Surgical outcome of distal tibia Salter Harris II fracture in osteopetrosis patient

INTRODUCTION

Osteopetrosis is a rare genetic disorder characterized by increased bone density. This condition is clinically manifested with a brittle intramedullary structure and reduced bone toughness, increasing the risk of fracture. A limited case has been reported on the management of physeal fracture in patients with osteopetrosis. The objective of this study is to report a rare osteopetrosis patient who sustains Salter-Harris II at the distal tibia with its long-term follow-up along with its literature review.

PRESENTATION OF CASE

We report a case of a four-year-old boy with an established a diagnosis of osteopetrosis brought by the parents to the emergency department after sustaining a fall while playing in the playground. Radiological examination revealed a Salter-Harris type II distal tibial fracture. The patient underwent closed reduction and fixation using the cannulated screw. 18-month postoperative patients have an uneventful healing.

DISCUSSION

Osteopetrosis is caused by impaired osteoclast function and differentiation, leading to impaired in remodelling. Salter-Harris type II distal tibial fracture can be treated by either closed reduction or open reduction. A closed reduction was performed successfully with cannulated screw in his patient.

CONCLUSION

There is a delayed union of fracture in osteopetrosis patient. This will increase the risk of displacement which will eventually resulted in growth disturbance. Delayed weight bearing and stable fixation is highly recommended.

Umbilical cord mesenchymal stem cells combined with secretome for treating congenital pseudarthrosis of the Tibia: a case series

INTRODUCTION

Most patients with congenital pseudoarthrosis of tibia (CPT) do not have promising outcomes despite multiple attempts using conventional surgeries. The combination of umbilical cord-derived mesenchymal stem cells and conditioned medium (secretome) contains major components pivotal for the enhancement of fracture healing. The purpose of this study was to address fracture healing in CPT cases that were treated using the combined implantation of umbilical-cord mesenchymal stem cells (UC-MSCs) and secretome.

MATERIALS AND METHODS

From 2016 to 2017, six patients with CPT who were treated by one senior pediatric orthopedic consultant at a single center (3 girls and 3 boys; mean age of 5.8 years) were included in this case series. A combined procedure including resection of hamartomatous fibrotic tissue, implantation of MSCs and secretome, and fixation using a locking plate and screws was performed. Patients were followed up for a mean of 29 months. Leg-length discrepancy, refracture rate, functional outcome, and radiological outcomes were assessed preoperatively, immediately postoperatively and at the final follow-up.

RESULT

Five out of 6 (83%) of the patients experienced primary union. One patient experienced refracture; however, 8 months later, after another implantation and reconstruction were performed, union eventually occurred. Significant functional improvement was achieved after at least 1 year of follow-up.

CONCLUSION

This case series suggests that the combination of secretome and UC-MSCs is a potential treatment for CPT, it highlights the efficacy of the combined procedure in treating CPT and in achieving satisfying results. A larger number of subjects and longer follow-up are required for further study.

Genetic Role in Recurrence of Idiopathic CTEV: A Systematic Review

Background

Congenital Talipes Equinovarus (CTEV) is a multitude of deformities involving equinus, varus, adductus, and cavus deformities. Clubfoot affects 1 in every 1000 infants born worldwide, with various incidences according to geographical areas. It has been previously hypothesized that the possible genetic role in Idiopathic CTEV (ICTEV) might have a treatment-resistant phenotype. However, the genetic involvement in recurrent ICTEV cases is yet to be determined.

Aim

To systematically review existing literature regarding the discovery of genetic involvement in recurrent ICTEV to date to further understand the etiology of relapse.

