Orthopedic oncology residency education, how broad and how deep?

Orthopedic residency training has long been an area of active research and discussion, and as the knowledge and concepts in subspecialties evolve, it is crucial to investigate the implications of these advancements in the musculoskeletal oncology field. It is important to note that the acquisition of surgical skills and scientific knowledge from orthopedic texts alone is not sufficient in this area. Orthopedic residents must also acquire multidisciplinary communication and leadership skills, as well as the mental capacity to make sound clinical decisions. Therefore, this commentary highlights the importance of assessing whether the current curriculum provides adequate preparation for residents' future careers, despite the fact that the expansion of subspecialties in orthopedic education has undoubtedly enhanced the depth of knowledge and concepts in the field. In addition, orthopedic residents must adopt an open-minded and scientific approach toward orthopedic oncology, which has unique principles. Moreover, it is crucial that general orthopedic surgeons have the necessary skills to manage patients and know when to refer them. By exploring these issues, we hope to continually contribute to ongoing discussions about how to improve orthopedic residency education.

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.

Gorham-Stout syndrome, the challenge in diagnosis and unique in treatment: a case report.

BACKGROUND: Gorham-Stout disease is a rare condition with fewer than 400 reported cases in the literature. The presentation of Gorham-Stout disease varies on the basis of location, extent, fracture, and accompanying symptoms. It lacks a specific histopathological appearance but is characterized by vascular changes and the absence of cellular atypia. CASE PRESENTATION: This article presents a case study of a 16-year-old Persian boy with an entire femur with Gorham-Stout disease, highlighting the difficulties in managing this condition. The lack of a clear diagnosis resulted in prolonged procedures, delayed medical treatments, and ultimately required total femoral replacement with an endoprosthesis. CONCLUSION: It is important to note that raising awareness of this disease and its potential complications can facilitate timely and appropriate treatment for patients presenting in the early stages of the disease.

Job satisfaction, Career Burnout, and Work-Related Well-Being Prevalence among Orthopedic Surgeons: A Nationwide Study.

Background: Burnout is a well-known consequence of chronic stress. Orthopedic surgery is among the most desired specialty among Iranian medical students. The nature of the job, the income, and the ability to deal with stress can all be stressful factors for orthopedic surgeons. Nonetheless, little is known about how these medical doctors work and live in Iran. The present study aimed to assess job satisfaction, engagement, and burnout among Iranian orthopedists. Methods: A nationwide online survey was conducted in Iran. Job satisfaction, engagement, and burnout were evaluated using the job description index (JDI), Utrecht Work Engagement Scale, and Maslach Burnout Scale. They were also asked some additional questions related to career choice. Results: A total of 456 questionnaires (41% response rate) were retrieved. Overall, 56.8% of the participants experienced burnout. The burnout levels significantly differed based on age, years from graduation, working in public hospitals, operating more than 10 patients in a week, monthly income, having less than two children, and being single (P<0.05). They scored higher on work questions on the present job and jobs in general but lower scores on pay and opportunities for promotion. Conclusion: In a national study of orthopedic surgeons, their primary concern in JDI was "pay and promotion." Burnout was substantially associated with respondents' characteristics, such as younger age and having fewer children. This will lead to impaired performance, increased patient complaints, and the tendency to immigrate.

Talus osteohondroma with syndesmosis problem; case report.

INTRODUCTION AND IMPORTANCE: Osteochondroma, commonly known as exostosis, is a benign osteocartilaginous mass lesion frequently encountered in orthopaedic clinics. While its benign nature is of little concern, the impact on surrounding tissues can be significant, especially in the case of exostosis located in the distal tibia and fibula, which can damage the syndesmosis. CASE PRESENTATION: This report presents a rare case of exostosis of the talus that has progressed into the syndesmosis, causing distinct clinical and radiographic symptoms. The patient underwent excision of the lesion through the posterolateral ankle approach, and our main concern was about the approach to the syndesmosis. Ultimately, open reduction and screw fixation were performed for the patient. CLINICAL DISCUSSION: Exostosis in the talus area is generally uncommon in the literature review, and the presence of the lesion in the posteromedial surface area, as well as its entry and damage to the syndesmosis area, is even less common. Diagnosing the lesion through appropriate methods and a multidisciplinary team approach is crucial for correct diagnosis and treatment. Different approaches to managing syndesmosis have been reported, and suitable treatment for these cases is required. CONCLUSION: In conclusion, correct diagnosis and excision of the exostosis lesion are essential, but it is also necessary to appropriately identify and manage its adverse effects. The selection of an appropriate treatment strategy for managing these lesions is crucial.

