Platelet-rich plasma versus corticosteroid: a randomized controlled trial on tennis elbow patients resistant to nonsurgical treatments.

Background: Although some studies on tennis elbow indicate corticosteroid (CS) effectiveness in the short term, according to the role of race, this study evaluates the efficacy of platelet-rich plasma (PRP) compared with CS for a more cost-effective treatment. Methods: This randomized controlled trial included 30 positive-resisted wrist extension patients with a minimum five visual analog scale (VAS) pain score. Participants were randomly assigned to treatment or control groups via computer-generated randomization and were matched for baseline and clinical characteristics. Cases received either 40 mg of prednisolone acetate or 2 ml of PRP, followed for 1 month. VAS and Disabilities of the Arm, Shoulder, and Hand (DASH) scores were the primary outcomes. Results: The median VAS and the mean DASH scores had a statistically significant difference in the PRP and CS groups before and after injection (P<0.001).The mean DASH difference between preinjection and follow-up time in the PRP and CS groups was 59.72±14.17 and 43.16±10.87, respectively, with a mean difference of 16.55 (95% CI 7.10-26.00) and a significant difference (P=0.001).The mean VAS pain score difference in preinjection and follow-up time had a statistically significant difference between the PRP and CS groups (P=0.026), and the mean VAS pain score difference in the CS group was 6.46±1.50 and 7.73±0.96 in the PRP group. Conclusion: In conclusion, larger studies with parallel groups and more diverse CS doses and types with baseline matching are needed to confirm the short-term benefits of PRP. Investigating the effects of different CS doses using ultrasound techniques is recommended.

A shotgun-induced nonunion humeral fracture treated by Masquelet technique and arthrodesis: a case report.

Introduction and importance: The Masquelet technique remains one of the procedures with low rates of failure and infection. The use of this technique in humeral defects is still rare. Case presentation: A 38-year-old male patient with an open humeral comminuted fracture induced by shotgun injury was referred to our hospital. The Masquelet technique was chosen as the best option with a lower risk of infection and the lower expenses at this stage due to the second time of open reduction and internal fixation and bone graft failure, low patient compliance, and the increasing size of the defect due to bone absorption. An arthrodesis procedure was performed 5 days after the second Masquelet stage as restoring the elbow joint's range of motion was impossible. Clinical discussion: The Masquelet technique, is a two-step surgical procedure to manage pseudoarthroses and bone defects. Various surgical options are available for performing this procedure. There are several reasons behind the rising popularity of this technique during recent years. Some of these reasons include the reproducibility of this technique, as well as requiring less time, not being technically challenging, and having fewer neurovascular complications. Conclusion: This case was one of the limited examples of successful implementation of the Masquelete procedure on severe traumatic injuries of the upper limb with bone defects providing more evidence on the safety and efficacy of this technique in similar conditions.

Two case reports of adult traumatic inferior hip dislocations following road traffic accidents without complications.

Inferior dislocation of the hip is the rarest type of hip dislocation, mainly occurring from high-energy incidents, mostly from road traffic accidents or sports. It is generally an injury among adults. Case presentation: A 17-year-old male sustained injuries as a pedestrian, and a 30-year-old male sustained a traffic accident as a motorcycle rider. Both patients complained of severe pain in the hip, decreasing range of motion, and the inability to weight bearing. In both, the affected hip joint was fixed in 90° flexion, abduction, and external rotation, and the leg was slightly shorter than the other limb. An X-ray showed the inferior dislocation of the right hip and left hip, respectively, without any sign of fracture. We reduced both dislocations closely after sedation without any complications during follow-ups. Conclusion: This injury should be treated as an emergency, and reduction performed as soon as possible, within 6 h. It can be managed usually with closed reduction under general anesthesia. Close follow-up is necessary to prevent its complications, including avascular necrosis, associated fractures, neurovascular compromise, and articular cartilage injuries.