Methods

A comprehensive search was performed on medical databases, and the review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. A comprehensive search was performed on several medical databases: PubMed (MEDLINE), Scopus, the Cochrane Library, and European PMC on May 10, 2022. We included studies reporting patients with recurring idiopathic CTEV or CTEV of unknown cause after treatment, reporting whole-genetic sequencing, whole-exome sequencing, Polymerase Chain Reaction, or Western blot analysis as methods of genetic analysis (intervention) and providing results of idiopathic CTEV genetic involvement. Non-English studies, literature reviews, and irrelevant articles were excluded. Quality and risk of bias assessments were performed using Newcastle-Ottawa Quality Assessment Scale for non-randomized studies where appropriate. The authors discussed data extracted with the primary outcome of gene(s) frequency being reported of their involvement in recurrent ICTEV cases.

Results

Three pieces of literature were included in this review. Two studies analyzed the genetic involvement in CTEV occurrence, while one analyzed the protein types found.

Discussion

With included studies of less than five, we could not perform other forms of analysis apart from qualitatively.

Conclusion

The rarity of literature exploring the genetic etiology of recurrent ICTEV cases has been reflected in this systematic review, giving opportunities for future research.

Clinical Outcomes of Delayed Osteoarticular Tuberculosis: A Review of 30 Cases

Purpose

The lack of knowledge regarding osteoarticular tuberculosis (TB) cases in Indonesia leads to delayed and chronic conditions. This study aims to evaluate clinical outcomes of patients with osteoarticular TB.

Materials and Methods

Thirty osteoarticular cases were retrospectively analyzed, with a focus on non-immunocompromised patients without spine involvement. Chemotherapy length, operative treatment method, and infection recurrence were evaluated.

Results

The majority (60%) of patients were aged between 19 to 49 years. The most common complaint was painful swelling, particularly during physical activity. Weight-bearing joints, such as the hips, knees, and ankles, were the most affected. Laboratory results showed over half of the patients had anemia, 96% had elevated erythrocyte sedimentation rate (ESR), and 76% had elevated C-reactive protein (CRP) levels. Radiological findings varied, with lytic lesions, abscesses, and joint destruction observed. All patients presented with pathognomonic histological tubercle appearances, with caseous necrosis, lymphocytes, and Langhans giant cells present. Twenty-nine cases were treated with anti-TB drugs for 12 months, while one recurrent case received the drugs for 24 months. All patients underwent surgery to gain local infection control.

Conclusion

Osteoarticular TB is a common manifestation of extrapulmonary TB and must not be overlooked. Early detection of osteoarticular TB may prevent limb morbidity. Although anti-TB drugs are the primary treatment for osteoarticular TB, in some cases, surgery is required to establish a diagnosis and gain local infection control.

C75. Premature Coronary Artery Disease in Young Male Patient with Strong Family History

Background

Coronary artery disease (CAD) occurring in less than 45 years of age is termed as premature CAD (PCAD). Recent studies showed a prevalence of 4-10 % of PCAD. PCAD is associated with unfavorable outcomes for the patients and had a greater impact on the quality of life. Family History is the best method to explained complex interaction between shared risk factor.

Case Summary

A 37-years old male admitted to Saiful Anwar Hospital for further evaluation of anginal pain. The patient complains of recurrent chest pain since 5 months ago but still relieved by rest. The electrocardiogram showed Wellens Type B which is specific for critical stenosis of the left anterior descending artery (LAD). Then the patient undergoing DCA Ad Hoc. The implantation of a 46 mm DES at proximal until distal LAD was performed. The patient discharged after a day observation.

Discussion

The challenging point, in this case, was it happen at a young age with strong family history. There was positive family history of PCAD in 1st degree relative on her brother and mother, despite several risk factors were identified in this case consist of smoking, and dyslipidemia, which make CAD risk higher. Despite adequate control of risk factors, family screening is important to reveal subclinical atherosclerosis.

C75. Premature Coronary Artery Disease in Young Male Patient with Strong Family History

Background

Coronary artery disease (CAD) occurring in less than 45 years of age is termed as premature CAD (PCAD). Recent studies showed a prevalence of 4-10 % of PCAD. PCAD is associated with unfavorable outcomes for the patients and had a greater impact on the quality of life. Family History is the best method to explained complex interaction between shared risk factor.

