Pain management in acute musculoskeletal injury: Effect of opioid vs nonopioid medications

BACKGROUND

The use of opioids for pain is linked to an increased risk of developing opioid use disorder, and has resulted in the emergence of the opioid crisis over the last few years.

AIM

The systematic review question is “How does the use of opioid medications in pain management, compared with non-opioid medications, affect pain intensity over the short, intermediate, and long-term in adults with acute traumatic pain?”.

METHODS

The protocol was prospectively registered on the International Prospective Register of Systematic Reviews: CRD42021279639. Medline and Google Scholar were electronically searched for controlled peer-reviewed studies published in full, with the PICO framework: P: Adult patients with traumatic injuries, I: Opioid medications, C: Non-opioid medications, O: A minimum clinically important difference (MCID) in pain.

RESULTS

After full-text screening, we included 14 studies in the qualitative synthesis. Of these 14 studies, 12 were randomized clinical trials (RCTs) and 2 were pseudo-RCTs with a total of 2347 patients enrolled. There was heterogeneity in both medication utilized and outcome in these studies; only two studies were homogeneous regarding the type of study conducted, the opioid used, its comparator, and the outcome explored. The MCID was evaluated in 8 studies, while in 6 studies, any measured pain reduction was considered as an outcome. In 11 cases, the setting of care was the Emergency Department; in 2 cases, care occurred out-of-hospital; and in one case, the setting was not well-specified. The included studies were found to have a low-moderate risk of bias.

CONCLUSION

Non-opioids can be considered an alternative to opioids for short-term pain management of acute musculoskeletal injury. Intravenous ketamine may cause more adverse events than other routes of administration.

Evolution of treatment options for juvenile idiopathic arthritis

A recent study published in World J Clin Cases addressed the optimal non-steroidal anti-inflammatory drugs (NSAIDs) for juvenile idiopathic arthritis (JIA). Herein, we outline the progress in drug therapy of JIA. NSAIDs have traditionally been the primary treatment for all forms of JIA. NSAIDs are symptom-relief medications, and well tolerated by patients. Additionally, the availability of selective NSAIDs further lower the gastrointestinal adverse reactions compared with traditional NSAIDs. Glucocorticoid is another kind of symptom-relief medications with potent anti-inflammatory effect. However, the frequent adverse events limit the clinical use. Both NSAIDs and glucocorticoid fail to ease or prevent joint damage, and the breakthrough comes along with the disease-modifying antirheumatic drugs (DMARDs). DMARDs can prevent disease progression and reduce joint destruction. Particularly, the emergence of biologic DMARDs (bDMARDs) has truly revolutionized the therapeutics of JIA, compared with conventional synthetic DMARDs. As a newly developed class of drugs, the places of most bDMARDs in the management of JIA remain to be well established. Nevertheless, the continuous evolution of bDMARDs raises hopes of improving long-term disease outcomes for JIA.

Investigating clubfoot in Saudi Arabia: Prevalence, factors, and future directions

This editorial discusses the significant findings and implications of the study conducted by Alomran et al. This retrospective study, soon to be published, provides valuable insights into the epidemiology of and risk factors associated with clubfoot in a specific Saudi population. By highlighting the study’s key outcomes and discussing its broader implications for public health and clinical practices, this editorial aims to underscore the importance of continued research and targeted interventions in addressing congenital deformities such as clubfoot.

Conservative management of spinal pathology with autologous conditioned serum: A systematic review of the literature

BACKGROUND

Chronic inflammatory pain is associated with increased expression of interleukin (IL)-1, an inflammatory cytokine, and activity on its receptor (IL-1R). In response, the body produces IL-1R antagonist (IL-1Ra) to reduce this signaling. Autologous conditioned serum (ACS) is the only biologic therapy for spinal pathologies that enhances the action of endogenous IL-1Ra reserves to improve symptoms. This systematic review investigates the effectiveness of ACS in treating pain and disability caused by spinal pathologies.

AIM

To evaluate the use of ACS as a conservative management option for spinal pathology.

METHODS

A systematic review of PubMed/Medline was performed to identify studies investigating administration of ACS for treatment of any spinal pathology.

RESULTS

Six articles were included, comprising 684 patients treated with epidural (n = 133) or transforaminal (n = 551) ACS injections. Patients had an average age of 54.0 years with slight female predominance (53.2%). The lumbar spine was most commonly treated, with 567 patients (82.9%) receiving injections for lumbar radiculopathy (n = 67), degenerative disc disease (DDD) (n = 372), or spinal stenosis (n = 128); cervical injections were performed in 109 patients (15.9%). Mean (SD) follow-up was 21.7 (4.8) weeks from first ACS injection. All studies investigating mechanical lumbar and lumbar or cervical radicular pain reported significant pain reduction at final follow-up compared to baseline. ACS achieved comparable or superior results to lumbar epidural steroid injections. Adverse events were reported in 21 patients (3.1%), with no serious adverse events.

