Tehran University of Medical Sciences Journal of Orthopedic and Spine Trauma 2538-2330 2 3 2016 09 17 60 60 Mohammad Zarei Orthopedic Surgeon, Joint Reconstruction Research Center, Department of Orthopedic Surgery, Imam-Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran Seyyed Saeed Khabiri Resident of Orthopedic Surgery, Joint Reconstruction Research Center, Department of Orthopedic Surgery, Imam-Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran Ramin Espandar Orthopedic Surgeon, Joint Reconstruction Research Center, Department of Orthopedic Surgery, Imam-Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran Mahmoud Farzan Orthopedic Surgeon, Joint Reconstruction Research Center, Department of Orthopedic Surgery, Imam-Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran 2019 07 18 Introduction: Ewing sarcoma of bone represents the second most common primary malignant tumor of the bone in children and adolescents. The most common primary bony sites include the long bones, pelvis, chest wall, and spine. However, it is responsible for only 3% to 5% of cases in bones of the hands and feet. Case Presentation: The case was a 13-year-old girl, who attended our clinic with a complaint of 8 months of left ankle swelling and pain. Eight months earlier, she recalled an ankle torsion for which treatment was performed with long leg splint. Her pain was better, but, her swelling remained. The X ray showed a sclerotic lesion in the calcaneus with soft-tissue mass. Next, she underwent open biopsy, and was diagnosed with Ewing’s sarcoma. She underwent chemoradiotherapy and obtained below knee amputation. She was followed up at our clinic. Conclusions: There are a few articles about early diagnotic effects of Ewing's sarcoma prognosis. Therefore, this study aimed at presenting an anatomical-rare case of Ewing’s sarcoma as preliminary diagnosis could help the patient and lead to better outcomes. https://jost.tums.ac.ir/index.php/jost/article/view/60 https://jost.tums.ac.ir/index.php/jost/article/download/60/60

Tehran University of Medical Sciences Journal of Orthopedic and Spine Trauma 2538-2330 2 3 2016 09 19 98 98 Nima Bagheri Orthopedic Surgeon, Joint Reconstruction Research Center, Tehran University of Medical Sciences, Tehran, Iran Seyyed Saeed Khabiri Resident of Orthopedic Surgery, Joint Reconstruction Research Center, Tehran University of Medical Sciences, Tehran, Iran SM Javad Mortazavi Orthopedic Surgeon, Joint Reconstruction Research Center, Tehran University of Medical Sciences, Tehran, Iran Mahmoud Farzan Orthopedic Surgeon, Joint Reconstruction Research Center, Tehran University of Medical Sciences, Tehran, Iran 2019 07 18 Background: Fibular fractures are the most common associated fractures with tibia injuries. The current study aimed at collecting data on segmental fibular fractures in the patients and investigating the prognostic and functional significance of this injury pattern in outcomes. Methods: The charts were retrospectively reviewed from 2013 to 2016 to find patients with segmental fibular fractures. Patients’ history, physical examinations, initial radiographic findings, surgical reports, and follow-up data were evaluated. The patients were also assessed for union status, infection, limb shortening, and complications. Fractures were defined as segmental when the bone was disrupted in 2 points and a segment of bone with circumferential cortices was apart from the main bone proximally and distally. Results: During the 3-year period of the current study, out of 212 patients with leg fracture (tibiofibular fracture) treated in Imam Khomeini hospital, 17 patients (8%) had segmental fibular fractures. In the observed fibular fractures, the number of fracture fragments was between 3 and 6 segments. After 6 months, the rate of union was 70% in the tibia and 88% in the fibula. Overall, 6 patients needed re-operation, 1 of them had below knee amputation, and 5 other had surgeries because of tibial nonunion. Conclusions: The current study results showed that presence of a segmental fibular fracture may be associated with higher rates of complications. Fixation of the fibula in this situation can lead to nonunion. However, more studies are needed to approve or reject this conclusion. https://jost.tums.ac.ir/index.php/jost/article/view/98 https://jost.tums.ac.ir/index.php/jost/article/download/98/98

