Association between dietary selenium and zinc intake and risk of dilated cardiomyopathy in children: a case-control study.

BACKGROUND: Dilated cardiomyopathy (DCMP) is characterized by the enlargement and weakening of the heart and is a major cause of heart failure in children. Infection and nutritional deficiencies are culprits for DCMP. Zinc is an important nutrient for human health due to its anti-oxidant effect that protects cell against oxidative damage. This case-control study aimed to investigate the relationship between dietary intake of zinc and selenium and the risk of DCMP in pediatric patients. METHODS: A total of 36 DCMP patients and 72 matched controls were recruited, and their dietary intakes were assessed via a validated food frequency questionnaire. We used chi-square and sample T-test for qualitative and quantitative variables, respectively. Logistic regression analysis was applied to assess the relationship between selenium and zinc intake with the risk of DCMP. RESULTS: After fully adjusting for confounding factors, analyses showed that selenium (OR = 0.19, CI = 0.057-0.069, P trend < 0.011) and zinc (OR = 0.12, CI = 0.035-0.046, P trend < 0.002) intake were strongly associated with 81% and 88% lower risk of pediatric DCMP, respectively. CONCLUSIONS: This study highlights the protective role of adequate dietary intake of selenium and zinc in decreasing the risk of DCMP in children. Malnutrition may exacerbate the condition and addressing these micronutrient deficiencies may improve the cardiac function. Further studies are recommended to detect the underlying mechanisms and dietary recommendations for DCMP prevention.

The Outcomes of Distraction Osteogenesis over an Intramedullary Nail for the Treatment of Bone Defects in Infectious Nonunions.

Objectives: The concurrent utilization of an external fixator and intramedullary nail (IMN) for segment transportation may potentially decrease the duration of external fixator implementation and reduce associated complications. This study aimed to report the outcomes of bone transport utilizing a combination of IMN and Ilizarov frame in a cohort of individuals who had tibia or femur critical-sized bone deficiency resulting from nonunion. Methods: The present research used a single-arm clinical trial design to enroll a series of patients presenting with critical-sized bone defects resulting from infectious nonunion of the tibia or femur. The study was conducted during the period of 2017-2020 in a referral Orthopedic Surgery Center located in Tehran, Iran. The management of patients with infectious nonunion was carried out through two main stages, including infection eradication and bone transportation. The process of bone healing and segment transportation was evaluated by radiographic assessment throughout the follow-up period. Results: A total of 39 patients with bone defects in the tibia (19 cases) or femur (20 cases) with a mean age of 31.44 (±11.95, range=18-60) were included in this study. Twenty-nine (74.3%) patients had open fractures. The bone defect exhibited an average size of 6.31 ± 1.95 cm. The mean of the consolidation index (CI) was 0.97 (range=0.51-1.32) mo/cm, and the mean of the external fixator index was 0.67 (range=0.41-1.10). Although the CI was longer in patients with open fracture compared to those with closed fracture, the difference was not statistically significant (P=0.353). After the end of the two-year follow-up, complete union was observed in 35 patients (89.7%). Conclusion: Intercalary segmental bone transportation using the Ilizarov technique over an IMN, as well as preserving the advantages of the conventional callotasis method, reduces the complications of long-term use of the Ilizarov frame and increases patient adherence to treatment.

Treatment options and outcomes for delayed scapular anatomical neck fractures: a case report and review of the literature.