CONCLUSION

ACS injection is a safe and effective intervention for pain reduction in many spinal pathologies, including cervical and lumbar radiculopathies.

Platelet-rich plasma for de Quervain’s tenosynovitis: A systematic review and meta-analysis

BACKGROUND

Platelet-rich plasma (PRP) injection is used as an alternative non-operative management for de Quervain’s tenosynovitis (DQT) to regenerate tendon healing.

AIM

To assess and conclude the research-based study systematically to analyse the efficacy of PRP on DQT.

METHODS

This systematic review used the Cochrane Handbook for Systematic Reviews and the guideline of preferred reporting items for systematic review and meta-analysis. A systematic literature search was applied to 11 databases. The authors assessed the study quality and risk of bias of each included study. Results of the meta-analysis were presented using mean difference (MD)/standardized mean difference (SMD) and 95% confidence interval (CI).

RESULTS

The authors evaluated 275 studies found in the literature search; 12 studies met the criteria for this review, and then the study quality and risk of bias were assessed. Pooled analysis of data from two studies involving 194 subjects with DQT showed that, compared with conservative treatment, PRP injection was associated with a greater reduction in visual analog scale pain in one month and six months after treatment (MD: -0.67, P value < 0.00001; MD: -1.16, P value < 0.00001) and the increase of Mayo’s wrist score in one month and six months after treatment (SMD: 3.72, P value < 0.00001; SMD: 4.44, P value < 0.00001).

CONCLUSION

PRP can be used as an alternative non-operative treatment for DQT due to the tissue regenerative effect of PRP.

Pediatric flexible flatfoot: Does obesity influence the outcomes of arthroereisis?

BACKGROUND

Childhood obesity has emerged in the last decades as an important public health problem worldwide. Although relationships between obesity and flatfoot have been shown, no studies have investigated the influence of obesity on arthroereisis outcomes.

AIM

To evaluate correlations between childhood overweight/obesity and clinical and radiographic outcomes after subtalar arthroereisis with self-locking implants.

METHODS

This retrospective study included one hundred and sixty-nine pediatric patients (10-14 years old) who underwent subtalar arthroereisis (PEEK PitStop^® device) for severe flexible flatfoot. Exclusion criteria were additional procedures, revision of previous corrective surgeries, rigid flatfoot with severe deformity, and neurological or post-traumatic flatfoot. Preoperative/postoperative European Foot and Ankle Society (EFAS) and visual analogue scale (VAS) scores were determined; radiographic assessment was conducted on weight-bearing foot X-rays: Kite angle, first metatarsal-talus angle, Meary angle, calcaneal pitch angle and lateral talo-calcaneal angle were analyzed.

RESULTS

EFAS and VAS scores improved post-operatively in the whole population. Only seven cases with complications were reported. Radiographic assessment revealed an improvement in all angles. Statistical analysis demonstrated that the impact of obesity was significant on arthroereisis outcomes: Relationships were reported between BMI and postoperative EFAS/VAS scores, postoperative calcaneal pitch angle, Kite angle, Meary angle and talo-first metatarsal angle.

CONCLUSION

Although arthroereisis represents a very effective and valid treatment for flatfoot both in normal weight and obese children, obesity significantly influences clinical and radiographic outcomes of arthroereisis, and obese children tend to perceive more pain and discomfort.

Impacts of radiation therapy on quality of life and pain relief in patients with bone metastases

Bone metastases (BM) are a common complication in advanced cancer patients, significantly contributing to morbidity and mortality due to their ability to cause pain, fractures, and spinal cord compression. Radiation therapy (RT) is vital in managing these complications by targeting metastatic lesions to ease pain, improve mobility, and reduce the risk of skeletal-related events such as fractures. Evidence supports the effectiveness of RT in pain relief, showing its ability to provide significant palliation and lessen the need for opioid painkillers, thereby enhancing the overall quality of life (QoL) for patients with BM. However, optimizing RT outcomes involves considerations such as the choice of radiation technique, dose fractionation schedules, and the integration of supportive care measures to mitigate treatment-related side effects like fatigue and skin reactions. These factors highlight the importance of personalized treatment planning tailored to individual patient needs and tumor characteristics. This mini-review aims to provide comprehensive insights into the multifaceted impacts of RT on pain management and QoL enhancement in BM patients, with implications for refining clinical practices and advancing patient care through the synthesis of findings from various studies.