Case Summary

A 37-years old male admitted to Saiful Anwar Hospital for further evaluation of anginal pain. The patient complains of recurrent chest pain since 5 months ago but still relieved by rest. The electrocardiogram showed Wellens Type B which is specific for critical stenosis of the left anterior descending artery (LAD). Then the patient undergoing DCA Ad Hoc. The implantation of a 46 mm DES at proximal until distal LAD was performed. The patient discharged after a day observation.

Discussion

The challenging point, in this case, was it happen at a young age with strong family history. There was positive family history of PCAD in 1st degree relative on her brother and mother, despite several risk factors were identified in this case consist of smoking, and dyslipidemia, which make CAD risk higher. Despite adequate control of risk factors, family screening is important to reveal subclinical atherosclerosis.

Prognostic value of myocardial injury biomarker in COVID-19: a systematic review and meta-analysis

Background

An accurate prognostic tool that can help with risk stratification at first admission is crucial in COVID-19 patients, as severe complications and mortality rate can be reduced with prompt treatment and close follow up. The myocardial injury biomarker, Troponin, is reported to be a potential predictor of mortality in COVID-19 cases.

Purpose

This study aims to investigate the utility of cardiac troponin level as a prognosis tool in COVID-19 patients.

Methods

On March 12th, 2021, data was collected from PMC, PubMed, Google Scholar, Science Direct, and Scopus, using combination of keywords associated with myocardial injury biomarker, Troponin, and its prognostic value for mortality in COVID-19 patients. Included publications are original clinical trials, limited to those with English manuscripts, and all were reviewed and evaluated by 5 authors to minimise bias. Inclusion criteria for studies are original clinical trials with a study population of adults (≥18 years old) patients with confirmed SARS-CoV-2 infection through PCR. The quality of each studies included was assessed using the Newcastle-Ottawa Scale (NOS) and data synthesis and statistical analysis were carried out using Review Manager software.

Results

A total of 19 studies consisting of 13,789 COVID-19 patients were included. All 19 studies were good quality according to the NOS. Studies found that myocardial injury, indicated by the elevation of its biomarker, Troponin, is a strong predictor of in-hospital mortality. Furthermore, elevated troponin level itself is an independent marker of mortality, regardless of its concomitant cardiac disease. Meta-analysis of 9 included studies revealed a significant association between elevated cardiac troponin levels and mortality (HR 4.13; 95% CI 3.42 - 5.00; P<0.001). Based on GRADE, the result of this systematic review and meta-analysis proved to be moderate in quality as there are no inconsistency and variability in results and there are no publication biases.

Conclusion

Cardiac troponin level is found to be a strong predictor of mortality in COVID-19 patients and therefore should be treated both as an evaluation for cardiac involvement and as an important prognostic marker. Patients with elevated troponin levels within admission should be closely monitored and given prompt treatment to decrease mortality.

Funding Acknowledgement

Type of funding sources: None. Forest plot figure

Spontaneous healing of a traumatic critical radius bone defect in adolescent: A rare case report

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Osteogenesis in fracture requires osteogenic cells, osteoconductive components, and osteoconductive scaffold.

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Intact periosteum and sufficient soft tissue perfusion could be biologically required.

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Pediatric patient with significant bone defect is able to heal the defect speontaneously.

Introduction and importance

Fracture with a critical bone loss is associated with a profound burden of disease impact. Although there are several options exist for its treatment, but still those reconstructive procedures are technically demanding, relatively expensive and sometimes the result is less than what was expected. The objective of this study is to report a rare case of spontaneous healing of a critical radial bone defect in an adolescent.

Case presentation

We reported a 15 year old boy with a segmental open fracture of left radius, open fracture of left distal shaft ulna and closed fracture of left intercondylar humerus. The middle fragment of a fractured radius was extruded out, pulled out and then thrown away by his parent. Debridement, open reduction, and internal fixation for ulna were performed as well as reposition and internal fixation for the intercondylar humerus fracture. The plan was to wait until the ulnar fracture and intercondylar fracture to heal without any sign of infection and proceed to overcome the radial critical bone defect. This case report had been reported in line with SCARE criteria. The patient showed up seven months later with solid union of the critical radius bone defect and fully functioning hand with only slight limitation in pronation.