Cortical bridging a union predictor: A prospective study after intramedullary nailing of the femoral shaft fractures.

Early prediction of the union helps for timely intervention, reduction of hospitalization, treatment costs, and disability in cases of nonunion. With this in mind, we tried to find how long any cortical bridging predicts the union in femoral shaft fractures. A prospective study of 113 femoral shaft fractures treated with reamed, locked intramedullary nailing was performed. Radiographs were taken during months 2 to 4, 6, 9, and one-year follow-up. The cortical bridging (presence and number) was assessed by anterior-posterior and lateral views. The ROC curve provides the prediction of the union. The overall nonunion rate was 10.6% (12 of 113 fractures). Age and diabetes mellitus were statistically significant with nonunion (p value < 0.001). The final analysis demonstrated that any cortical bridging at four months postoperatively was the most accurate and earlier indicator (105 of 113, 92.9% accuracy), while it was 84.9% at six months in bicortical and 80.5% accuracy at nine months in tricortical bridging. Low-cost and simple radiographic imaging presents cortical bridging in any form 4 months after surgery that precisely predicts a union in femoral shaft fractures.

Minimally Invasive Repair of Acute Achilles Tendon Rupture Using Gift Box Technique.

BACKGROUND: This study aimed to introduce a modified technique for minimally invasive Achilles tendon (AT) rupture repair using gift box sutures. The preliminary clinical and functional outcomes were investigated among a number of patients. METHODS: In a consecutive case series study, 24 patients with acute AT rupture underwent modified minimally invasive AT repair using two mini-incisions and gift box sutures. The patients were followed up for 24 months. The AT rupture score (ATRS) and the American Orthopedic Foot and Ankle Society (AOFAS) measure score were obtained from all patients. The other measured variables included pain intensity and satisfaction using a visual analog scale (VAS), calf atrophy, the range of sagittal ankle motion, development of wound complications, sural nerve injury, and re-rupture. RESULTS: After two years, the mean scores of AOFAS and ATRS were obtained at 83±4 and 81.9±6.3, respectively. Approximately 87.5 % of the patients regained their previous level of activity. The mean VAS score was 7.7±0.9 regarding the satisfaction with the outcomes. Moreover, isokinetic testing of plantar flexion and dorsiflexion strength were 82.7±5.8 and 87.7±4.1%, respectively, compared to those of the normal side. The calf atrophy was not statistically significant. In total, five patients reported pain during their activities. The range of operated ankle motion decreased significantly, compared to that of the other side; however, the differences were not significant functionally. There was no patient with wound complications, nerve injury, or complaint about problem with footwear. CONCLUSION: Minimally invasive repair of acute AT rupture using two mini-incisions and gift box sutures offers good functional and clinical outcomes without wound complications which can be usually observed following open repair of AT ruptures.

National Joint Registry of Iran.

Joint replacement is currently on the rise with a high community burden. A registry was designed to evaluate the costs, possible complications, and rate of revisions as well as finding the most effective techniques, risk factors associated with poor results, indications for revision surgeries, and also demographic evaluation of patients undergoing joint replacement surgery in Iran.

Ponseti Casting Method in Idiopathic Congenital Clubfoot and Its Correlation with Radiographic Features Abstract.