Choosing ankle tourniquets in foot and ankle surgery: Beyond postoperative pain considerations

This editorial critically explores the use of ankle vs thigh tourniquets in foot and ankle surgery based on a recent study that found no significant difference in postoperative pain between the two placement techniques. Despite these findings, we argue for the preferential use of ankle tourniquets, highlighting their potential benefits in reducing venous blood stasis and minimizing soft tissue injury. This approach underscores the importance of considering long-term patient outcomes and vascular health beyond immediate postoperative pain. By integrating study findings with broader clinical considerations, we hereby advocate for a nuanced approach to tourniquet use that prioritizes patient safety and long-term recovery in conjunction with immediate postoperative pain.

Lateral femoral neck stress fractures: A case report

BACKGROUND

Sport-induced injuries particularly affect young, healthy, and active individuals. Running, a popular and accessible sport, can cause a wide range of injuries, including stress fractures. Stress fractures can occur during high-intensity training or competitions, especially among well-trained amateurs and professional athletes. Adequate diagnosis can be complicated by the typically young age, unremarkable medical history, and vital condition of the patient. Stress fractures present insidiously, and this is specifically the case with stress fractures of the femoral neck. Timely intervention is crucial to prevent progressive displacement, as this can damage the blood supply to the femoral head.

CASE SUMMARY

A 30-year-old male runner presented to our outpatient clinic with persistent pain 3 weeks after running a marathon. X-ray showed a complete lateral fracture of the left femoral neck, which was treated surgically with a dynamic hip screw.

CONCLUSION

It is essential for healthcare providers to be vigilant for the subtle symptoms of stress fractures to ensure timely treatment. Early recognition prevents complication and leads to a better prognosis.

Intra-articular interventions in osteoarthritis: Navigating the landscape of hyaluronic acid, mesenchymal stem cells, and platelet-rich plasma

Osteoarthritis (OA) poses a substantial burden on patients, leading to pain, functional decline, and reduced quality of life. While conventional treatments focus on symptom management, disease-modifying interventions are yet to be established. This review explores the efficacy of intra-articular interventions, particularly hyaluronic acid (HA), mesenchymal stem cells (MSCs), and platelet-rich plasma (PRP), in the context of OA management. HA injections, with diverse formulations like Hylan G-F20, sodium hyaluronate, and hyaluronan, present varying outcomes, necessitating a nuanced understanding of their effectiveness and timing. MSC therapy, derived from adipose tissue, umbilical cord, or bone marrow, shows promising results in clinical improvement, with adipose-derived MSCs demonstrating efficacy in maintaining benefits over 6 mo. Conversely, bone-marrow-derived MSCs show limited effectiveness, highlighting the need for source-specific considerations. PRP has emerged as a superior option for long-term pain reduction and quality of life improvement, with leukocyte-poor formulations and a critical platelet count of 10 billion demonstrating optimal results. This comprehensive analysis underscores the potential of intra-articular interventions in OA management, emphasizing the need for personalized and evidence-based approaches to enhance treatment efficacy and patient outcomes.

Neglected congenital bilateral knee dislocation treated by quadricepsplasty with semitendinosus and sartorius transfer: A case report

BACKGROUND

Congenital knee dislocation (CKD) is a rare condition, which accounts for 1% of congenital hip dislocations. It can present as an isolated condition or coexist with other genetic disorders. Treatment options include serial casting, percutaneous quadriceps recession, and V-Y quadricepsplasty (VYQ). The pathogenesis and hereditary patterns of CKD are not fully understood, with most cases being familial. CKD is usually managed immediately after birth. However, in this report, the patient was neglected for 2 years.

CASE SUMMARY

A 2-year-old girl with bilateral CKD after birth presented to our hospital after failed serial casting; the patient had seizures and limited access to healthcare because of her family's low socioeconomic status. Her birth was noted for a breech presentation accompanied by oligohydramnios. The delivery took a long time, requiring immediate medical interventions. As an infant, she had chronic diseases, including a small patent ductus arteriole, multicystic dysplastic kidney disease, and epilepsy. She was found to have a bilateral knee dislocation of approximately -90° on hyperextension. A multidisciplinary team was involved, and medical care was optimized. She underwent VYQ plus semitendinosus and sartorius transfer. After four postoperative follow-ups, her knees were regaining mobility, and she could walk for 2-3 steps without assistance.

CONCLUSION

This report highlights the importance of early intervention and recommends extensive studies of the management in similar cases.

Blood metal concentrations and cardiac structure and function in total joint arthroplasty patients

BACKGROUND

There is concern regarding potential long-term cardiotoxicity with systemic distribution of metals in total joint arthroplasty (TJA) patients.

AIM

To determine the association of commonly used implant metals with echocardiographic measures in TJA patients.

