Knee Flexion Deformity and Increased Posterior Tibial Slope Associated with Osgood Schlatter Disease: A Case Report and Review of Literature.

Genu recurvatum associated with Osgood-Schlatter disease (OSD) has been reported in several studies. In this report, we describe a rare complication of a case of OSD with flexion contracture (tfighat is the exact opposite of the knee deformity classically associated with OSD) and increased posterior tibial slope. In the current article, we report a 14-year-old case of OSD referred to our center with a fixed knee flexion contracture. Radiographic evaluation revealed a tibial slope of 25 degrees. There was no limb length discrepancy. Bracing that was prescribed in the primary center before referring to us was not successful in treating this deformity. He underwent anterior tibial tubercle epiphysiodesis surgery. After a year, the flexion contracture of the patient was significantly reduced. The tibial slope decreased by 12 degrees and reached 13 degrees. The present report suggests that OSD may affect the posterior tibial slope and lead to knee flexion contracture. Surgical epiphysiodesis can correct the deformity.

Using Blumensaat's line to determine the sagittal alignment of the distal femur.

BACKGROUND: A coherent measurement approach for sagittal alignment of the distal femur after fracture reduction or distal femur osteotomies is not available. The present study aims to introduce a new method using Blumensaat's line and tangent lines to the femoral cortexes to determine the sagittal alignment of the distal femur. METHODS: 113 patients who had true lateral knee radiographs were included. All of the radiographs were evaluated by one fellowship-trained knee surgeon and one radiologist using the PACS system. The Blumensaat's line was determined on the true lateral knee radiographs. Then, three long lines were drawn on the distal third of the femoral shaft. The first line is tangent to the anterior cortex of the femur, the second line is along with the anatomical axis of the femur, and the third line is tangent to the posterior cortex of the femur. The angles between Blumensaat's line and these lines were measured. Intraclass Correlation Coefficient (ICC) was used to measure the strength of inter-and intra-rater agreement. RESULTS: The mean angle between the Blumensaat's line and the anatomical axis of the femur was 35.4 ± 3°. The mean angle between the Blumensaat's line and the line tangent to the anterior femoral cortex and the line tangent to the posterior femoral cortex were 34.5 ± 3° and 35.2 ± 3°, respectively. Excellent inter-and intra-rater reliabilities were observed between the measurements (ICC = 0.96 and ICC = 0.98, respectively). The angle between the Blumensaat's line and the line tangent to the posterior femoral cortex was significantly higher in participants aged < 38 years (p = 0.049). No other significant association was found between the angles and demographic characteristics of the patients. CONCLUSIONS: The expected mean angles between the Blumensaat's line and the distal femur were 34.3 to 35.4 degrees. This finding could be useful to determine the normal sagittal alignment of the distal femur. LEVEL OF EVIDENCE: II.

Comparing the Radiologic and Functional Outcome of Radial Shortening Versus Capitate Shortening in Management of Kienböck's Disease.

BACKGROUND: Kienböck's disease is the avascular necrosis of the lunate bone. There is no consensus on the treatment strategy to avoid joint deterioration. This trial is conducted to compare the functional and radiological outcomes of radial shortening and capitate shortening techniques, in patients with avascular necrosis of lunate. METHODS: Patients with a confirmed diagnosis of Kienböck's disease who met the inclusion criteria were randomly divided into radial shortening and capitate shortening groups and treated by allocated technique. Physical examination and radiologic evaluations were performed before and 6 and 12 months after the operation. RESULTS: A total of 52 patients (52 wrists) of stage II or III Kienböck's disease were assessed for eligibility, 12 patients in the radial shortening group, and 17 patients remained until the end of the study. Patients in both groups achieved a satisfactory outcome, with no report of postoperative complications. None of the outcome measures, ranges of motion, grip, and pinch strengths were significantly different between the groups. The outcome was not considerably different in patients with positive or negative ulnar variances who were treated by capitate shortening technique. CONCLUSIONS: The capitate shortening technique which is performed through a smaller incision, and takes less time as compared with radial shortening can be advantageous for patients with stage II or III Kienböck's disease regardless of the ulnar variance. This method can be as effective as classical methods such as radial shortening in improving clinical and functional symptoms after surgery while causing fewer complications.

Closed Reduction and Percutaneous Pinning for Treatment of Proximal Interphalangeal Joint Pilon Fractures.