INTRODUCTION: Scapular anatomical neck fractures are among the most infrequent shoulder girdle fractures. Only seven radiologically confirmed cases of scapular anatomical neck fractures have been documented in the literature to date, of which only one case underwent delayed surgery. CASE PRESENTATION: A 34-year-old male Persian patient with morbid obesity was diagnosed with a scapula anatomical neck fracture after a motor vehicle collision. The radiographic assessment of the patient indicated an increase in the scapular glenopolar angle (73.9°). Due to concurrent chest and head injuries, surgical intervention was deferred until 6 weeks following the injury. The posterolateral limited Dupont-Evrard approach was used because of the patient's extremely high body mass index. Two plates were utilized to achieve stable fixation of the glenoid neck fracture. Following a 1 year follow-up period, complete fracture union was successfully attained, resulting in a constant score of 79. CONCLUSIONS: The most accurate radiographic indicators of these fractures are a superior fracture line located laterally to the coracoid process, a small inferior spike, and an elevated glenopolar angle. The only tendon attached to the glenoid is the long head of the triceps, making these fractures unstable; therefore, surgery is required in the majority of instances. The small size of the fractured component makes stabilization more difficult. Overall, anatomical scapular neck fractures are extremely uncommon and distinguished from other scapular fractures by their unique radiological and biomechanical characteristics. This case highlights the challenges encountered when managing scapular fractures in patients with morbid obesity. The delayed surgical intervention and the choice of surgical approach tailored to the patient's specific anatomical and physiological considerations proved to be effective in achieving a favorable outcome.

Primary seronegative intermuscular hydatidosis in a child, an infection that should be approached like a tumor: a case report and review of the literature.

INTRODUCTION: Intermuscular hydatid cyst is one of the rarest types of hydatid cyst, and as far as we know, only nine cases were reported in the literature before this study. CASE PRESENTATION: We present a 10-year-old Iranian child with an intermuscular cystic mass in the medial-distal thigh. Despite the typical imaging findings, the patient's serological and hematological tests were negative for hydatid cyst. The cyst underwent wide excision accompanied by neoadjuvant and adjuvant chemotherapy with Albendazole. No evidence of recurrence was detected during the one-year follow-up. CONCLUSION: Hydatid cysts should always be considered in the differential diagnosis of soft tissue cystic masses in endemic areas, and aspiration or drainage should be avoided as much as possible, even when serological tests are negative and imaging is non-diagnostic. In cases where the diagnosis of a hydatid cyst has been confirmed before the surgery, it is recommended to approach the cyst, like a tumor with chemotherapy using Albendazole both before and after wide cyst excision.

Outcomes of the Modified Stoppa Approach in Acetabular Fracture Management: Incidence of Nerve Injuries.

Objectives: Displaced acetabular fractures are complex injuries that necessitate precise surgical intervention. Obturator nerve injuries occur in approximately 2% of cases. The modified Stoppa approach, offering enhanced exposure of the quadrilateral plate, has gained attraction as an alternative technique for anterior acetabular fractures. However, its proximity to the obturator nerve poses a risk of iatrogenic injury. This study aimed to investigate the incidence of nerve injuries and functional outcomes in patients undergoing the modified Stoppa approach for traumatic acetabular fractures. Methods: This retrospective study involved 86 patients with anterior column fractures, whose data were prospectively collected. The fractures were treated using the modified Stoppa approach. Exclusion criteria were pathological fractures, alternative surgical approaches, prior nerve injuries, hip issues, refusal to participate, or inadequate follow-up. Data collection involved pre-operative imaging, thorough post-operative neurological assessments, and post-operative radiographic evaluation. Functional outcomes were assessed using the Harris Hip Score (HHS). Results: Most patients were male (n=54) with a mean age of 40±17.3 years. Post-operative infection occurred in six cases, with resolution in four through antibiotics and two necessitating device removal. Obturator nerve damage was detected in 14 patients, comprising nine traumatic and five iatrogenic cases. During the follow-up, symptoms improved in all patients, except for the four patients with iatrogenic nerve damage. Conclusion: Traumatic nerve injuries generally heal naturally over time. In contrast, iatrogenic injuries have a less optimistic prognosis, potentially resulting in lasting neurological deficits.

Antibiotic-loaded spacer arthroplasty in a terrible triad injury with unreconstructable radial head fracture: a case report.

