Unintended consequences: Hypotonic serum-induced acute kidney injury in shoulder arthroscopy.

Arthroscopic shoulder surgery is an orthopaedic technique that involves the use of normal saline or hyperosmolar serums as irrigation. The mentioned operation is commonly regarded as a safe medical intervention. Occasionally, it may have serious repercussions for the patient. Fluid extravasation into muscle tissues and tissue injury and instability are possible consequences. This can be affected by the type and amount of serum used and the length of the surgery. The objective of this study was to document four cases of shoulder arthroscopy in which sterile distilled water, wrongly labelled as irrigation fluid, was utilized during the surgical procedure. Patients were readmitted a week after discharge due to acute kidney injury symptoms like fatigue and lethargy. All four patients were released after haemodynamic stability and normalization after haemodialyses. Due to the incident, serums should be closely monitored and labeled for the safety of patients. Additionally, distilled water as an irrigation solution in arthroscopic surgeries can harm patients. Although normal saline and hyperosmolar serums are unavailable, this remains true. LEVEL OF EVIDENCE: Level IV.

Comparison of the angle deviation of the nose line to the mentum and Mallampati test in predicting the difficult airway before anesthesia.

Introduction: A high percentage of dangerous events in anesthesia occur due to airway problems, and proper airway management is always one of the key points during anesthesia. Airway management in critically ill patients is one of the most stressful situations for primary care physicians and even for anesthesiologists. The aim of this study was to evaluate the anatomical features of patients' airways, including the angle of deviation of the nasal line from the nasal to the mentum (NMLD), and perform a Mallampati test. Method: This cross-sectional study was performed on all patients admitted to Shohada Hospital in Tabriz, Iran, who were candidates for elective surgery for 1 year and 6 months, and underwent endotracheal intubation. Based on laryngeal observation, patients were classified into four groups. Then, all data related to individuals including type of surgery, age, sex, weight, height, body mass index (BMI), and nasal mentum line deviation (NMLD) were recorded. Then, all the collected data were analyzed using SPSS software version 19. Results: A total of 85 patients from 17 to 67 years with a mean age of 37.64 ± 12.89 were studied. There was a statistically significant relationship between laryngoscopy difficulty and Mallampati score (P = 0.001). The findings showed a statistically significant relationship between laryngoscopy difficulty and the mean NMLD (P = 0.01). A Mallampati of 85% indicates laryngoscopy difficulty. Also, NMLD can predict laryngoscopy difficulty by up to 66%. Conclusion: The present study demonstrated that both the Mallampati score variable and NMLD are related to the difficult airway problem. Furthermore, the Mallampati score has a higher predictive value for difficult intubation than the NMLD.

Epidemiology of Generalized Ligamentous Laxity in Iran: A National Study Including Different Iranian Ethnic Groups and its Relationship with Musculoskeletal Disorders.

Background: Ligamentous laxity is a condition that leads to joints' hypermobility beyond their average and normal range of motion. It can cause musculoskeletal and joint injuries. This national multi-centered study investigated the epidemiology of generalized ligamentous laxity and its relationship with musculoskeletal disorders among Iranian adults with different ethnic backgrounds. Methods: A total of 1,488 people (age range: 17-40 years) were selected from eight cities and six different ethnicities of Iran and included in this cross-sectional study. The presence of ligamentous laxity with clinical examinations was searched according to Beighton score criteria. They were also examined for any kind of musculoskeletal disorders that might accompany ligamentous laxity. The Chi-square test was used to compare the frequency of ligamentous laxity based on gender and ethnicity; moreover, the t-test was utilized to compare the frequency of ligamentous laxity based on age. Results: In total, 280 (18.8%) participants had generalized ligamentous laxity, and it was more prevalent in women (22.7%), compared to men (14.4%). Regarding ethnicity, the highest and lowest prevalence rates were in Gilak (37.9%) and Persian-Arab (6%) ethnicities, respectively (P<0.001). Ligamentous laxity showed a significant relationship with sports injury, joint complaint, joint dislocation, ligament sprain, sciatica and back pain, Baker's cyst, and varicose veins (P<0.001). Most participants with generalized ligamentous laxity (93.6%) had no knowledge of their problem and its importance in choosing an appropriate sports activity. Conclusion: The prevalence of generalized ligamentous laxity seems to be relatively high among the 17-40-year-old population of Iran, especially in women. It seems to be significantly related to ethnicity. It is strongly recommended that examinations, screening, and information be provided at an early age in schools or at least in areas with a high prevalence as national programs.

