Misdiagnosis of Post-traumatic Osteomyelitis: A Case Report

Chronic osteomyelitis is a severe and persistent condition that engages bone and bone marrow. The infection can be limited to the bone, or it can propagate to the bone marrow, the periosteum, and the surrounding soft tissues. It represents a major financial every health system and impacts the quality of life of the affected patients. Diagnosing chronic osteomyelitis remains difficult. Accordingly, laboratory and imaging studies are necessary in this respect. A 49-year-old man after high energy trauma underwent debridmant and fixation. After 3 years’ patient admitted in infection ward with fever presentation. The clinical examination didn't reveal any sign of localization of fever. Chronic osteomyelitis is not always associated with fever in this situation Other diagnoses should be considered after role out other disease osteomyelitis

Valgus Osteotomy Outcome for Treating Femoral Neck Nonunion in Young and Active Patients

Background: Femoral neck fracture nonunion is a frequent and challenging complication, with several surgical options. Objectives: The present study reported the outcome of valgus osteotomy for treating femoral neck nonunion in patients aged <65 years. Methods: This case series research included young patients who underwent valgus osteotomy for treating femoral neck nonunion or device failure of the index surgery. The fixation of the osteotomy site was performed using either a dynamic hip screw or a fixed angle blade. The union of the neck and osteotomy site (subtrochanteric region) was evaluated by monitoring callus formation in the postoperative radiographs. Limb length discrepancy, Pauwels’ angle, and the neck-shaft angle were evaluated before the surgery and at the last follow-up. Postoperative complications were extracted from the explored patients’ profiles. Results: Twenty patients with a Mean±SD age of 27.2±10.8 years were examined in this study‎. The Mean±SD follow-up time of the patients was 6.1±3.9 years. The femoral neck was united in 18 patients in a Mean±SD period of 5.1±2.3 months. The Mean±SD limb length discrepancy was measured as 1.3±0.8 cm before and 0.5±0.7 cm after the ‏osteotomy. The Mean±SD Pauwels’ angle was calculated as 65.5±16.9º before and 32.4±16.2º after the osteotomy. The Mean±SD neck-shaft angle was computed to be 121.9±22.8º before and 144.5±17.7º after the osteotomy. Revision surgery was performed for 6 (30%) patients. This measure included device removal in 4 and total hip arthroplasty in 2 patient. Conclusion: Valgus osteotomy is a safe and efficient technique for managing femoral neck nonunion. Therefore‎, this approach is suggested as a good alternative for total hip arthroplasty, particularly in young and active patients‎.

The Inter- and Intra-observer Reliability of Three Methods for Evaluating Carpal Collapse

Background: Kienbock’s disease is a rare and debilitating condition. The decision for surgical intervention majorly depends on the extent of the carpal collapse. Therefore, the accurate measurement of carpal collapse is of critical importance. Objectives: The current study assessed the inter and intra-observer reliability of the three most frequent methods in measuring carpal height and determining carpal collapse. Methods: Fifty-Nine photocopied radiograms were reviewed by three observers (one senior orthopedic resident, one fellowship-trained hand surgeon, and one senior radiology resident) at 3 consecutive time points. Besides, one-week intervals were considered between the evaluations. The evaluated measures included the Carpal Height Ratio (CHR), Revised Carpal Height Ratio (RCHR), and Capitate-Radius (CR) index. The reliability of the measurements in determining the carpal height was examined using the Intraclass Correlation Coefficient (ICC). The agreement of the measures on determining the presence or absence of the carpal collapse was assessed by Cohen’s Kappa (K) value. Results: The overall inter and intra-observer reliability of the CR index in quantifying the carpal collapse was measured as 0.863 and 0.942, respectively. The overall inter and intra-observer reliability of CHR in quantifying the carpal collapse was computed to be 0.615 and 0.891, respectively. The overall inter and intra-observer reliability of RCHR in quantifying the carpal collapse equaled 0.412 and 0.792, respectively. The overall K for determining the presence or absence of a carpal collapse was calculated as 0.776, 0.683, and 0.549 for CR index, CHR, and RCHR, respectively. Conclusion: The CR index is the most reliable approach to measure carpal height. Furthermore, it is appropriate for determining the presence or absence of carpal collapse.