METHODS

The study comprised 110 TJA patients who had a recent history of high chromium, cobalt or titanium concentrations. Patients underwent two-dimensional, three-dimensional, Doppler and speckle-strain transthoracic echocardiography and a blood draw to measure metal concentrations. Age and sex-adjusted linear and logistic regression models were used to examine the association of metal concentrations (exposure) with echocardiographic measures (outcome).

RESULTS

Higher cobalt concentrations were associated with increased left ventricular end-diastolic volume (estimate 5.09; 95%CI: 0.02-10.17) as well as left atrial and right ventricular dilation, particularly in men but no changes in cardiac function. Higher titanium concentrations were associated with a reduction in left ventricle global longitudinal strain (estimate 0.38; 95%CI: 0.70 to 0.06) and cardiac index (estimate 0.08; 95%CI, -0.15 to -0.01).

CONCLUSION

Elevated cobalt and titanium concentrations may be associated with structural and functional cardiac changes in some patients. Longitudinal studies are warranted to better understand the systemic effects of metals in TJA patients.

Three-dimensional analysis of age and sex differences in femoral head asphericity in asymptomatic hips in the United States

BACKGROUND

The sphericity of the femoral head is a metric used to evaluate hip pathologies and is associated with the development of osteoarthritis and femoral-acetabular impingement.

AIM

To analyze the three-dimensional asphericity of the femoral head of asymptomatic pediatric hips. We hypothesized that femoral head asphericity will vary significantly between male and female pediatric hips and increase with age in both sexes.

METHODS

Computed tomography scans were obtained on 158 children and adolescents from a single institution in the United States (8-18 years; 50% male) without hip pain. Proximal femoral measurements including the femoral head diameter, femoral head volume, residual volume, asphericity index, and local diameter difference were used to evaluate femoral head sphericity.

RESULTS

In both sexes, the residual volume increased by age (P < 0.05). Despite significantly smaller femoral head size in older ages (> 13 years) in females, there were no sex-differences in residual volume and aspherity index. There were no age-related changes in mean diameter difference in both sexes (P = 0.07) with no significant sex-differences across different age groups (P = 0.06). In contrast, there were significant increases in local aspherity (maximum diameter difference) across whole surface of the femoral head and all quadrants except the inferior regions in males (P = 0.03). There were no sex-differences in maximum diameter difference at any regions and age group (P > 0.05). Increased alpha angle was only correlated to increased mean diameter difference across overall surface of the femoral head (P = 0.024).

CONCLUSION

There is a substantial localized asphericity in asymptomatic hips which increases with age in. While 2D measured alpha angle can capture overall asphericity of the femoral head, it may not be sensitive enough to represent regional asphericity patterns.

Clinical effect of operative vs nonoperative treatment on humeral shaft fractures: Systematic review and meta-analysis of clinical trials

BACKGROUND

Whether operation is superior to non-operation for humeral shaft fracture remains debatable. We hypothesized that operation could decrease the nonunion and reintervention rates and increase the functional outcomes.

AIM

To compare the clinical efficacy between operative and nonoperative approaches for humeral shaft fractures.

METHODS

We searched the PubMed, Web of Science, ScienceDirect, and Cochrane databases from 1990 to December 2023 for clinical trials and cohort studies comparing the effects of operative and conservative methods on humeral shaft fractures. Two investigators independently extracted data from the eligible studies, and the other two assessed the methodological quality of each study. The quality of the included studies was assessed using the Cochrane risk bias or Newcastle-Ottawa Scale. The nonunion, reintervention and the overall complications and functional scores were pooled and analyzed using Review Manager software (version 5.3).

RESULTS

A total of four randomized control trials and 13 cohort studies were included, with 1285 and 1346 patients in the operative and nonoperative groups, respectively. Patients in the operative group were treated with a plate or nail, whereas those in the conservative group were managed with splint or functional bracing. Four studies were assessed as having a high risk of bias, and the other 13 were of a low risk of bias according to the Newcastle-Ottawa Scale or Cochrane risk bias tool. The operative group had a significantly decreased rate of nonunion [odds ratio (OR) 0.30; 95%CI: 0.23 to 0.40), reintervention (OR: 0.33; 95%CI: 0.24 to 0.47), and overall complications (OR: 0.62; 95%CI: 0.49 to 0.78)]. The pooled effect of the Disabilities of Arm, Shoulder, and Hand score showed a significant difference at 3 [mean difference (MD) -8.26; 95%CI: -13.60 to -2.92], 6 (MD: -6.72; 95%CI: -11.34 to -2.10), and 12 months (MD: -2.55; 95%CI: -4.36 to -0.74). The pooled effect of Visual Analog Scale scores and the Constant-Murley score did not significantly differ between the two groups.

