Factors influencing the selection criteria of Saudi board orthopedic surgery applicants: a national survey of program directors.

BACKGROUND: Annually, medical students vie to secure a seat with an orthopedic residency program. This rigorous competition places orthopedic surgery as one of the most competitive specialties in the medical field. Although several international studies have been published regarding the factors that influence program directors when choosing their ideal applicant, the data for Saudi Arabia in that regard is absent. METHODS: In this cross-sectional study, we aimed to survey all orthopedic program directors regarding the factors that influence them when choosing their ideal orthopedic surgery applicant. A survey was sent to all program directors via email during the month of August 2022. A reminder was sent 2 weeks later to maximize the response rate. The survey was completed by 22 out of 36 orthopedic program directors, which gave us a response rate of 61.11%. RESULTS: In this study, 22 orthopedic surgery program directors responded to our survey. When program directors were asked to rank the factors of residency selection criteria, the top ranked factors were good impression on interviews; prior experience in orthopedic surgery with, for example, electives; and performance on ethical questions during interviews, with means of 9.18, 8.95, and 8.82 out of 10, respectively. Furthermore, program directors preferred letters of recommendation from recommenders that they personally know, clinical experience such as electives taken at the program director's institution, and the quality of publications as the most important aspects of research. Most program directors (90.9%) relied on their residents' and fellows' opinions when selecting candidates, and 77.3% did not think gender has an influence on selection of applicants. CONCLUSION: By providing comprehensive data regarding the factors that influence and attract program directors of orthopedic surgery when choosing residency candidates. With the data provided by this study, applicants for orthopedic surgery have the advantage of early planning to build a strong application that may help persuade program directors to choose them.

Clinical outcomes of percutaneous screw fixation of acetabular fracture: A minimally invasive procedure.

Objective: Open reduction with internal fixation is the surgical intervention of choice for acetabular fractures (AFs). Percutaneous screw fixation for AFs is a new procedure that is desirable because of the complex anatomy of the pelvis. In this study, we aimed to assess the functional outcomes, mobility, healing, and distal neurovascular abnormalities in patients who underwent percutaneous retrograde screw fixation. Methods: Our study included 36 patients with AFs treated with percutaneous screw fixation between January 2016 and June 2021. There were 18 cases with anterior column AF, 7 cases with transverse AF, and 11 cases with associated AF, 6 of which had a T-shaped AF. Frequencies and percentages were used to describe characteristics and clinical outcomes. Mean and standard deviation were used for continuous variables. SPSS version 23 (IBM Corporation, Armonk, NY, USA) was used for statistical analysis. Results: The average time to regain full mobility with full weight bearing was 12.9 ± 5.4 weeks, and approximately 11.1 ± 2.8 weeks was required for patients to be pain-free with satisfactory fracture healing. Only a minority (8.3%) of patients had abnormalities affecting the distal neurovascular system, and 11.1% experienced sexual dysfunction. Pain severity was assessed with a visual analogue scale. The average pain severity on the first and third post-operative days was 4 ± 2.4 and 3.8 ± 2.6, respectively. However, the average pain intensity before discharge was 1.7 ± 2.6. Conclusion: Percutaneous screw fixation is the most efficient surgical choice for most pelvic/AFs.

Assessment of opioid administration patterns following lower extremity fracture among opioid-naïve inpatients: retrospective multicenter cohort study.