BACKGROUND: Proximal interphalangeal (PIP) joint pilon fractures are among the challenging hand injuries, which are often associated with a wide range of complications. This study aimed to report the clinical and radiological outcomes of closed reduction and percutaneous Kirschner wire (KW) insertion with or without bone cement application (for the fabrication of an external fixator) in the treatment of PIP joint pilon fractures. METHODS: Twenty pilon fractures underwent closed reduction and percutaneous KW fixation through a modified technique. At the end of the follow-up period, 3 questionnaires-Quick Disabilities of the Arm, Shoulder, and Hand (Quick DASH), Visual Analogue Scale for pain, and Patient-Rated Wrist Evaluation-were completed. The radiological outcome was assessed by radiography. Range of motion, and grip and pinch strength were measured. RESULTS: The mean follow-up period was 14.57 ± 4.03 months (range, 12-20 months). The mean range of motion of PIP at the end of the follow-up period was 89.64° ± 10.82° (range, 65°-100°). The mean difference in the range of motion in the contralateral side was 21.4° ± 13°. The mean of the Quick DASH score was 13.50 ± 2.92 (range, 11-21). Two patients had residual articular malalignment, and 3 patients had angular or rotational malunion. CONCLUSION: By treating pilon fractures with the proposed technique, we achieved a satisfactory outcome. The acceptable articular and axial alignment was achieved in 75% of patients, and complications were low. The flexibility of percutaneous KW insertion and handmade external fixators makes these approaches convenient for treating PIP joint pilon fractures.

Anatomic reconstruction of the medial collateral ligament in multi-ligaments knee injury using achilles allograft : a modification of Marx's technique.

Medial Collateral Ligament (MCL) injury may require operative treatment. Marx et al. described the latest technique for reconstruction of MCL. While good results have been reported using the Marx technique, some issues have been observed. To address the mentioned issues, a modification to the Marx technique has been devised. Eleven patients were enrolled and their ligaments were repaired by the fixation of allograft on the proximal and distal attachment footprints of the superficial MCL. For preventing loss of knee ROM, MCL and other ligaments were reconstructed in 2 separate stages. At the last follow up the ROM, knee ligament laxity and functional outcome scores, subjective (IKDC) and Lysholm score were evaluated and recorded. Knee motion was maintained in all cases. Two cases demonstrated 1+ valgus instability at 30 degrees of knee flexion. Both were treated for combined MCL and PCL tear, the rest were stable. The average IKDC-subjective score was 93 ± 4 and the average Lysholm score was 92 ± 3. All patients were satisfied and returned to their previous level of activity. In this technique, the superficial MCL was recon- structed closer to its anatomical construct. Patients didn't have any complaints of hardware under the skin and the need for a second surgery for hardware removal was avoided. Patients didn't have any complaints of hardware under the skin and the need for a second surgery for hardware removal was avoided. Also reconstructing the ligaments in 2 stages helped to preserve the knee motion. Level of Evidence : Level IV therapeutic.

The best strategy for red blood cell transfusion in severe burn patients, restrictive or liberal: A randomized controlled trial.

INTRODUCTION: Although blood transfusion is common in burns, data are lacking in appropriate transfusion thresholds. It has been reported that a restrictive blood transfusion policy decreases blood utilization and improves outcomes in critically ill adults, but the impact of a restrictive blood transfusion policy in burn patients is unclear. We decided to investigate the outcome of decreasing the blood transfusion threshold. MATERIAL AND METHODS: Eighty patients with TBSA > 20% who met our inclusion criteria were included. They were randomly divided into control and intervention groups. The intervention group received packed cells only when Hemoglobin declined to less than 8 g/dL at routine laboratory evaluations. While the control group received packed-cell when hemoglobin was declined to less than 10 g/dl. The total number of the received packed cell before, during and after any surgical procedure was recorded. The outcome was measured by the evaluation of the infection rate and other complications. RESULT: The mean hemoglobin level before transfusion was 7.7 ± 0.4 g/dL in the restrictive group and 8.8 ± 0.7 g/dL in the liberal group. The mean number of RBC unit transfusion per patient in the restrictive group was significantly lower than the traditional group (3.28 ± 2.2 units vs. 5.9 ± 3.7 units) (p-value = 0.006). The total number of RBC transfused units varied significantly between the two groups (p-value = 0.014). The number of transfused RBC units outside the operation room showed a significant difference between groups (restrictive: 2.8 ± 1.4 units vs. liberal: 4.4 ± 2.6 units) (p = 0.004). We did not find any significant difference in mortality rate or other outcome measures between groups. CONCLUSION: Applying the restrictive transfusion strategy in thermal burn patients who are highly prone to all kinds of infection, does not adversely impact the patient outcome, and results in significant cost savings to the institution and lower rate of infection. We conclude that the restrictive transfusion practice during burn excision and grafting is well tolerated and effective in reducing the number of transfusions without increasing complications. CLINICAL TRIAL REGISTRATION REFERENCE: IRCT20190209042660N1.