Investigation of litigation in trauma orthopaedic surgery.

BACKGROUND: It has been said that the number of orthopaedic claims has increased in the last few years. Investigation through the most prevalent cause would help to prevent further cases. AIM: To review the cases of medical complaints in orthopedic patients who had been involved in a traumatic accident. METHODS: A retrospective multi-center review of trauma orthopaedic-related malpractice lawsuits from 2010 to 2021 was conducted utilizing the regional medicolegal database. Defendant and plaintiff characteristics along with fracture location, allegations, and litigation outcomes were investigated. RESULTS: A total of 228 claims referred to trauma-related conditions with a mean age of 31.29 ± 12.56 were enrolled. The most common injuries were at hand, thigh, elbow, and forearm, respectively. Likewise, the most common alleged complication was related to malunion or nonunion. In 47% of the cases, the main problem that led to the complaint was the inappropriate or insufficient explanation to the patient, and in 53%, there was a problem in the surgery. Eventually, 76% of the complaints resulted in a defense verdict, and 24% resulted in a plaintiff verdict. CONCLUSION: Surgical treatment of hand injuries and surgery in non-educational hospitals received the most complaints. The majority of litigation outcomes were caused by a physician's failure to fully explain and educate the traumatic orthopedic patients and technological errors.

Successful Reconstruction of Proximal Phalanx Condylar Fracture in an Athlete Using Auto-Osteochondral Graft from the Base of Fifth Metacarpus: A Case Report and Review of Literature.

Intra-articular fractures of the proximal phalanx head, especially with the condylar defect, are relatively rare but challenging for surgical treatment. Although several surgical procedures are available to reconstruct articular cartilage defects, the optimal method is unclear. This study reports a successful osteochondral reconstruction of proximal phalanx condylar defect in an athlete using the articular portion of the fifth metacarpal base.

Wide-awake local anesthesia for open rotator cuff repair: A case report.

INTRODUCTION AND IMPORTANCE: Improper treatment of rotator cuff tear might result in progression of tear and deterioration of patient function. The rotator cuff tear can be managed conservatively in most cases however surgical treatment is inevitable in persistent patients. PRESENTATION OF CASE: A 45-year-old woman presented to our clinic with shoulder pain and restricted range of motion following a fall from a height three months before the current presentation. Due to the lack of favorable response to conservative treatment and the fact that rotator cuff rupture was traumatic, she became a candidate for rotator cuff repair surgery. Due to financial issues and the patient's refusal of undergoing general anesthesia we considered the WALANT technique. Prior to surgery, we explained the whole procedure to the patient, referring to its pros and cons. CLINICAL DISCUSSION: The WALANT procedure is a relatively recent technique that has become widespread in orthopedic surgery in the past decade. The advantages of the WALANT technique are that it is simple, feasible, and safe and that the analgesic is adequate during the operation and for the first few hours afterward (5). Concerns with this method include patient discomfort and pain during surgery, which can be managed by educating the patient and minute-by-minute explanation during the procedure. CONCLUSION: We advocate open rotator cuff repair with the WALANT approach as an effective, cost-saving, safe, simple, and quick alternative to general and regional anesthesia for certain patients or with limited anesthetic resources. LEVEL OF EVIDENCE: V.

Electric shock sign after digital nerve injury; report of a case and review of literature.

