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Introduction In cases of sacral nerve avulsion injuries, proximal nerve stumps are not available because of its protected position in pelvis, and results of nerve repair or graft are unsatisfactory. Nerve transfer can reduce the regeneration time and improve the results of recovery. Hypothesis The obturator nerve transfer to the tibial nerve via saphenous nerve graft is possible and feasible. Materials and methods Ten male adult cadaveric lower limbs dissected to identify the location of the anterior branch of obturator nerve, the saphenous nerve and the medial gastrocnemius branch. The saphenous nerve was cut from its origin and transferred to the anterior branch of obturator nerve. As well, it was cut distally and transferred to the medial gastrocnemius branch. After nerve coaptation, surface area and fascicle count were determined by histological methods. Results In all limbs, the proximal and distal stumps of saphenous nerve were reached the anterior branch of obturator and the medial gastrocnemius branch, respectively without tension. The mean of fascicle number in the anterior branch of obturator nerve, proximal and distal stump of the saphenous nerve and stump of medial gastrocnemius nerve branch were 2.90 ± 0.99, 4.50 ± 2.70, 4.00 ± 2.26 and 4.30 ± 1.25, respectively. Discussion This study showed that it is possible to transfer the obturator nerve to the medial gastrocnemius branch via saphenous nerve bridge; and their histological parameters are match in a good manner. Therefore, this technique is suggested for patients with sacral nerve avulsion injuries. Level of evidence IV, case series of cadaveric study.

BackgroundThe incidence of brachial plexus injuries (BPI) is increasing due to improvement in transportation technology. Those with BPI have upper limb performance limitation depends on the type of injury. Various surgical treatments have been used in this group of the subjects to restore their performance. The aim of this study was to evaluate the efficiency of supinator transferred to wrist extensors in those with lesion level at C7-T1 based on OpenSim modelling approach.MethodThe motions of the upper limb during vertical reaching, transverse reaching and wrist motion of a normal subject were achieved by use of motion analysis system. The ranges of motion of the upper limb joints were evaluated by inverse kinematic. OpenSim software was used to determine the muscles forces during aforementioned tasks. Tendon of supinator was transferred to extensors in modified models of OpenSim. Forward dynamic approach was used to determine the range of motion in tendon transferred condition. ResultsThe range of wrist motion in normal condition (extensors intake) were 85, 103 and 140 degrees for the first task (transverse reaching), the second task (vertical reaching) and the third task (only flexion/extension of wrist), respectively. Although the force of supinator was significantly less than that of wrist extensors, the pattern of its force is the same as wrist extensors.

Aim Previous studies have suggested medial antebrachial cutaneous nerve of forearm (MACN) as a proper nerve graft to anastomosis of medial pectoral (MPN) and musculocutaneous (MCN) nerves.Evaluating the compatibility of MACN with MPN and MCN for the anastomosis from anatomical and histopathologic aspects. Material and methods Ten brachial plexus specimens from five cadavers were dissected. The distance of distal ends of MPN and MACN and proximal ends of MACN and MCN were measured from coracoid. Histopathologic slides from the four mentioned nerve ends provided. The Number of fascicles, cross-section diameter, and area of each nerve ends were measured. Results The distance of proximal and distal ends of MACN were adjacent to MPN and MCN. The mean number of fascicles (4.5 ± 1.2 vs. 2.9 ± 1.0), area (6.0 ± 2.5 vs. 2.8 ± 2.4) and diameter (2.7 ± 0.6 vs. 1.8 ± 0.7) of the distal end of MACN was significantly more than MCN. The mean number of fascicles (4.4 ± 1.4 vs. 2.6 ± 0.5), area (5.6 ± 2.4 vs. 2.0 ± 1.0) and diameter (2.6 ± 0.6 vs. 1.6 ± 0.4) of the proximal end of MACN was significantly more than MPN. The mentions parameters were similar between MCN and MPN. Conclusion Our study reveals that MACN is not a proper graft for MCN and MCN anastomosis due to the incompatibility of its diameter, area, and number of fascicles.

This systematic review focus on the application of bilayer scaffolds as an engaging structure for the engineering of multilayered tissues, including vascular and osteochondral tissues, skin, nerve, and urinary bladder. This article provides a concise literature review of different types of bilayer scaffolds to understand their efficacy in targeted tissue engineering.To this aim, electronic search in the English language was performed in PMC, NBCI, and PubMed from April 2008 to December 2019 based on the PRISMA guidelines. Animal studies, including the "bilayer scaffold" and at least one of the following items were examined: osteochondral tissue, bone, skin, neural tissue, urinary bladder, vascular system. The articles which didn't include "tissue engineering" and just in vitro studies were excluded.Totally, 600 articles were evaluated; related articles were 145, and 35 full-text English articles met all the criteria. Fifteen articles in soft tissue engineering and twenty items in hard tissue engineering were the results of this exploration. Based on selected papers, it was revealed that the bilayer scaffolds were used in the regeneration of the multilayered tissues. The highest multilayered tissue regeneration has been achieved when bilayer scaffolds were used with mesenchymal stem cells and differentiation medium before implanting. Among the studies being reported in this review, bone marrow mesenchymal stem cells are the most studied mesenchymal stem cells. Among different kinds of multilayer tissue, the bilayer scaffold has been most used in osteochondral tissue engineering in which collagen and PLGA have been the most frequently used biomaterials. After osteochondral tissue engineering, bilayer scaffolds were widely used in skin tissue engineering.The current review aimed to manifest the researcher and surgeons to use a more sophisticated bilayer scaffold in combinations of appropriate stem cells, and different can improve multilayer tissue regeneration. This systematic review can pave a way to design a suitable bilayer scaffold for a specific target tissue and conjunction with proper stem cells.

