Knee Scores (OKS) or WOMAC scores. Conclusion: A single shot adductor canal block is not inferior to an intra-articular catheter for perioperative pain management in total knee arthroplasty.
8 Spinal Surgical Indication: Surgeon Benefit versus Patient Benefit? , Farzad Omidi-Kashani1*
In the world of surgery, spinal surgery is one of the topics that their surgical indications largely depend on the patient’s clinical symptoms and physical examination, while the para-clinics have only auxiliary or confirmatory roles. For instance, lumbosacral magnetic resonance imaging in asymptomatic population has a 30-35% incidental finding that is not necessarily associated with clinical complaints. These incidental findings include vertebral hemangioma, degenerative disc, transitional vertebra, thickened filum terminal, synovial cyst of the facet joint, or even spondylolysis or spondylolisthesis. None of these findings require treatment when they are not accompanied by clinical symptoms, but only the physician knows this principle, not the patient. On the other hand, inventing new attractive and minimally invasive techniques in the field of spine surgery, has led to the over-popularity of these surgeries. Because the greater the number and complexity of surgeries, the greater the surgeon’s benefit, these factors have cumulatively led to the over-prevalence of spinal surgeries, especially in the lumbar region. In this turmoil and mess bazar, real surgical indications which is the most important and vital parts of medicine, has faded or may have been deliberately forgotten.  It seems that it is time to go back to the beginning and remember the holy oath at the medical graduation ceremony. And at least as altruism, we should always put the patient’s benefit ahead of our own and come to believe that I may be the patient of a physician in a very soon future, and in this scenario, what do we expect from our trusted physician? Let us not allow the financial gain to be a barrier for the sense of humanity.
9 Top Major Traumas in Benghazi , Abdulrahim Aljayar1*
This work is done to study different aspects of the topic; in any case, during our assortment and investigation of the information, we observed the presence of other shocking issues sharing largely the road traffic accident’s increasing frequency and heavy impacts that need collective efforts of everyone, individuals and authority. In spite of the fact that street car crashes stay a significant issue compromising lives and assets in Benghazi, we are additionally encircled by other upsetting awful mishaps generally sharing the recurrence, genuine effect and expanding occurrence of street auto collisions. Therefore, our enthusiasm against RTA should not overshadow such painful, dangerous events including AFD and VT.
10 Changing Demographics of Paediatric Femoral Fractures in a District General Hospital: A 9-year Review , Georgina Kakra Wartemberg1*, Faris Ali1, James Davies1, Karolina Mazur1, Parvathi Varma1, Sade Uwaoma1, Nirmal Tulwa1
Introduction: Paediatric femoral fractures are not uncommon. We noted an anecdotal change in the age of patients that were treated over a number of years. We reviewed all the femoral fracture cases that we have seen since 1st January 2011 to observe if there has been a change in the demographics of paediatric femoral fractures. Method: We utilised our online theatre system and reviewed every operation list from January 2011 until December 2019, noting all paediatric femoral fracture operations, the age, co-morbidities, and the type of surgery. Results: 108 cases were identified. All were unilateral cases. 75% were male. The ages ranged from 11 months to 16 years. Children under 5 years of age, sustained injuries from slips and trips, playing in nursery or play areas, and trampoline. There were a good number of fractures caused by family members falling on them. There were 10 suspected non accidental injuries, including one confirmed in this group. Contact sports, skateboarding and cycling dominated in those 6 years and older. Discussion: There has been a gradual decline in the number of paediatric femoral fracture admissions from 2012. The average age of patients declined from 6.8 years in 2011 to 3.8 years in 2019. Prior to 2014, there were cases of high energy injury from road traffic collisions and motor-cross racing in children aged 12 years and over. After 2014, we did not have any admissions of children over the age of 13 years. This is likely due to Leeds General Infirmary gaining its major trauma centre status for our local region and the increased sedentary lifestyle of modern children. Conclusion: The ages and number of patients presenting with femoral fractures are decreasing in our unit. This is likely due to sedentary lifestyles or due to the effect of having major trauma centre nearby.
11 Toes Flexions Test to Recognize the Functional Status of the Foot: Examples of Pathology: Knowledge from 1971 , Tomasz Karski1*, Jacek Karski2
In children, various deformities of the feet can be found congenital, neurological, post trauma. In adults, foot deformities and pain syndromes can be a result of a changed anatomy of the foot and restricted movement of foot joints. In this article, we present the deficit of toes flexion in metatarsal-phalange joint and results of this pathology. The problem was discovered in 1971 and its many cases have been observed throughout long years of author’s professional activity.