CONCLUSION

This systematic review and meta-analysis revealed a trend of rapid functional recovery and decreased rates of nonunion and reintervention after operation for humeral shaft fracture compared to conservative treatment.

Readmission rate and early complications in patients undergoing total knee arthroplasty: A retrospective study

BACKGROUND

Total knee arthroplasty (TKA) can improve pain, quality of life, and functional outcomes. Although uncommon, postoperative complications are extremely consequential and thus must be carefully tracked and communicated to patients to assist their decision-making before surgery. Identification of the risk factors for complications and readmissions after TKA, taking into account common causes, temporal trends, and risk variables that can be changed or left unmodified, will benefit this process.

AIM

To assess readmission rates, early complications and their causes after TKA at 30 days and 90 days post-surgery.

METHODS

This was a prospective and retrospective study of 633 patients who underwent TKA at our hospital between January 1, 2017, and February 28, 2022. Of the 633 patients, 28 were not contactable, leaving 609 who met the inclusion criteria. Both inpatient and outpatient hospital records were retrieved, and observations were noted in the data collection forms.

RESULTS

Following TKA, the 30-day and 90-day readmission rates were determined to be 1.1% (n = 7) and 1.8% (n = 11), respectively. The unplanned visit rate at 30 days following TKA was 2.6% (n = 16) and at 90 days was 4.6% (n = 28). At 90 days, the unplanned readmission rate was 1.4% (n = 9). Reasons for readmissions included medical (27.2%, n = 3) and surgical (72.7%, n = 8). Unplanned readmissions and visits within 90 days of follow-up did not substantially differ by age group (P = 0.922), body mass index (BMI) (P = 0.633), unilateral vs bilateral TKA (P = 0.696), or patient comorbidity status (30-day P = 0.171 and 90-day P = 0.813). Reoperation rates after TKA were 0.66% (n = 4) at 30 days and 1.15% (n = 8) at 90 days. The average length of stay was 6.53 days.

CONCLUSION

In this study, there was a low readmission rate following TKA. There was no significant correlation between readmission rate and patient factors such as age, BMI, and co-morbidity status.

Offset restoration in total hip arthroplasty: Important: A current review

Normal vertical and horizontal offset is essential for hip biomechanics, muscle functioning and gait pattern. Total hip arthroplasty (THA) should aim to restore normal offset with implantation of femoral and acetabular components. This would be possible with proper preoperative planning, templating and ensuring implant options are available for offset restoration. Templating is essential for understanding the vertical and horizontal offset change, especially in hip arthritis presenting late with significant limb length discrepancy at THA. Planning should include appropriate soft tissue releases and the use of ideal implants to achieve restoration of horizontal and vertical offset. Under correction of horizontal offset at THA for fracture neck of femur could result in abductor fatigue, limp and increased wear. Restoration of horizontal offset is imperative at THA for a fractured neck of the femur to achieve optimal abductor function. Horizontal offset is necessary for optimal abductor muscle tension and function. Revision THA for acetabular bone loss would require hip center restoration with the acetabular and femoral offset correction to achieve limb length correction and abductor length. The inability to achieve vertical and horizontal offset correction could lead to dislocation or signs of abductor fatigue. Careful vertical and horizontal femur offset restoration is required for normal hip biomechanics, decreased wear and increased longevity.

Coronal plane stability of cruciate-retaining total knee arthroplasty in valgus gonarthrosis patients: A mid-term evaluation using stress radiographs

BACKGROUND

Total knee arthroplasty (TKA) using implants with a high level of constraint has generally been recommended for patients with osteoarthritis (OA) who have valgus alignment. However, studies have reported favorable outcomes even with cruciate-retaining (CR) implants.

AIM

To evaluate the coronal plane stability of CR-TKA in patients with valgus OA at the mid-term follow-up.

METHODS

Patients with primary valgus OA of the knee who underwent TKA from January 2014 to January 2021 were evaluated through stress radiography using a digital stress device with 100 N of force on both the medial and lateral side. Gap openings and degrees of angulation change were determined. Descriptive statistical analysis was performed for both continuous and categorical variables. Inter-rater reliability of the radiographic measurements was evaluated using Cronbach's alpha.

RESULTS

This study included 25 patients (28 knees) with a mean preoperative mechanical valgus axis of 11.3 (3.6-27.3) degrees. The mean follow-up duration was 3.4 (1.04-7.4) years. Stress radiographs showed a median varus and valgus gap opening of 1.6 (IQR 0.6-3.0) mm and 1.7 (IQR 1.3-2.3) mm and varus and valgus angulation changes of 2.5 (IQR 1.3-4.8) degrees and 2.3 (IQR 2.0-3.6) degrees, respectively. No clinical signs of instability, implant loosening, or revision due to instability were observed throughout this case series.