BACKGROUND: Radial head arthroplasty is a viable option in cases with terrible triad injuries of elbow, wherein the radial head sustains significant comminution that precludes reconstruction. Nevertheless, this alternative is not recommended for individuals with poor elbow skin conditions, accompanied neuropsychiatric disorders, or low patient compliance. This case report presents a patient with bilateral terrible triad injury, along with the aforementioned conditions. The report outlines the treatment challenges of such a case and proposes potential solutions. CASE PRESENTATION: A 37-year-old Persian male patient presenting with a bilateral terrible triad fracture-dislocation and a history of psychoactive substance abuse, was admitted to our emergency department. The patient underwent radial head replacement using a cement spacer containing antibiotics, due to the comminuted radial head in the presence of a contaminated wound on the left elbow. The fracture of the right side was successfully fixed. Subsequent to discharge, the patient did not attend any follow-up appointments. After a period of 6 months, he was admitted to the psychiatric ward and orthopedic consultation was requested to evaluate the patient. CONCLUSION: In acute terrible triad injuries with unreconstructable radial head fractures where arthroplasty with metallic prostheses may not be suitable due to contaminated wounds, unstable psychiatric condition, and low patient cooperation, temporary orthopedic cement spacers can maintain elbow biomechanics, stability, and sterility.

Single-stage bilateral conversion arthroplasty for hip fusion via direct anterior approach in a patient with severe ankylosing spondylitis and kyphoscoliosis: a case report.

BACKGROUND: Severe ankylosing spondylitis (AS) frequently involves hip joints and, occasionally, presents with concurrent spinal deformities, such as kyphoscoliosis, creating complex challenges for surgical management. CASE PRESENTATION: We present a 26-year-old Persian male with a history of AS and severe kyphoscoliosis, leading to bilateral hip fusion and immobility. Following spinal deformity correction, a one-stage bilateral conversion to total hip arthroplasty (THA) was conducted through the direct anterior approach. CONCLUSION: Primary correction of spinal deformities allows for extended surgical procedures under general anesthesia. Single stage bilateral hip conversion arthroplasty via the direct anterior approach enhances postoperative mobilization, reduce the risk of re-ankylosis, and improve the overall quality of life for AS patients with this unique presentation.

A comparative analysis of suture-augmented and standard hamstring autograft single-bundle ACL reconstruction outcomes: short-term functional benefits without long-term impact.

BACKGROUND: Augmentation of the biologic graft with nonabsorbable suture material during anterior cruciate ligament reconstruction (ACLR) is a relatively new technique to enhance its biomechanical properties and add additional support to the critical process of healing. We aimed to compare the short-term functional patient-reported outcome measures (PROMs) and complication rates of patients treated with either standard single-bundle four-strand hamstring ACLR or added suture augmentation (SA). METHODS: Patients undergoing arthroscopic ACLR between February 2015-January 2017 and in the standard ACLR group, and between February 2017-September 2019 in the SA-ACLR group operated by adding a no.5 FiberWire® (Arthrex, Naples, FL, USA) braided suture to the hamstring autograft, were retrospectively reviewed and the PROMs were compared. Patients were followed up for a 24-month period and PROMs were assessed by the International Knee Documentation Committee (IKDC) Subjective Knee Form and Tegner-Lysholm knee score. Patients' demographic and clinical characteristics, and postoperative complications including graft retear requiring revision surgery, deep vein thrombois, and surgical site infection were recorded and analyzed. RESULTS: We included 79 patients with mean age of 31.6 ± 8.3 years in the standard ACLR group, and 90 patients with mean oge of 30.5 ± 7.6 in the SA-ACLR group. There was no statistically significant difference between the two groups in terms of age, sex, body mass index, and medical comorbidities. The values of the IKDC scores increased to 75.8 ± 18.9 in the standard ACLR group, and 85.6 ± 12.6 in the SA-ACLR group, 24 months after the operation (P < 0.05). The 24-month postoperative Tegner-Lysholm scores escalated to 79.3 ± 21.0 in the standard ACLR group and 91.0 ± 13.7 in the SA-ACLR group (P < 0.05). Four (5.1%) patients in the standard ACLR group and 4 (4.4%) in the SA-ACLR group experienced graft retear requiring revision surgery (P > 0.05). Incidence of surgical site infection and deep vein thrombosis showed no significant differences between the two groups, 24 months after ACLR. CONCLUSION: SA-ACLR is associated with improved short-term functional PROMs compared to the standard hamstring ACLR. Although SA did not reduce the retear rate, and infection and DVT rates did not differ between study groups, superior improvement of PROMs in SA approach, leverages this method for ACLR.