Purpose This systematic review focus on the application of bilayer scaffolds as an engaging structure for the engineering of multilayered tissues, including vascular and osteochondral tissues, skin, nerve, and urinary bladder. This article provides a concise literature review of different types of bilayer scaffolds to understand their efficacy in targeted tissue engineering.

Background Triangular fibrocartilage complex (TFCC) injections can be applied using anatomical landmarks or under the guide of ultrasound (US). US is not always available, and the physician may rely on the anatomical landmarks. Objective The study aims to evaluate the effectiveness and safety of TFCC injection with anatomic landmarks. Methods Forty wrist specimens from cadavers were randomly assigned to four rapid blue stain injection groups as follows: Group A: perpendicular to skin with 5 mm depth; Group B: perpendicular to skin with 10 mm depth; Group C: 45-degree angulation to skin surface, oriented from proximal to distal with 10 mm depth; and Group D: 45-degree angulation to skin surface, oriented from distal to proximal with 10 mm depth. TFCC specimens were excised and evaluated with microscopy, and adjacent neurovascular structures were checked for any injury. Results Injections in group A were more accurate than others, in which 8/10 injections were successful. Group C injections were least accurate in that only 4/10 were successful. The other remaining groups (groups B and D) revealed similar results (5/10 were successful). However, statistical analyses did not show any significant difference (p-value = 0.35). No injury to neurovascular structures was seen. Conclusion Needle placement perpendicular to skin with 5 mm depth and just medial to ulnar styloid can be used as an accurate method of palpation-guided technique for TFCC injections.

Background: Today, the incidence of septic arthritis by Staphylococcus aureus has increased due to intra-articular injections, prosthetic joints, and underlying conditions such as rheumatoid arthritis and immunosuppression. Pistacia atlantica has significant antioxidant, anti-inflammatory, and antibacterial activities. Objectives: Considering S. aureus as the most important etiology of septic arthritis, this experimental study aimed to evaluate the effects of P. atlantica on septic arthritis. Methods: Septic arthritis was induced by intra-articular injection of S. aureus suspension in left stifles of rats, which were divided randomly into eight groups, containing ten per group, including normal: no intervention; control: septic arthritis was induced but not treated; Oral Placebo (OP): 14 days daily P.O.; Local Injected Placebo (LIP): a single dose intra-articular (IA injection) of normal saline; Oral P. atlantica (OPa): 14 days daily P.O. P. atlantica extract; Local Injected P.atlantica (LIPa): a single-dose IA injection of P. atlantica extract; Prophylactic Oral P. atlantica (ProOPa): prophylactic P.O. P. atlantica extract daily one week before the induction for 21 days; Prophylactic Local Injected P. atlantica (ProLIPa): a prophylactic single-dose IA injection of P. atlantica extract one week before the induction. For further evaluations, blood and histopathological samples were obtained. Results: Pistacia atlantica oral medication reduced the physical symptoms of inflammation. Although hematological analysis showed a fall in the control group compared to the normal group, all medicated groups increased. The OPa group showed the closest WBC count (9.46 ± 4.12 × 109/L) to the normal group (P = 0.073). All histopathological parameters had significantly higher scores in the control group compared to the normal group. Although the scores increased in the groups that received P. atlantica, they decreased in the groups that received placebo, except for synovitis degree. The OPa group demonstrated a lower degree of synovitis (1.40 ± 0.51) than the control group; however, it was not significant (P = 0.690). Local injections revealed higher erosion scores (2.80 ± 0.63 for the LIPa group and 2.70 ± 0.48 for the ProLIPa group) than the control group (P < 0.05). Conclusions: Oral administration of P. atlantica alleviated the clinical symptoms. Cellular immunity activation and systemic benefits of oral P. atlantica were assessed. Histopathology confirmed the immune system involvement and antibacterial activity of P. atlantica. More erosion may be due to more bacterial debris with arthritogenic properties. Meanwhile, the probability of the stimulatory effect of P. atlantica extract for synovial content should not be ignored.