CONCLUSION

The present study demonstrated that using CR-TKA for patients with valgus OA of the knee promoted excellent coronal plane stability.

Total hip arthroplasty for sequelae of childhood hip disorders: Current review of management to achieve hip centre restoration

Adults requiring total hip arthroplasty (THA) for childhood disorder sequelae present with shortening, limp, pain, and altered gait. THA, which can be particularly challenging due to altered anatomy, requires careful planning, assessment, and computed tomography evaluation. Preoperative templating is essential to establish the appropriate acetabular and femoral size. Information regarding neck length and offset is needed to ensure the proper options are available at THA. Hip centre restoration must be planned preoperatively and achieved intraoperatively with appropriate exposure, identification, and stable fixation with optimum-size components. Identifying the actual acetabular floor is essential as changes include altered anatomy, distortion of the margins and version changes. Proximal femur changes include anatomical variation, decreased canal diameter, cortical thickness, changes in anteversion, and metaphyseal and diaphyseal mismatch. Preoperative assessment should consist of limb assessment for variations due to prior surgical procedures. Evaluation of the shortening pattern with the relationship of the lesser trochanter to the teardrop would help identify and plan for subtrochanteric shortening osteotomy, especially in high-riding hips. The surgical approach must ensure adequate exposure and soft tissue release to achieve restoration of the anatomical hip centre. The femoral components may require modularity to enable restoration of anteversion and optimum fixation.

Hemophagocytic lymphohistiocytosis triggered by relapsing polychondritis: A case report

BACKGROUND

Hemophagocytic lymphohistiocytosis (HLH) is a rare, life-threatening disorder caused by abnormal histiocytes and T cell activation. In adults, it is predominantly associated with infections, cancers, and autoimmune diseases. Relapsing polychondritis (RP), another rare disease, is diagnosed based on symptoms without specific tests, featuring cartilage inflammation characterized by swelling, redness, and pain, rarely inducing HLH.

CASE SUMMARY

A 74-year-old woman visited the emergency room with a fever of 38.6 °C. Blood tests, cultures, and imaging were performed to evaluate fever. Results showed increased fluorescent antinuclear antibody levels and mild cytopenia, with no other specific findings. Imaging revealed lymph node enlargement was observed; however, biopsy results were inconclusive. Upon re-evaluation of the physical exam, inflammatory signs suggestive of RP were observed in the ears and nose, prompting a tissue biopsy for confirmation. Simultaneously, persistent fever accompanied by cytopenia prompted a bone marrow examination, revealing hemophagocytic cells. After finding no significant results in blood culture, viral markers, and tissue examination of enlarged lymph nodes, HLH was diagnosed by RP. Treatment involved methylprednisolone followed by azathioprine. After two months, bone marrow examination confirmed resolution of hemophagocytosis, with normalization of hyperferritinemia and pancytopenia.

CONCLUSION

Thorough physical examination enabled diagnosis and treatment of HLH triggered by RP in patients presenting with fever of unknown origin.

Native and prosthetic septic arthritis in a university hospital in Saudi Arabia: A retrospective study

BACKGROUND

Septic arthritis, whether native or prosthetic, poses a significant challenge in clinical practice due to its potentially devastating consequences. Despite its clinical importance, there remains a dearth of comprehensive studies and standardized diagnostic criteria, particularly in the Kingdom of Saudi Arabia.

AIM

To investigate the epidemiology, microbiological profiles, and clinical characteristics of native and prosthetic septic joints in the Saudi Arabian population.

METHODS

Medical records of patients diagnosed with septic arthritis between January 1, 2015, and December 31, 2022, were retrospectively reviewed. Data regarding patient demographics, clinical presentation, microbiological cultures, treatment modalities, and outcomes were analyzed.

RESULTS

In a retrospective review of 52 cases of septic arthritis, a balanced gender distribution was observed (1:1 ratio), with the knee being the most commonly affected joint (80.8%). Methicillin-resistant Staphylococcus aureus predominated in native joints (24.2%), while Brucella spp. was more prevalent in prosthetic joints (21.1%). Joint preservation was achieved in most cases (84.6%), with no significant difference in clinical features between native and prosthetic joints. However, certain comorbidities were more common in native joint cases, including renal impairment (P = 0.002), hemodialysis (P = 0.004), heart disease (P = 0.013), and chronic liver disease (P = 0.048). At the same time, osteoarthritis was more prevalent in prosthetic joint cases (P = 0.013). Vancomycin was the most frequently used antibiotic (26.9%), and most patients received antibiotics before joint aspiration (57.7%). Surgical intervention, predominantly arthrotomy, was required in most cases (32.7%). Notably, a significant association was found between joint type and mortality (odds ratio = 0.587, P = 0.048), as well as the Charlson comorbidity index and mortality (P = 0.001).