Concurrent ipsilateral fractures of acetabular posterior wall and femoral shaft associated with posterior hip dislocation: A case report and literature review of a rare injury.

INTRODUCTION: A floating hip injury involving the acetabulum and femur, often complicated by hip dislocation, necessitates a timely and appropriate management strategy to preserve the extremity and patient well-being. CASE PRESENTATION: We present a case of a 20-year-old male with concurrent fractures of the acetabular posterior wall, a comminuted femoral shaft, and posterior hip dislocation. Reduction of the dislocated hip posed a challenge due to the femoral shaft fracture. We successfully employed an innovative technique, using pins proximal and distal to the shaft fracture in conjunction with a temporary external fixator, later replaced by an interlocking nail after hip reduction. Subsequently, we addressed the acetabular fracture through a posterior hip approach, enabling the patient to regain full weight-bearing capacity within a few months. DISCUSSION: In managing concurrent injuries in a floating hip, particularly when a femoral shaft fracture is involved, innovative approaches, such as the one described in this study, are crucial for timely hip reduction. Following hip reduction, a series of surgeries are required to address the multiple lower extremity injuries, prioritizing those with the highest risk of adverse events and neurovascular complications. CONCLUSION: Urgent procedures for multiple fractures in orthopedic trauma surgery are pivotal for the best long-term outcomes. Prioritizing these urgent procedures, even through unconventional transient methods when conventional means are unavailable, can prevent long-term complications such as avascular necrosis. Effective and timely management is paramount for optimal patient recovery.

Evaluation of quality of life and associated factors in patients with intertrochanteric femoral fracture.

BACKGROUND: Intertrochanteric fracture is a common injury among the elderly, causing fundamental lifestyle derangements, influencing the patients' social and psychological functioning. We aimed to study the quality of life (QoL) and its different parameters in patients with this type of injury. MATERIALS AND METHODS: In this cross-sectional study, all patients hospitalized with intertrochanteric fracture aged above 50 from 2020 to 2022 at the Shahid Beheshti Hospital in Babol, Iran, were included. Patients were primarily managed surgically and, in exceptional cases non-surgically, were followed up for at least 12 months after receiving treatment. During the follow-up period, patients were dialled and completed a questionnaire to assess the patient's QoL by the 36-item Short Form Health Survey (SF-36). QoL parameters were analyzed based on patients' sex, age, type of treatment, and height of fall causing fracture. RESULT: A total number of 200 patients, including 101 (50.5%) males and 99 (49.5%) females, with a mean age of 74.76±11.36 years (range: 50-99), were included. Regarding the received treatment, 192 (96.0%) patients underwent surgery, and 8 (4.0%) underwent non-surgical treatment. In the study of SF-36 scores, the mean score of male patients was 42.31±14.58, and females scored 37.83±15.35, and the difference was statistically significant (P = 0.04). The mean score of QoL and its subscales among the 50-75 group patients was significantly higher than the 76-99 group (P<0.001). The average score of QoL was considerably higher in patients who had surgery (40.75±14.57) compared to those who had non-surgical treatment (24.30±19.85) (P = 0.01). Patients having a fall from a higher height had higher QoL after treatment. CONCLUSION: This study revealed that patients with an intertrochanteric femoral fracture had poor QoL in all aspects. The overall QoL was significantly higher among male patients, younger patients, those who underwent surgical treatment, and the falls from higher heights. These findings highlight the necessity of long-term follow-up and support in patients with intertrochanteric fractures.