Outcome of open reduction and Kirschner wire fixation in pediatric radial neck fracture.

BACKGROUND: Radial neck fracture in children is rare. This study attempted to evaluate the outcome of surgically treated patients and any associated complications. METHODS: This study evaluated 23 children under 15 years of age with radial neck fracture who were treated with open reduction between 2006 and 2016 to determine their range of motion, postoperative complications, and radiographic outcomes. The results were assessed clinically using the Mayo clinic elbow performance score. RESULTS: The mean follow-up duration for patients was 34.6 months. The average postoperative angulation was 3.6°. Hypoesthesia was reported in only 9% of patients, and none of the patients complained of postoperative pain. The postoperative X-ray results were excellent in 60% and good in 40%. No radiographic complications were identified. The elbow score was excellent in 87% and good in 13% (mean score, 96.74). There was a statistical relationship between range of motion limitations and age, degree of fracture, initial displacement, and surgical pin removal time. CONCLUSIONS: Although most patients accept the closed reduction method as a primary treatment, the present study suggests that an open-reduction approach has been associated with optimal therapeutic outcomes for patients in whom closed reduction was not satisfactory or indicated.

Calcitonin effects on shoulder adhesive capsulitis.

INTRODUCTION: Adhesive capsulitis (frozen shoulder) is a relatively prevalent disease of shoulder and affects soft tissue of glenohumeral joint. Signs include painful restricted motion and disability of the patient in daily activities. Calcitonin is a thyroid hormone, and its effectiveness has been demonstrated in painful conditions. The presents study aims to evaluate the effect of calcitonin in treating shoulder adhesive capsulitis. METHOD: This double-blinded randomized clinical trial was conducted on 64 patients suffering from shoulder adhesive capsulitis. The intervention and control groups were given intranasal calcitonin and placebo for 6 weeks, respectively. For both groups, physiotherapy and non-steroidal anti-inflammatory drugs were administered correspondingly. The patients were evaluated pre- and post-treatment for shoulder pain and shoulder range of motion (ROM). Shoulder functional outcome (secondary outcome) was evaluated using Disability of Arm, Shoulder, and Hand, Shoulder Pain and Disability Index, and Health Assessment Questionnaire disability criteria. RESULTS: The mean age of patients in calcitonin and control group was 52.4 ± 4.6 and 53.2 ± 4.9, respectively. Demographic characteristics and pre-treatment scores were similar in both groups (all P > 0.05). In post-treatment follow-up, shoulder pain, ROM, and the patients' functional scores were significantly improved in both groups (P < 0.001); however, the improvement in calcitonin group was more effective than that of placebo group. CONCLUSION: Intranasal calcitonin spray could be an additional safe alternative in shoulder adhesive capsulitis with regard to the efficiency in alleviating pain and improving functional outcome. LEVEL OF EVIDENCE: II.

Effects of preoperative non-steroidal anti-inflammatory drugs on pain mitigation and patients' shoulder performance following rotator cuff repair.

