seyyed morteza kazemi

Tenosynovial giant cell tumor (TGCT) is a rare hyperplastic disease of the synovial membrane of the joint with a high recurrence rate and tumor-like features, affecting large joints such as the hip, knee, and ankle. Dull and chronic pain is common, as is swelling of the joint, which can make definitive diagnosis difficult. The gold standard of treatment is complete resection of the lesion. In this case report, we present a TGCT at the knee joint of an adult patient with nonspecific clinical presentation.

Case Report:

 We present a 33-year-old male patient who presented with chronic swelling, warm sensation, and limited range of motion (ROM) in the knee. He had no history of trauma and infectious disease had been ruled out. After several nonspecific orthopedic procedures and inadequate treatment of signs and symptoms, he was finally diagnosed with local TGCT.

To make the correct diagnosis, the unusual and somehow deceptive clinical presentation of TGCT must be considered.

Background and The tibial shaft fracture is the most common long bone fracture in children. This type of fracture has a high capacity for deformity correction, a process known as remodeling. In many circumstances, casting is the choice of treatment.

This study aims to investigate the rate of tibial fracture remodeling after 6 months of non-rigid fixation.

This research was a retrospective study conducted from March 2017 to March 2018. The study population included 74 children with tibial shaft fracture, treated with a long leg plaster under general anesthesia. Patients were evaluated by obtaining anteroposterior (AP) and lateral view x-rays in the first week, second week, 2 months, and 6 months after casting.

Seventy-four individuals were admitted with a diagnosis of tibial shaft fracture. A total number of 39 patients (52%)-13 girls and 26 boys- were treated with the long-leg casting under general anesthesia. The patients’ average age was 7.94±2.69 years (2-14 years). In the second week, four cases were excluded. Remodeling in the fracture site was significant in AP radiography at the end of the second month (P=0.044). Six-month follow-up showed that the remodeling in AP was significant (P=0.017) while in lateral was partially significant (P=0.05).

Due to the presence of the growth plate and a dense periosteum, remodeling of the tibial shaft fracture is extremely likely, and the remaining deformity is corrected over time by casting, and no surgical intervention is required. Level of evidence: IV

Immobility and limited usage of operated limbs lead to weakness and atrophy of the muscle after anterior cruciate ligament (ACL) reconstruction. However, training programs for preventing biomechanical risk factors such as lower limb alignment and increased muscular contraction are very limited. Thus, the current study was carried out to evaluate the recovery of quadriceps muscle strength and the improvement of knee function using adjuvant electromyographic biofeedback (EMG-BF) after ACL reconstruction.

This prospective randomized controlled trial was conducted among 40 patients (20 = EMG-BF group, 20 = Control group) with ACL reconstruction, who were referred to Akhtar Hospital from 2021 to 2022. In the EMG-BF group, EMG BFB was added to the standard rehabilitation protocol, and in the control group, the standard rehabilitation protocol with full postoperative weight-bearing, knee brace (zero degree of extension, 90 degrees of flexion), and electrical stimulation with maximal voluntary isometric knee extension was performed. Each group was intervened for 4 weeks and three sessions of 30 minutes per week. It should be noted that each patient participated in 16 outpatient physiotherapy sessions after surgery. Nicholas Hand-Held Dynamometer (HHD) was used for measuring quadriceps strength, and Knee Outcome Survey-Activities of Daily Living (KOS-ADLs) and Knee Outcome Survey Sports Activities Scale (KOS-SAS) questionnaires were used for assessing the knee function.

Four weeks after the treatment, the EMG-BF group showed a significant increase in quadriceps strength (P = 0.0001). Quadriceps strength had a significant difference before and after 4 weeks of intervention (P = 0.0001), but in the control group, no significant difference was observed (P = 0.368). The EMG-BF group had a significant increase in KOS-ADLs and KOS-SAS scores after 4 weeks of intervention (P = 0.0001).