Background: The medical profession has always been an inspiration for human societies throughout its diverse history. This position and historical authority in the field of ethics has had a different and higher status, in such a way that many of the norms of general ethics and professional ethics, especially principles, such as trust, confidentiality and respect for human dignity, have been developed by medical professionals. Developing guidelines of general and professional ethics is one of the inherent duties of the Medical Council of the Islamic Republic of Iran (IRIMC) as a professional organization. In this regard, the Supreme Council of IRIMC has approved the "Code of Ethics for Medical Professionals" and, in accordance with its legal authority, has annexed it to the disciplinary regulations of IRIMC. Methods: A draft document, the result of extensive literature review, was discussed in 27 expert panel meetings and after receiving and endorsing the stakeholders’ point of view, was approved by the IRIMC Supreme Council. Results: The first edition of "Code of Ethics for Medical Professionals, Medical Council of Islamic Republic of Iran" was developed on July 6, 2017 by the Supreme Council of IRIMC. The guideline was set to take effect one year after its enactment. The first edition was revised and completed and final edition was adopted on August 9, 2018 by IRIMC in 13 chapters and 140 articles (original full text is available in the Supplementary file 1). Conclusion: According to the approved decision by the Supreme Council of IRIMC on May 10, 2018, the final edition takes effect as of October 7, 2018.

Objective Kienbock's disease is an unusual disorder caused by osteonecrosis and the collapse of lunate bone which leads to pain and a chronic decrease in wrist function. The treatments in this disease aim to relieve pain and maintain wrist function and movement. Various surgical procedures have been recommended for the subjects with Kienbock's disease; however, the main question posed here is which of the selected procedures are more successful in relief of the pressure applied on lunate. Methods and Materials Computed tomography (CT) scan images of a normal subject were used to create a three-dimensional model of the wrist joint. The effects of several surgical procedures, including radial shortening, capitate shortening, and a combination of both radial and capitate shortening, on the joint contact force of the wrist bones were investigated. Results The pressure applied to the lunate bone in articulation with radius, scaphoid, capitate, hamate, and triquetrum varied between 19.7 and 45.4 MPa. The Von Mises stress, maximum principal stress, and minimum principal stress decreased in the model with a combination of radius and capitate shortening. Conclusion It can be concluded from the results of this study that the combinations of radius and capitate shortening seem to be an effective procedure to decrease joint pressure, if the combined surgery could not be done, shortening of radius or capitate would be recommended. Level of Evidence This is a Level III study.

Background In cases of high ulnar nerve palsy, result of nerve repair in term of intrinsic muscle recovery is unsatisfactory. Distal nerve transfer can diminish the regeneration time and improve the results. But, there was no perfect distal nerve transfer for restoring intrinsic hand function in combined proximal median and ulnar nerve injuries. This cadaveric study aims to evaluate the possibility and feasibility of supinator nerve transfer to motor branch of ulnar nerve (MUN). Methods Ten cadaveric upper limbs dissected to identify the location of the supinator branch, anterior interosseous nerve (AIN), and MUN. The AIN was cut from its origin and transferred to the supinator branches. Also, the AIN was distally cut and transferred to the MUN. After nerve coaptation, surface area, fascicle count, and axon number were determined by histologic methods. Results In all limbs, the proximal and distal stumps of AIN reached the supinator branch and the MUN without tension, respectively. The mean of axon number in the supinator, proximal stump of AIN, distal stump of AIN and MUN branches were 32,426, 45,542, 25,288, and 35,426, respectively. Conclusions This study showed that transfer of the supinator branches to the MUN is possible via the in situ AIN bridge. The axon count data showed a favorable match between the supinator branches, AIN, and MUN. Therefore, it is suggested that this technique can be useful for patients with combined high median and ulnar nerve injuries.

BACKGROUND: One of the major challenges in orthopedic surgery is the prevention of arthrofibrosis, which can be successfully alleviated in its early stages. Many studies suggest the administration of methylene blue (MB) as an accessible and effective agent for the prevention of post-operation adhesions. The purpose of this study was to evaluate the efficacy of MB in the prevention of arthrofibrosis. METHODS: This study was conducted on 18 New Zealand white female mature rabbits. The anterior cruciate ligament of the left stifle joint of each animal was cut during aseptic surgery. In the next step, the rabbits were divided into three groups based on their treatments. The rabbits in the first, second, and third groups were subjected to the injection of normal saline, 1% MB solution, and 2% MB solution into their synovial space, respectively. The postoperative stifle range of motion was measured every week. After 4 weeks, the animals were euthanized and all joints were dissected for histopathology. RESULTS: The histopathological evaluation of tissues indicated the presence of fibrotic connective tissue as a sign of fibrosis in all groups. The fibrosis rate, inflammatory rate, tissue disarrangement, fibroblastic cellularity, and granulation tissue formation were at their highest levels in the 1% MB group. The integrity of articular cartilage in the 2% MB group was lower than the other groups. The level of bone degeneration was similar in both MB groups; however, it was more than the control saline group. The range of motion was reduced during the first week, then increased in the second and third weeks, and finally decreased in the fourth week. CONCLUSION: The MB was not an effective method regarding the prevention or treatment of arthofibrosis and the subsequent osteoarthritis. In contrast with previous studies, fibrosis was lower in the high dose MB group, compared to the low dose MB group. The alterations in the range of motion were related to the reduced movement caused by the pain and stiffness of the operated joints. The current study can be considered as the first report addressing the adverse effect of MB on synovial components. LEVEL OF EVIDENCE: I