CONCLUSION

This study highlighted distinctive microbiological profiles and etiological factors in septic arthritis cases in the Saudi Arabian population.

Comparative efficacy of proximal femoral nail vs dynamic condylar screw in treating unstable intertrochanteric fractures

BACKGROUND

Among the most frequent hip fractures are trochanteric fractures, which usually occur from low-energy trauma like minor falls, especially in older people with osteoporotic bones.

AIM

To evaluate the treatment efficacy of dynamic condylar screws (DCS) and proximal femoral nails (PFN) for unstable intertrochanteric fractures.

METHODS

To find pertinent randomized controlled trials and retrospective observational studies comparing PFN with DCS for the management of unstable femoral intertrochanteric fractures, a thorough search was carried out. For research studies published between January 1996 and April 2024, PubMed, EMBASE, Scopus, Web of Science, Cochrane Library, and Google Scholar were all searched. The complete texts of the papers were retrieved, vetted, and independently examined by two investigators. Disputes were settled by consensus, and any disagreements that persisted were arbitrated by a third author.

RESULTS

This study included six articles, comprising a total of 173 patients. Compared to the DCS, the PFN had a shorter operation time [mean difference (MD): -41.7 min, 95% confidence interval (95%CI): -63.04 to -20.35, P = 0.0001], higher success rates with closed reduction techniques [risk ratio (RR): 34.05, 95%CI: 11.12-104.31, P < 0.00001], and required less intraoperative blood transfusion (MD: -1.4 units, 95%CI: -1.80 to -1.00, P < 0.00001). Additionally, the PFN showed shorter fracture union time (MD: -6.92 wk, 95%CI: -10.27 to -3.57, P < 0.0001) and a lower incidence of reoperation (RR: 0.37, 95%CI: 0.17-0.82, P = 0.01). However, there was no discernible variation regarding hospital stay, implant-related complications, and infections.

CONCLUSION

Compared to DCS, PFN offers shorter operative times, reduces the blood transfusions requirements, achieves higher closed reduction success, enables faster fracture healing, and lowers reoperation incidence.

Needle arthroscopic-assisted repair of tibio-fibular syndesmosis acute injury: A case report

BACKGROUND

Acute injuries to the tibiofibular syndesmosis, often associated with high ankle sprains or malleolar fractures, require precise diagnosis and treatment to prevent long-term complications. This case report explores the use of needle arthroscopy as a minimally invasive technique for the repair of tibiofibular syndesmosis injuries.

CASE SUMMARY

We report on a 40-year-old male patient who presented with a trimalleolar fracture and ankle subluxation following a high ankle sprain. Due to significant swelling and poor soft tissue quality, initial management involved external stabilization. Subsequently, needle arthroscopy was employed to assess and treat the tibiofibular syndesmosis injury. The procedure, performed under spinal anesthesia and fluoroscopic control, included nanoscopic evaluation of the ankle joint and reduction of the syndesmosis using a suture button. Follow-up assessments showed significant improvement in pain levels, range of motion, and functional scores. At 26 weeks post-procedure, the patient achieved full range of motion and pain-free status. Needle arthroscopy offers a promising alternative for the management of acute tibiofibular syndesmosis injuries, combining diagnostic and therapeutic capabilities with minimal invasiveness.

CONCLUSION

This technique may enhance clinical outcomes and reduce recovery times, warranting further investigation and integration into clinical practice.

Factors that influence the results of indirect decompression employing oblique lumbar interbody fusion

BACKGROUND

Indirect decompression is one of the potential benefits of anterior reconstruction in patients with spinal stenosis. On the other hand, the reported rate of revision surgery after indirect decompression highlights the necessity of working out prediction models for the radiographic results of indirect decompression with assessing their clinical relevance.

AIM

To assess factors that influence radiographic and clinical results of the indirect decompression in patients with stenosis of the lumbar spine.

METHODS

This study is a single-center cross-sectional evaluation of 80 consecutive patients (17 males and 63 females) with lumbar spinal stenosis combined with the instability of the lumbar spinal segment. Patients underwent single level or bisegmental spinal instrumentation employing oblique lumbar interbody fusion (OLIF) with percutaneous pedicle screw fixation. Radiographic results of the indirect decompression were assessed using computerized tomography, while MacNab scale was used to assess clinical results.