Clinical discussion

Osteogenesis in fracture requires osteogenic cells, osteoinductive components, osteoconductive scaffold, and stability. Despite the fact that critical bone defect poses great challenge for its management, intact periosteum and sufficient soft tissue perfusion were able to provide those biologic requirements adequately for fracture healing and ensure spontaneous healing of a traumatic critical bone loss in adolescent without any reconstructive procedure.

Conclusion

Spontaneous healing in critical bone defect is possible, provided all the favorable factors present to support this phenomenon.

Effectiveness of granulocyte colony stimulating factor to enhance healing on delayed union fracture model Sprague-Dawley rat

INTRODUCTION

Delayed union is a problem that can occur after fracture healing. Many studies were conducted based on the diamond concept approach to solve the problem of delayed union. Granulocyte-colony stimulating factor (G-CSF) is one of the various substances known to have a positive role in healing skeletal tissue or adjuvant regeneration. This study was conducted to see the effect of G-CSF in affecting delayed union fracture healing.

MATERIALS AND METHOD

The experimental study was conducted by randomized posttest only control group design on 24 experimental animals Sprague-Dawley white rats that had experienced delayed union models. The study compared the treatment group injected with subcutaneous G-CSF with a control group and was divided into four groups (n = 6). Harvest and follow-up histomorphometry and immunohistochemistry were performed in the second week and in the fourth week the histomorphometry analysis consisted of the percentage of immature bone area, cartilage, and fibrous area. The semiquantitative evaluation of immunohistochemistry with the expression of BMP-2 through the immunoreactive score (IRS).

RESULT

In the evaluation of histomorphometry and immunohistochemical parameters, there were significantly more woven bone area (p = 0,015), less fibrosis area (p = 0,002) and higher BMP 2 expression (p = 0,004) in treatment group week four compared to control. .

CONCLUSION

G-CSF was shown to increase the speed of healing in Sprague-Dawley rats on delayed union models evaluated from histomorphometry and immunohistochemical aspects.

A rare case of septic arthritis of the knee caused by Salmonella typhi with preexisting typhoid fever in a healthy, immunocompetent child - A case report

Introduction

Septic arthritis is a rapid and progressive infection caused by invasion of bacteria into the synovial joint. Disease of the joint causedby Salmonella spp in healthy children is an unusual event, with an estimated incidence of 0.1 to 0.2% of septic arthritis cases among children. The incidence of knee septic arthritis caused by Salmonella typhi with preexisting typhoid fever is very rare.

Method

We reported a case of 2-years old boy with a history of saddle-type fever 2 weeks prior to right knee pain. Typhoid fever was confirmed by immunoassay test. Knee septic arthritis was established from clinical findings, increased CRP level, ultrasonography, and joint aspiration. Culture of the aspirate subsequently grew Salmonella typhi. This case report had been reported in line with SCARE criteria.

Result

Arthrotomy and debridement were immediately performed.Intravenous piperacillin tazobactam was given for 6 days and replaced by amoxicillin clavulanic acid after the culture and sensitivity test was available. Patient recovered completely 5 months post surgery and showed excellence result with normal range of knee joint motion.

Conclusion

This case report suggests that any episode of joint swelling following preexisting typhoid fever should arise the physician’s awareness toward the possibility of septic arthritis and warrant immediate as well as proper management.

Emergency orthopaedic surgery in the pandemic era: A case series at Cipto Mangunkusumo national tertiary hospital in Jakarta, Indonesia

INTRODUCTION

Every emergency surgery performed is aimed at saving lives; however, during COVID-19 pandemic, surgeries are often postponed. Many existing recommendations take into account postponing surgery during a pandemic. How these surgeries can lead to increasing infection rates has not been widely published. This study aims to investigate the relationship of emergency orthopaedic surgery and the incidence rate of COVID-19.