12 Opioid Use for Postoperative Pain Control in Pediatric Supracondylar Humerus Fractures: A Pain-Diary Based Prospective Study , Ryan J O’Leary1, Leah Herzog1, Sara Van Nortwick1, Matthew A Dow1, Robert F Murphy1*
Introduction: There is limited research on postoperative pain control in pediatric populations following operative fixation of a Supracondylar Humerus (SCH) fractures. The purpose of the current study is to characterize the effectiveness of opioids vs non-opioid medication for postoperative pain control in pediatric patients following Closed Reduction Percutaneous Pinning (CRPP) of a SCH fracture. Methods: An IRB-approved prospective study was conducted from November 2019 to June 2020 and eight patients were enrolled in the study. They received CRPP for a SCH fracture at our institution. These patients were instructed to complete a postoperative pain diary recording their level of pain as well as medication usage. For pain control, the patients were counselled to alternate acetaminophen and ibuprofen and were also prescribed a short course of hydrocodone-acetaminophen for severe pain. T-tests were performed to compare pain ratings and medication usage between each group. Results: Of the eight patients in the study, three of the patients used opioid medication for pain control (in addition to acetaminophen and ibuprofen) and five patients used exclusively non-opioid medication for pain control (only acetaminophen and ibuprofen); from here-in these patients will be referred to as the “opioid group” and the “non-opioid” group, respectively. The opioid group and the non-opioid group did not differ significantly in age, weight, Gartland fracture type, or percent female (Table 1). The average total pain scores were 6.2 in the opioid group and 3.3 in the non-opioid group (p=0.03). For both groups, average pain scores were highest on the day of surgery and were lowest on postoperative day 4. The opioid group had higher pain scores on postoperative day 4 when compared with the non-opioid group and these results were statistically significant (p=0.04). The difference in acetaminophen and ibuprofen use between the two study groups was not statistically significant. Discussion: Our results demonstrate that 62% of our patient cohort managed their post-operative pain control with non-opioid pain medication. When compared with the opioid group, the non-opioid group had lower overall average pain scores. These results suggest that appropriate pain control can be achieved without opioids in the majority of patients.
13 Alpha-Lipoic Acid Effectiveness in Early Stages of Carpal Tunnel Syndrome: Short Term Follow-up , Pegoli Loris1,2, Lombardo Michele DM3*, Mangiavini Laura4,5, Peretti Giuseppe M4,5
Carpal Tunnel Syndrome (CTS) is still the most common nerve compression syndrome of the upper extremity. The aim of this paper is to analyze the effectiveness of Alpha-Lipoic Acid (ALA) in early stages of carpal tunnel syndrome. We conducted a double-blind prospective study. A total of 84 patients with instrumental diagnosis of carpal tunnel syndrome at an early stage, based on nerve conductions study, were evaluated. The primary endpoint was the search for improvement of parameters in electrophysiological studies, correlated with the administration of ALA. Secondary endpoints were static 2-points discrimination and the Boston Carpal Tunnel Syndrome Questionnaire (BCTSQ). The statistical analysis has not shown any type of correlation between the evolution of electromyographic measurements and the administration of ALA (p-value> 1.2) On the other side, the statistical analysis showed an improvement regarding the 2-point discrimination and the BCTSQ (p-value <0.05). Alpha-lipoic acid did not improve nerve conduction velocity, but a statistically significant reduction of symptoms referred by the Boston Carpal Tunnel score, and an improvement of the two-point discrimination test was obtained.
14 Schwannomatosis a Rare Entity: Classic Imaging features , Ritu Sharma1, Suresh Kumar2*, Sandeep Moudgil1, Anupam Jhobta1
Schwannomatosis is rare neurocutaneous disorder. It is characterised by multiple schwannoma without involvement of vestibular apparatus. Being genetically different from NF2, now considered third form of neurofibromatosis. Imaging plays an important role in diagnosing schwannomatosis and helps in differentiating it from NF2.
15 Functional Outcome of Surgical Management of AO Type-C Fractures of Distal Femur Treated with Distal Femoral Locking Platesusing Swashbuckler Approach , Girish Sahni1, Kanwarjeet Singh Sandhu2, Sanjeev Kumar3, Harjit K Singh Chawla1*, Sanjeev Sreen1, Nirmal Dass4
Background: Orthopaedic injuries near a joint are often disabling with residual deficits. Distal femur fractures are one of such challenging injuries for orthopedic surgeons, due to their high complication rate. Use of swashbuckler approach while fixing such fractures with Distal Femoral Locking Plate (DFLP) bestows better outcome with lesser complications. Materials and Methods: 30 patients with AO Type C fractures of distal femur were treated with DFLP using Swashbuckler Approach. Cases were followed for up to 12 months post operativelyand evaluated by the NEER’S knee Score. Results: Mean time of fracture union was17.35 weeks (range 12-20 weeks). Average duration of surgery was 88.4 minutes and mean Neer’s score was 80.76. Conclusion: Swashbuckler approach is a good alternative to other classical approaches. Use of DFLP in type C distal femur fractures with swashbuckler approach may provide excellent results.