This study aimed to determine factors affecting the survival of patients with hip fracture in Shiraz, Iran. Alzheimer’s disease, hypertension, and cardiovascular diseases were risk factors, while female gender and living with family members or in nursing homes were protective factors against mortality following hip fracture. Hip fractures are the most common orthopedic fractures in elderly. This study aimed to determine the factors affecting the survival of patients with hip fracture in Shiraz. This historical cohort study was conducted in Shiraz, Iran. All patients with hip fracture who were admitted to any of the hospitals providing orthopedic services in Shiraz, from September 1, 2011, to August 30, 2012, were included in the study. The log rank test, Kaplan–Meier methods, and the univariate and multivariate Cox regression model were used for data analysis. A total of 631 patients were enrolled, of these, 264 (41.8%) were male. The mean age of patients was 74.9 ± 11.5. The patients’ survival rate after the 1st, 2nd, 3rd, 4th, and 5th year were 81.1%, 73.7%, 69.4%, 64.8%, and 60.2%, respectively. After adjusting data for age, Alzheimer’s disease (HR = 4.9, 95% CI 1.4–7.3, P = 0.023), hypertension (HR = 2.27, 95% CI 1.3–3.8, P = 0.003), and cardiovascular diseases (HR = 2.02, 95% CI 1.04–3.09, P = 0.039) remained as risk factors for mortality in patients with hip fracture. However, female patients (HR = 0.46, 95% CI 0.27–0.8, P = 0.006) and those who lived with family members or in nursing homes (HR = 0.43, 95% CI 0.19–0.92, P = 0.03) were protective factors. This study showed that women are more likely to have hip fractures, but mortality among men is more observable. Alzheimer’s disease, hypertension, and cardiovascular diseases were considered as risk factors, while patients who were female and those who lived with the family member or in nursing homes had better survival.

AIM Complicity and slow rate of axons regeneration necessitates microsurgery that adjuvant therapy can help it. Improving nerve metabolic capacity and response to neural growth factors are positive effects of simvastatin and L-carnitine. To decrease neuronal loss after axotomy and improve neuronal regeneration, this study was designed to assay effects of these agents on nerve repair. MATERIAL AND METHODS Left sciatic nerve of 70 female rats were cut and repaired under aseptic microsurgery. Based on medications and treatment period, seven groups were formed. CONTROL no medication. SIM1W: one week daily oral simvastatin. LC1W: one week daily oral L-carnitine. Plb1W: one week daily oral placebo. SIM1M: one month daily oral simvastatin. LC1M: one month daily oral L-carnitine. Plb1M: one month daily oral placebo. Following 90 days, behavioral assessments and then histopathology were done. RESULTS Mean reflex time of withdrawal reflex latency and toe out angle in all experimented groups increased than normal. Long-term drug-medication significantly improved toe out angle. In long-term drug-medication, inflammation and neural bundle differentiation were significantly lower and higher, respectively. Vascular index showed reduction but number of myelinated nerve fibers had rises in drug-medicated groups compared to control and placebo groups. No obvious differences were detected in myeline diameter. CONCLUSION Both Simvastatin and L-carnitine can accelerate and improve the process of nerve regeneration in a long enough treatment period. The regulatory influence of these exogenous neurotrophic drugs may be essential to optimize regeneration of nerve fibers; so can broaden horizons for novel therapeutic modalities to decrease neuronal apoptosis.

Introduction Fracture of the scaphoid bone is the most common fracture of the carpus. However, the fracture union occurs late or may not heal. Sometimes, fracture healing requires prolong immobilization. Because of potential for joint stiffness, muscle atrophy, or the inability to use the hand during and after prolonged immobilization, there is great incentive to develop therapies that will accelerate bone healing and allow a quick return to work. To date, the effect of platelet-rich plasma (PRP) on scaphoid fracture has not been studied. We aimed to assess the effect of intra-articular PRP injection on union: pain, range of motion, and function in patients with scaphoid fracture. Hypothesis Union: pain reduction and functional improvement can be noticed after PRP use in scaphoid fracture. Materials and Methods A randomized controlled trial was designed with 14 patients with scaphoid fractures (Herbert type B2). Casting was done for them. Seven patients received intra-articular autologous PRP. Patients were followed up 2 weeks after casting using radiography and then at 2 months using radiography and computed tomography (CT) scan to check bone healing. Then patients were followed up for 3 and 6 months and after evaluation of healing by CT scan, the patient-rated wrist evaluation questionnaire was completed and the range of motion of the wrist was measured. Results Analysis revealed significant improvement in pain at rest, as well as during specific and usual activities following PRP injection in the case group. However, no statistically significant difference in wrist motion including radial and ulnar deviation, flexion, and extension was found in 6 months follow-up except some improvement in ulnar deviation after 3 months. However, this study showed that scaphoid union occurred earlier in the case group, but it was not statistically significant. Conclusion PRP may have a significant effect on pain reduction at rest and amount of difficulty in functions including specific and usual activities in patients with scaphoid fractures. Level of Evidence This is a level III, therapeutic trial.

