Medical education during the COVID-19 pandemic: lessons for the orthopedic departments.

BACKGROUND: After the Coronavirus pandemic, many educational routines were stopped for the safety of medical staff. To achieve educational goals, we have implemented new policies in our hospitals. In this study, we aimed to evaluate the effect of such strategies. METHOD: This survey-based study uses questionnaires to assess newly implemented educational strategies. We surveyed 107 medical staff of the orthopedic department of Tehran University of Medical Sciences, including faculty members, residents, and students. The survey contained three series of questionnaires for these groups. RESULTS: The maximum satisfaction for all three groups was observed in the platform and facilities for using e-classes, and the cost- and time-saving capabilities (Respectively, faculty members (FM): 81.8%, residents (R): 95.2%, students/interns (S/I): 87.0%; FM: 90.9%, R: 88.1%, S/I: 81.5%). The new policies have been shown to reduce the stress level of most trainees, increase the quality of knowledge-based education, increase the opportunity for reexamining educational content, expand discussion and research opportunities, and improve work conditions. There was a broad acceptance of the virtual journal clubs and morning reports. However, there were discrepancies between residents and faculty members on issues such as the evaluation of trainees, the new educational curriculum, and flexible shift schedules. Our strategies failed to improve skill-based education and patient treatment status. Most participants indicated that e-learning should be used with face-to-face training post-pandemic (FM: 81.8%, R: 83.3%, S/I: 75.9%). CONCLUSION: Our efforts to optimize the educational system during this crisis have generally improved trainees' work conditions and educational experience. Most participants believed that e-learning and virtual methods should be used alongside traditional training as a complementary component after the pandemic.

Single High-Dose Systemic Methylprednisolone Administered Preoperatively Improves Pain Control and Sleep Quality After Total Hip Arthroplasty: A Double-Blind, Randomized Controlled Trial.

Background: This study was performed to evaluate the efficacy of preoperative high-dose methylprednisolone on pain levels and sleep quality following primary total hip arthroplasty. Material and methods: A double-blind, randomized controlled trial was performed in adults underdoing total hip arthroplasty. A computer-generated, permuted-block randomization scheme with a 1:1 ratio between the intervention (125 mg methylprednisolone) and control groups (normal saline) was utilized. Patients underwent a similar preoperative and postoperative protocol. Pain was assessed using the visual analog scale (VAS). Sleep quality was assessed at the 2-week postoperative visit using the Pittsburgh Sleep Quality Index (PSQI). Results: With a total of 70 patients, 35 patients were included in the intervention and placebo groups. Hospital stay was significantly shorter in the intervention group (1.5 ± 0.7 vs 2.0 ± 0.5 days, P = .03). Preoperative pain levels were similar between groups, while satisfactory pain control was achieved in a significantly larger number of patients in the intervention group (18 vs 8 patients, P = .009). The intervention group was significantly more likely to have a good sleep quality than the placebo groups (74% vs 31%, P = .001). No significant differences were found between preoperative and postoperative blood sugar levels. We did not observe any cases of early postoperative wound complication, infection, or deep vein thrombosis among our patients. Conclusion: In this randomized controlled trial, preoperative administration of 125 mg of methylprednisolone was found to improve pain control, as measured by VAS, 24 hours after surgery, and sleep quality, as measured by PSQI, 2 weeks following surgery.

Evaluation of the Degenerative Changes of the Distal Intervertebral Discs after Internal Fixation Surgery in Adolescent Idiopathic Scoliosis.