16 Our Experience in Meniscus Tears and Differences in Sport Recovery between Medial and Lateral Partial Meniscectomy in Young Athlete , Gianluca Testa1, Luca Gurrieri1*, Marco Andolfi1, Marco Caponnetto1, Danilo Di Via1, Gianluca Puglisi1, Salvatore D’Amato1, Vito Pavone1
Meniscus tears are the most frequent knee injuries. Menisci provide joint stability and local pressure distribution. A meniscus injury contributes to the early development of osteoarthritis. The aim of our study is to analyze the results of partial meniscectomy at 4 years follow-up, comparing time of sport recovery between lateral and medial partial meniscectomy. At our institute 94 young athletes with meniscal tear were surgically treated with partial meniscectomy. 75 (80%) were males and 19 (20%) females. Medial meniscus was interested in 74 cases (79%), lateral meniscus in 20 (21 %). Mean age at treatment was 26 ± 4, 98 (range 18-35) years. 15 (16%) patients with medial meniscus tear had associated an ACL tear, which was repaired with an arthroscopic reconstruction by hamstring. Return to sport happened significantly earlier in the medial meniscus tears group than in the lateral meniscus tears group (average time 40±4, 14 days versus 59±7, 24 days). Student’s T- test showed statistical significance (p-value = 0.0147). The average results of the clinical evaluation through the “KOOS” Score questionnaire comparable with previously published data. Patients with associated LCA lesions obtained scores comparable to those obtained from patients with isolated meniscal injury. Time to return to sports is longer after lateral than medial meniscectomy, because lateral meniscectomy has a higher incidence of adverse events in the early recovery period, including pain/swelling. A functional ACL is the best guarantee for preserving joint cartilage from degeneration.
17 Post-Operative Radiological Outcome of Hamstring Graft in ACL Reconstruction after Augmentation of Graft with Periosteal Envelope , DS Bhamare1, Girish Nathani2*, Clevio Desouza2, Ishan Shevate2, Ashwin Deshmukh2
Introduction: Anterior Cruciate Ligament (ACL) reconstruction with hamstring graft is usually done for the surgical management of ACL tear. The post-operative outcome of ACLR is mainly dependant on graft healing its integration into the femoral and tibia tunnels. For the tendon to bone integration it can take up to several months post-surgery. Incorporation of graft into the bony tunnels plays an important role in post-operative outcome after ACL reconstruction surgery. In our study we have aimed to compare hamstring graft healing time post ACL reconstruction when graft was enveloped with periosteum as envelope. Material and Methods: 30 patients with isolated ACL tear were selected between age group of 18 to 40 years and were grouped randomly into 2 groups. In first group the hamstring graft was enveloped with the surrounding periosteum harvested were as second group the patients were not augmented with periosteal envelope. Post-operative rehabilitation remained similar in both the groups and MRI scan was done at 6 months, 9 months and 1 year post operatively to check for graft maturity. Results: Graft healing was faster in the group which was augmented with periosteum (Mean time 7.5 months) as compared to the group which was not augmented (Meantime 9.5 months). Conclusion: Periosteum allows for faster graft healing in patients of ACL reconstruction.
18 Observational Study of Incidence of Rotator Cuff Tear in Patients with Shoulder Pain and Stiffness , Vinodkumar AC1, Ravish VN2, Amit Bilagi2*
Aims and Objectives: To observe the incidence of rotator cuff tears in patient with shoulder pain and stiffness with help of USG. Introduction: All the shoulder pains associated with stiffness of shoulder and restriction of movements, according to literature are adhesive capsulitis with normal radiographs. The current study is conducted to observe the rotator cuff tears in patients with shoulder pain and stiffness. Methods: All patients with shoulder pain having stiffness and restrictions of movements, attending orthopedic OPD were evaluated clinically, radiologically and USG to identify rotator cuff tears. Most of the shoulders associated with pain and stiffness have normal radiological study and hence sonography was used to evaluate the rotator cuff tears as USG is a simple, cost effective and reliable investigation to assess soft tissues of the shoulder joint. Results: In our study we found that out of 51 patients, 24 (47.1%) patients with shoulder pain associated with stiffness and restriction of movements had associated capsular or tendon tears with majority being females. Conclusion: Therefore, all the patients having shoulder pain with stiffness and restricted movements and normal radiographs need to undergo ultrasound scan to rule out rotator cuff tears before continuing further treatment as most of the rotator cuff tears need intervention. USG is a reliable, simple and cost-effective method to rotator cuff tears.