Compressive cervical myelopathy due to calcium pyrophosphate dihydrate deposition in ligamentum flavum: A case report and review of literature.

INTRODUCTION: Symptomatic calcification of ligamentum flavum (CLF) is a rare condition of the cervical spine compared to other degenerative diseases. CLF manifests as myelopathic symptoms due to the compression of the spinal cord. Calcium pyrophosphate dihydrate (CPPD) deposition disease is the most prevalent cause of CLF. This is the first reported case of CLF caused by CPPD in the Middle East. PRESENTATION OF CASE: A 75-year-old female patient presented with gait disturbance for two years. The imaging studies demonstrated two symmetric bulging masses with a density similar to bone between the inferior border of the C5 laminae and the superior border of the C6 laminae. Histologic evaluation of the resected tissue confirmed the CLF and CPPD disease pathology. The patient underwent a C5-C6 laminectomy. The symptoms resolved, and in a six-month follow-up period, the walking improved. DISCUSSION: The diagnosis of CLF due to CPPD is based on the interpretation of the symptoms concurrent with MRI, CT scan, and histopathological examination. Due to the high reoccurrence rates of the condition following the pharmacological treatment and sub-optimal response in those with negative inflammatory markers, open decompression with either cervical laminectomy or laminoplasty is considered the gold-standard therapeutic option in CFL due to CPPD deposition disease. CONCLUSION: CLF is a rare cervical spine disorder that compresses the spinal cord and manifests as myelopathic symptoms. Early surgical intervention, preferably in the first five months of the disease initiation, is associated with favorable outcomes.

Arthroscopic management of ankle primary synovial chondromatosis (Reichel's syndrome): A case report with literature review.

INTRODUCTION AND IMPORTANCE: Primary Synovial chondromatosis is a rare disease characterized by metaplastic cartilaginous nodules originating from the synovium, which rarely involves the ankle joint. To date, there has been a limited number of reported cases regarding the arthroscopic treatment of this disease, which can be attributed to its rare incidence. This article aims to illuminate the advantages and challenges of this technique by presenting a case study. Furthermore, we delve into the existing literature to assess the different treatments used for this disease and their outcomes. CASE PRESENTATION: A 59-year-old male patient presented with ankle pain, swelling and limited dorsiflexion. Subsequent imaging findings led to the diagnosis of anterior ankle primary synovial chondromatosis. Following this, the patient underwent arthroscopic assisted loose body removal and partial anterior synovectomy, conducted via anteromedial and anterolateral portals. During the five-year follow-up period, no recurrence was observed, and the American Orthopedic Foot and Ankle Score (AOFAS) was assessed as 88. CLINICAL DISCUSSION: Given the uncommon occurrence of this disease, no standardized treatment approach has been established in the literature. While many researchers advocate for surgical intervention to alleviate symptoms and prevent potential complications like osteoarthritis and malignancy, there exists a diversity of perspectives concerning the specific strategies and techniques to employ. CONCLUSION: Partial anterior synovectomy and loose body removal using arthroscopy via anteromedial and anterolateral portals demonstrate a notably efficacious and low-risk technique for addressing primary synovial chondromatosis affecting the anterior chamber of the ankle.

Mortality following proximal femoral fractures in elderly patients: a large retrospective cohort study of incidence and risk factors.