BACKGROUND Hip fracture and its consequences are one of the major causes of morbidity and disability in the elderly. The purpose of this study was to collect epidemiologic data and assess the daily activities and walking ability of patients 3 months and 1 year following surgery because of a hip fracture. MATERIAL AND METHODS We prospectively obtained data of all consecutive patients more than 50 years of age with any type of hip fracture from 2008 to 2013. After excluding pathologic fractures, hip fracture dislocations, non-surgically treated cases, and dead patients, functional status of the subjects at 3 months and 1 year after surgery was evaluated using a 10-degree scale of pain, modified Barthel index of daily activity, and independent walking ability. RESULTS In total, 1015 cases were enrolled. Mean age was 75.6 year with a female to male ratio of 1.33. Left-sided hip fractures were seen in 51.7 % of cases. Intertrochanteric fractures were the most common type (72.1 %), followed by femoral neck (24.0 %) and subtrochanteric fractures (3.9 %). At both 3-month and 1-year follow-up visits, 562 subjects (317 women and 245 men) completed the questionnaires. Activities of daily living and independent walking ability were improved significantly at 1 year and the improvements were statistically superior to the results obtained at 3 months (p-value < 0.001 for both variables). CONCLUSION By continuing rehabilitation of elderly patients with surgically-treated hip fractures for one year, improvement in activities of life and walking independence can be expected even if they have a poor result after the first 3 months of rehabilitation.

Introduction Distal radius fractures are common injuries that cause pain and disability. There is a clear need for biomedical engineering research to develop novel strategies to improve functional results following intra-articular distal radius fractures. However, no pharmacotherapeutic agent has been investigated to resolve this problem. The aim of this study was to evaluate whether the platelet-rich plasma (PRP) can be considered a novel additional therapy to improve the outcomes of this injury. Hypothesis Pain reduction and functional improvement can be noticed after PRP use in distal radius fracture. Materials and methods A randomized trial study was designed with 30 patients who had intra-articular distal radius fractures (Frykman type 3, 4, 7, 8). Closed reduction and percutaneous pinning under guide of fluoroscopy were done for them. Fifteen cases received intra-articular autologus PRP. Patients were followed for 3 and 6 months and “patient-rated wrist evaluation” (PRWE) questionnaire was completed and range of motion of the wrist was measured. Results The mean of pain score and the score of specific and usual activities at 3 months follow-up in the case group and in the control group were (8.33 versus 19.67), (10.66 versus 26.8), and (6.2 versus 13.4), respectively. The mean of pain score and score of specific and usual activities at 6 months follow-up in the case group and in the control group were (3.6 versus 12), (3 versus 15.7), and (1.2 versus 6.8), respectively. The case group was significantly different from the control group. The mean of loss of flexion and extension of the wrist at 3 months follow-up in the case group was significantly different from the control group as well. Conclusion PRP may have significant effect on reduction of pain and amount of difficulty in functions, including specific and usual activities after intra-articular distal radius fractures. Level of evidence Level III, Therapeutic trial.

Introduction In cases of sacral nerve avulsion injuries, proximal nerve stumps are not available because of its protected position in pelvis, and results of nerve repair or graft are unsatisfactory. Nerve transfer can reduce the regeneration time and improve the results of recovery. Hypothesis The obturator nerve transfer to the tibial nerve via saphenous nerve graft is possible and feasible. Materials and methods Ten male adult cadaveric lower limbs dissected to identify the location of the anterior branch of obturator nerve, the saphenous nerve and the medial gastrocnemius branch. The saphenous nerve was cut from its origin and transferred to the anterior branch of obturator nerve. As well, it was cut distally and transferred to the medial gastrocnemius branch. After nerve coaptation, surface area and fascicle count were determined by histological methods. Results In all limbs, the proximal and distal stumps of saphenous nerve were reached the anterior branch of obturator and the medial gastrocnemius branch, respectively without tension. The mean of fascicle number in the anterior branch of obturator nerve, proximal and distal stump of the saphenous nerve and stump of medial gastrocnemius nerve branch were 2.90 ± 0.99, 4.50 ± 2.70, 4.00 ± 2.26 and 4.30 ± 1.25, respectively. Discussion This study showed that it is possible to transfer the obturator nerve to the medial gastrocnemius branch via saphenous nerve bridge; and their histological parameters are match in a good manner. Therefore, this technique is suggested for patients with sacral nerve avulsion injuries. Level of evidence IV, case series of cadaveric study.