19 Non Metastatic Rhabdomyosarcoma in Children and Adolescents: Prognostic Factors and Survival View or Download PDF   , Feryel Letaief-Ksontini1*, Mouna Ayadi1, Azza Gabsi1, Safia Yahiaoui2, Houcine Magherbi3, Amina Mokrani1, Khedija Meddeb1
Background: Rhabdomyosarcoma (RMS) is the most common softttissue tumor in childhood. We aimed to study the prognostic factors of non-metastatic RMS in Tunisian paediatric patients. Methods: We reviewed data of paediatric patients (aged < 18 years), with histologically confirmed RMS treated in Salah Azaiez Institute for a non-metastatic RMS during 20 years. Prognostic factors were studied and survival data analysed. Results: 75 patients were included (42 males and 33 females). Embryonal RMS was the most common histologic type (72%) followed by alveolar (21%) and pleomorphic (1%). The most frequently affected sites were head and neck (43%) and genito-urinary (28%). 5-year OS and DFS were 50% and 26%, respectively. By univariate analysis, DFS was significantly correlated to chemotherapy, Radiotherapy (RT) and post-surgical RT with p=0.02, 0.003 and 0.01, respectively. No factor was significant in multivariate analysis. By univariate analysis, 5-year OS was significantly and adversely influenced by 4 factors: tumour size > 4 cm, non-alveolar RMS, positive regional nodes and para-meningeal location, with p=0.050, 0.05, 0.04 and 0.04, respectively. RT and postsurgical RT were associated with a good prognosis in OS p=0.009 and 0.05, respectively. By multivariate analysis, OS was strongly correlated to radiotherapy p=0.03, Odds Ratio (OR) 3.1, (IC) 95% [1.05-9.3] and para-meningeal site p=0.04, (OR) 0.3, (IC) 95% [0.1-0.9]. Conclusions: This study showed that tumor size, histological type, tumor location, node involvement, t CT and RT were prognostic factors for OS and PFS. However, survival remains poor. So we should improve it by encouraging clinical research.
20 Is Nail Dynamization Useful In Delayed Union of Tibial Shaft Fractures? A Systematic Review and Meta-Analysis , Germán Garabano1*, Leonel Perez Alamino1, Daniel Veloz Serrano1, Santiago Iglesias1, Javier Mariani2, Cesar Angel Pesciallo1
Background: Nail dynamization is a controversial strategy used to treat delayed union in tibial shaft fractures. Reported union rates of nail dynamization varies within a wide range that goes from 19% to 100%. The purpose of this study was to perform a systematic review and a meta-analysis of the literature to explore post-dynamization union rates in cases of delayed union of tibial fractures following locked intramedullary nailing. Methods and Findings: This systematic review was conducted following the PRISMA (Preferred Reported Items for Systematic Reviews and Meta-Analyses) guidelines. We searched the Cochrane Database, PubMed, and the first 100 references of Google Scholar to June 2020.  Inclusion criteria were as follows: English-language original research articles that included patients over 14 years of age with tibial shaft fractures treated with locked intramedullary nailing and posterior dynamization of static screws. Methodology quality was assessed using a modified version of Coleman’s score. We identified 14 studies that included 1198 fractures for full analysis. The mean age was 35.8 (range; 14-82 years) and the average follow-up period was 27 months (range; 3-100). Statically locked intramedullary nails were found in 922 (76.9%) fractures. Dynamization was reported for 260 fractures (28.2%) with an overall union rate of 89.6%. Our meta-analysis showed a weighted effect size of 95.1% (CI95% 83.5 – 98.6%) regarding union after the dynamization. Conclusions: This meta-analysis demonstrates that nail dynamization represents an effective treatment strategy in delayed union of tibial shaft fractures. High union rates (up to 95%) can be achieved with this procedure.
21 Distinctive Spine Deformities in Patients with Hurler (IH) and Hurler-Scheie (I-H/S) Syndrome , Sergey Ryabykh1, Polina Ochirova1, Mohammad Shboul2, Alexander Gubin3, Alexander Burtsev1, Marat Saifutdinov1, Susanne Gerit Kircher4, Ali Al Kaissi1*
Purpose: Progressive kyphoscoliosis is not of uncommon occurrence in patients with MPSs. Cranio-cervical junction in patients with MPSs are under the threat of three life threatening elements, namely GAGs accumulation, C1-2 instability, and progressive cervical vascular abnormalities. Material and Methods: Seven patients’ two girls and five boys with age range from 3 to 9 years presented with progressive kyphoscoliosis and atlanto-axial instability. Phenotype/genotype confirmed the diagnosis of Hurler syndrome and Hurler-Scheie syndrome. Though, spine deformities were to a certain extent similar in both types but with different age of onset. Results: Children with kyphoscoliosis of apical Cobb’s angle ranging between 60/65° were corrected up to 5° with normal sagittal spine balance. All showed an improvement in the neurological and functional status of Frankel motor scale (PreOp – C / PostOp – D) and Nurick scale (PreOp – 2-3 / PostOp – 2-3). The severity of myelopathy on the mJOA scale decreased (PreOp – 12 / PostOp – 10). Three children were excluded from surgical interventions because their contrast- enhanced computed tomography angiography of the cervical and cerebral arteries showed three hazardous abnormalities. Two children showed variable coiling and kinking of the vertebral and the basilar arteries resulting in an exaggerated redundancy which is compatible with the diagnosis of dolichoarteriopathy. Third child showed progressive narrowing of the left subclavian artery. Conclusion: The method of spine operations in children with Hurler and Hurler-Scheie syndromes depend on the age of the child, the site and type of spine malformation and the proper assessment of any associated cervical/cerebral malformation via contrast- enhanced computed tomography angiography. Patients were operated on, via the correction of kyphoscoliosis with the 5.5 trans pedicular system. Patients with atlanto-axial instability underwent decompression at the C0-C2 or C0-C3 level and occipito spondylodesis by costal autograft accordingly.