PURPOSE: Pain is one of the most important factors adversely affecting clinical outcomes of operated patients. The present study aims at evaluating effects of preoperative COX2 non-steroidal anti-inflammatory inhibitors on pain mitigation and performance of patients with shoulder rotator cuff tear. METHODS: This case-control study was conducted on 60 patients suffering from rotator cuff injury candidate for arthroscopic repair. The patients were classified in two parallel and matched groups. One group (case group) was treated using Celecoxib (200mg/12h) started 48 hours before surgery and continued for 10 days after operation. In the control group, the placebo was prescribed in the same way. Postoperative pain, side effects, sleep disturbance, and short-term outcomes were compared between two groups using DASH questionnaire. RESULTS: Postoperative pain in the Celecoxib group significantly decreased in comparison with the control one. The difference was statistically meaningful (P<0.001). Well motion ability was seen in 80% of patients of the Celecoxib group. It was 26.6% in the placebo group since pain inhibited them from exercising more motions. In this regard, there was a statistically meaningful difference between these two groups (P=0.02). Sleep disturbance was meaningfully at higher levels in the placebo group (P=0.001). Following up the patients for three months, it was made clear that performance of the Celecoxib group was better than that of the placebo one. CONCLUSION: COX2 inhibitors are well efficient in patients' pain management after arthroscopic rotator cuff repair surgery. It results in less life complications, less sleep disturbances, improvement of patients' short-term clinical outcome, and more quick recovery.

Osteoid osteoma in the neck of the Scapula; A misleading case.

Osteoid osteoma is a benign bone tumor that when located on the base of the coracoids process of the scapula is very rare and diagnosis and treatment is often delayed because of its rarity. Almost any bone can be involved, but half of cases involve the femur or tibia. The radiologic features of osteoid osteoma are well known, but these tumors may present with unusual features and be easily misdiagnosed. In this report, we present a case of osteoid osteoma of the neck of the left scapula that took almost 27 months to be diagnosed accurately.

Simultaneous Dorsal Base Fracture and FDP Avulsion of Distal Phalanx of the Little Finger.

Avulsion injury of the flexor digitorum profundus (FDP) with concomitant fracture of the distal phalanx dorsal base is uncommon. Simultaneous avulsion fractures of the insertion of this tendon associated with rupture of the tendon from the bony fragment and combination with dorsal base fracture is very rare and also complicated. A 36- year- old man fell and injured his right little finger. FDP avulsion with simultaneous dorsal base fracture (containing extensor Tendon insertion) was detected. Our surgical repair by a single midlateral incision the avulsed fragment was replaced on the palmar base of the distal phalanx and successfully immobilized with 1.5 mm screw. After three months, patient had 20 degrees range of motion in the DIP joint. The digit was pain free and also relatively functional. It seems that FDP avulsion classification need to be extended and include this uncommon type as described in this case report for better management of these uncommon type.

Prevalence of malignant soft tissue tumors in extremities: an epidemiological study in syria.

BACKGROUND: Although the majority of soft tissue masses are benign, it is important to consider malignancy in differential diagnoses. Because most soft tissue sarcomas present as a painless mass, clinicians must watch for signs suggestive of malignancy, including large size, rapid growth, and site deep into the deep fascia. The purpose of this study was to determine the relative prevalence according to sex and age, site of tumor, skeletal distribution, and treatment (surgery, chemotherapy and radiotherapy) before and after surgery, and ascertain the relative frequency of these tumors in specific anatomic sites and age groups based on pathological studies. METHODS: A total of 308 patients, with a musculoskeletal tumor were evaluated retrospectively. All of the patients enrolled into this study were referred to the Beirouni Hospital of Damascus University with a proven diagnosis of malignant soft tissue tumors from the beginning of January 2008 until the end of 2010. The prevalence of the malignant soft tissue tumors in these patients was analyzed. For purposes of analysis, all lesions were placed in 1 of 9 categories: hand and wrist, forearm, humorous (arm), proximal limb girdle (axilla and shoulder), foot and ankle, thigh, hip and buttocks region, trunk, and other lesions. Age and sex also were recorded. RESULTS: MALIGNANT TUMORS CONSISTED OF SEVEN DIAGNOSTIC CATEGORIES: malignant fibrous histiocytoma (23%), liposarcoma (22%), rhabdomyosarcoma (9%), leiomyosarcoma (8%), malignant schwannoma (5%), dermatofibrosarcoma protuberans (5%), synovial sarcoma (10%), fibrosarcoma (13%), extraskeletal chondrosarcoma (1%), and extraskeletal Ewing sarcoma (4%). CONCLUSIONS: Despite the multitude of pathologic possibilities, most malignant soft-tissue tumors are classified into a small number of diagnoses. These may be further defined when the site of the lesion and the age of the patient are considered. Knowledge of tumor prevalence will assist radiologists in establishing a suitably ordered differential diagnosis when a soft-tissue tumor has a nonspecific radiologic appearance.