Objectives: To determine the effects on urine calcium excretion of immobilization by skin traction in patients with pelvic fracture. Methods: In a prospective study, a consecutive series of patients with pelvic fracture treated by skin traction were enrolled. Serum (calcium, phosphorous, alkaline phosphatase, sodium, potassium, uric acid, BUN, creatinine) and fasting urine calcium, creatinine, sodium, potassium and uric acid were checked within 48 hours of hospitalization and at 7, 14 and 21 days of immobilization and then after 3 months of mobilization. Trends in changes of variables were recorded. Results: Fifty five patients were enrolled in this study; they were 45 (81.8%) males and 10 (18.2%) females with a mean age 19.4 ± 12.7 years. We found that serum levels of calcium (p = 0.004), phosphorous (p = 0.047) and alkaline phosphatase (p = 0.001) increased significantly during the 3 weeks of immobilization. In the same way, urine calcium/ urine creatinine ratio increased significantly in the study period (p = 0.004). No symptomatic renal stone formation was observed during the study period. Conclusions: Immobilization even in short term causes hypercalciuria in orthopedic patients. Although it is transient and improves with subsequent mobilization, it is needed to be considered specifically by the team caring for this group of patients.

Background In cases of high ulnar and median nerve palsy, result of nerve repair in term of intrinsic muscle recovery is unsatisfactory. Distal nerve transfer can alleviate the regeneration time and improve the results. Transfer of the extensor digiti minimi (EDM) and extensor carpi ulnaris (ECU) nerve branches to the deep branch of ulnar nerve (DBUN)/recurrent branch of median nerve (RMN) at wrist had been used to restore intrinsic hand function but, incomplete recovery occurred. The axon count at the donor nerve has a strong influence on the final results. Hypothesis This cadaveric study aims to analyses the histology of this nerve transfer to evaluate whether these donor nerves are suitable for this transfer or another donor nerve may be considered. Materials and methods Ten cadaveric upper limbs dissected to identify the location of the EDM, ECU, RMN and DBUN. Surface area, fascicle count, and axon number was determined by histological methods. Results The mean of axon number in the EDM, ECU, RMN and DBUN branches was 5931, 7355, 30960 and 35426, respectively. In this study, the number of axons in the EDM and ECU branches was 37% (13281/35426) of that in the DBUN. Also, the number of axons in the EDM and ECU branches was 42% (13281/30960) of that in the RMN. Conclusion The axon count data showed an unfavorable match between the EDM, ECU and DBUN/RMN. Therefore, it is suggested that another donor nerve with higher axon number to be considered. Type of study Cadaver study (histological study).

We evaluate the incidence of hip fracture in 50 years old or above in southwest of Iran. Age-adjusted incidence rates of hip fracture, standardized to the 2000 US white population, were 79.55 per 105 in total and 66.51 and 92.37 per 105 in male and female, respectively. Osteoporosis-related hip fracture is associated with considerable morbidity, mortality, and costs in older people. The aim of this study was to evaluate the incidence rate of hip fracture in the capital of Fars Province, southern Iran. This study was conducted in Shiraz, Iran, from September 1, 2011, to August 30, 2012. All 50-year-old or above patients with hip fracture diagnosis, lived in Shiraz at least 6 months prior to hospital admission, were included in this study. All statistical analyses were performed using SPSS, version 18.0, and Microsoft Excel 2007 software. The mean age of 608 patients was 75.95 ± 11.07 and 353 (58.3%) were female. Age-adjusted incidence rates of hip fracture, standardized to the 2000 US white population, were 79.55 per 105 in total and 66.51 and 92.37 per 105 in male and female, respectively. The adjusted incidence rate of neck of the femur fracture (30.62 per 105 versus 23.49 per 105, p = 0.61) and intertrochanteric fracture (40.48 per 105 versus 28.5 per 105, p = 0.74) were higher in females than males but the differences were not statistically significant. Under the age of 65 years, the incidence rate of hip fracture was significantly higher in men, but after 65 years, it was higher among women. The rate of osteoporotic hip fracture was relatively low in southern Iran. However, by aging population, this rate will increase and health policy makers should implement targeted osteoporosis screening and management programs.

Background: Proper suturing technique is needed to ensure good outcome in extensor tendon surgery. Different techniques have been reported for the repair of extensor tendon injuries at the level of the metacarpophalangeal joint (MCPJ). These reports were in vitro studies on cadaver models. Repair techniques must be clinically tested, to determine results. Objectives: The purpose of this in vivo study was to compare results of extensor tendon repair, using roll stitch and core suture techniques. Patients and Methods: Forty two fingers, in 38 patients (aged 15- 45 years), with simple complete extensor tendon injuries in the MCPJ area, were identified and operated by a single surgeon. The patients were divided into two groups, according to the technique used for tendon repair. The first group consisted of 21 digits, in 19 patients, who were repaired with roll stitch technique, while the second group consisted of 21 digits, in 19 patients, who were repaired with core suture technique. The same splint and rehabilitation regimen (early passive range of motion) were given to all patients. The splints were removed at 6 weeks after surgery and range of motion of the operated fingers was measured and compared to uninjured hands, after 12 weeks. Results: Five patients were lost to follow up or excluded from the study. There was no rupture of the repaired tendons in the groups. There was no statistically significant difference in mean MCPJ flexion, proximal interphalangeal joint (PIPJ) flexion, distal interphalangeal joint (DIPJ) flexion and total range of motion of the fingers, between the two groups. However, extension lag was significantly more common in the second group (11 of 19 digits) compared the first group (four of 17 digits). Conclusions: Roll stitch technique had superior outcome compared to the modified Kessler technique, when performed in the MCPJ area. Level of evidence: Therapeutic (Level III)