INTRODUCTION AND IMPORTANCE: Digital nerve lacerations are rationally common, especially following penetrating injuries. The majority of patients suffer from numbness as the main complaint. However, electric shock pain is a rare manifestation of partial nerve injury. CASE PRESENTATION: A 65-year-old woman with partial digital nerve injury and an electric shock sign due to a 1 cm laceration on the volar side of the proximal phalanx three weeks earlier. The surgical exploration revealed a neuroma-like mass in the digital nerve; however, the continuity of the nerve was grossly intact. CLINICAL DISCUSSION: Due to the superficiality of digital nerves, penetrating nerve injuries are rationally common in this area. Laceration of the digital nerve could lead to loss of sensation, clumsiness, and even loss of function. Gradually, neuroma formation would add a local pain and electric shock sign to the mentioned symptoms. CONCLUSION: Electric shock sign is characteristic for partial digital nerve injury with unknown mechanism. It seems the symptoms would be progressive and more complicated with neuroma formation. LEVEL OF EVIDENCE: V.

Orthopedic Trauma During Pregnancy; a Narrative Review.

Introduction: Blunt traumas, like road accidents and falls, are common causes of injuries to pregnant women, and the major risk factors are young age and low socioeconomic level. Due to physiological and anatomical changes specific to pregnancy, such as changes in blood pressure and hemoglobin drop, trauma management involves certain complexities. Physical trauma is estimated to cause at least 1 complication in every 12 pregnancies. This study aims to evaluate orthopedic trauma during pregnancy and appreciate the different approaches to circumvent the resultant challenges. Methods: We reviewed 55 articles, published on orthopedic trauma during pregnancy between 2011 and 2021. The articles were identified by searching PubMed, google-scholar, Scopus, and Science-Direct. We utilized the search terms: fall in pregnancy, traumas in pregnancy, motor vehicle accident/crash in pregnancy, blunt trauma in pregnancy, pregnant trauma patient, penetrating injury during pregnancy, assault, interpersonal violence in pregnancy, and mortality and pregnancy. Results: According to available reports, after stabilizing the pregnant patient, diagnostic procedures, including radiography, and even gadolinium-based techniques when needed, can be performed to examine extensive trauma. In contrast to elective orthopedic surgery, emergency orthopedic surgeries, including reduction of open fractures, should be performed promptly. Conclusion: Based on our investigation, pregnant women with orthopedic injuries that are severe, or even seemingly less severe, experience significantly increased adverse pregnancy outcomes, which include preterm birth, placental abruption, poor infant condition at birth, infant death, and even maternal death.

Evaluation of vitamin D levels in COVID-19 patients referred to Labafinejad hospital in Tehran and its relationship with disease severity and mortality.

BACKGROUND AND AIMS: Novel Coronavirus (COVID-19) first appeared in China in late 2019 which was rapidly spread worldwide. As the COVID-19 pandemic continues to spread, it is crucial to determine the prognostic factors contributing to the development of severe disease and higher mortality. Herein we aimed to evaluate the correlation between the severity and prognosis of patients with COVID 19 with serum 25(OH)D levels. METHOD: This descriptive retrospective study was performed from March to April 2020 at a referral center for patients with COVID-19, Tehran, Iran. The data collection was performed by a checklist consisting of the demographic features and laboratory assessments consisted of serum 25(OH)D were evaluated and recorded. And investigate the relationship between serum 25(OH)D and clinical outcomes of patients. RESULT: 205 patients with a mean age of 59.71 years were enrolled. Our findings did not reveal a significant difference in mean levels of vitamin between improved (34.09) and deceased patients (34.54). However, in patients with severe disease, there was a considerable difference in levels of vitamin D in improved and deceased patients (P.value: 0.021). According to our results, the mortality rate was slightly higher in men (odds ratio:2.2). Furthermore, the mean age (64.20 vs. 58.51) and the presence of at least two comorbidities (odds ratio: 2.40) were significantly higher in deceased patients. CONCLUSION: In this study, we did not reveal a statistical difference in mean levels of vitamin D and the outcome of patients with COVID-19. We concluded that in patients with severe disease, vitamin D deficiency could affect the course of the disease and mortality, especially in comorbidity and older people.

Extraperitoneal Bladder Injuries Associated With Pelvic Fracture Requiring Internal Fixation: What Is the Evidence?