STUDY DESIGN: Retrospective study. PURPOSE: Lumbar intervertebral disc degeneration is an important cause of low back pain. OVERVIEW OF LITERATURE: Spinal fusion is often reported to have a good course for adolescent idiopathic scoliosis (AIS). However, many studies have reported that adjacent segment degeneration is accelerated after lumbar spinal fusion. Radiography is a simple method used to evaluate the orientation of the vertebral column. magnetic resonance imaging (MRI) is the method most often used to specifically evaluate intervertebral disc degeneration. The Pfirrmann classification is a well-known method used to evaluate degenerative lumbar disease. After spinal fusion, an increase in stress, excess mobility, increased intra-disc pressure, and posterior displacement of the axis of motion have been observed in the adjacent segments. METHODS: we retrospectively secured and analyzed the data of 15 patients (four boys and 11 girls) with AIS who underwent a spinal fusion surgery. We studied the full-length view of the spine (anterior-posterior and lateral) from the X-ray and MRI obtained from all patients before surgery. Postoperatively, another full-length spine X-ray and lumbosacral MRI were obtained from all participants. Then, pelvic tilt, sacral slope, curve correction, and fused and free segments before and after surgery were calculated based on Xray studies. MRI images were used to estimate the degree to which intervertebral discs were degenerated using Pfirrmann grading system. Pfirrmann grade before and after surgery were compared with Wilcoxon signed rank test. While analyzing the contribution of potential risk factors for the post-spinal fusion Pfirrmann grade of disc degeneration, we used generalized linear models with robust standard error estimates to account for intraclass correlation that may have been present between discs of the same patient. RESULTS: The mean age of the participant was 14 years, and the mean curvature before and after surgery were 67.8 and 23.8, respectively (p<0.05). During the median follow-up of 5 years, the mean degree of the disc degeneration significantly increased in all patients after surgery (p<0.05) with a Pfirrmann grade of 1 and 2.8 in the L2-L3 before and after surgery, respectively. The corresponding figures at L3-L4, L4-L5, and L5-S1 levels were 1.28 and 2.43, 1.07 and 2.35, and 1 and 2.33, respectively. The lower was the number of free discs below the fusion level, the higher was the Pfirrmann grade of degeneration (p<0.001). Conversely, the higher was the number of the discs fused together, the higher was the Pfirrmann grade. CONCLUSIONS: we observed that the disc degeneration aggravated after spinal fusion for scoliosis. While the degree of degeneration as measured by Pfirrmann grade was directly correlated by the number of fused segments, it was negatively correlated with the number of discs that remained free below the lowermost level of the fusion.

A New Modified Method for Inserting Iliosacral Screw versus the Conventional Method.

STUDY DESIGN: Methodological study. PURPOSE: To our knowledge, this is the first study to introduce a new modified method for inserting iliosacral screws and to compare its results with those of a conventional method. OVERVIEW OF LITERATURE: Previous techniques, such as open reduction and internal fixation, are associated with perioperative hemorrhage, postoperative infection, and neurological deficits. Although percutaneous iliosacral screw insertion confers the advantage of being minimally invasive, leading to less blood loss and a low postoperative infection rate, it harbors the risk of screw malpositioning due to narrow sacral proportions and a high interindividual variability. METHODS: Nine cadaveric pelvises were included in this study, with one hemipelvis of each being assigned to the new modified method and the other to the conventional iliosacral screw insertion method. In the new modified method, the guidewire entry point was determined using a lateral sacral X-ray. To do so, we first identified the anterosuperior quadrant of the S1 body on one hemipelvis. The anterosuperior quadrant was further divided into four imaginary quadrants, and the guidewire was inserted into the posteroinferior quadrant. The guidewire trajectory was perpendicular to the sagittal plane so that the guidewire resembled a single point in the lateral sacral view. Guidewires were inserted into corresponding hemipelves using the conventional method as described in the literature. Subsequently, an axial computed tomography scan with 1-mm fine cuts was obtained, and sagittal and coronal views were reconstructed. The distance of the guidewire from the sacral canal, anterior sacral cortex, and first sacral foramen was measured in axial, sagittal, and coronal views. The minimum measurement among different views was defined as the safety index of the insertion methods. The conventional and new modified methods were then compared in terms of safety and duration of the procedure. RESULTS: The minimum distance of the guidewire from the S1 foramen and anterior sacral cortex was not significantly different between the two methods. However, the minimum distance between the guidewire and sacral canal was significantly greater in the new modified method than in the conventional method. The duration of guidewire insertion was significantly shorter in the new modified method than in the conventional method. CONCLUSIONS: This new modified method of iliosacral screw insertion could be safely and simply implemented while taking less surgical time than the conventional methods.