In our study, isometric strengthening of quadriceps with adjuvant EMG-BF significantly increased the strength of quadriceps and knee function during 4 weeks. EMG-BF is a low risk, low cost, and less invasive intervention and has high safety and adjustment ability. It is a valuable adjuvant method for achieving better functional recovery in a shorter time.

In order to improve the efficacy of requesting knee radiography and reduce unnecessary radiation expo-sure, some clinical decision rules have been proposed for the assessment of knee injuries. Among them, the Ottawa KneeRule (OKR) was considered as one of the best guidelines with several validation studies. Therefore, in this meta-analysis,we aimed to investigate the accuracy of OKR for diagnosis of fracture in patients presenting with knee trauma.

A systematic search was conducted in PubMed, Web of Science, Scopus, Google Scholar, and EBSCO from inception toSeptember 2022. Quality assessment of the included studies was performed using QUADAS-2 tool. Diagnostic accuracyparameters were analyzed using random-effects model. Statistical analysis was performed using Meta-Disc and Statasoftwares.

The meta-analysis of the 18 included studies (6702 patients) showed that the pooled sensitivity andspecificity of OKR for diagnosis of fractures were 0.98 (95% CI: 0.96-0.99) and 0.43 (95% CI: 0.42-0.45), respectively. Thepooled positive likelihood ratio (PLR) and negative likelihood ratio (NLR) were 1.56 (95% CI: 1.39-1.75) and 0.12 (95%CI: 0.05-0.26), respectively. The area under curve (AUC) of the hierarchical summary receiver operating characteristic(HSROC) curve was 0.54.

This meta-analysis indicates that OKR has a high diagnostic performance fordiagnosis of fracture, with a pooled sensitivity of 98% and a pooled specificity of 43%. These results propose potentialeffects of OKR on reduction of unnecessary radiography, time spent in emergency departments, and direct and indirectcosts, which should be confirmed using high-quality studies in the future.

Polymethylmethacrylate (PMMA) has been extensively used as bone cement in orthopedic procedures. Pulmonary cement embolisms (PCEs) are supposed to originate from cement extravasation into the basivertebral veins before draining into the inferior vena cava and eventually becoming lodged in the pulmonary capillaries. Few cases of bone cement embolism have been reported. This study reported a case of pulmonary embolism (PE) after thoracolumbar fixation and kyphoplasty and reviewed the current literature.

Case Report: 

We presented an 81-year-old woman who had undergone thoracolumbar vertebroplasty three months before admission and became symptomatic due to PE after total knee arthroplasty (TKA).

This case illustrates that clinicians must be aware of the probable occurrence of respiratory distress syndrome in patients with a history of vertebroplasty.

Studies have proved that in addition to the inlet and outlet views, the intraoperative lateral sacral viewis required to ensure the correct entry point, reduce operating time, and lower radiation exposure. Considering thecomplex anatomy of the sacrum, we showed a safe corridor for sacroiliac joint (SIJ) screw insertion that was accessibleusing only inlet and outlet fluoroscopic views. From 2013 to 2020, we enrolled 215 patients who underwent percutaneous SIJ screw insertion. Ourexperience in SIJ screw insertion is presented using only two views (inlet and outlet). We reported on the radiationexposure time, operating time, rate of screw malposition, neurologic injury, and revision surgery. The screw malposition rate was 5.5%, including 11 foraminal perforations and one perforated anterior sacralcortex. Paresthesia after the surgery was observed in six patients (2.8%). No revision surgery or screw removal wasperformed. The radiation exposure and operation time for each screw were 21 ± 4.5 s and 13.5 min, respectively. The most anterior and the lowest part of the S1 vertebra can be easily found using intraoperative inletand outlet views. It is a safe corridor for SIJ screw insertion with low radiation time, neurologic injury, and revision rates.Level of evidence: IV

Balance is a perquisite for performance of daily activities ranging from maintenance of static postures to complex dynamic activities and is considered as a functional independence index. Besides routine rehabilitation techniques, neurofeedback is an almost novel used to enhance balance. The aim of this study is to review the current literature on the role of neurofeedback on balance rehabilitation with a comprehensive and critical approach.

