Iranian Journal of Orthopedic Surgery

Abstract Intrathecal opioids, such as morphine and fentanyl, are increasingly being used as adjuncts to spinal anesthesia and improve the quality of pain relief during and after surgery. This review investigates the mechanisms, benefits, and side effects of using these opioids, particularly in the context of femoral surgeries. The pharmacokinetics of these agents, including their rapid distribution in cerebrospinal fluid and binding to spinal receptors, contribute to effective pain management but also carry risks such as respiratory depression and urinary retention. Additionally, the impact of hemodynamic changes in femoral surgery is reviewed, emphasizing the importance of carefully adjusting anesthetic regimens and close postoperative monitoring to minimize complications. Evidence suggests that intrathecal opioids may reduce the incidence of postoperative delirium and opioid consumption in elderly patients, although further research is needed to confirm their efficacy in various surgical settings. This review underscores the need for more research into multimodal pain control using intrathecal opioids.

Abstract In clinical photography a patient with a disease or a problem is presented. The aim of clinical photography is to provide accurate and precise information and the disease or problem is the main subject of the photography. The art of photography helps doctors and surgeons in education, scientific presentations, scientific publications, patient counseling, discussion among colleagues, and evaluation of pre and post treatments, treatment planning and medico-legal works. Acknowledge of some useful points help to a better implication of the art of photography in everyday practice.                     

Abstract Background: Knee dislocation, although a rare injury, is a severe injury which can endanger the limb viability or cause a significant impairment in the knee function. The purpose of this study was to evaluate the knee function and knee osteoarthritis in the patients who had sustained an acute traumatic knee dislocation . Methods: In a retrospective study, 19 consecutive patients with knee dislocation who were treated by different therapies were studied during 5 years in a teaching hospital in Urmia, Iran. Vascular injuries lead to amputation in 3 patients. The follow-up study was performed on the remaining 16 patients within 37±13 months. The patients were evaluated for knee stability, range of motion and the "Tegner-Lysholm" knee function scores. The development of knee osteoarthritis was classified according to Kellgren and Lawrence classification . Results: The knee function was excellent in one, good in 3, fair in 9, and poor in 3 cases. The younger patients and knees with wider range of motion had better "Tegner-Lysholm" scores. The knee scores had significant correlation with the severity in the class of dislocation. The time of surgical reconstruction, whether early or delayed, had no significant effect on the outcome. The mean knee range of motion for the 12 patients who were treated surgically was 120±15 degrees and for the 4 patients who were treated non-surgically was 115±28 degrees. There was a significant correlation between the "Tegner-Lysholm" scores and knee range of motion. Conclusions: Knee dislocation is a very severe complex trauma and normal knee functional outcome is not often achieved. The knees with the more extensive ligament injuries have less favorable outcomes. Younger patients and knees with larger range of motion had better functional outcomes.

Abstract Background: This study presents the distribution of ulnar variance among Iranian patients with Kienbock’s disease and a control group of normal adults of Iranian population. We evaluated the relationship between ulnar negative variance and Kienbock’s disease in our patients. Methods: This study included two groups. In the first group, we, retrospectively, reviewed our orthopaedic department clinic charts in two hospitals in Urmia-Iran, and collected the distribution of ulnar variances in 60 patients with Kienbock’s disease. The second group comprised the distribution of ulnar variances in 400 standard wrist radiographies of normal adult population. Comparisons were made between the findings of the two groups. Results: The mean ulnar variance of the Kienbock’s group was negative 1.1±1.7 and the mean ulnar variance of the general population was positive 0.7±1.5. The difference of the ulnar variance means was statistically significant (p < /i>=.027). There were 56 (14%) ulnar negative, 160 (40%) neutral and 184 (46%) ulnar positive variance in the control group and there was no correlation with age or sex. There was an association between ulnar negative variance and development of Kienbock’s disease in this study (p < /i>

Abstract Background: This study evaluated the long-term (>5 y) outcomes of radial shortening osteotomy and vascularized bone graft in Kienböck disease patients. Methods: In a retrospective study of 16 patients with early stage Kienböck disease, 9 patients with average follow-up of 6.4 years had radial shortening osteotomy (group 1), and 7 with average follow-up of 6.5 years had pedicled vascularized bone graft (group 2). The 2 groups were similar in age, sex, operated side, initial Lichtman stage, and follow-up duration. There were significant differences in ulnar variance between the 2 groups. At the last follow-up, the patients were evaluated for pain, wrist motion, grip strength, functional status, and radiographic assessment. The overall results were evaluated by Cooney wrist function score and Nakamura scoring system for Kienböck disease. Results: The 2 groups had no significant difference in pain, motion, grip strength, and radiologic assessment however, grip strength percentage was better in group 2. There was no significant difference between the radiographic changes of the 2 groups. In group I, 7 patients had satisfactory Nakamura scores, and 5 patients had satisfactory Cooney scores. All of the patients in group 2 had satisfactory Cooney and Nakamura scores.The difference in the mean Cooney wrist function score in the 2 groups was significant. The difference of Nakamura scores in the 2 groups was not significant. Conclusions: Both groups had reasonable long-term outcomes. We were unable to recognize a substantial clinical or radiological difference between the 2 surgical treatments in long-term outcome.