Down-regulation of microRNA-182 and microRNA-183 predicts progression of osteosarcoma.

INTRODUCTION: The aim of this study was to investigate the expression levels of microRNA-182 and microRNA-183 and their association with clinicopathological features in patients with osteosarcoma. MATERIAL AND METHODS: Total RNA was purified from samples and noncancerous bone tissues and then quantitative real-time polymerase chain reaction was applied to evaluate the expression levels of microRNAs, and their relationship with clinicopathological features and survival in osteosarcoma patients. RESULTS: Our findings showed that expression of MiR-182 was clearly lower in osteosarcoma bone tissue (mean ± SD: 2.84 ±.07) compared with noncancerous bone tissues (6.23 ±1.72, p = 0.004). On the other hand, lower expression of MiR-183 was seen in osteosarcoma bone tissue (1.43 ±0.59) when compared with normal tissues (4.36 ±2.47, p = 0.036). Decreased expression of MiR-182 was clearly correlated with advanced clinical stage (p = 0.001), metastasis or recurrence (p = 0.024), and large tumor size (p = 0.032). Decreased expression of MiR-183 was associated with advanced TNM stage (p = 0.004), and metastasis or recurrence (p = 0.002). A multivariate Cox proportional hazards model revealed that low expression of MiR-182 and MiR-183 (p = 0.02; p = 0.016), TNM stage (p = 0.04), and metastasis or recurrence (p = 0.03) were significantly associated with poor survival as independent prognostic factors. CONCLUSIONS: These findings suggest that MiR-182 and MiR-183 may be associated with progression and metastasis of osteosarcoma.

A comparative study between multiple cannulated screws and dynamic hip screw for fixation of femoral neck fracture in adults.

PURPOSE: In younger adults with fractures of the femoral neck, anatomic reduction is compulsory and maintaining the reduction is crucial. Both cannulated screws and dynamic hip screw (DHS) have the capacity of compression in the fracture site but the strength for keeping reduction is not the same. The aim of this study was to compare the results with fixations of the femoral neck fractures with cannulated screws versus dynamic hip screw. METHODS: This is a randomized clinical trial study on 58 cases with a minimum of one year follow-up. Leg length discrepancy, Harris Hip Score, infection, avascular necrosis of femoral head, and union of the fracture site were evaluated. RESULTS: There were two failures in the first trimester in the cannulated screw group and three more failures in the second and third trimesters in this group. In the DHS group, there was no reduction and fixation failure in the follow-up period. There was no fixation failure (0 %) in Group B (DHS) but there were five fixation failures (18 %) in Group A (screw), and there is significant difference between the groups (p < 0.001). The rate of avascular necrosis was the same in both groups. CONCLUSIONS: It seems to us that in our practice the fixation of femoral neck fracture in young adults with the DHS is a better option compared with the osteosynthsis with multiple cannulated screws.

Pelvic incidence and lumbar spine instability correlations in patients with chronic low back pain.

PURPOSE: Many factors such as lumbar instability and spinopelvic alignment are associated with low back pain. Our purpose was to analyze the pelvic incidence - one of spinopelvic alignment parameters- and spine instability correlations in patients with chronic low back pain. METHODS: Fifty-two patients suffering from chronic low back pain entered this case control study. Lateral spine radiography was taken from patients. pelvic incidence and L3, L4 and L5's vertebral body width were measured for all patients, and lumbar instability was evaluated in 3 different levels: L5-S1, L4-L5 and L3-L4. RESULTS: Thirty-two patients having lumbar instability formed group A and 20 patients without lumbar spine instability allocated to group B. Average age, mean weight, height, body mass index and mean vertebral width of both groups did not differ meaningfully. Pelvic incidence's mean amounts set to 53.9 in group B and 57.7 in group A without any significant difference; but pelvic incidence was significantly lower in patients with lumbar instability of L5-S1 origin (P=0.01). CONCLUSIONS: Overall, pelvic incidence did not differ between two groups. However, separate evaluation of each level revealed lumbar instability of L5-S1 segment to be associated with lower pelvic incidence.