The literature was searched for relevant papers published between 1995 and 2018 with the keywords of “postural control”, “balance”, “neurofeedback”, “cognition” and “attention” in PubMed, Scopus, Web of science,Google Scholar and Web of Knowledge databases. Among the 60 papers found during the initial search, 22 passed the inclusion and exclusion criteria and were further investigated.

The 22 included studies were categorized into two protocols of neurofeedback balance training with Beta wave reinforcement/ theta wave inhibition (18 studies) and sensorimotor wave reinforcement (4 studies). The studies had investigated the effect of neurofeedback balance training on balance, dual and manipulative tasks, gait parameters, concurrent working memory functions and attention processes.

The findings of this systematic review showed that neurofeedback is effective on balance improvement, dual task performance and attention. It might be considered as safe method besides other modalities in the management of balance and attentional disorders.

Low levels of 25-hydroxyvitamin D (25(OH)D) have been related to depression and anxiety. It seems that anemia is associated with vitamin D deficiency. We aimed to evaluate the effects of iron-vitamin D co-supplementation versus vitamin D alone on depression scores in anemic females with low levels of serum 25-hydroxyvitamin D.

This randomized controlled trial was conducted on eighty premenopausal females who were recruited between May 2015 and October 2015 from primary health care centers. Women with anemia and low concentrations of 25(OH)D were randomized to either 1000 IU/d vitamin D plus 27 mg/d iron (D-Fe) or vitamin D plus placebo supplements (D-P) for 12 weeks. Depressive and anxious symptoms were evaluated with the Beck Depression Inventory (BDI) with subscales 1–13 and 14–21 and Beck Anxiety Inventory (BAI). To compare the groups, Mann–Whitney or chi-squared tests were used and within groups comparison was performed using Wilcoxon signed ranks test. The study was registered on www.clinicaltrial.org as NC 01876563.

The serum concentrations of 25(OH)D were increased significantly in both groups at the end of the study. In both groups, there was a significant improvement in total BDI, the BDI subscale, and the BAI scores (p<0.001). No differences were found between groups (p>0.05).

Although the potential positive effect of vitamin D on mental health was evident, iron plus vitamin D co-supplementation did not demonstrate any significant benefits over vitamin D alone, neither in depression score reduction nor anxiety symptoms.

Due to the obvious differences in the natural course of rheumatoid arthritis (RA) and osteoarthritis (OA), different functional outcomes might be expected after Total Knee Arthroplasty (TKA) in these distinct patients. Although several studies have reported the objective outcome of TKA in RA and OA patients, few studies have compared postoperative patient-satisfaction levels. In this clinical cohort study 171 patients (RA: n=33, OA: n=138) who underwent TKA with posterior stabilizing knee prosthesis were included. The Knee Injury and Osteoarthritis Outcome Score (KOOS) and Oxford Knee Score (OKS) were used to evaluate and compare patients’ satisfaction 6 and 12 months after TKA relative to their preoperative state and to make an assessment between two groups. Both of patient-reported scoring systems showed a statistically significant improvement for OA and RA patients at 6 and 12 months after surgery, relative to their preoperative scores. The results of the OKS and KOOS did  not show statistically significant improvement from 6 to 12 months n RA patients. Unlike RA group, OKS and KOOS revealed further improvement between 6 and 12 months for the osteoarthritic patients. OA patients had continuous improvement in their satisfaction in the first year after TKA with a gentle upward curve. In contrast, in RA patients, recovery was faster and greater in the first six months after surgery and slowed down in the second six months. Patient-reported outcome scores were not significantly different between two groups at the end of the first year.