Knee Muscle Activity During Jump Landing Tasks Following Anterior Cruciate Ligament Reconstruction: A Review Study

Background: Changes in knee muscle activity remain years after Anterior Cruciate Ligament (ACL) surgery. However, the literature on the successful or unsuccessful recovery of lower limb muscle activation during jump landing is controversial. Objectives: The present review intended to compare the surface Electromyography (EMG) of knee muscle activity in healthy and Anterior Cruciate Ligament Reconstruction (ACLR) groups in jump landing tasks. Methods: PubMed, Embase, and Web of Science databases were searched papers from 1990 to 2020 using the keywords “anterior cruciate ligament or ACL, EMG or Electromyography or Muscle activation, Landing or Jumping or Hopping”. After screening the titles, abstracts, and full text of the collected articles, 7 studies met the inclusion criteria of this review. The Critical Appraisal Skills Program tool was used for the quality assessment of the included papers. Results: The present research results suggested earlier onset muscle activity for quadriceps and hamstring in ACLR subjects, compared to healthy subjects. Furthermore, the ratio of activation of quadriceps/hamstring in the ACLR group was higher than that in the healthy individuals considering the type of rehabilitation, the time elapsed from surgery, and gender. The methodological quality of the observational studies ranged from 6 to 8 out of 12 that reflects the overall quality of the methodology. Conclusion: According to this review, we can conclude that the ACLR group exhibited different neuromuscular strategies in the pre-landing phase that might increase the recurrent risk of ACL injury.

Hyperlordosis Secondary to Myasthenia Gravis Successfully Treated With Brace-wearing and Lordosis Exercises: A Case Report

Spinal deformities secondary to Myasthenia Gravis (MG) are rarely reported and mainly include scoliosis. In this study, we report a case of hyperlordosis with MG origin, which has not been reported earlier. The patient was a 12-year-old boy who underwent thymectomy at the age of three, and the disease was well-controlled afterward. One year ago, the patient presented with fatigue and severe low back pain associated with walking, while his parents noticed his buttocks jut out more than normal. The radiologic evaluation revealed a hyperlordosis of 100º. The patient was treated with a Milwaukee brace and lordosis exercises. One year after the treatment, an improvement of 27º was observed in the hyperlordosis of the patient. While bracing does not typically treat a neuromuscular deformity, the present case reveals the value of bracing in the treatment of hyperlordosis with MG origin.‎

Scapholunate Instability Following the Surgical Excision of Dorsal Ganglion Cyst of the Wrist: A Case Report

Ganglion cysts of the dorsal wrist are generally attached to the scapholunate interosseous ligament, and surgical removal could injure this ligament. Such injury could rarely result in postoperative scapholunate instability. To date, a few cases of scapholunate instability following the excision of the dorsal ganglion cyst of the wrist have been reported. In this report, we present a 23-year-old man with scapholunate instability following the surgical resection of the dorsal ganglion cyst of his wrist. The instability was treated with open reduction and reconstruction. One year follow-up of the patient was event-free. The patient had no pain and limitation and resumed his preoperative activities. According to this case, the iatrogenic or pre-existing nature of scapholunate instability following the surgical excision of the dorsal ganglion cyst of the wrist‎‏ cannot be determined. However, the patients should be informed of this complication before undergoing surgery.

Evaluation of Recurrence Rate and Risk Factors Affecting Recurrence of Recurrent Shoulder Dislocation in Kashani Hospital in 2017-2018

Background: In this article, the prevalence of recurrent anterior dislocation of the shoulder and the effect of factors such as age, occupation, primary cause and gender on it have been investigated. Objectives: This study aimed to investigate the factors related to the frequency of recurrent anterior shoulder dislocation in clients of the Orthopedic Ward of Kashani Hospital, Isfahan City, Iran, in 2017-2018. Methods: The present research is a cross-sectional study. The study population comprised all patients with traumatic and anterior shoulder dislocation referred to Kashani Hospital during 2017-2018. The sampling method in the present study was census. The patients were asked by phone or in person after their presence about the recurrences of dislocations between the beginning of 2017 and the end of 2018. The obtained data were analyzed in SPSS version 25. Results: Out of 256 patients, 22% had a recurrence of dislocation. The recurrence rate of dislocation in less than 20 years patients was 40%, and in 20 to 40 years was 63%. The highest recurrence rate of dislocation was reported in the age group of 20 to 40 years in the present study. Based on the present study results, the recurrence rate of dislocation in the age-group of 20-40 years was significantly higher than in other groups. There was no significant relationship between gender and recurrence of dislocation in the subjects (P>0.05). Significance was observed in the primary cause and type of occupation in recurrence of dislocation (P<0.05). Conclusion: The recurrence rate of dislocation in the patients who suffered from dislocations for the first time was 22%. Based on the results, the rate of recurrence of dislocation in the present study was lower than the rate of recurrence of dislocation in similar studies.