BACKGROUND: Prescribing habits during admission have largely contributed to the opioid epidemic. Orthopedic surgeons represent the third-highest opioid-prescribing specialty. Since more than half of body fractures in Saudi Arabia have been lower extremity fractures, it is imperative to understand opioid administration patterns and correlates among opioid-naïve inpatients. OBJECTIVES: Assess opioid administration patterns and correlates among opioid-naïve inpatients with lower extremity fractures. DESIGN AND SETTINGS: Retrospective cohort PATIENTS AND METHODS: Opioid naïve individuals aged 18 to 64 years, admitted due to lower extremity fracture from 2016 to 2020 were included. Data was collected from health records of the Ministry of National Guard Health Affairs (MNG-HA) at five different medical centers. The high-dose (≥50 MME) patients were compared with low dose (<50 MME) patients. Any association between inpatient factors and high-dose opioid use was analyzed by multiple logistic regression. MAIN OUTCOME MEASURES: Opioids taken during inpatient admission as measured by milligram morphine equivalents (MME)/per day. SAMPLE SIZE: 1520 patients RESULTS: Most of the 1520 patients (88.5%) received an opioid medication, while (20.3%) received high-dose opioids at a median daily dose of 33.7 MME/per day. The proportion of patients received naloxone (20.7%) was double among high-dose opioid inpatients. High-dose opioid patients during admission were two times more likely to receive an opioid prescription after discharge (odds ratio, 2.32; 95% confidence interval, 1.53, 3.51), and three more times likely to receive ketamine during admission (odds ratio, 3.02; 95% confidence interval, 1.64, 5.54). CONCLUSION: Notable variabilities exist in opioid administration patterns that were not explained by patient factors. Evidence-based opioid prescribing practices should be developed for orthopedic patients to prevent opioid overprescribing and potential opioid overdose among orthopedic patients. LIMITATIONS: Retrospective, unmeasurable confounders might have biased our results. Since based on National Guard employees, results may not be generalizable. CONFLICT OF INTEREST: None.

The Outcomes and Revision Rate of Total Hip Arthroplasty in a Single Tertiary Center: A Retrospective Study.

Introduction Total hip arthroplasty (THA) is a commonly performed and successful orthopedic practice procedure. However, failure of arthroplasty may require revision THA and pose substantial clinical challenges for orthopedic surgeons. Therefore, this retrospective study aimed to estimate the revision rate of THA and its risk factors at a tertiary care hospital. Methods A retrospective cohort study was conducted in 2021 of patients who had undergone THA during 2016-2020 in a tertiary care hospital. All patients above 18 years old who had a THA were included in the study. The data was collected from patients' medical charts/electronic databases. Results A total of 148 THAs were included in this study. In total, 77 (52%) were females, and 71 (48%) were males. The average age of our patients was 49±17 years old, and the mean recorded BMI was 29.6. A total of 62% (n=92/148) of our participants were shown to have at least one comorbid disease, with hypertension being the most common comorbidity. Our findings show that half of the patients, 74 (50%), had a THA due to both primary and secondary osteoarthritis, 37 (25%) patients had avascular necrosis of the hip, and 25 (17%) were due to trauma. The most performed surgical approach was Kocher-Langenbeck (posterior) approach on 128 (86%), followed by the Hardinge (lateral) approach on 20 (13.51%). The most observed complication in the patients was postoperative pain in 35 (23.65%), followed by UTIs in 5 (3.38%). Of the 148 patients, nine (6.08%) had revision surgery. Regarding the revision rate, male patients were associated with a significantly higher rate of revision (P=<0.001), and older patients had a significantly increased risk of revision (P=0.026). Patients who developed complications, such as UTI, were associated with a higher revision rate (P=0.035). Also, a posterior approach (Kocher-Langenbeck) of the procedure was significantly linked to an increased risk of revision (P=0.014). Conclusion All in all, there are multiple associated factors with an increased incidence of revision THA. For example, male patients, older patients, complication development during the hospital stay, and posterior surgical approach were all associated with a significantly higher rate of revision.

Cost of healthcare rehabilitation services following road traffic injuries: Results from a Level-I trauma center in Saudi Arabia.