BACKGROUND: The aim of this study was to evaluate the idiopathic congenital clubfoot deformity treated by Ponseti method to determine the different factors such as radiological investigations that may have relations with the risk of failure and recurrence in mid-term follow-up of the patients. METHODS: Since 2006 to 2011, 226 feet from 149 patients with idiopathic congenital clubfoot were treated with weekly castings by Ponseti method. Anteroposterior and lateral foot radiographies were performed at the final follow-up visit and the data from clinical and radiological outcomes were analysed. RESULTS: In our patients, 191(84.9%) feet required percutaneous tenotomy. The successful correction rate was 92% indication no need for further surgical correction. No significant correlation was found between the remained deformity rate and the severity of the deformity and compliance of using the brace (P=0.108 and 0.207 respectively). The remained deformity rate had an inverse association with the beginning age of treatment (P=0.049). No significant correlation was found between the percutaneous tetonomy and passive dorsiflexion range (P=0.356). CONCLUSION: According to our results treatment with the Ponseti method resulted in poor or no correlation. The diagnosis of clubfoot is a clinical judgment; therefore, the outcome of the treatment must only be clinically evaluated. Although the Ponseti method can retrieve the normal shape of the foot, it fails to treat the bone deformities and eventually leads to remained radiologic deformity. Further studiesare suggested to define a different modification that can address the abnormal angles between the foot and ankle bones to minimize the risk of recurrence.

Management of postoperative pain after Lumbar surgery-pregabalin for one day and 14 days-a randomized, triple-blinded, placebo-controlled study.

OBJECTIVES: Despite the progress in understanding acute pain physiology during recent decade, eighty percent of patients still suffer from post-operative discomfort. Pregabalin is an anticonvulsant agent that is approved for painful neuropathies in diabetic patients and post herpetic neuralgia. The main objective of the present study was to compare the improvement in post-operative pain management and patient lifestyle in 3 groups, as first group received placebo, second who received Pregabalin for one day and the last group those who received it for 14 days. METHODS: This was a prospective single center, randomized, triple-blind, 3-arm, parallel group study. In this triple-blind study, patients were randomized to 1 of 3 groups using computer-generated random number table. 1) The first group received placebo for 14 days, the second group received Pregabalin 300mg 8h preoperatively and 150mg 12 and 24h postoperatively and for the rest of 13days received placebo and the third group received Pregabalin 300mg eight hours preoperatively and 15mg every 12h postoperatively for 14 days. Name, age, gender, height, weight, education, duration of pain, past medical history, drug history,total morphine requirement at the time of discharge and MRI findings of all the patients were recorded, also they Numerical scale system (NRS) and Oswestry low back pain disability index (ODI) questionnaire were completed for them. All the patients were operated based on standard surgery techniques, bilateral foramenotomy and interlaminar discectomy. RESULTS: Of the 105 patients who entered the run-in period, 47 patients (44.8%) were female and 58 (55.2%) were male. The Patients radicular pain mean score based on NRS estimated before surgery was 7.22±1.95 in pregabalin14, 7.71±1.84 in pregabalin1 and 7.45±1.9 in control group. There were no statically significant differences between three groups (P-Value>0.05). The Patients back pain mean score based on NRS was 5.2±2.87 in pregabalin14, 5.11±3.23 in pregabalin1 and 6.4±3.06 in control group. This means that there were no significant differences in the overall score among those three groups (P-Value>0.05). In comparison to their preoperative pain, the average radicular pain in each group of patients improved significantly 4, 8, 12 and 24h after the operation (P-Value<0.001), but there were no significant differences in radicular pain improvements comparing three groups. CONCLUSION: The results of this study indicate that 1day and 2 weeks post-operative 300mg pregabalin administration may not improve acute pain, morphine consumption and quality of life of patients after surgery. It seems that the diseases cause chronic pain that requires long-term treatment with higher doses.

Neglected Alkaptonuric Patient Presenting with Steppage Gait.

Even though intervertebral disc degeneration can be found in the natural course of alkaptonuria, detection of the disease by black disc color change in a patient without any other presentation of alkaptonuria is an exceptionally rare condition. We have reported a very rare case of alkaptonuria presented with low back pain and steppage gait in a 51-year-old male with a complaint of chronic low-back pain and steppage gait who was operated on for prolapsed lumbar disc herniation. Intraoperatively his lumbar disk was discovered to be black. The alkaptonuria diagnosis was considered after histopathological examination of the black disc material and elevated urinary concentration of homogentisic acid confirmed the diagnosis. To our knowledge, this presentation has not been reported previously in literature.