Traumatic bladder injuries are commonly associated with pelvic fractures. While the majority of intraperitoneal bladder injuries are surgically repaired, extraperitoneal bladder injuries (EBIs) can be managed nonoperatively in the absence of complex injury patterns such as bladder neck injury or presence of bone spicules in the bladder. Concern for pelvic hardware contamination is one of the most common reasons for repairing EBIs at the time of orthopedic interventions for pelvic fracture (usually open reduction and internal fixation). However, given the inconsistent and limited evidence, practice patterns are different and largely depend on surgeon preferences and institutional management. In this review, we explore the roots for this concern and summarize the current evidence on risk of pelvic hardware infection with nonoperative management of EBIs.

Epidemiological pattern of pediatric trauma in COVID-19 outbreak: Data from a tertiary trauma center in Iran.

INTRODUCTION: In Iran, like most other countries, COVID-19 has had a deep impact on children's lives. Our hypothesis was that, a significant change in the number of pediatric injuries has happened in trauma centers. In the current study, we intend to identify the possible epidemiological shift in pediatric fracture patterns, by comparing the data from 'COVID-19 era' and the mean data from the past 2 years. To the best of our knowledge there are only few reports on epidemiology of pediatric fractures during the COVID-19 outbreak. METHODS: Data are reported in two sections. In the descriptive section, epidemiological data regarding pediatric fractures referred to Taleghani tertiary trauma center, including demographics, distribution curves, etiologies and fracture types are presented during the 'COVID era', from 1 March 2020 to 15 April 2020. In the comparative section, the aforementioned data are compared with mean data from the past 2 years, the 'non-COVID era'. RESULTS: Altogether 117 of the 288 trauma children (40.62%) had a fractured bone (145 fractures). Patients were mostly boys, with a mean age of 9.87 years (SD=5.27). The three most common fracture types in children included distal radius, mid-forearm and humeral supracondylar fractures. Compared to non-COVID era, the number of pediatric trauma admissions dropped from 589 to 288. No significant change happened in the mean age, male/female ratio and percentage of motor vehicle accidents. Proportion of proximal humeral, proximal forearm, carpal, and hand fractures declined. The number of open fractures significantly dropped (from 12 to 2). CONCLUSIONS: In Iran, overall trend of pediatric trauma has been decreasing during the outbreak; but the lack of reduction in proportion of accidents may pose an alarm that an effective lock-down has not been imposed. This study has implications as to preparing appropriate resources particular to common "COVID era fractures".

Fracture Surgery in Known COVID-19 Infected Patients: What Are the Challenges?

BACKGROUND: Surgery in the time of COVID-19 pandemic is a challenging issue while treatment of affected fracture patients is inevitable. The present study summarizes the challenges that an orthopedic surgeon is confronting during the surgical treatment of fracture patients with concomitant COVID-19 infection. METHODS: Demographic and fracture related data of 13 fracture patients with concomitant COVID-19 infection who were treated with surgery was collected from three trauma centers in Tehran and Kermanshah cities from 21, February 2020 to April 3, 2020. RESULTS: All patients were male with mean age of 38.6±19.5 years. Eight patients had high energy fracture and seven patients had multiple fractures and trauma. Wrist and hand were the common sites of fracture following hip and pelvis. The mean interval time period between the diagnosis of COVID-19 infection and surgery was 2.3±1.5 days. Before surgery, all patients except one had been admitted to the corona dedicated wards, while two patients were admitted to the intensive care unit (ICU). One of the ICU admitted patients died. All the 12 alive patients remained in home isolation after discharge. CONCLUSION: Fracture surgery in COVID-19 patients has many challenges such as lack of medical resources, delay of surgery, medial staff fear, and patient isolation. However, a multidisciplinary approach using all potential hospital resources would lead to successful operation and acceptable outcome.

Current Management of Extraperitoneal Bladder Injuries: Results from the Multi-Institutional Genito-Urinary Trauma Study (MiGUTS).