BACKGROUND: Road traffic injuries (RTIs) are the second leading cause of mortality in Saudi Arabia. The high rate of RTIs puts a strain on rehabilitation services. Yet, little is known of the economic burden of nonfatal RTIs and rehabilitation services. This study, therefore, aims to describe the annual rehabilitation costs associated with RTIs at a local trauma center. MATERIALS AND METHODS: This study was conducted among all the 17 years or older patients hospitalized at King Abdulaziz Medical City in Riyadh following RTIs and required rehabilitation care. We included 299 patients who met the inclusion criteria and were followed for one year after discharge from the index hospital. The data was abstracted through retrospective review of patients' medical records. All rehabilitative services utilized by the healthcare system were recorded. To describe the economic burden, the mean, median, standard deviation, and interquartile range (IQR) were calculated. Total costs were aggregated for all patients to estimate overall costs. RESULTS: The study population was relatively young (31 years ± 14.4). The total annual rehabilitation cost of patients was Saudi Riyals (SAR) 6,113,781 (IQR: 20,589.3 - 3,125 = 17,464.3), and the average for each patient was SAR 20,447 (median = 7875). Patients aged 40-59 years and ≥60 years accounted for the highest average rehabilitation cost of SAR 31,563.99 and 32,639.21, respectively. Rehabilitation visits incurred the highest cost (mean SAR 1,494,124), followed by bed utilization which cost SAR 1,311,972 and radiology examination at SAR 1,032,261. The cost of motorcycle injuries was relatively higher (SAR 44,441.0) than other injury mechanisms. CONCLUSION: This study underlines the economic burden of rehabilitation services resulting from RTIs. Public health interventions are needed to reduce the burden of RTIs by dealing with their preventable causes and improving road safety measures. These findings may be useful to policymakers and researchers to support and improve rehabilitation services in Saudi Arabia.

Total knee replacement in a polio patient with prior extension osteotomy: a case report.

Poliomyelitis is an infectious disease characterized by a loss of motor neurons. Affected individuals usually suffer from many abnormalities predisposing them to degenerative joint disease. We report a case of a young male, with a history of poliomyelitis, distal femoral extension osteotomy and previous tendon transfer, suffering from severe knee pain. The patient underwent total knee arthroplasty with posterior stabilized Triathlon® for the femoral side reconstruction and Total-stabilizer Triathlon® for the tibia with short stem. At 2-year follow-up, his range-of-motion had improved, and he could walk without pain. This case report emphasizes the value of careful preoperative planning for a complex case with suitable implants and expecting realistic outcomes.

Use of high-dose denosumab in the management of immobilization-related hypercalcemia in an end-stage renal disease patient on hemodialysis: A case report and review of the literature.

BACKGROUND: There is limited evidence on the safety and efficacy of denosumab for the management of immobilization-related hypercalcemia in hemodialysis patients. We report a case of successful treatment of immobilization-related hypercalcemia with a high dose of denosumab (120 mg). CASE PRESENTATION: A 55-year-old, bed-ridden woman was admitted to the intensive care unit with suspected catheter-related bacteremia and septic shock. 13 days following admission, the patient's corrected serum calcium levels rose from 2.52 mmol/L at baseline to 3.39 mmol/L. Cinacalcet, subcutaneous calcitonin, intravenous zoledronic acid, and subcutaneous 60-mg dose of denosumab were administered but resulted in an inadequate response. Consequently, subcutaneous 120-mg dose of denosumab was administered and resulted in a gradual decline of corrected serum calcium levels from 4.18 mmol/L to 2.45 mmol/L within 3 weeks; corrected serum calcium levels were maintained above 2.10 mmol/L and less than 2.80 mmol/L for 3 months after high-dose denosumab administration. CONCLUSION: High-dose denosumab could be a viable treatment option for end-stage renal disease patients developing immobilization-related hypercalcemia.

One-year postoperative mortality rate among the elderly with hip fractures at a single tertiary care center.

