Archives of Bone and Joint Surgery
Volume:3 Issue: 1, Jan 2015

Doctor Shoja-ad-Din Sheikholeslamzadeh (also known as Dr. Sheikh) (1931-2014) was an outstanding orthopedic surgeon. He is credited for the establishment of the Iranian Association of Rehabilitation, Shafa Yahyaian Hospital as an Orthopedic and Rehabilitation Center, the Social Welfare Organization, Iran’s emergency dispatch center (115) and many other major projects that led to the upgrading of health care services in Iran. He also served as the Minister of Social Welfare and Minister of Health and Welfare before the Islamic revolution. The history of modern health care management and modern orthopedic surgery in Iran are indebted to the great leadership and executive abilities of Dr. Sheikh

There is controversy in the literature regarding a number of topics related to anterior cruciate ligament (ACL)reconstruction. The purpose of this article is to answer the following questions: 1) Bone patellar tendon bone (BPTB) reconstruction or hamstring reconstruction (HR); 2) Double bundle or single bundle; 3) Allograft or authograft; 4) Early or late reconstruction; 5) Rate of return to sports after ACL reconstruction; 6) Rate of osteoarthritis after ACL reconstruction. A Cochrane Library and PubMed (MEDLINE) search of systematic reviews and meta-analysis related to ACL reconstruction was performed. The key words were: ACL reconstruction, systematic reviews and meta-analysis. The main criteria for selection were that the articles were systematic reviews and meta-analysesfocused on the aforementioned questions. Sixty-nine articles were found, but only 26 were selected and reviewed because they had a high grade (I-II) of evidence. BPTB-R was associated with better postoperative knee stability but with a higher rate of morbidity. However, the results of both procedures in terms of functional outcome in the long-term were similar. The double-bundle ACL reconstruction technique showed better outcomes in rotational laxity, although functional recovery was similar between single-bundle and double-bundle. Autograft yielded better results than allograft. There was no difference between early and delayed reconstruction. 82% of patients were able to return to some kind of sport participation. 28% of patients presented radiological signs of osteoarthritis with a follow-up of minimum 10 years.

Elbow surgery is shared by several subspecialties. We were curious about the most common elbow surgeries and their corresponding diagnoses in the United States. We used the National Hospital Discharge Survey (NHDS) and the National Survey of Ambulatory Surgery (NSAS) data gathered in 2006-databases that together provide an estimate of all inpatient and ambulatory surgical care in the US. An estimated 150,000 elbow surgeries were performed in the US in 2006, 75% in an outpatient setting. The most frequent diagnosis treated operative was enthesopathy (e.g. lateral epicondylitis) and it was treated with several different procedures. More than three quarters of all elbow surgeries treated enthesopathy, cubital tunnel syndrome, or fracture (radial head in particular). Arthroscopy and arthroplasty accounted for less than 10% of all elbow surgeries. Elbow surgery in the United States primarily addresses enthesopathies such as tennis elbow, cubital tunnel syndrome, and trauma. It is notable that some of the most common elbow surgeries (those that address enthesopathy and radial head fracture) are some of the most variably utilized and debated.

Giant cell tumor of tendon sheath (GCTTS) is often thought of as a volar finger mass. We hypothesized that GCTTS are equally common on the dorsal and volar aspects of the hand. In addition, we hypothesized that there are no factors associated with the location (volar versus dorsal) and largest measured dimension of a GCTTS. A total of 126 patients with a pathological diagnosis of a GCTTS of the hand or finger were reviewed. Basic emographic and GCTTS specific information was obtained. Bivariable analyses were used to assess predicting factors for location (volar or dorsal side) and largest measured diameter of a GCTTS. Seventy-two tumors (57%) were on the volar side of the hand, 47 (37%) were dorsal, 6 (4.8%) were both dorsal and volar, and one was midaxial (0.79%). The most common site of a GCTTS was the index finger (30%). There were no factors significantly associated with the location (volar or dorsal, n=119) of the GCTTS. There were also no factors significantly associated with a larger diameter of a GCTTS. A GCTTS was more frequently seen on the volar aspect of the hand. No significant factors associated with the location or an increased size of a GCTTS were found in this study.

Modern knee designs have popularized its use in younger patients due to its better performance. There remains uncertainty whether higher demands of these patients can affect implant survivorship. To assess whether modern knee designs have provided similar results in patients younger than 70 years versus older patients. We included 203 consecutive patients (236 knees) who underwent knee replacement for osteoarthritis with a mean follow-up of 11.4 years (range: 8.8 to 12). The mean age was 70 years (range: 31 to 85). Knee replacements were stratified into two groups: 109 were younger than 70 years and 127 were older than 70 years (70 years of age is the mandatory retirement age). There were no significant pre-operative differences between groups with regards to knee alignment, alpha or beta angles, knee score or function score. Fourteen implants were radiographically loose at last follow up visit. Groups were matched in terms of demographic data. We found that patients older than 70 years had significantly better mean survivorship at 12 years. (97% vs. 88%; P=0.010). Patients under 70 years presented with a higher rate of polyethylene wear which was further associated with radiolucent lines in the femur and tibia as well as the presence of osteolysis. There was also an association between migration and presence of osteolysis. Patients over 70 years old undergoing cemented total knee replacement for osteoarthritis showed better implant survivorship versus patients under 70 years old.