22 Recovery of Hip Muscle Strength after Rotational Acetabular Osteotomy Using the Combined Approach , Shigeru Nakamura1*, Kosuke Ishizaka1, Masaki Hirai2, Hitoshi Taneda1
Background: Either a combined approach or a transtrochanteric approach, performed with the patient in the lateral decubitus position, is used in Rotational Acetabular Osteotomy (RAO) to treat symptomatic hip dysplasia. Muscle strength after RAO using the transtrochanteric approach has been reported, but muscle strength after RAO using the combined approach has not been well studied. We aimed to investigate muscle strength and gait speed over a one-year follow-up period after RAO using the combined approach. Methods: Data from 124 patients who underwent RAO (129 hips) were analyzed retrospectively. Patients’ mean age was 44 years (14-64) and mean Body Mass Index (BMI) was 23 kg/m2 (16-36). Isometric hip flexion, abduction, and extension strengths and gait speed were measured before surgery and three months, six months, and one year after surgery. We assessed whether age and BMI were correlated with one-year post- to pre-operative strength ratio. Results: Muscle strength had not changed significantly three months after surgery but had significantly improved at six months, exceeding pre-operative strength. One year after surgery, muscle strength of the treated hip exceeded that of the contralateral hip. Gait speed was significantly lower than pre-operative speed three months after surgery, recovered to pre-operative levels at six months, and exceeded pre-operative gait speed one year after surgery. Age and BMI were not correlated with muscle strength recovery ratio. Conclusions: Six months after having undergone RAO using the combined approach, patients exhibited hip flexion, abduction, and extension strengths that exceeded preoperative strengths. Gait speed exceeded pre-operative gait speed one year after surgery.
23 Van Lohuizen Syndrome: A Late-Diagnosed Case in 18 Years Old Female , Abdulrahim Aljayar1*, Moattaz Aljayar1
Cutis Marmorata Telangiectatica Congenita is a very rare birth defect involving cutaneous blood vessels. Of unknown cause, uncertain pathophysiology, unclear epidemiology. Described as a localized, or generalized marbled skin appearance (cutis marmarota), in addition to the skin, it may involve any other body organs, with, or without a wide variety of associated congenital anomalies. Kato van Lohuizen described the first case in 1922. Since then, there have been less than 300 cases reported worldwide to date. We are adding one more case, and the first reported in Libya.
24 A Novel Device to Prevent Undesired Arthroscopic Camera Rotation , Barroso Rosa Sergio1*, Viera-Artiles, Jaime2, Valdiande-Gutiérrez José Julian3, Grant Andrea4
Objective: This experimental study intends to test a novel device for preventing unintentional camera rotation during arthroscopic knee procedures. Methods: The system consists on a multi-axis gyroscopic sensor that can be universally attached to any camera model in the market. A preliminary experience was designed to evaluate the operability of the device during actual arthroscopic meniscectomies. Results: The system provided accurate real-time insight about camera orientation in relation to a selected working plane. The system is more useful when used within the tibio-femoral space and in the anterior (suprapatellar) compartment. Conclusion: This device is able to assist orthopedics trainees and novel surgeons during arthroscopic training, reducing undesired camera rotation, disorientation, fatigue and surgical times.