BACKGROUND: Hip fractures are one of the leading causes of disability and dependency among the elderly. The rate of hip fractures has been progressively increasing due to the continuing increase in average life expectancy. Surgical intervention is the mainstay of treatment, but with an increasing prevalence of comorbid conditions and decreased functional capacity in elderly patients, more patients are prone to postoperative complications. OBJECTIVES: Assess the value of surgical intervention for hip fractures among the elderly by quantifying the 1-year mortality rate and assessing factors associated with mortality. DESIGN: Medical record review. SETTING: Tertiary care center. PATIENTS AND METHODS: All patients 60 years o age or older who sustained a hip fracture between the period of 2008 to 2018 in a single tertiary healthcare center. Data was obtained from case files, using both electronic and paper files. MAIN OUTCOME MEASURES: The 1-year mortality rate for hip fracture, postoperative complications and factors associated with mortality. SAMPLE SIZE: 802 patients. RESULTS: The majority of patients underwent surgical intervention (93%). Intra- and postoperative complications were 3% and 16%, respectively. Four percent of the sample died within 30 days, and 11% died within one year. In a multivariate analysis, an increased risk of 1-year mortality was associated with neck of femur fractures and postoperative complications (P=.034, <.001, respectively) CONCLUSION: The 1-year mortality risk in our study reinforces the importance of aggressive surgical intervention for hip fractures. LIMITATION: Single-centered study. CONFLICT OF INTEREST: None.

Adductor canal blockade versus continuous epidural analgesia after total knee joint replacement: A retrospective cohort study.

BACKGROUND: Total knee arthroplasty is associated with intense pain postoperatively. Thus, adequate pain relief is essential in the immediate postoperative period to enable ambulation, initiation of physiotherapy, and prevention of postoperative complications. The objective of this study was to compare the effectiveness and early outcomes of adductor canal blockade (ACB) and continuous epidural analgesia (CEA) in patients who underwent a unilateral total knee replacement (TKR). MATERIALS AND METHODS: This is a retrospective cohort study that was conducted in Riyadh with 80 patients receiving a unilateral total knee arthroplasty from August 2017 to July 2018. Forty patients received ACB, and 40 received CEA exclusively. The primary outcomes measured were the degree of knee flexion and extension in physiotherapy sessions on postoperative day 1 and discharge, how soon patients walked after surgery, length of hospital stay (LOS), local anesthetic and total opioid consumption, postoperative blood drainage output, incidence of nausea and vomiting, and pain scores. RESULTS: Significantly more patients receiving ACB could flex their knee in the first 24 h postoperatively (P < 0.05), and the total drain output was also significantly less (P < 0.05). Pain in the first 8, 24, and 48 h was less in the ACB group using a Visual Analog Scale (P < 0.05). In addition, LOS, total opioid consumption, postoperative blood drain output, incidence of nausea and vomiting, and pain scores were significantly decreased after using ACB compared with epidural analgesia. CONCLUSION: This study provided evidence that ACB as postoperative analgesia after TKR is associated with better outcomes in terms of facilitating early functional recovery and mobility, and consequently prevents major postoperative complications.

Level of evidence of clinical orthopedic surgery research in Saudi Arabia.

OBJECTIVE: To evaluate the level of evidence (LOE) of Saudi clinical orthopedic research. METHODS: In July 2012, a list of Saudi orthopedic surgeons (N=93) affiliated with all major universities and hospitals in Saudi Arabia were obtained. PubMed and Embase searches were performed for all eligible studies over the last 2 decades (August 1991 to May 2012). The Oxford LOE scale was utilized to determine the LOE of these studies (Level V studies were excluded). The LOE trends were compared between the last 2 decades. In addition, the LOE of Saudi orthopedic studies was compared with North American studies. RESULTS: Of 251 articles, 159 met the inclusion criteria for the LOE evaluation. Most of the published studies are Level IV (86%). The average level of evidence was 3.75. There was no statistically significant difference when we compared the LOE trend between the last 2 decades. North American studies contained higher proportions of high-level studies when compared to Saudi studies (p<0.05). CONCLUSION: Most of the published studies are low LOE. Academic staff, institutions, and training programs are required to develop research strategies to improve orthopedic research quality in Saudi Arabia.