Treatment of neglected malunion of the distal radius: a cases series study.

BACKGROUND: Malunion is the most common complication following distal radius fractures. Aim of this study was to evaluate the results of distal radius corrective osteotomy and plate fixation by dorsal approach in the malunion. METHODS: In this retrospective study, 14 patients with neglected distal radius malunion from 2005 to 2011 were studied. All patients were treated with an opening wedge osteotomy with a dorsal plate and cancellous bone grafting. Radiological and clinical measurements were performed pre and postoperatively. All patients were followed at least for two years. RESULTS: Fourteen patients with a mean age of 42.5±10.2 years including 2 females (14.2%) and 12 males (85.8%) were studied. Radiological healing was achieved in all osteotomies at a mean of 11.5 (range: 11 to 14) weeks. There were significant differences between wrist function and radiological findings before and after treatment. Following the operation, all patients were relieved of pain. There were not any complications. CONCLUSION: Based on our findings, dorsal approach for osteotomy and plate insertion is an effective approach with good final results and no major complication for the treatment of distal radius malunion.

Long-term follow-up results of delayed fixation of femoral neck fractures in adults.

BACKGROUND: Femoral neck fractures are urgent injuries that require precise reduction and stable fixation. In some cases, however, early treatment is not possible. OBJECTIVES: The present study aimed to evaluate long-term results of delayed fixation of femoral neck fractures using cannulated screws. PATIENTS AND METHODS: This retrospective descriptive-analytical study was conducted on 26 patients with femoral neck fractures. The patients were treated through a closed reduction and fixation method using cannulated screws. Patients were followed up for at least five years and the rate of complications was determined. RESULTS: In this study, 26 patients with mean age of 34.3 years were assessed. Average time interval from injury to surgery was 46.4 ± 12.2 hours; 18 patients (69%) were operated on with more than 36 hours of delay. Incidence of AVN and nonunion was reported in 10 (38.4%) and 3 (11.5%) patients, respectively. CONCLUSIONS: Time plays an important role in treatment results of femoral neck fractures. To treat the fractures, closed reduction and fixation using cannulated screws may still be the best option.

Effects of non-steroidal anti-inflammatory drugs on flexor tendon rehabilitation after repair.

BACKGROUND: Peritendinous adhesions after repairing an injury to the digital flexor tendons are a major problem in hand surgery. Non-steroidal anti-inflammatory drug therapy may affect tendon healing and the development of peritendinous adhesions. The aim of this study was to evaluate ibuprofen effect in patients function after flexor tendon surgical repair. METHOD: Thirty-five patients, who had sharp-edge lacerations of hand-zone II requiring flexor tendons repair, participated in this randomized double-blind clinical trial study. The patients were randomly classified into two parallel and matched groups (21 patients in the intervention group and 14 patients in the control group). The groups were matched considering age, gender, and laceration size. The control group received a placebo with the same appearance and dosage. In the intervention group, ibuprofen was prescribed at a high dosage (2400 mg/day). The range of motion improvement rate of the involved fingers and the patients' performance after their follow-up period were compared. RESULTS: There was a statistically significant difference between the two groups for range of motion of the involved finger joints (P=0.03). According to the DASH score, there was a statistically significant difference between the final performance of the patients, such that it was 11±2.4 and 18.4±6.3 in the intervention and control groups, respectively (P=0.01). There was not any case of re-tear or need to re-operate in the intervention and control groups. CONCLUSION: Our findings reveal that ibuprofen with an anti-inflammatory dose was effective in improving the range of motion of the involved fingers joints after flexor tendon injury.