25 Intraoperative Fluoroscopic Grid in Total Hip Arthroplasty in Supine Position: Improving Cup Position, Leg Length and Hip Offset , Takahito Yuasa1*, Kohei Aoki1, Kohei Shiota1
Introduction: Accurate placement of implants is important to prevent a variety of complications including dislocation, decreased range of motion, and premature polyethylene wear in Total Hip Arthroplasty (THA). In addition, the difference in leg length after THA affects postoperative gait and low back pain, and the femoral offset is related to gait and abductor muscle function. The purpose of this study is to investigate whether implant placement, leg length difference, and hip offset are improved in supine THA using a 9-inch fluoroscopic HipGrid Drone. Materials and Methods: We retrospectively reviewed consecutive 80 patients who underwent primary unilateral primary THA through direct anterior approach at supine position: 40 THAs with the use of fluoroscopy and 9-inch Drone, and 40 THAs with the use of fluoroscopy alone. We compared the accuracy of component positioning, leg length discrepancy, and hip offset with or without Drone. Results: There was no significant difference in the inclination angle of the cup between the Drone group 37.9 degrees and the control group 39.0 degrees (p=0.175), but the variation from the target angle was more less in the Drone group compared with the control group (2.37 vs 3.82 degrees, p=0.013). With the use of the Drone, significantly more THAs had restoration of leg length compared with the control group (3.55 vs 4.95 mm, p=0.011). Hip offset restoration was also significantly improved in the Drone group compared with the control group (4.42 mm vs 5.56 mm, p=0.048). Surgical time was decreased in the Drone group (92.6 vs 97.8 minutes, p=0.043). Conclusions: Using the easily adjustable grid system, we have demonstrated an efficient method for consistent and accurate cup positioning and restoration of hip offset for anterior supine THA. We recommend the use of this simple and effective device to anterior supine THA.
26 A Novel Bone Void Filler for Use in Prosthetic Joint Infections , David C Evans1, Ashok C Khandkar2, Bruce G Evans3*
Bone grafts and Bone Void Fillers (BVF) have multiple applications in total joint reconstruction surgeries. However, despite their widespread use, they are contraindicated in Prosthetic Joint Infections (PJI). A BVF device is needed that will provide sustained antimicrobial protection to prevent biofilm formation and, ultimately, will resorb and be replaced by host bone. Currently, BVF are only used in noninfected cases in which powder antibiotics are added in hopes of preventing future infections. These BVF do not provide a sustained antibiotic level and, therefore, are not recommended for infected cases. A novel BVF, EP Granules with Tobramycin, was designed to fulfill the need for successful bone growth when infection is present. To create this unique and original BVF, an osteoconductive biomaterial was combined with clinically used degradable polymers, resulting in a composite ceramic polymer. Initial in-vitro elution studies followed by successful and animal in-vivo testing have demonstrated its effectiveness.
27 Soft Tissue Release for Varus Knees during Posterior Stabilized Total Knee Arthroplasty: A New Algorithm , Mohamed Elkabbani1, 2*, Kamel Youssef1, Mohamed Ragab2, Omar Ibrahim2, Amr Osman2, Apostu Dragos3, Samih Tarabichi2
Introduction: Total Knee Replacement (TKA) surgeries are frequently performed surgeries used to treat knee osteoarthritis. Several methods of medial soft tissue balancing in the varus knee during total knee replacement surgeries have been reported. Traditionally, they included releasing the superficial Medial Collateral Ligament (sMCL) in severe varus cases by several methods. However, this release can create instability in the knee. The aim of this study was to create an algorithm for soft tissue release in varus osteoarthritic knees and to evaluate its efficacy in achieving intraoperative gap balancing without releasing the superficial MCL. Materials and Methods: One hundred and five varus osteoarthritic knees who received primary posterior stabilized total knee arthroplasties between October 2015 and January 2016 were included in this study. Varus deformities ranged between 10 to 40 degrees. Sequential balancing was done into 5 steps: step 1 – releasing of deep MCL, step 2 – excision of osteophytes, step 3 – excision of scarred tissue in the posteromedial corner, step 4 – excision of the posteromedial capsule and step 5 – release of semimembranosus. The V-STAT® Variable Soft Tissue Alignment Tensor was used to ensure a balanced medial and lateral gap following each step. Once the gaps were balanced, no further soft tissue release were carried out. Results: All knees were balanced without releasing the superficial MCL ligament. The maximum release step necessary was: step 1 (0 cases), step 2 (31 cases), step 3 (35 cases), step 4 (25 cases) and step 5 (14 cases). Conclusion: Superficial medial collateral ligament should not be released during intraoperative varus knees soft tissue balancing in posterior stabilized total knee arthroplasties. Preserving the superficial MCL is beneficial in maintaining implant stability without any increase in the constraint level of the implant even in cases with severe deformity.