RESULTS

After indirect decompression employing anterior reconstruction using OLIF, the statistically significant increase in the disc space height, vertebral canal square, right and left lateral canal depth were detected (Р < 0.0001). The median (M) relative vertebral canal square increase came to М = 24.5% with 25%-75% quartile border (16.3%; 33.3%) if indirect decompression was achieved by restoration of the segment height. In patients with the reduction of the upper vertebrae slip, the median of the relative increase in vertebral canal square accounted for 49.5% with 25%-75% quartile border (2.35; 99.75). Six out of 80 patients (7.5%) presented with unsatisfactory results because of residual nerve root compression. The critical values for lateral recess depth and vertebral canal square that were associated with indirect decompression failure were 3 mm and 80 mm2 respectively.

CONCLUSION

Indirect decompression employing anterior reconstruction is achieved by the increase in disc height along the posterior boarder and reduction of the slipped vertebrae in patients with degenerative spondylolisthesis. Vertebral canal square below 80 mm2 and lateral recess depth less than 3 mm are associated with indirect decompression failures that require direct microsurgical decompression.

Anterior cruciate ligament reconstruction: Effect of graft tunnel position on early to mid-term clinical outcomes

BACKGROUND

Patient reported outcome measures (PROMs) can be used to assess knee function following anterior cruciate ligament (ACL) reconstruction. Intra-operatively, femoral and tibial tunnels are created to accommodate the new ACL graft. It is postulated that there is an optimum position and orientation of these tunnels and that outcomes from this procedure are affected by their position.

AIM

To evaluate the influence of graft tunnel position on early to mid-term clinical outcomes following ACL reconstruction.

METHODS

Six PROMs were collected following ACL reconstruction which included the Knee Injury and Osteoarthritis Outcome Score (KOOS), International Knee Documentation Committee, Lysholm, Tegner, EuroQol-5 Dimension-5 level, and Short Form 12-item Health Survey. A total of 8 radiological parameters were measured from post-operative X-rays relating to graft tunnel positions. This data was analysed to assess for any correlations between graft tunnel position and post-operative PROMs.

RESULTS

A total of 87 patients were included in the study with a mean post-operative follow-up of 2.3 years (range 1 to 7 years). Posterior position of tibial tunnel was associated with improved KOOS quality of life (rho = 0.43, P = 0.002) and EQ-5D VAS (rho = 0.36, P = 0.010). Anterior position of EndoButton femoral tunnel was associated with an improved EQ-5D index (rho = -0.38, P = 0.028). There were no other significant correlations between any of the other radiological parameters and PROM scores.

CONCLUSION

Overall, graft tunnel position had very little correlation with clinical outcomes following ACL reconstruction. A few (posterior) tibial tunnel and (anterior) EndoButton femoral tunnel measurements were associated with better PROMs.

Two-stage corrective operation for the treatment of pes cavovarus in patients with spina bifida

BACKGROUND

Pes cavovarus has an estimated incidence of 8%-17% in patients with spina bifida (SB). The majority of the current literature on surgical treatment of cavovarus feet in children and adolescents includes a variety of diagnoses. There are currently no case series describing a treatment algorithm for deformity correction in this specific patient population. The authors of this study present the results of a retrospective case series performed to assess the radiographic outcomes of two-stage corrective surgery in patients with SB.

AIM

To assess the radiographic outcomes of a staged operation consisting of radical plantar release followed by osteotomy for pes cavovarus in patients with SB.

METHODS

Retrospective chart review was performed on patients with SB with a diagnosis of pes cavovarus at a freestanding children's hospital who underwent surgical correction of the deformity. Patients were excluded for lack of two-stage corrective operation, nonambulatory status, lack of at least six months follow-up, and age > 18 years at the time of surgery. This resulted in a cohort of 19 patients. Radiographic analysis was performed on 11 feet that had a complete series of preoperative and postoperative weightbearing X-rays. Preoperative and postoperative radiographic outcome measurements were compared using a two-sample t-test.

RESULTS

Significant changes between the preoperative and postoperative measurements were seen in Meary's angle, the anteroposterior talo-first metatarsal (AP TMT1) angle, and the talonavicular coverage. Mean values of Meary's angle were 17.9 ± 13.1 preoperatively and 4.7 ± 10.3 postoperatively (P = 0.016). Mean AP TMT1 angle was 20.6 ± 15.1 preoperatively and 9.3 ± 5.5 postoperatively (P = 0.011). Mean talonavicular coverage values were -10.3 ± 9.6 preoperatively and -3.8 ± 10.1 postoperatively (P = 0.025).

CONCLUSION

The two-stage corrective procedure demonstrated efficacy in correcting cavovarus deformity in patients with SB. Providers should strongly consider employing the staged surgical algorithm presented in this manuscript for management of these patients.