One of the common reasons for referral to healthcare centers are orthopedic injuries which may occur due to spontaneous pathologic injuries, traffic accidents, workplace injuries, and during exercise. This study aimed to determine the frequency, types and causes of orthopedic injuries refering to Akhatr teaching hospital in Tehran. In this study, records of all the patients presented to the emergency department of the Akhtar hospital in 2015 were reviewed. Data were collected by random completion of the "damage record questionnaire" by nurses. Data were analyzed using descriptive (frequency, mean and standard deviation) and inferential (Chi-square) statistics to evaluate the incidence rate of injuries and demographic characteristics of the participants and to compare the incidence rate of injuries in various body parts. Most injuries occurred in lower extremities, followed by upper extremities. In addition, there was a significant association between gender and cause of incidents (P<0.03). Moreover, a significant correlation was observed between gender and rate of injury in left (P<0.001) and right (P<0.049) lower extremities and also in the right (P<0.001) and left (P<0.001) upper extremities. Results demonstrated a higher rate of injury among men, compared to women. Furthermore, the ankle was the most commonly injured area in the lower extremities while the wrist was the most common area of injury in upper extremities. According to our results, the main cause of orthopedic injuries in the emergency department was traffic accidents (drivers, car occupants, and pedestrians), and the majority of patients were in the age range of 20- 40 years.

In the current study, we investigated that how sagittal femoral bowing can affect the sagittal alignment of the femoral component in total knee arthroplasty (TKA).
There were 25 patients underwent TKA. Long leg radiography in lateral view was performed. The sagittal femoral bowing (SFB) and component alignment in relation to the sagittal mechanical axis and distal anterior cortical line (DACL) were measured. Finally, the correlation of component alignment and SFB was examined.
Mean SFB was 7±2.7 degrees. The component was in flexion position in relation to mechanical axis and DACL as 8.4±2.9 degrees and 1.7±0.9 degrees, respectively. The flexion alignment of the component was significantly correlated with SFB.
Mechanical alignment of the limb in both coronal and sagittal axes should be preserved in TKA. SFB can significantly increased the flexion alignment of the femoral component.

Some studies have previously shown that geometry of proximal femur can affect the probability of fracture and type of fracture. It happens since the geometry of the proximal femur determines how a force is applied to its different parts. In this study, we have compared proximal femur’s geometric characteristics in femoral neck (FNF), intertrochanteric (ITF) and Subtrochanteric (STF) fractures.
In this study, 60 patients who had hip fractures were studied as case studies. They were divided into FNF, ITF and STF groups based on their fracture types (20 patients in each group). Patients were studied with x-ray radiography and CT scans. Radiological parameters including femoral neck length from lateral cortex to center of femoral head (FNL), diameter of femoral head (FHD), diameter of femoral neck (FND), femoral head neck offset (FHNO), neck-shaft angle (alpha), femoral neck anteversion (beta) were measured and compared in all three groups.
Amount of FNL was significantly higher in STF group compared to FNF (0.011) while ITF and STF as well as FNT and ITF did not show a significant different. Also, FND in FNF group was significantly lower than the other two groups, i.e. ITF and STF. In other cases there were no instances of significant statistical difference.
Hip geometry can be used to identify individuals who are at the risk of fracture with special pattern. Also, it is important to have more studies in different populations and more in men.

There are few studies comparing the biomechanical properties of angled blade plate and locking compression plates in supracondylar osteotomy. In the current randomized study, we prospectively compared the clinical and radiological outcomes of supracondylar osteotomy using these two plates. Forty patients with valgus knee malalignment were randomly assigned to two equal numbered groups: angled blade plate and locking compression plates. All of the patients underwent medial closing wedge supracondylar osteotomy and were followed for one year. Before and after the operation the valgus angle and mechanical lateral distal femoral angle were compared between groups. Also, the rate of complications were compared. After the operation, the mean valgus angle and mechanical lateral distal femoral angle improved significantly in the two groups (P<0.001). Although, the preoperative amount of the valgus angle and mechanical lateral distal femoral angle were the same, at the last visit the valgus angle (5.4±2.1 versus 3.1±1.8; P=0.032) and mechanical lateral distal femoral angle (87.6±2 versus 89.7±3.2; P=0.041) were significantly lower and higher in the angled blade plate group, respectively. Nonunion occurred in four patients (20%) in the locking compression plates group (P=0.35). Based on having a larger valgus angle and mechanical lateral distal femoral angle correction in the angled blade plate group and considerable rate of nonunion in the locking compression plate group, the authors recommend using the angled blade plate for fixation of medial closing wedge supracondylar osteotomy for patients with valgus malalignment. However, more long-term studies are required.