28 New Therapy Option: Maisonneuve Fracture without Trans-syndesmotic Fixation , Dachang Feng1, Zhaofa Liu1*, Haitao Chen1
Ankle fracture is one of the common injuries in orthopedic department, the Maisonneuve fracture is a specific type of ankle injury. This fracture is usually caused by rotational force. According to the Lauge-Hansen classification, it is a pronation and external rotation type injury, often resulting in inferior tibiofibular injury. Because it is extremely unstable, it is usually treated surgically. Operative treatment includes medial malleolus fixtion, reduction of the inferior tibiofibular joint and screw fixation. When the fibula fractured is without shortening or dislocation, it is still controversial if inferior tibiofibular joint needs fixation. The aim of this study is to introduce a new method-Maisonneuve without trans-syndesmotic fixation and analysis the follow-up result.
29 The Etiological Understanding of Spine Deformities in Patients with Neuromuscular Disorders , Egor Filatov1, Olga Sergeenko1, Dmitry Savin1, Polina Ochirova1, Susanne Gerit Kircher2, Sergey Ryabykh1, Ali Al Kaissi1*
Purpose: The etiology understanding is the corner stone for proper management of the spine deformities in patients with neuromuscular disorders. Methods: Progressive spine deformities have been encountered in 71 patients. All showed different forms of   neuromuscular disorders. We proceeded with applying prompt evaluation criteria which was mainly based on the etiological diagnosis of each type of NMS (clinical phenotype and genotype). Assessing the Functional Independence Measure (FIM), we observed deterioration in some aspects. The Cobb’s angle was assessed in two occasion’s i.e prior to corrective surgeries plus the post-surgery results. Followed by one year postoperative re-assessment. Surgical corrections have been performed via posterior pedicle screw fixation. Results: Surgical correction to re-align the C-shaped thoracolumbar scoliosis.  Lumbar hyper lordosis were common in cerebral palsy patients, though decreased thoracic kyphosis or even thoracic lordosis occurs more frequently in Duchenne Muscular atrophy patients. There was noticeable improvement in functional status according to Functional Independence Measure (FIM). Conclusion: Etiology understanding is the paramount element in re-aligning corrective surgeries of the spine in   patients with progressive spine deformities.   We concluded that rigid hyper lordosis has been and still the key problem encountered in patients with neuromuscular disorders.
30 Assessment of Radiation Safety Training, Practices and Knowledge amongst Canadian Orthopaedic Resident Training Programs , Bourget-Murray J1, Gusnowski E1, Kooner S1, Kwong C1, Meldrum A1, Montgomery S1, Thomas K1, Fruson L1, Kendal J1, Litowski M1, Sridharan S1, James M1, Ludwig T1, Purnell J1, Wong M1, You D1, Benavides B1, Lukenchuk J1, Abbott A1, Morrison L1, Davison E1, Flanagan C1, Heard B1, Hewison C1, Lienhard K1, Rondeau K1, Schneider P1*
Objective: There is ample literature demonstrating significant health risks associated with radiation exposure, yet there is no standardized radiation safety training for Canadian orthopaedic surgery residents. This is the first national survey investigating the prevalence of radiation safety training and radiation safety practices in Canadian orthopaedic residency programs. Methods: A nationaln online survey was distributed to orthopaedic residents currently enrolled in a Canadian program from all post-graduate (PGY) levels who were fluent in English or French with a medical doctorate or equivalent training. Fellows, international elective or observer ship students were excluded. Results: Overall response rate across Canada was 41% (n=116). Most respondents (94%, n=102) were concerned about the negative effects of radiation, yet only 11% (n=12) felt confident with their radiation safety knowledge. Of the residents who felt confident in their knowledge, only 42% (n=5) answered all three radiation safety screening questions correctly. Overall, 58% (n=66) of respondents had undergone some form of radiation safety training. Compliance with protective lead was high (92%, n=93) when available, but 82% (n=92) of respondents cited issues accessing properly fitting lead. Only 18% (n=20) of orthopaedic residents reported routinely wearing dosimeters. Conclusion: Limited access to properly fitting protective lead, poor radiation safety knowledge, and lack of routine radiation monitoring could be placing residents at risk for poor health outcomes in the future. These results provide impetus for orthopaedic residency programs across Canada to implement higher safety standards in the form of standardized radiation safety training, routine dosimeter use, improved lead availability, and continued abidance to radiation safety protocols.