Assessment of the EuroSCORE risk scoring system for patients undergoing coronary artery bypass graft surgery in a group of Iranian patients.

BACKGROUND AND AIMS: Previous studies around the world indicated validity and accuracy of European System for Cardiac Operative Risk Evaluation (EuroSCORE) risk scoring system we evaluated the EuroSCORE risk scoring system for patients undergoing coronary artery bypass graft (CABG) surgery in a group of Iranian patients. MATERIALS AND METHODS: In this cohort 2220 patients more than 18 years, who were performed CABG surgery in Massih Daneshvari Hospital, from January 2004 to March 2010 were recruited. Predicted mortality risk scores were calculated using logistic EuroSCORE and Acute Physiology and Chronic Health Evaluation II (APACHE II) and compared with observed mortality. Calibration was measured by the Hosmer-Lemeshow (HL) test and discrimination by using the receiver operating characteristic (ROC) curve area. RESULTS: Of the 2220 patients, in hospital deaths occurred in 270 patients (mortality rate of 12.2%). The accuracy of mortality prediction in the logistic EuroSCORE and APACHE II model was 89.1%; in the local EuroSCORE (logistic) was 91.89%; and in the local EuroSCORE support vector machines (SVM) was 98.6%. The area under curve for ROC curve, was 0.724 (95% confidence interval [CI]: 0.57-0.88) for logistic EuroSCORE; 0.836 (95% CI: 0.731-0.942) for local EuroSCORE (logistic); 0.978 (95% CI: 0.937-1) for Local EuroSCORE (SVM); and 0.832 (95% CI: 0.723-0.941) for APACHE II model. The HL test showed good calibration for the local EuroSCORE (SVM), APACHE II model and local EuroSCORE (logistic) (P = 0.823, P = 0.748 and P = 0.06 respectively); but there was a significant difference between expected and observed mortality according to EuroSCORE model (P = 0.033). CONCLUSION: We detected logistic EuroSCORE risk model is not applicable on Iranian patients undergoing CABG surgery.

Outcome Assessment of Operative Treatment of Humeral Shaft Fractures by Antegrade Unreamed Humeral Nailing (UHN).

The purpose of this study was to assess the outcome of humeral shaft fractures treated with Unreamed Humeral Nailing (UHN) system. Fixation of the humeral shaft fractures in this study was performed by minimal incision UHN system, without using its distal locking properties. Forty one patients were treated this way. Functional status of shoulder and elbow were evaluated using Society of the American Shoulder and Elbow Surgery (SASES) scoring system. During follow up period, no superficial or deep infections were observed. Mean union time was 13 weeks. Shoulder and elbow functions using SASES scale were excellent or good in 93 % of the patients. Complications included delayed union in 3(7.3 %), nonunion in 2(4.8 %) and radial nerve palsy in 1(2.4 %). Antegrade unreamed humeral Nailing is an acceptable, safe and reliable treatment for humeral shaft fractures.

Arthroscopic posterior cruciate ligament reconstruction by using hamstring tendon autograft and transosseous screw fixation: minimal 3 years follow-up.

BACKGROUND: The aim of this trial is to prospectively evaluate the outcomes of PCL reconstruction by means of quadruple hamstring tendon autograft with a double-fixation method at minimal 3-year follow-up. MATERIALS AND METHODS: Only patients who underwent PCL reconstruction without any other concomitant injury were included in this study. A hamstring tendon graft is composed of a quadruple-stranded gracilis tendon and semitendinosus tendon about 10 cm in length. An arthroscopic technique via a two incision and a double-fixation method was applied. Clinical evaluations were performed for 52 patients. Clinical assessment of patients included the Lysholm knee scores, International Knee Documentation Committee (IKDC) scores, thigh muscle evaluation, and radiographic investigation. RESULTS: On the Lysholm knee score, 90 % of the patients displayed good or excellent rating in the final assessment. In the IKDC rating analyses, 60 % of the patients demonstrated 3-5-mm ligament laxity. For the IKDC final rating, 81 % were normal or nearly normal. Seventy-nine percent of the cases revealed less than a 10-mm difference in thigh girth between their reconstructed and contra lateral limbs. CONCLUSION: Arthroscopic PCL reconstruction using quadruple hamstring tendon autograft provides acceptable outcomes at a minimum 3-year follow-up. The four-stranded hamstring tendon graft is suitable in graft size and results in minimal harvesting morbidity. We recommend that quadruple hamstring tendon graft be chosen for PCL reconstruction to achieve good ligament reconstruction. A double-fixation method which has been applied in this trial can be used to provide rigid fixation.