Introduction The development of a carpal tunnel syndrome has become an increasingly recognized problem in patients who are treated by long-term hemodialysis. Arteriovenous fistula has been identified as one of the possible cause for the development of carpal tunnel syndrome. Materials and methods Wrists of 558 hemodialysis patients who had fistula at least 1 year served as the case group and the other intact wrists of the same patients served as the control group. Carpal tunnel syndrome was diagnosed clinically; however, 232 random patients underwent electrodiagnostic studies the day after hemodialysis. Results In 170 (30.5%) wrists with arteriovenous fistula developed carpal tunnel syndrome versus 68 (12.2%) in the contralateral wrist. Three patients had a concurrent diagnosed radial steal syndrome. In all three wrists that had radial steal syndrome developed carpal tunnel syndrome. There was a correlation, however, between the development of the carpal tunnel syndrome, and the side of the longest vascular access. Contrary to the clinical assessment, electrodiagnostic studies did not indicate any significant association between the frequency of carpal tunnel syndrome and arteriovenous fistula or its duration. Conclusion Hemodialysis patients are at considerable risk of developing carpal tunnel syndrome in the wrist with an arteriovenous fistula. Close observation and routine clinical examination is mandatory to prevent further problems.

Background: Iron-loaded cardiac complication is the essential cause of mortality in patients with thalassemia. Early detection and treatment of cardiac over-load can reduce mortality. Objectives: The current study aimed to evaluate the relationship between serum ferritin levels and T2* magnetic resonance imaging (MRI) of heart and liver and liver iron concentration (LIC) to diagnose iron over load in countries with limited access. Patients and Methods: In the current cross-sectional study, 85 Iranian patients with thalassemia with the mean age of 22.7 ± 7 years were randomly selected. All patients were on regular blood transfusion. Echocardiography of heart and liver T2* MRI, determination of serum ferritin levels, and LIC were performed in all subjects at the same time. The correlation of serum ferritin levels with T2*MRI of heart and liver, and LIC was assessed. P value < 0.05 was considered statistically significant. Results: Abnormal myocardial iron load (T2* MRI < 20 ms) was detected in 58% of the patients and among whom, 36% had severe myocardial iron load (T2* MRI < 10 ms). Median and interquartile range of serum ferritin levels were 1434 and 2702 respectively in patients with thalassemia. Serum ferritin levels showed a statistically significant positive correlation with LIC (r s = 0.718, P < 0.001) and significant negative correlation with T2* Heart (r s = -0.329, P = 0.002), and T2* Liver (r s = -0.698, P < 0.001). However, Ejection fraction was not significantly correlated with serum ferritin levels in the patients (P = 0.399). Conclusions: Serum ferritin levels can be used to diagnose iron over-load in patients with thalassemiaas an alternative method in areas where T2* MRI is not available.

between the graft and recipient site, which was evaluated with photo analyzer in Photoshop software. Results: The grafted skins were compared between groups. Clinically, TPD and light touch were better (lower thresholds) in the wrist group (P < 0.05). Moreover, The amount of skin contracture, color difference between grafted skin and recipient site, and hair follicle counts were less in the wrist group (P < 0.001). In both groups, there were no ulcer and fissuring. Conclusions: For fingertip injures, full thickness skin grafts harvested from the wrist have significantly better cosmetic and functional results including better TPD and light touch, less hair follicles, less color difference, and less contracture.

Background In cases of high ulnar and median nerve palsy, result of nerve repair in terms of intrinsic muscle recovery is unsatisfactory. Distal nerve transfer can alleviate the regeneration time and improve the results. Transfer of the extensor digiti minimi (EDM) and extensor carpi ulnaris (ECU) nerve branches to the deep branch of ulnar nerve (DBUN)/recurrent branch of median nerve (RMN) at wrist had been used to restore intrinsic hand function but, incomplete recovery occurred. The axon count at the donor nerve has a strong influence on the final results. Hypothesis This cadaveric study aims to analyses the histology of this nerve transfer to evaluate whether these donor nerves are suitable for this transfer or another donor nerve may be considered. Materials and methods Ten cadaveric upper limbs dissected to identify the location of the EDM, ECU, RMN and DBUN. Surface area, fascicle count, and axon number was determined by histological methods. Results The mean of axon number in the EDM, ECU, RMN and DBUN branches was 5931, 7355, 30,960 and 35,426, respectively. In this study, the number of axons in the EDM and ECU branches was 37 % (13,281/35,426) of that in the DBUN. Also, the number of axons in the EDM and ECU branches was 42 % (13,281/30,960) of that in the RMN. Conclusion The axon count data showed an unfavorable match between the EDM, ECU and DBUN/RMN. Therefore, it is suggested that another donor nerve with higher axon number to be considered. Type of study Cadaver study (histological study).