Tehran University of Medical Sciences Journal of Orthopedic and Spine Trauma 2538-2330 2 3 2016 08 30 99 99 Shayan Abdollah Zadegan Research Center for Neural Repair (RCNR), University of Tehran, Tehran, Iran Masoumeh Firouzi Research Center for Neural Repair (RCNR), University of Tehran, Tehran, Iran Reza Erfanian Research Center for Neural Repair (RCNR), University of Tehran, Tehran, Iran Mohammad Hossein Nabian Department of Orthopedic and Trauma Surgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran Leila Oriady Zanjani Department of Orthopedic and Trauma Surgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran Reza Shahryar Kamrani Department of Orthopedic and Trauma Surgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran 2019 07 18 Background: Nerve repair with microsurgical techniques is the gold standard and the most widely used surgical treatment for nerve reconstruction. However, the optimum number of microsutures for approximation of nerve ends has not been investigated thoroughly, as the focus of previous studies has been on in vitro examination of biomechanical strength of the repaired nerve. Objectives: In this study, we investigated the effect of the number of suture on nerve repair, concerning mechanical, functional, and morphometric aspects. Methods: Twenty-four male Wistar rats were subjected to tibial nerve transection and randomly divided into three groups: control with no repair; repair with 1 suture; and repair with 3 sutures. Tibial functional index (TFI) was determined weekly for two months to assess the functional recovery. At the end of the study, macroscopic and microscopic evaluations as well as adhesive strength quantification at the site of the injury were performed. Results: There was no significant difference in the TFI measures between 1-suture and 3-suture groups during 8 weeks (P > 0.05). Adhesive strength was not significantly different between three groups (P > 0.05); however, it was higher in both suture groups compared with the control group. Scar index was 0.50 (SD = 0.06, n = 2) in control, 0.54 (SD = 0.08, n = 4) in 1-suture, and 0.58 (SD = 0.13, n = 4) in 3-suture groups. The comparison of the mean of differences in scar index and vascular index did not imply significant differences (P > 0.05). Conclusions: Repair of rat’s tibial nerve with one or three microsutures gave comparable outcomes. This may suggest that for functional recovery of the fine nerves, simple approximation with minimum number of sutures is sufficient. https://jost.tums.ac.ir/index.php/jost/article/view/99 https://jost.tums.ac.ir/index.php/jost/article/download/99/99

Tehran University of Medical Sciences Journal of Orthopedic and Spine Trauma 2538-2330 2 3 2016 09 19 103 103 Hossein Aslani Associated Professor of Orthopedics and Pediatric Orthopedic Surgeon, Tabriz University of Medical Sciences, Shohada Educational Hospital, Tabriz, Iran Amirmohammad Navali Professor of Orthopedics, Tabriz University of Medical Sciences, Tabriz, Iran Taghi Baghdadi Associated Professor of Orthopedics and Pediatric Orthopedic Surgeon, Tehran University of Medical Sciences, Tehran, Iran Reza Abdy Assistant Professor of Orthopedics and Pediatric Orthopedic Surgeon, Birjand University of Medical Sciences, Birjand, Iran 2019 07 18 Background: Supracondylar humerus fracture is the most common elbow fracture in children. While closed reduction and percutaneous pining is the standard treatment method, the ideal pin arrangement is controversial. Objectives: The current study aimed at evaluating the outcome of the closed lateral cross-pinning to treat displaced supracondylar humeral fractures. Patients and method: After closed parallel lateral pin fixation, reduction was unstable in 35 patients, who underwent cross- pinning from lateral entry point. The mean follow-up period was 6 months and all patients were evaluated for the loss of reduction, iatrogenic ulnar nerve injury, and elbow range of motion. Results: The mean age of the patients was 7 years. All fractures were type III according to the Gartland classification. There was no case of reduction loss or iatrogenic ulnar nerve injury. Elbow range of motion was full. Two patients had malreduction. Conclusions: Although medial and lateral cross-pinning has the highest stability of pinning techniques, the risk of iatrogenic ulnar nerve injury is significant. Total lateral entry cross-pin fixation method of pediatric supracondylar humerus fractures has similar results to the conventional cross-pin methods regarding the fixation stability, but with lower ulnar nerve injury cases. https://jost.tums.ac.ir/index.php/jost/article/view/103 https://jost.tums.ac.ir/index.php/jost/article/download/103/103