Ligament reconstruction is a common procedure in orthopedic surgery. Although several popular techniques are currently in use, new methods are proposed for secure fixation of the tendon graft into the bone tunnel. We sought to introduce our new technique of Bashti bone plug for fixation of soft tissue graft in anterior cruciate ligament (ACL) reconstruction and to compare its biomechanical features with conventional absorbable interference screw technique in a bovine model. Twenty pairs of bovine knees were harvested after death. Soft tissue was removed and the Achilles tendon was harvested to be used as an ACL graft. It was secured into the bone tunnel on the tibial side via two different Bashti Bone Plug technique and conventional screw method. Biomechanical strength was measured using 200 N and 300 N cyclic loading on the graft. Pull out strength was also tested until the graft fails. No graft failure was observed after 200 N and 300 N cyclic loading in either fixation methods. When testing for pull out failure, 21 tendons (53%) were torn and 19 tendons (48%) slipped out. No fixation failure occurred, which did not reveal a significant difference between the bone plug or interference screw group (P=0.11). The mean pull out force until failure of the graft was 496±66 N in the screw group and 503±67 N in the bone plug group (P=0.76). Our suggested fixation technique of Bashti bone plug is a native, cheap, and feasible method that provides comparable biomechanical strength with interference screw when soft tissue fixation was attempted in bovine model.

Distal femur wedge osteotomies for varus or valgus alignment of the lower extremity could be done in either uniplanar or biplanar fashion.Union time and stability of the osteotomy site has been considered important in this anatomic region. In this study, clinical and radiographic findings of biplane distal femur osteotomy were reported. Clinical, functional, and radiological findings of eight patients (10 knees)underwent biplane distal femur osteotomy were evaluated. Visual analogue score (VAS) and Lysholm-Tegner knee score were used for the assessment of pain and function before and three months after surgery. In this study, eight patients were included. All patients were female. The mean age was 28±6.3. The mean pre-operativemechanical anglewas 8.7±2.2˚and the post-operativeangle was 1.4±0.53˚ in patients with valgus alignment whileit was 7.0±1.0˚preoperatively and 0.66±1.2˚ postoperatively in patients with varus alignment. The mean lateral distal femoral angle (LDFA)was 85±8.0˚ before surgery and was 88±1.3˚ after surgery. According to Lysholm- Tegner knee score, in the post-operative visit, sixknees were good and four were excellent. The mean union time was 9.2±2.3 weeks. Biplane distal femur osteotomy is a reliable technique that creates larger surfaces and more stability at the osteotomy site with further rapid union.

Primary bone lymphoma or non-Hodgkin lymphoma of bone is a rare disease. There are only a few case series of stage IE of this condition in medical literature. The aim of this study is to determine the rate of survival for stage IE after combined modality treatment, the rate of local recurrence, and the results of limb salvage in cases of local recurrence. We collected data from 61 patients with histologically confirmed PBL treated at the Musculoskeletal Oncology Department of our hospital from 2000 to 2010. Retrospective evaluation included demographics, symptoms, tumor locations, outcomes of surgical treatment for local recurrence and survival rates. All patients received Combined Modality Therapy. Overall,five year survival was 89% and five year disease free survival rate was 78%. Local recurrence occurred in 6 patients during follow up period, which was treated surgically by wide excision and reconstruction. The mean follow-up for the local recurrence group was 36(24-54) months and mortality rate in this group was 17%. Combined Modality Therapy for stage IE primary bone lymphomaresults in good survival rate. In case of local recurrence, wide excision and reconstruction improves the outcomes.

We aimed to develop and validate the Persian version of Short Form McGill Pain Questionnaire-2 (SF-MPQ-2) in patients with knee osteoarthritis. Translation and back translation was performed using Beaton’s guideline. After a consensus has achieved on the Persian version of SF-MPQ-2, it was administered to 30 patients with knee osteoarthritis in a pilot study. Then, we enrolled 100 patients with knee osteoarthritis to fill the final SF-MPQ-2 as well as SF-36 and WOMAC questionnaires. Forty-three patients returned 3 days after the initial visit to fill the Persian SF-MPQ-2 for the second time. Construct validity was tested by Pearson’s correlation coefficient between subscales of SF-MPQ-2 and subscales of SF-36 and WOMAC. Internal consistency for total and subscales was calculated by Cronbach’s alpha and reliability between test retest was performed using Intraclass correlation coefficient (ICC). ICC for subscales of SF-MPQ-2 ranged from 0.73 to 0.90. The ICC for total SF-MPQ-2 was 0.90. Cronbach’s alpha for subscales was 0.65-0.74 at the first visit and 0.58-0.81 at the second visit. Cronbach’s alpha for the total questionnaire was 0.88 and 0.91 at the first and second visit, respectively. Pearson’s correlation coefficient was highly significant when comparing subscales specifically with WOMAC (r=-0.47 to -0.61; P<0.001). Interscale correlation between subscales of SF-MPQ-2 was significant as well (r: 0.43-0.88, P<0.001). Persian SF-MPQ-2 showed excellent reliability and good to excellent internal consistency throughout the questionnaire. It is a valid and reliable instrument for measuring the pain intensity and applicable in osteoarthritic pain assessment.