Brown tumor is an osteolytic lesion caused by excessive production of parathyroid hormone. We present a 20 year old man with symptoms of severe muscle weakness and multiple fractures of shoulder and hip that the Brown tumor was observed in most of his bones

''Suprascapular nerve block'' is a well known technique for treating chronic shoulder pain. Ultrasonography-guided nerve block is a new technique hoping to decrease the complications of inadvertent injection of drug into the vessels or nerve sheet by increasing the accuracy and efficacy of the injections. In a trial clinical study، 50 Patients suffering from chronic shoulder pain were divided randomly into two groups. In the first group، nerve block was applied under the ultrasonograpy guide; and in the second group using direct anatomic landmarks (Moore technique). Pain score was assessed using a visual analog scale (VAS) and shoulder function was evaluated by constant shoulder score (CSS) before the injection and after the block. The patients'' satisfaction rate and efficacy were also evaluated and compared between the two groups. There was no statistically significant difference between the two groups in pain or shoulder functional scores before the procedure (p≥. 05). One week after the nerve block، the first group revealed significantly improvement in pain score p=. 035). Although shoulder function improved in both groups، the difference was not significant. (p≥. 05). One month later، pain and shoulder functional scores showed better improvement in group one compared to group two (p=. 000). No complication occurred in either group. Ultrasonography-guided suprascapular nerve block has better outcome in pain score and shoulder function compared with ''blindly'' blocking the nerve.

Posterior tibial slope is the normal anteroposterior inclination of the tibia slope and plays an important role in the biomechanics of the knee and function of the cruciate ligaments. Posterior tibial slope angle varies in different populations and there is no report about its measurement in the Iranian population. The aim of this study was to investigate the normal posterior tibial slope in a teaching hospital in Tehran-Iran.

In a desreptive study 108 knees in 70 men and 38 female patients with no history of prior knee problem were evaluated by lateral knee rodiographs in a teaching hospital in Tehran-Iran. The average age in these cases was 38 years (23-60 years). These patients had refered because of recent knee trauma but no fracture or intra-articular derangement had been found. The angle of tibial slope was measured in all the cases and analyzed.

The mean slope angle was 9.4±1.8 degrees. There was no statistical relationship between age and gender and posterior tibial slope (p≥.05).

The normal posterior tibial slope angle in this Iranian population was different from other countries. It may be necessary to consider these differences in designing tibial and femoral components for knee arthroplasty.

Arthroscopic reconstruction of the anterior cruciate ligament is one the most common orthopaedic surgeries. There are scattered reports about the beneficial effects of post operative cox2-inhibitors administration on knee motion. The purpose of the current study was to determine the effects of cox-2 inhibitor on pain range of motion and weight bearing after arthroscopic reconstruction of the anterior cruciate ligament. In this clinical trial 70 patients who underwent arthroscopic reconstruction of the anterior cruciate ligament were assessed in a teaching hospital in Tehran-Iran. They were divided into case (cox2-inhibitor) and control groups. Postoperatively pain inflammation range of motion and ability for full weight bearing were measured. The mean of pain at the postoperative day 3 was 5.3±1.04 (visual analogs scale of 0 to 10) in the control and 3.3±0.71 in the case group. 29.6% of the patients in the control group and 82.8% in the case group were able to flex the knee more than 90° one week postoperatively. In the first week all of the patients in the case group and only 28.6% in the control group were able to walk without any assistive device. The post operative knee circumstances were 2.73±0.59 and l.61±0.92 centimeters smaller respectively in case and control groups. Statistical analysis showed significant differences between the two groups in the above measurements. Cox-2 inhibitor is effective in relieving pain; reducing the inflammation and accelerating the rehabilitation program after arthroscopic reconstruction of the anterior cruciate ligament.