Comparison of morphologic consequences of open and endoscopic carpal tunnel release.

OBJECTIVES: The objective of this study is to evaluate the carpal canal morphologic consequences following endoscopic carpal tunnel release compared with open approach. METHODS: 48 Patients with CTS were enrolled in our prospective trial. Participants were classified in 2 groups: 24 patients underwent open surgery technique and 24 underwent endoscopic carpal tunnel decompression. Carpal canal shape and volume, configuration and position of contents, were analyzed by using imaging techniques. RESULTS: Preoperative carpal canal volume in endoscopic patient group averaged 5.7±1.4 cc and 7.3±2.9 cc at 6 weeks postoperatively (28%±7%, p=0.018). In contrast preoperative carpal canal volume in open carpal tunnel release group averaged 4.9±1.1 cc (and increased to 6.2±1.7 cc at 6-week follow up investigation (36%±5%, p=0.002). Preoperative carpal arch width calculation in endoscopic carpal tunnel release group averaged 21.7±1.1mm and 21.5±1.9mm in open carpal tunnel release patients (p=0.6575). Postoperative carpal arch width measurements in endoscopic carpal tunnel decompression group averaged 22.6±4.1mm and 22.1±2.9mm in open carpal tunnel release patient population at 6-week follow-up investigation (p=0.628). CONCLUSION: Endoscopic approach causes an increment in carpal canal volume comparable to open technique and provides equivalent anatomic outcomes and will produce at least equivalent long-term clinical relief.

Prospective outcomes of arthroscopic treatment of dorsal wrist ganglia.

The purpose of this study was to assess the results of arthroscopic resection of dorsal wrist ganglia. Between November 2002 and September 2007, all patients with dorsal wrist ganglia underwent arthroscopic resection in our institution. Average follow-up was 39.2 months (range, 24-71 months). Fifty-two patients (40 women and 12 men; mean age, 29.8 years) were treated with our operative technique. Symptoms at presentation were unpleasant appearance in 15 patients (28.8 %), pain in 30 (57.6%), and unpleasant appearance and pain in 7 (13.5%). The ganglion cyst site was in front of the midcarpal joint in 41 patients (78.8%), in front of the radiocarpal joint in 6 patients (11.5%), and in front of the radiocarpal and midcarpal joints in 5 patients (9.6%). Our surgical technique resulted in a significant improvement in flexion, extension, and grip strength (P≤.005). In patients with painful ganglia, treatment also had a significant effect. Nine (17.3%) recurrences were observed. Mean time off work was 14 days, but 19 patients returned to work immediately. According to the results of this study, we recommend the use of arthroscopy as the primary treatment method for dorsal wrist ganglion excision.

Intraosseous ganglion cyst of the lunate.

Intraosseous ganglia can affect the carpal bones of the hand and must be considered in the differential diagnosis of wrist pain. A 38-year-old female presented with a 14-month history of left wrist pain and a radiolucent cystic lesion was seen computed tomography (CT) scanning. Characteristic radiographic findings of a cyst in association with a fine sclerotic rim was apparent. We report an unusual presentation of a ganglion cyst in the lunate bone with excellent treatment outcome.