An epidemiological and etiological report on lower extremity amputation in northwest of iran.

BACKGROUND: Lower extremity amputation has different etiologies and the purpose of the study was to describe the demographics and etiologies of amputations. This study was designed to evaluate amputations performed in the province of Eastern Azerbaijan (north-west of Iran) and to determine specific causes of amputations associated with geographical and cultural characteristics of the region. METHODS: We have done this retrospective and descriptive study from June 1st, 2005 to June 1st, 2010 in Tabriz Shohada Hospital (Tabriz, Iran). The patients were evaluated with respect to age, sex, etiology, side and level of amputations, prevalence of amputations among the sexes at different ages and surgical interventions performed. RESULTS: One-hundred-sixty files were identified with a diagnosis of lower limb amputation. Trauma was the most frequent cause in 67 patients (46%), followed by vascular disease in 61 patients (42%), and then infection in 18 c patients (12%). Eighty percent of patients were male and 20% were female. CONCLUSION: This investigation shows that trauma (especially due to car accidents) is the most common cause of amputations in our region, followed by vascular problems.

Treatment of chronic anterior shoulder dislocation by open reduction and simultaneous Bankart lesion repair.

BACKGROUND: Untreated chronic shoulder dislocation eventually leads to functional disability and pain. Open reduction with different fixation methods have been introduced for most chronic shoulder dislocation. We hypothesized that open reduction and simultaneous Bankart lesion repair in chronic anterior shoulder dislocation obviates the need for joint fixation and leads to better results than previously reported methods. METHODS: Eight patients with chronic anterior dislocation of shoulder underwent open reduction and capsulolabral complex repair after an average delay of 10 weeks from injury. Early motion was allowed the day after surgery in the safe position and the clinical and radiographic results were analyzed at an average follow-up of one year. RESULTS: The average Rowe and Zarin's score was 86 points. Four out of eight shoulders were graded as excellent, three as good and one as fair (Rowe and Zarins system). All patients were able to perform their daily activities and they had either mild or no pain. Anterior active forward flexion loss averaged 18 degrees, external active rotation loss averaged 17.5 degrees and internal active rotation loss averaged 3 vertebral body levels. Mild degenerative joint changes were noted in one patient. CONCLUSION: The results show that the overall prognosis for this method of operation is more favorable than the previously reported methods and we recommend concomitant open reduction and capsulolabral complex repair for the treatment of old anterior shoulder dislocation. LEVEL OF EVIDENCE: Therapeutic study, Level IV (case series [no, or historical, control group]).

A study on the radiation dose of the orthopaedic surgeon and staff from a mini C-arm fluoroscopy unit.

In this study, radiation exposure to the surgeon and supporting staff from a mini C-arm unit during fluoroscopically guided orthopaedic surgeries was studied. A Diadose dosemeter and Gamma-Scout meter were used for air-kerma measurements for primary and scattered radiations. The entrance dose of hands, eyes and thyroid of the surgeon was measured during direct observation. Scattered air-kerma rate was measured to quantify the received entrance dose of the supporting staff. During direct observation, the skin-entrance exposure rates of the surgeon's hand, eye and thyroid gland were 8036, 0.85 and 0.9 microGy min(-1), respectively. The scattered exposure rate was precipitously dropped beyond the path of the primary radiation beam, and reached 0.51 microGy min(-1) at a distance of 40 cm from the beam's central axis. This study showed that the surgeon's hand was the most dose-limiting organ for fluoroscopically guided orthopaedic surgery procedures when it was exposed to primary radiation. The exposure of supporting staff at a working distance of >20 cm from the beam was minimal during fluoroscopy by mini C-arm unit.