PRESENTATION OF CASE

This was a case series of 14 patients. The study was performed at the emergency department unit at a national tertiary hospital in Jakarta, Indonesia. A total of 14 patients underwent orthopaedic surgery in the emergency room of our institution. The mean age of the subjects was 40.07 ± 20.5 years. Twelve (85.7%) were male patients and 2 (14.3%) were female patients. The average duration of surgery was 125 minutes. The most used type of anaesthesia was general anaesthesia for 6 operations (50%). Patients were hospitalized for an average length of 4 days. Three patients had infiltrates found on plain x-ray examination, which required further examination to determine whether the cause was COVID-19 infection or not. There was no ground glass appearance (GGO) in the three patients in further follow-up examination.

CONCLUSIONS

We found that emergency orthopaedic surgery was not associated with increasing number of COVID-19 cases. Factors including duration of surgery, length of stay, types of anaesthesia and comorbidities were also not associated with COVID-19 cases in this study.

Does elective orthopaedic surgery in pandemic era increase risk of developing COVID-19? A combined analysis of retrospective and prospective study at Cipto Mangunkusumo Hospital, Jakarta, Indonesia

BACKGROUND

To date, no recommendations have been published on when and how to start again carrying out elective, non-urgent surgery on COVID-19-negative patients after the epidemic peak has been reached in a given country or region and the pressure on healthcare facilities, healthcare workers and resources has been released by so far that elective surgery procedures can be safely and ethically programmed again. This study aims to investigate whether elective orthopaedic surgery will increase the risk of developing COVID-19.

MATERIALS AND METHODS

This was a combined retrospective and prospective studies performed at a national tertiary hospital in Jakarta, Indonesia. Subjects were patients who underwent elective orthopaedic surgeries at our institution from April to May 2020. Those who were previously infected with COVID-19 from polymerase chain reaction (PCR) reverse transcriptase (RT) examination obtained via nasopharynx and oropharynx swab, as well as those who were reluctant to participate were excluded from the study.

RESULTS

A total of 35 subjects (mean age 32.89 ± 17.42) were recruited. Fifteen (42.9%) subjects were male, and 20 subjects (57.1%) were female. Mean duration of surgery was 240 min with the longest and shortest duration of 690 and 40 min, respectively. General anaesthesia was performed in the majority of cases in 18 surgeries (51.4%) with local anaesthesia as the least in 2 surgeries (5.7%). Length of stay of our study was 6 days of average. None of the patients developed symptoms suggestive of COVID-19 infection.

CONCLUSION

We found that elective orthopaedic surgery may not be associated with increased cases of COVID-19 cases. However, our study was limited by short duration of follow-up. Further studies are required in order to investigate the affect of undergoing elective surgery and the number of COVID-19 cases.

Various Surgical Treatment of Hemophilic Pseudotumor : A Case Series

BACKGROUND

Bleeding episodes in severe hemophilia may occur more frequently and spontaneously after mild trauma or daily activities. An inadequate treatment of that bleeding in hemophilia may result in pseudotumor, usually in the muscle adjacent to the bone. We reported haemophilic pseudotumor treated with various surgical interventions.

METHODS

This study was conducted inthe Department of Orthopaedic and Traumatology at a government hospital over a period of 7 years(2010 -2017). Patients Perioperative management was done in accordance with the Integrated Hemophilia Team of our institution protocol.Diagnosis and management planning of hemophilic pseudotumor was confirmed via Integrated HemophiliaTeam meeting. After the surgery, all patients were asked to come for routine follow up.

RESULTS

We reported six Haemophilia-A patients with pseudotumor in the pelvis, proximal femur and lower leg. One case in pelvic bone underwent hematoma evacuation, acetabular reconstruction using the Harrington procedure, and total hip arthroplasty.Two cases, a case in the proximal femur and another case in the distal fibula, were treated with amputation, other two cases, one was soft tissue psedotumor in the pelvic region and was treated by hematoma evacuation, and the remaining casewas managed with wide excision and followed by defect closure.