Corrigendum to "Pain Relieving Effect of Intraoperative Chemical Splanchnicectomy of Celiac Ganglions in Patients with Resectable Pancreatic or Gastric Masses: A Randomized Clinical Trial".

[This corrects the article DOI: 10.1155/2020/2675940.].

Comparison of characteristic features and local recurrence in syndromic versus non-syndromic multifocal non-ossifying fibroma.

BACKGROUND: Multiple non-ossifying fibromas (MNOF) could be presented with other extraskeletal anomalies (syndromic) or not (non-syndromic). In this study, we aimed to compare characteristic features and local recurrence between symptomatic syndromic and non-syndromic MNOFs. METHODS: Thirty-five patients with symptomatic MNOF were included in this study, comprised of 30 patients without the café-au-lait spot (non-syndromic) and five with café-au-lait spots plus other signs of neurofibromatosis type 1 (syndromic). Characteristic features of the patients and lesions were compared between syndromic and non-syndromic MNOFs. The lesions were treated with curettage and bone graft. The rate of local recurrences was also compared between the two groups of syndromic and non-syndromic MNOF. RESULTS: Study population included 19 (54.3%) males and 16 (45.7%) females with the mean age of 7.63 ± 3.1 years (range 4-11). The mean follow-up of the patients was 65.6 ± 38.2 months (range 24-96). The lesion was bilateral in 13.3% of non-syndromic MNOFs and 80% of syndromic MNOFs. This difference was statistically significant (p = 0.01). After curettage and bone grafting, the lesion recurred in 6.7%of non-syndromic MNOFs and 60% of the syndromic MNOF. This difference was statistically significant, as well (p = 0.01). No other significant difference was found between syndromic and non-syndromic MNOFs. CONCLUSIONS: The syndromic form of MNOF is much less prevalent and is associated with a higher rate of recurrence after surgical removal. Therefore, a more rigorous removal of the MNOF lesions might be necessary when presented in a syndromic context.

The Efficacy of Intravenous Versus Topical Use of Tranexamic Acid in Reducing Blood Loss after Primary Total Knee Arthroplasty: A Randomized Clinical Trial.

BACKGROUND: Blood loss during and immediately after total knee arthroplasty (TKA) is among the most challenging concerns. It has been demonstrated that Tranexamic acid (TXA) can help to reduce perioperative blood loss. TXA can be used as an oral, topical or intravenous injection. Many studies evaluated the effectiveness of each route of administration but few works on a comparison between them. The current study aimed to compare the effectiveness of intravenous injection versus topical use of TXA in reducing perioperative blood loss after primary total knee arthroplasty. METHODS: Eighty-five patients who were a candidate for total knee arthroplasty were randomized into two groups: one group received Intravenous injection of 15 mg/kg TXA, 10 min before tourniquet inflation while the other group received 1 g diluted TXA during wound closure. The postoperative blood loss was estimated by measuring the whole drain output and also hemoglobin (HB) drops. Both groups compared based on the need for allogenic blood transfusion and also thromboembolic events. RESULTS: Patients who received topical TXA had a higher total drain output (p <0.0001) compared to intravenous injection. The hemoglobin drop also was more in the topical group although it was marginally significant (p =0.05). CONCLUSION: Intravenous injection of TXA is more effective in reducing postoperative blood loss after primary TKA compared to topical administration.

Huge renal epithelioid angiomyolipoma - A case report of a giant, benign renal mass.