BACKGROUND: Global prevalence of osteoporosis and fragility fractures is increasing due to the aging population. Proximal femoral fractures are among the most common orthopedic conditions in elderly that significantly cause health deterioration and mortality. Here, we aimed to evaluate the mortality rates and risk factors, besides the functional outcomes after these injuries. METHODS: In a retrospective cohort study, all patients admitted with a femoral neck or intertrochanteric fracture between 2016 and the end of 2018 were enrolled in this study. Medical records were reviewed to include patients over 60 years of age who had a proximal femoral fracture and had a complete medical record and radiographs. Exclusion criteria included patients with pathological fractures, cancer under active treatment, follow-up loss, and patient access loss. Demographic and clinical features of patients alongside the details of fracture and patient management were recorded and analyzed. In-hospital and post-discharge mortalities due to included types of fractures at one and 12 months were the primary outcome. Modified Harris Hip Scores (mHHS) was the measure of functional outcome. RESULTS: A total of 788 patients including 412 females (52.3%) and 376 males (47.7%) with a mean age of 76.05 ± 10.01 years were included in this study. Among patients, 573 (72.7%) had an intertrochanteric fracture, while 215 (27.3%) had a femoral neck fracture, and 97.1% of all received surgical treatment. With a mean follow-up of 33.31 months, overall mortality rate was 33.1%, and 5.7% one-month and 20.2% 12-months rates. Analysis of 1-month mortality showed a significant mortality difference in patients operated after 48 h of fracture (p = 0.01) and in patients with American Society of Anesthesiologists (ASA) scores of 3-4 compared to ASA scores of 1-2 (p = 0.001). One-year mortality data showed that the mortality rate in femoral neck fractures was lower compared to other types of fracture. Surgical delay of > 48 h, ASA scores of 3-4, and treatment by proximal femoral plate were associated with shorter survival. The overall mean mHHS score was 53.80 ± 20.78. CONCLUSION: We found several risk factors of mortality, including age ≥ 80 years, a > 48-hour delay to surgery, and pre-operative ASA scores of 3-4 in patients with proximal femoral fracture. Furthermore, the use of a proximal femoral plate was a significant risk factor for mortality and lower mHHS scores.

Successful treatment of a multifocal comminuted open fracture of humerus with severe soft tissue defect: a case report.

BACKGROUND: Choosing the appropriate treatment approach for a multifocal comminuted open fracture of humerus with severe soft tissue defect is a challenging issue, which could be interesting for every orthopedic surgeon especially for those working in the trauma centers. CASE PRESENTATION: This study described an innovative approach using titanium elastic nailing to treat a multifocal comminuted open fracture of humerus with severe soft tissue defect. In this study, we report a 40-year-old Persian female patient in whom the treatment achieved complete fracture union and skin graft healing by elastic medullary nailing, vacuum dressing, and skin grafting. CONCLUSIONS: Elastic medullary nailing is a viable option for reconstruction of simultaneous comminuted fracture and soft tissue defect.

Simultaneous acromioclavicular dislocation, proximal humeral fracture, and reverse Hill-Sachs lesion: a case report.

BACKGROUND: In cases with injuries to the shoulder region, the combination of acromioclavicular joint dislocation, reverse Hill-Sachs lesion, and proximal humeral fracture is a very rare condition. CASE PRESENTATION: This study described a 38-year-old male Persian patient with simultaneous acromioclavicular joint dislocation, proximal humeral fracture, and reverse Hill-Sachs lesion due to motor vehicle crash injury who underwent arthroscopic acromioclavicular joint fixation using tight rope technique. In the 7-month follow-up period following the surgical fixation, range of motion was approximately normal. Reduction and hardware were intact, no dislocation or apprehension to dislocation was observed. Patient only had minor shoulder pain at the end of range of motion and a dull pain on the site of incision over the clavicle in deep touch. Our findings showed acceptable arthroscopic outcomes in the management of such complex case. CONCLUSION: Our experience on this case showed acceptable outcomes of the arthroscopic treatment of the acromioclavicular joint dislocation in the management of such a complex case with associated injuries to the shoulder region.