Abstract Background: Delivery of high quality services to the patients requires continuous refreshment with up-to-date information. This study was aimed at investigating the search behavior of Iranian orthopaedic surgeons in obtaining new information in their fields.Methods: During the 16th Annual Iranian Orthopaedic Association Meeting, questionnaires related to study were distributed among the participants. The questions were mainly related to: What source is commonly used for solving clinical problems? How often new journals of the field are utilized? What scientific route is used to increase personal information on subjects of specific interest? 178 orthopaedic surgeons completed the form.Results: The orthopaedic textbooks were the most common source on information used by the clinical problem cases. Orthopaedic seminars and conferences were the next common source followed by the journals. Direct one to one information seeking form colleagues were a very usual practice for specific clinical problem solving. 45% would use internet for new orthopaeic knowledge updating.Conclusion: Internet and online services are not commonly used for knowledge updating by the orthopaedic group that we studied.

Abstract Background: Anatomic attainment of anterior cruciate ligament (ACL) to the femoral notch is not quite easily visible due to the synovial covering. There is no information on femoral attachment of ACL in Iranian population. Our aim is to study the topography of this ligament in a group of fresh cadavers.Methods: Ten fresh cadavers that were all younger than 50 years of age and had no evidence of trauma to or surgery on their knees were chosen for the study. The knees were dissected and the presence or absence of double ACL strands was evaluated. The ligaments were then taken off the femur and insertion sites were carefully studied and documented by digital photography. The distances were measured using a ruler.Results: In 90º flexion with distal traction onto the ACL, the ligament was like a twisted interwoven cord. The twist would decrease by releasing the traction or decreasing the knee bent. Two separate bundles (antero-medial and postero-lateral) were identified in 7 cadavers. In the 3 remaining ones in gross inspection and without dissection one could not recognize two separate bundles in the ACL’s. The femoral attachment sites were curve, triangle or oblong. In cross-sectional, however, they were oblong.Conclusion: Anterior cruciate ligament could have both variable femoral attachment sites and also different bundle patterns in different individuals.

Abstract Four patients with the intra-articular bony avulsion of the deep finger flexor (FDP) were treated by open reduction and internal fixation with mini screw. They were examined for the tendon function, and range of motion of the distal interphalangeal (DIP) joint. The follow-up period was from 6 months to 60 months. DIP joint surface was involved in all the cases. Although the FDP function was restored, there was reduced range of motion in DIP joints in all the patients. Beside the restoration of FDP function, the condition of the DIP joint surface is another important factor which influences the prognosis and the treatment of FDP avulsion injuries.

Abstract Background: Treatment of femoral fractures in children sometimes requires open reduction and plate fixation. There is potential for complication in any type of fixation, leg length discrepancy being one of them. We are reporting the results of plate fixation, with special emphasis on limb length inequality problem.Materials: In a cross-sectional study, 42 patients at 6-12 years of age with femoral shaft fractures treated dynamic compression plate fixation were assessed for mal:::union:::, non:::union:::, infection, device failure, and limb length discrepancy in a mean follow-up of 26 months (18-60 months). Physical examination, serial X-rays and scanogram were used for assessment.Results: Out of the 42 cases, 32 (76.2%) were boys and the remaining 10(23.8%) were girls. Seven patients had comminuted fractures, 5 fractures were open Gustillo type 1. Twenty four were associated with polytrauma. The mean limb length discrepancy at the end of treatment was 1.17 centimeters (0.4-2.4 centimeters). There were no device failure, mal-:::union:::, or infection.Conclusion: Treatment of paediatric femoral shaft fracture with dynamic compression plating has minimal side effects and causes minimal, if any, inequality in the length of the femur.

Abstract How would you deal with a large bony piece which has vital value for stability and function, has fallen out of wound in an open fracture and is brought to you in a severely contaminated shape? How about a large bony fragment falling out of your hand onto the operating room floor during surgery?Can one take an osteochondral piece as an autologus composite graft out of a badly contaminated amputated limb. If yes, how one may prepare such a graft?There is scanty information in the literature on this subject. The following is an overview of the sporadic reported cases on such issues.

Abstract Posterior cruciate ligament (PCL) avulsion associated with traumatic posterior hip dislocation is extremely rare in children. It is therefore, easily missed. We are reporting such an occurrence in an 8 year old boy.

Abstract Background: We evaluated the short term results of reconstruction of anterior cruciate ligament ruptures using a four strand hamstring autograft and cross pin femoral fixation.Methods: In a cross-sectional study 24 patients (1 female, 23 males) with mean age of 25 years (20-34) with chronic ACL ruptures were studied in a hospital in Urmia. The patients were treated with a four-strand hamstring autograft, cross pin femoral fixation (transfix) and an interference srcrew on the tibial side. Eight patients received simultaneous treatment for meniscal pathology. Final evaluation was performed 9 months after surgery, using the Lysholm and tegner scales, radiographs and a simple arthrometer.Results: The Lysholm score was good or excellent in 22 petients, fair in one and poor in one patient. Mean Lysholm score was 85.9. Tegner activity scores demonstrated that 16 patients had moved at least one level up, and the remaining cases stayed at their pre-operative level. Arthrometer showed a significant decrease in anterior tibial translation. Two patients developed septic arthritis one of whom required graft, pin and screw removal. Because of graft harvest failure, hamstring graft was taken from the contra lateral side in 2 patients.Conclusions: Reconstruction of ACL using four-strand hamstring tendons and cross pin femoral fixation results in considerably high success rate in short term. Infection and graft harvest failure are the major complications.