The role of increased posterior tibial slope in rupture of the anterior cruciate ligament (ACL) is controversial. The purpose of current study was to determine the effect of posterior slope on the ACL injury.

In a case control study 61 consecutive cases with ACL injury who were candidates for reconstruction were compared with 61 persons with normal knees who were matched for age and sex over a 2-year period at a teaching hospital in Tehran Iran. The posterior tibial slope angles were measured on true lateral radiographs on all the cases. The measurement variations were analyzed between the two groups.

The mean posterior tibial slope was 9.4±1.8 degrees in controls and 12.3±4.4 in patients with ruptured ACL (p

Considering the increasing number of musculoskeletal disorders, insufficiency of current assessment tools, and successful reports about SMFA (short musculoskeletal function assessment) questionnaire in evaluating and assessing these disorders, this study was designed.

The original questionnaire was in English. At first, SMFA was translated to Farsi and then back to English. Then the questionnaire was evaluated for validity and reliability, regarding content validity, visual validity and concurrent validity. For concurrent validity, the SF-36 health survey which had been translated to Farsi and had been adapted to Iranian culture was used.

326 patients (56.77% male) with mean age of 51±16 years contributed in this study. The translation to Farsi and back to English was done successfully. The content validity was assessed by 20 orthopedic surgeons and was approved. Simplicity and clearance was evaluated by physicians and patients and was confirmed. Also visual validity was confirmed by the same group. Concurrent validity was 0.91 and in subscales was 0.89-0.93 (p<0.001). ‍

A reliable and valid Farsi version of the SMFA was developed. It will facilitate assessing functional performance within a large patient population and allows cross-cultural comparisons.

There are different conservative treatments for the osteoarthritis of the medial compartment of the knee and valgus bracing is considered as important one. The purpose of current study was to examine the efficacy of the brace unloading in changing floor reaction force. Ten patients with osteoarthritis in medial compartment of the knee contributed in this quasi-experimental study with and without using knee braces. The magnitude of the mediolateral vector of the ground reaction force and center of pressure displacement in mediolateral direction were measured by using a force plate system (Kistler Swiss). Statistical tests were used to analyze the data. The mean of displacement of center of pressure (COP) was 25 mm and 5 mm with and without brace respectively (p≥.05). The mean of mediolateral vector of the ground reaction force was 28.17 with and 22.45 without brace and there was no significant difference (p≥.05). In contrast there was a significant difference between the magnitudes of the mediolateral vector of the ground reaction force within pre-and post-brace situations (p=.000). Valgus bracing can reduce the magnitude of the mediolateral vector of the ground reaction force and displacement of the COP in the mediolateral direction. It might be concluded that this method can reduce the pain and instability and improve function in patients with osteoarthritis of the medial compartment of the knee.

The role of a mobile-bearing knee arthroplasty is still not clear. This study was designed to compare the mobile and fixed-bearing prosthesis.

In 30 knees a fixed-bearing and in 38 knees a mobile-bearing prosthesis was used. The results were compared using the "Knee Society Scoring System".

The mobile-bearing group of patients had an average age of 65 and 34 months average follow-up. The fixed-bearing group had an average age of 69 years and a mean follow-up of 30 months. The average knee score functional score and overall score in the mobile-bearing group rose from 29 45 73 to 64 67 128; and in the fixed-bearing group from 31.7 34 65.9 to 68 57 125 prospectively. The difference between two groups was not significant statistically.

Although in both groups the average knee scores increased after the operation there were however no significant difference between knee scores in the two types in short-term and no preference between two types of prosthesis.