Shoulder Disorders: The Challenging Issue Among Orthopedic Surgeons

Background: Choose a proper therapeutic approach for various shoulder joint involvements is still a significant challenge. Objectives: The study aimed to assess the knowledge and attitude of orthopedic surgeons in managing patients with shoulder problems. Methods: In a cross-sectional survey, a questionnaire consisted of 2 different parts was directly presented to orthopedic surgeons. Part 1 investigated the experience of shoulder surgeries, and part 2 evaluated their knowledge and attitude toward 4 patients with different scenarios. Results: The surgeons were divided into 2 groups: shoulder surgeons (n=17) and general orthopedic surgeons (n=192). The first scenario is about a 21-year-old male with first anterior shoulder dislocation. In this scenario, shoulder surgeons chose surgical intervention more than general surgeons (88.21% vs 33.54%, P<0.05). The second scenario presents a 55-year-old male with shoulder osteoarthritis and complete and repairable rupture of supraspinatus and rupture of the long head of the biceps tendon. Shoulder surgeons chose total shoulder arthroplasty (43.8%) and arthroscopic rotator cuff repair (37.5%). But, only 21.87% of general orthopedic surgeons choose these two items together. The third scenario is a 65-year-old male with supraspinatus and infraspinatus tendon rupture. Sixteen of 17 shoulder surgeons answered this case, and 100% chose surgical interventions (62.5% arthroscopic and 37.5% open repair). On the other hand, 180 general surgeons of 192 answered this case scenario, and only 41.11% chose surgical treatment. The fourth scenario presents a 52-year-old female with refractor adhesive capsulitis. Arthroscopic capsular release and manipulation was the most frequent answer among shoulder surgeons compared to general surgeons (64.71% vs 31.38%). Conclusion: It seems that an advanced course of shoulder surgeries is necessary to improve the knowledge of general orthopedic surgeons about shoulder diseases and treatment choices

Is Obesity a Risk Factor for Spinal Surgeries? A Retrospective Study in a Specialized Orthopedic Spine Center

Background: Various studies have shown the effects of morbid obesity on the adverse consequences of various surgeries, especially postoperative infections. However, some studies have shown that the complications of spinal surgery in obese and non-obese patients are not significantly different. Objectives: This study investigated and compared the duration of surgery, length of hospital stay, and complications after common spinal surgeries by orthopedic spine fellowship in obese and non-obese patients in a specialized spine center in Iran. Methods: All patients who underwent decompression with or without lumbar fusion were included in this retrospective study. These patients were classified into two groups: non-obese (BMI <30 kg/m2) and obese (BMI ≥30 kg/m2). The data related to type and levels of surgery, 30-day hospital complications, length of hospital stay, rate of postoperative wound infection, blood loss, and need for transfusion were all extracted and compared between the two groups. Results: A total of 148 patients (74%) were in the non-obese group and 52 patients (26%) in the obese group. The number of patients that need packed cells was significantly higher in the obese group (51.8% vs 32.6%) (P=0.01). Otherwise, there were not a significant difference between type of treatment (fusion or only decompression) (P=0.78), interbody fusion (P=0.26), osteotomy (P=0.56), duration of surgery (P=0.25), length of hospital stay (P=0.72), mean amount of blood loss (P=0.09), and postoperative complications (P=0.68) between the two groups. Conclusion: Our results suggest that duration of surgery, length of hospital stay, and postoperative complications are not associated with the BMI of the patients.

Investigating the Prevalence of Peripheral Neuropathy in Chemical Burns

Background: With the growing number and variety of chemical agents used in industry and for home purposes, chemical burns and their consequences have drawn physicians’ attention. Involvement of the nervous system that is a major consequence of systemic chemical exposure can be problematic in local chemical burns, as well. This study was designed to evaluate the peripheral nervous system in chemical burn victims. Objectives: Investigating the peripheral neuropathy prevalence in patients with chemical burn in a Burn Hospital, Shiraz. performing electrodiagnostic (EDX) study for all patients both on tibial and median nerve based on the reference data and in order to rule out polyneuropathy. Examining Motor nerve conduction velocities using standard procedures with concentric needle electrodes among all samples. Defining Peripheral neuropathies scored as mono- or polyneuropathy compared with the number of involved nerves. Methods: In this cross-sectional study, 59 patients with chemical burns were recruited from those referring to Shiraz Central Burn Hospital. The patients underwent a nerve conducting study besides electromyography in order to evaluate the tibial and median nerves after filling the informed consent. Also, a questionnaire covering the demographic data, the chemical agent responsible for the burn, and some other relevant information was given to each patient. The incidence of peripheral neuropathy and distance was calculated with a 95% incidence. Results: Twenty-three patients (38.9%) had peripheral neuropathy, of whom 19 cases (32.2%) had mono-neuropathy and 4 cases (6.78%) had poly-neuropathy. Axonotmesis was frequently found in patients with mono-neuropathy. The most frequent chemical agent responsible for burn was acid (56.4%). Hands were the most common site of burn (n=22 35.4%). We also evaluated the mean of total body burned surface area as 2.24±1.03% (1-9%). Conclusion: Based on our results, peripheral neuropathy has a high prevalence in localized chemical burns.