Tehran University of Medical Sciences Journal of Orthopedic and Spine Trauma 2538-2330 2 3 2016 09 22 104 104 Ankur S. Narain Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St Suite 300, Chicago, IL, 60612 Fady Y. Hijji Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St Suite 300, Chicago, IL, 60612 Kelly H. Yom Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St Suite 300, Chicago, IL, 60612 Krishna T. Kudaravalli Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St Suite 300, Chicago, IL, 60612 Kern Singh Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St Suite 300, Chicago, IL, 60612 2019 07 18 Context: Thoracolumbar injuries are common manifestations of spinal trauma. While non-operative therapy is indicated in certain cases of isolated injury, operative therapy via open approaches are widely utilized. Recently, minimally invasive surgical (MIS) approaches have been adapted for the management of thoracolumbar trauma in an effort to avoid the operative morbidity of open thoracolumbar procedures. Purpose: The purpose of this review is to perform a critical analysis of the literature regarding the clinical efficacy and safety of MIS procedures in the management of thoracolumbar trauma. Evidence Acquisition: PubMed and MEDLINE databases were searched for articles published on the topic of MIS treatment of traumatic thoracolumbar injuries. Studies included in this review were comprised of clinical case series, retrospective cohort studies, non-randomized prospective cohort studies, prospective randomized controlled trials, and meta-analyses. Results: The majority of published studies were retrospective clinical case series comprising level IV evidence. The majority of studies demonstrated the viability of MIS approaches as a treatment modality for thoracolumbar trauma in regards to clinical outcomes, radiographic outcomes, and complication rates. Additionally, MIS procedures were associated with reductions in operative time, intraoperative blood loss, and immediate postoperative pain. Conclusions: MIS approaches to thoracolumbar trauma are viable treatment strategies in regards to clinical efficacy and safety. While the results for MIS procedures are promising, more high-quality prospective studies are necessary in order to make definitive conclusions regarding the superiority of MIS over open surgical strategies. https://jost.tums.ac.ir/index.php/jost/article/view/104 https://jost.tums.ac.ir/index.php/jost/article/download/104/104

Tehran University of Medical Sciences Journal of Orthopedic and Spine Trauma 2538-2330 2 3 2016 09 19 105 105 Seyed Mojtaba Hosseini Department of Health Services Management, College of Management and Social Science, Tehran North Branch, Islamic Azad University, Tehran, Iran Khalil Ali Mohammadzadeh Assistant Professor of IAU, Tehran North Branch Manager of Department of Health Services Management of IAU, Tehran Medical Branch, Tehran, Iran Fatemeh Zahraei Bakhsh Ms of Health Services Management, Tehran North Branch, Islamic Azad University, Tehran, Iran Mohammad Hossein Nabian Assistant Professor of Orthopaedics Surgery Tehran University of Medical Science Children Medical Center, Tehran, Iran 2019 07 18 Background: Medical tourism is one of the most influential factors in industrial growth and development. To increase medical tourism, it is crucial to promote the quality of medical care and facilities to the level of international standards. This study aimed at identifying service quality as perceived by medical tourists admitted to the children’s Medical center of Tehran. Methods: All patients admitted to the children’s Medical center between years 2014 and 2015, in all hospital wards, were included. For data collection, a 24-item questionnaire and the Likert scale for scoring were used. The reliability of the questionnaire was assessed with Cronbach’s Alpha coefficient, which was 0.87. The data was presented as descriptive measures. Results: The findings revealed that therapeutic care and facilities were rated as “good”, by 56.67% and 65% of the patients, respectively. The clarity of medical costs was rated as “very poor” by 50% of the patients. Furthermore, payment system was clearly causing problems for a large percentage of patients (48.33%), mainly due to the weak currency exchange capability. Conclusions: The findings of this study suggest that the center has satisfactory medical services and therapeutic care, however, it fails to provide a good payment service and enough currency exchange counters for the patients, which need proper planning and monitoring. https://jost.tums.ac.ir/index.php/jost/article/view/105 https://jost.tums.ac.ir/index.php/jost/article/download/105/105