PURPOSE: We studied the current management trends for extraperitoneal bladder injuries and evaluated the use of operative repair versus catheter drainage, and the associated complications with each approach. MATERIALS AND METHODS: We prospectively collected data on bladder trauma from 20 level 1 trauma centers across the United States from 2013 to 2018. We excluded patients with intraperitoneal bladder injury and those who died within 24 hours of hospital arrival. We separated patients with extraperitoneal bladder injuries into 2 groups (catheter drainage vs operative repair) based on their initial management within the first 4 days and compared the rates of bladder injury related complications among them. Regression analyses were used to identify potential predictors of complications. RESULTS: From 323 bladder injuries we included 157 patients with extraperitoneal bladder injuries. Concomitant injuries occurred in 139 (88%) patients with pelvic fracture seen in 79%. Sixty-seven patients (43%) initially underwent operative repair for their extraperitoneal bladder injuries. The 3 most common reasons for operative repair were severity of injury or bladder neck injury (40%), injury found during laparotomy (39%) and concern for pelvic hardware contamination (28%). Significant complications were identified in 23% and 19% of the catheter drainage and operative repair groups, respectively (p=0.55). The only statistically significant predictor for complications was bladder neck or urethral injury (RR 2.69, 95% 1.21-5.97, p=0.01). CONCLUSIONS: In this large multi-institutional cohort, 43% of patients underwent surgical repair for initial management of extraperitoneal bladder injuries. We found no significant difference in complications between the initial management strategies of catheter drainage and operative repair. The most significant predictor for complications was concomitant urethral or bladder neck injury.

Universal goniometer and electro-goniometer intra-examiner reliability in measuring the knee range of motion during active knee extension test in patients with chronic low back pain with short hamstring muscle.

BACKGROUND: Both universal goniometer and electro-goniometer are used for measuring joint range of motion in physiotherapy. Active knee extension test is a way to assess hamstring shortness in patients with chronic low back pain. The aim of this study was to assess universal goniometer and electro-goniometer reliability in measuring knee angle during active knee extension test. METHODS: This was an intra-examiner reliability study between three measurements of knee extension angle that conducted on 45 patients with chronic low back pain having short hamstring muscle that referring to Kermanshah University of Medical Sciences clinic from 2016 to 2017. Knee extension angle was measured three times during active knee extension test with both universal goniometer and electro-goniometer.The measurement of knee extension angle was done at the beginning, middle and the end of one single session by one experienced physiotherapist.The intra-class correlation coefficient (ICC) and standard error of measurements (SEM) were used to quantify intra-examiner reliability. RESULTS: For both methods, the reliability test values were found to be greater than 0.7 in the range of 0.92 to 0.99 (CI 95% ranged over = 0.94 to 0.99), which are classified as good reliability. The SEMs ranged from 1.04° to 2.16° for both scales. CONCLUSION: Universal goniometer in clinical evaluations of patients (as they are easy to be employed) and electro-goniometer in laboratory studies (as they are more accurate) are reliable.

The Outcome of Salter Innominate Osteotomy for Developmental Hip Dysplasia before and after 3 Years Old.

BACKGROUND: Developmental dysplasia of the hip (DDH) is one of the most important and challenging conditions in the field of pediatric orthopedics; if not diagnosed and treated in time, it would lead to remarkable morbidity. Methods of treatment based on the patient's age can vary. The aim of this study is to compare the outcomes of Salter osteotomy surgery in two groups of patients under and over three years old. METHODS: In this retrospective study, medical records of patients who had undergone innominate Salter osteotomy, within the past ten years, due to non-pathological DDH were collected. Mean follow up of all patients is 70.28 months (min=25, max=118). RESULTS: eventy patients were selected including 85 operated hips. Radiological satisfaction based on modified Severin score system rate was 86% and 85% for lower three years old group and second group, respectively. In clinical assessment, it was found that results in 82% of the patients under 3 years old and 82.9% of patients older than three years old were satisfactory. There was no statistically significant difference between the two groups based on Modified MacKay criterion. CONCLUSION: Results in both groups of patients under and over 3 years old were found satisfactory. Difference in patient satisfaction rates based on clinical and radiological outcomes was not statistically significant between the two groups. It should also be noted that complications such as redislocation and deep wound infection would cause poor clinical and radiological outcomes.