INTRODUCTION: Renal angiomyolipoma (also called renal hamartoma) is a benign Tumor, composed of adipose tissue, smooth muscle tissue, and blood vessels. Tumors more than 10 cm (referred to as "giant" AMLs) are infrequent and a very small number of reported cases were measured more than 20 cm. Epithelioid angiomyolipoma (EAML), is a rare variant of angiomyolipoma with malignant potential. There are less than 10 cases of huge EAML reported in English literature, that were all associated with recurrence and complications. CASE PRESENTATION: Here we report a rare case of renal EAML in a 48-year-old male patient that was not associated with tuberous sclerosis. He was admitted to our hospital with a complaint of severe abdominal pain. Computer Tomography Scan (CT-scan), revealed two masses attached to the left kidney with a size of 32 × 22 × 8 cm and 20 × 10 × 3 cm. The patient underwent a radical left nephrectomy. Postoperative histopathological examination confirmed the diagnosis of an EAML. The two-year follow-up CT-scan showed no recurrence. CONCLUSION: Malignant EAML, although rare, does exist. Thus, besides evaluations required for ruling out the diagnosis of renal sarcomas, surgeons must follow patients after total nephrectomy for possible recurrence. Benign cases can be completely cured by surgery and do not show recurrence at the end of the follow-up period.

Focal hematopoietic hyperplasia of the rib-A form of pseudo-tumor. Case report and review of articles.

INTRODUCTION: Focal hematopoietic hyperplasia (FHH) is an unusual benign lesion that can rarely involve the ribs. In general, FHHs is a tumor-like expansion of ribs due to the abnormal proliferation of bone marrow. FHHs are mostly found incidentally at radiologic studies performed for other reasons. They are characterized by gradually enlarging osteolytic masses that involve the rib. PRESENTATION OF CASE: Here, we present an unusual case of focal hematopoietic hyperplasia of the rib who arrived to our institute with a complaint of severing back pain at the level of T5-T6 vertebrae. The diagnosis of FHH has been made based on clinical and radiologic findings and confirmed by histopathologic evaluations. We also reviewed all previously reported cases of Focal Hematopoietic hyperplasia of the rib in the literature. DISCUSSION: None of the previously reported cases, same as our patient, gave a history of trauma to the site involved or family history of malignancy. There was no association with hematological disorders or other malignancies that might have initiated FHH. Histologic evaluations of previously reported cases represented a hyper cellular bone marrow merging with the fatty marrow. The morphology and maturation of all hematopoietic cell lines were normal and there was no report of morphologically abnormal hematopoietic cell or malignant tumor cells. CONCLUSION: Physicians must consider the FHH among differential diagnosis of secondary rib lesions. Surgical resection is the treatment of choice; the risk of recurrence or metastasis is neglectable.

Long-term Results, Functional Outcomes and Complications after Open Reduction and Internal Fixation of Neglected and Displaced Greater Tuberosity of Humerus Fractures.

BACKGROUND: Humerus fractures include 5% to 8% of total fractures. Non-union and delayed union of GT (GT) fractures is uncommon; however they present a challenge to the orthopedic surgeons. Significant controversy surrounds optimal treatment of neglected fractures. The purpose of this article was to perform a comparative study to evaluate the outcomes of open reduction and internal fixation (ORIF) of neglected GT fractures. METHODS: We retrospectively evaluated the results of surgical intervention in 12 patients with displaced nonunion of GT fractures who were referred to our center. Before and minimally 25 months after surgery ROM, muscle forces, Constant Shoulder Score (Constant-Murley score) (CSS), Visual Analogue Scale (VAS), Activities of Daily Living (ADL) Score and American Shoulder and Elbow Surgeons (ASES) Score were all recorded. Additionally, the results were compared with undamaged shoulder. RESULTS: Between March 2006 and January 2013, 12 patients underwent surgical intervention and followed for 36.2 months in average. All fractures healed. Anatomic reduction achieved only in 6 cases with no report of avascular necrosis or infection. All ROMs and muscle forces increased significantly (Mean Forward Flexion: 49.16 to 153.3, Mean Internal Rotation: 3 to 9, Mean External Rotation: -5 to 27.5) (P value<0.0001). All functional scores including CSS, VAS, ADL and ASES score improved significantly (Mean VAS: 6.5 to 1.3, Mean CSS: 29.83 to 86, Mean ADL: 6.6 to 27.1,: Mean ASES: 28.6 to 88.9) (P value<0.0001). CONCLUSION: ORIF for neglected and displaced GT fractures has satisfactory functional outcomes, despite of non-anatomical reduction of the fracture.