Tehran University of Medical Sciences Journal of Orthopedic and Spine Trauma 2538-2330 2 3 2016 09 20 106 106 Martin Schuler Director Clinical Investigation and Documentation Institute (AOCID), Member of Executive Management at AO Foundation, AO Foundation, University of Rochester - William E. Simon Graduate School of Business Administration, Zurich Area, Switzerland Suthorn Bavonratanavech Past President of AO Foundation , Chief of Orthopedic and Trauma Network, BDMS, Senior Director of Bangkok Orthopedic Center 2019 07 18 https://jost.tums.ac.ir/index.php/jost/article/view/106 https://jost.tums.ac.ir/index.php/jost/article/download/106/106

Tehran University of Medical Sciences Journal of Orthopedic and Spine Trauma 2538-2330 2 3 2016 09 20 66 66 Gholam Hossein Kazemian Associate Professor of Orthopedi, Orthopedic Department, Shahid Beheshti University of Medical Sciences, Imam Hussein Hospital, Tehran, Iran Alireza Manafi Rasi Assistant Professor of Orthopedi, Orthopedic Department, Shahid Beheshti University of Medical Sciences, Imam Hussein Hospital, Tehran, Iran Farzad Amoozadeh Omrani Assistant Professor of Orthopedi, Orthopedic Department, Shahid Beheshti University of Medical Sciences, Imam Hussein Hospital, Tehran, Iran A Yamrali Senior Resident of Orthopedi, Shahid Beheshti University of Medical Sciences, Imam Hussein Hospital, Tehran, Iran 2019 07 18 Spontaneous fractures occur in patients with Paget disease, Multiple myelomas, and osseous metastasis. Furthermore, spontaneous fractures may be the result of physiological pressure and stress on bones with reduced elastic tenacity. In this report, we have introduced an elderly patient with multiple significant fractures without any history of a major trauma. In the discussion, we have considered important issues around the topic. https://jost.tums.ac.ir/index.php/jost/article/view/66 https://jost.tums.ac.ir/index.php/jost/article/download/66/66

Tehran University of Medical Sciences Journal of Orthopedic and Spine Trauma 2538-2330 2 3 2016 09 24 57 57 Papaioannou Ioannis Department of Orthopaedics, Spine Unit, General Hospital of Patras, Greece, Calcium Phosphate Leakage Causing Paraparesis Baikousis Andreas Department of Orthopaedics, Spine Unit, General Hospital of Patras, Greece, Calcium Phosphate Leakage Causing Paraparesis Korovessis Panagiotis Department of Orthopaedics, Spine Unit, General Hospital of Patras, Greece, Calcium Phosphate Leakage Causing Paraparesis 2019 07 18 Introduction: Bone cement leakage is the most common, however, it can have potentially disastrous complications during vertebroplasty and balloon kyphoplasty (BK). Polymethylmethacrylate (PMMA) is the most commonly used bone filler, however, calcium phosphate (CP) has been successfully used in spine surgery as a vertebral filler because it is not associated with exothermal reaction and is biologically very close to the vertebral bone. CP leakage during vertebral augmentation is extremely rare. Case Presentation: A 72-year-old woman with an A2/AO type fracture of L1-vertebra underwent a transpedicular BK at the L1-vertebra with CP plus short segment pedicle screw construct (T12-L2) by minimally invasive surgery (MIS). Continuous neuromonitoring and fluoroscopy were used in this case, although no pathological signs were recorded because of the low radiopacity of CP. Two days later, incomplete paraplegia was presented due to intra and extradural cement leakage. The patient underwent an emergency T12-L2 wide decompression for removal of an epidural leak of CP plus durotomy for intradural CP removal. After removal of the cement, there was improvement of neurologic function. CP leakage should have occurred because of a violation of the medial right pedicle wall by the BK trockar and subsequently CP injection both intra and extradural. Since no direct intraoperative nerve root injury occurred, there was no pathologic sign during intraoperative neuromonitoring. Conclusions: PMMA leakage is well documented in the literature as a common complication during BK. Calcium phosphate leakage during vertebral augmentation is rare. Furthermore, delayed onset of neurologic deficit due to CP leakage has never been reported in the current literature. Spine surgeons and interventional radiologists should always be aware of this potential disastrous complication. https://jost.tums.ac.ir/index.php/jost/article/view/57 https://jost.tums.ac.ir/index.php/jost/article/download/57/57