In a retrospective descriptive study, medical records of 204 hip fractured patients with the age of 60 or older who were admitted to the Department of Orthopedics was considered regarding routine laboratory tests. Predictive values of these tests were assessed using receiver operating characteristic curve (ROC). The incidence of death due to hip fracture was 24%. The mortality rate was significantly increased with age > 65 (OR= 15). There was no significant difference between mortality in regards to gender. High plasma BUN (more than 20 mg/dl) and creatinine (more than 1.3 mg/dl) significantly increased the chance of mortality. [OR= 3.0 and OR=2.5 for BUN and creatinine, respectively]. Patients’ mortality did not show any correlation with sodium and potassium plasma levels and blood hemoglobin. There is direct correlation between plasma levels of BUN and creatinine and 3-month mortality after hip fractures. Patients with high plasma levels of BUN were three times more likely to die than those with normal BUN. Also, patients with high plasma creatinine levels were 2.5 times more likely to die than those who had normal values. Mortality was also associated with increasing age but did not vary with gender. Patients aging more than 65 were 15 times more likely to die following a hip fracture than those with younger age.

To test the psychometric properties of the Persian version of Zarit Burden Interview (ZBI-12) in the Iranian opulation. After translating and cultural adaptation of the questionnaire into Persian, 100 caregiver spouses of Iran-Iraq war (1980-88) veterans with chronic spinal cord injury who live in the city of Mashhad, Iran, invited to participate in the study. The Persian version of ZBI-12 accompanied with the Persian SF-36 was completed by the caregivers to test validity of the Persian ZBI-12.A Pearson`s correlation coefficient was calculated for validity testing.In order to assess reliability of the Persian ZBI-12, we administered the ZBI-12 randomly in 48 caregiver spouses again 3 days later. Generally, the internal consistency of the questionnaire was found to be strong (Cronbach’s alpha 0.77). Intercorrelationmatrix between the different domains of ZBI-12 at test-retest was 0.78. The results revealed that majority of questions the Persian ZBI_12 have a significant correlation to each other. In terms of validity, our results showed that there is significant correlations between some domains of the Persian version the Short Form Health Survey -36 with the Persian Zarit Burden Interview such as Q1 with Role Physical (P=0.03),General Health (P=0.034),Social Functional (0.037), Mental Health (0.023) and Q3 with Physical Function (P=0.001),Viltality (0.002), Socil Function (0.001). Our findings suggest that the Zarit Burden Interview Persian version is both a valid and reliable instrument for measuring the burden of caregivers of individuals with chronic spinal cord injury.

Fat embolism syndrome is a clinical diagnosis, and diagnostic procedures are not specific. In every trauma patient, Fat embolism syndrome has to be considered as a possibility and supportive treatment should begin as soon as possible. The authors reported a rare case of Fat embolism syndrome whose only neurological symptom was motor aphasia. A young man sustained comminuted femoral shaft fracture following an accident presented dyspnea, motor aphasia and petechial rash. The Po2 and O2 Saturation were 53 and 91.1%. The body temperature was 38.5 °C. The hemoglobin decreased from 12.9 to 8.7 and platelet from 121000 to 84000 mg/dl. The pulse rate was 120 bpm. The CT scan and MRI were normal. Fat embolism syndrome was diagnosed according to both Gurd and Schonfeld criteria ruling out other possible causes. Patient recovered completely. Although rare, focal neurological symptoms and motor aphasia should be kept in mind as a part of diagnostic criteria.

A 25 year-old man presented with pain, swelling, and intermittent drainage from distal lateral aspect of his left knee three months after undergoing isolated ACL reconstruction with arthroscopic hamstring autograft and endobottom technique. His surgeon at that time tried to eliminate the pathology through arthroscopic wash out in two attempts. However, the pain, edema, and discharge recurred after a year of being symptom free. The patient underwent imaging assessment and anteroposterior and lateral radiographs demonstrated a sclerotic area beneath the femoral condoyle in femoral tunnel and a fusiform sclerotic area in the lateral aspect of femoral midshaft. Magnetic Resonance Imaging revealed necrotic tissue with bone edema consistent with the sclerotic area in radiographs indicating micro abscesses and osteomyelitis. A diagnosis of femoral chronic osteomyelitis was made and the patient underwent arthroscopic drainage and washout, followed by open surgery for diaphysial femoral osteomyelitis. Rehabilitation was started and after six months the patient returned to his work.