31 Morbid Constellation of Osseous and Vascular Abnormalities in a Female Patient with Congenital Central Hypoventilation/Overgrowth Syndrome , Ali Al Kaissi1*, Susanne Gerit Kircher2
Background: Congenital Central Hypoventilation Syndrome (CCHS), is a condition characterized by ventilatory impairment that results in arterial hypoxemia. Studies revealed that the vast majority of patients with CCHS are free from any associated pulmonary, cardiac or brainstem pathologies. Material and Methods: F.R is a 20 -year-old- Austrian-girl presented in my consultation seeking advice for her unpleasant clinical history. In her early life, seizures were the first serious clinical presentation. Followed later on with hypertension, bouts of respiratory dysfunction and impairment of consciousness. In 2019 she underwent surgical intervention to remove a 2 cm hamartoma (posterior upper aspect of the right thigh). Few years later, another hamartoma on the ventral side of the tongue has been identified as well. Early on, she received the diagnosis of Mediterranean fever syndrome and the geneticist encountered homozygosity to the MEFV M694V mutation as the reason behind the constellation of the current unpleasant symptomatology. Later on a presumptive diagnosis of Ehlers-Danlos syndrome-hypermobile type has been suggested in other Medical Institutions. We proceeded with our documentation via clinical and radiological phenotypic characterizations. Results: Clinical examination showed growth above the 97th percentile (overgrowth) with no specific facial dysmorphic features. She manifested generalized ligamentous hyper laxity. Her ligamentous hyperlaxity was compatible with 6 points out of 9 in correlation with Beighton scoring test. On the bases of skeletal survey; lateral skull radiograph showed features of mastoid and temporal bone characterized with extensive-pneumatization. Axial CT scan shows bilateral hyper-pneumatization of the temporal bones, demonstrating expansion of aerial spaces with loss of the bony trabeculae and thinning of the mastoid bone. Mastoid cells appear to be in communication with a large intracranial epidural air cavity in the temporal and parietal regions. Reformatted CT scan of temporal bone, through coronal and axial images, at the level of the cavum tympani and the mastoid, showed a defect in the right tegmen appeared as cloudy/ opaque lesions around the cavum and the surrounding air cells. Contrast- enhanced computed CT angiography of the cervical and cerebral vasculature showed unusual malalignment and spiral twisting along several vascular segments resulted in the mal-development of basilar artery stenosis without atherosclerosis. The current patient manifested overgrowth syndromic entity with a constellation of osseous and vascular abnormalities resulted in a clinical course of congenital central hypoventilation syndrome. Conclusion: The etiology behind the extension of pneumatization has most likely occurred because of defective ossification of the occipito-mastoid synchondrosis . The reason behind the extension of pneumatization into the occipital and parietal bone is probably due to incomplete closure of the occipito-mastoid synchondrosis, lambdoid and sagittal sutures, which usually close in early adulthood and later, even at the age of thirties. In our patient, we postulate that the history of multiple hamartomas and abnormal vascular phenotype in conjunction with extensive hyper-pneumatization of the skull were the main etiology behind her unpleasant course of her devastating ailment regardless the genetic results. Our impression is neither Mediterranean fever syndrome nor Ehlers-Danlos syndrome seem compatible with her current constellation of osseous and vascular abnormalities. The overall clinical and imaging findings are highly likely in connection with either one of the different types of overgrowth syndromes or might be a novel syndromic association. We believe that congenital central hypoventilation is a symptom complex rather than a diagnostic entity.
32 Minimally Invasive Anterolateral Approach Total Hip Arthroplasty Using Bone Preserving Short Femoral Stem: Intermediate Term Clinical and Radiological Results , Mohamed Elkabbani1,2*, Akram Hammad1, Mohammed Hammad1, Ahmed Mostafa Saied1, Bassam Ali Abouelnas1, Michael Schulte2  
Aim:  The objective of this study was to evaluate the intermediate term clinical and radiological results of a Bone preserving short stem hip implant being operated through a minimally invasive anterolateral hip approach. Methods:  In 20 consecutive patients suffering from osteoarthritis with 25 affected hip joints (five cases were bilateral), the clinical and radiological results of 25 hip arthroplasties performed in one hospital between October 2009 and May 2014 through   a minimally invasive anterolateral approach using a cementless short stem prosthesis type Aida and a cementless cup type Ecofit with a ceramic-on-ceramic pairing were evaluated prospectively. The median age of patients at time of surgery was 60 years (range, 42-71 years), 15 male (4 were bilateral) and 5 female   patients (one was bilateral) were included in the study. The median clinical follow up was 30 months (range, 2-88 months) and the median radiological follow up was 30 months (range, 2-88 months). Results:  Harris Hip Score improved from a median preoperative value of 53 to a median postoperative value of 96 (range, 73-100) at follow up. 22 hips (88%) showed an excellent postoperative Harris Hip Score, 2 hips (8%) a good postoperative Harris Hip Score and one hip (4%) a fair postoperative Harris Hip Score.  Only two patients complained of postoperative thigh pain. Regarding patient satisfaction, 15 patients (60%) were very satisfied, 10 patients (40%) were satisfied. None was unsatisfied.  Radiological analysis showed that 19 stems (76%) were with stable bony ingrowth, two cases (8%) showed stable fibrous ingrowth. Four cases need further follow up for proper evaluation of stem fixation. Conclusion: The intermediate term survival of the Aida short stem hip implant being operated through a minimally invasive anterolateral hip approach is very promising and achieving the goals of a standard hip arthroplasty.