CONCLUSION

Surgery is a preferable treatment for pseudotumors that have been present for years.It's associated with the best outcomes especially when selected as the primary line ofwith preventable and manageable bleeding complication. As previously published by many authors, this paper confirms that surgical excision is the treatment of choice but should only be carried out in major hemophilia centers by a multidisciplinary surgical team.

Evaluation of bone marrow-derived mesenchymal stem cell quality from patients with congenital pseudoarthrosis of the tibia

Background

The treatment of congenital pseudoarthrosis of the tibia (CPT) remains challenging in pediatric orthopedics due to the difficulties in bone union, continuous angulation, joint stiffness, and severe limb length discrepancy. Mesenchymal stem cells (MSCs) therapy offers a complementary approach to improve the conventional surgical treatments. Although the autologous MSC treatment shows a promising strategy to promote bone healing in CPT patients, the quality of MSCs from CPT patients has not been well studied. The purpose of this study is to investigate the quality of MSCs isolated from patients with CPT.

Methods

The bone marrow-derived MSCs from the fracture site and iliac crest of six CPT patients were isolated and compared. The cumulative population doubling level (cPDL), phenotype characteristics, and trilineage differentiation potency were observed to assess the quality of both MSCs.

Results

There were no significant differences of the MSCs derived from the fracture site and the MSCs from the iliac crest of the subjects, in terms of cPDL, phenotype characteristics, and trilineage differentiation potency (all p > 0.05). However, MSCs from the fracture site had a higher senescence tendency than those from the iliac crest.

Conclusion

MSC quality is not the main reason for delayed bone regeneration in those with CPT. Thus, autologous MSC is a promising source for treating CPT patients

Breast Cancer Education and Screening in Indonesian Rural Community: A Programme Trial

Background and context: Breast cancer has the highest incidence and prevalence among cancers in Indonesia. Indonesian rural society has low level of breast cancer knowledge and self examination practice. Difficulty for accessing breast cancer primary health care screening also caused negligence. Furthermore, ignorance and economy situation made patients chose alternative treatments. Hence, most cases are detected at late stages, in which late diagnosis and treatment resulted in high mortality. Aim: Decrease breast cancer mortality by increasing breast cancer knowledge level, monthly self-examination practice awareness, and mass screening for early detection of breast cancer. Strategy/Tactics: In conjunction with National Cancer Control Committee event at 2017, we did a one day social occasion of education and early detection screening for breast cancer in Indonesia rural communities. Participants were gathered with mass announcement from primary health care workers. An expert brought an education class, then parallel screening rooms were provided for all participants. Program/Policy process: Phase one (2017) consists of establishing a good basic education and screening system. We gave free invitation to district health office to be distributed to a local primary health care and participate in a small education class brought by breast cancer specialist. Materials consist of basic knowledge and risk factors, self-examination awareness, diagnostic and treatment procedure, and referral process. Afterward, participants got breast physical exam screening by general clinicians. In phase two (2018), we added questionnaires to assess the effectiveness of education class in increasing knowledge level and self-practice awareness. An ultrasonography examination was added to narrow the diagnosis. Participants with higher risk factor or positive findings were given extra consultation. All participants were referred to our secondary referral General Hospital at Karawaci district, Tangerang, Banten, Indonesia. Outcomes: In 2017, 10% of participants had positive results and referred for further tests. In 2018, education class significantly increase knowledge and breast self-exam practice awareness. Moreover, ultrasonography examination narrowed positive diagnosis from 13% to 7%. What was learned: Education and early detection screening to primary health cares across Indonesia are needed to gather breast cancer cases at earliest stadium, hopefully could decrease breast cancer mortality. Feedbacks from participants showed that feeling of importance played important role and can only be developed internally after the disease became personal. Mobile mammography examination will help establishing breast cancer diagnosis. Budget is an issue, participants must be filtered beforehand based on risk factors for positive diagnostic results. A follow up and reminder system is needed to ensure participants follows proper management steps.