Objective: Fingertip injuries, which are the most common hand injury, represent management challenges for hand surgeons. Full thickness skin grafts are routinely used to cover the fingertip site, but has significant donor site morbidity. As amniotic membranes (AM) are used as a dressing substitute in burns, we decided to evaluate the efficacy of AM as a biologic wound dressing material for coverage of these injuries. Method: In this clinical study, 30 patients with full-thickness zone 1 fingertip skin loss were included. The patients were divided into 2 groups using the block randomisation method. In the first group, a skin graft was used for coverage and in the second group, AM was used. All patients were operated on by the same hand surgeon between February 2012 to October 2012. The minimum follow-up period was 6 months. Two point discrimination (T.P.D), light touch, healing time, days lost from work and infection rate were evaluated and recorded. Result: This study recruited 30 patients with full-thickness zone 1 fingertip skin loss (age range 13–47 years). Fingertips in both groups were assessed. T.P.D, light touch and days lost from work were significantly lower in the AM group than in the skin graft group. Healing time was lower in the skin graft group. In the both groups, no infection was detected. Patients of both groups were satisfied of their treatment and healing progress. Conclusion: Our results showed the effectiveness and safety of AM for the treatment of fingertip amputation, which can produce better sensation and functional outcomes than skin graft transplantations. Declaration of interest: This paper was extracted from the thesis of Abouzar Fijan, MD. This study was supported by Shiraz University of Medical Sciences, grant number 4037. The authors have conflicts of interest to declare.

Although the locking compression plate (LCP) system offers a number of advantages in fracture management, its successful use requires careful preoperative planning, consideration of soft tissue dissection principles, and good surgical technique. Failure to address these issues can lead to potential pitfalls. Therefore, there are many reports about potential pitfalls that can arise with inappropriate LCP instrumentation technique. Moreover, these studies may mislead the orthopaedic colleagues that the only important tip in LCP using is its mechanical considerations. But, there is no study about the potential soft tissue pitfalls that may occur. There is an attempt in this study to achieve this objective.A prospective analysis was carried out on all patients who were hospitalized for metaphyseal fracture of tibia and LCP fixation was done for them in our trauma center over a 6-month period in 2003. Inclusion criteria included all patients with fracture of tibial metaphysis who were to undergo locking compression plating using long conventional incision (without percutaneus insertion). Therefore, 34 patients included.Many patients (23.5%) developed severe soft tissue damage with exposed plate, and all of them need flap coverage.Locking compression plates have a higher profile in comparison to DCP, requiring careful attention to soft tissue. Therefore, inadvisable locking compression plating with conventional incision method and retaining anatomical reduction of the fracture can lead to a higher soft tissue complication in comparison to dynamic compression plating.

To the Editor, I read with great interest an article that was written by Lange et al. This article was published in June 2013 and is about the effect of Denosumab on aneurysmal bone cyst [1].The authors showed well that Denosumab can be a new treatment option for aneurysmal bone cyst. I would like to complete the discussion of Lange and colleagues by introducing a major complementary route by which Denosumab could heal bone cyst. Reduced numbers of osteoblasts could decrease bone turnover and imbalanced remodeling leading to increased bone resorption. It is generally accepted that stem cell differentiation, which is essentially regulated by WNT/β-catenin signaling, plays an important determinant of osteoblastogenesis [2]. Recruitment of pre-osteoclasts by expression of the ligand for receptor activator of the nuclear factor-kappa b (RANKL) is essential for osteoclastogenesis [3]. Denosumab, a monoclonal RANKL antibody, not only effectively inhibits RANKL, which can lead to significant reduction of osteoclasts, but also increases osteoblastogenesis via inhibition of DKK1, which is antagonist of WNT/β-catenin pathway [4]. Therefore, these important mechanisms should be borne in mind as the major mechanisms for Denosumab for treatment of bone cyst.

Soft-tissue injuries of the hand are devastating injuries that may need coverage. Dorsal and/or lateral defects of the fingers with exposed tendon and/or bone are challenging obstacles in reconstructive hand surgery. There are several options for coverage of dorsal defects of the fingers, but all have shortcomings. A reliable 1-stage local flap to coverage the dorsolateral finger defects is needed. Anatomic study of Omokawa and their colleagues showed that palmar area is supplied by several perforators from the superficial palmar arch, and the common and proper digital arteries. The distal portion of the palm has numerous (range, 8 to 15) and large diameter (range, 0.1 to 0.5) perforators with good vascularity. Therefore, on the basis of this anatomic consideration, palmar island flap can be elevated. This flap is a simple, reliable, effective, and versatile flap which could be borne in mind as the best option to the hand surgeons treating soft-tissue defects of the hand.

Introduction Distal radius fractures are common injuries that cause pain and disability. There is a clear need for biomedical engineering research to develop novel strategies to improve functional results following intra-articular distal radius fractures. However, no pharmacotherapeutic agent has been investigated to resolve this problem. The aim of this study was to evaluate whether the platelet rich plasma (PRP) can be considered as a novel additional therapy to improve the outcomes of this injury. Hypothesis Pain reduction and functional improvement can be noticed after PRP use in distal radius fracture. Materials and methods A randomized trial study was designed with 30 patients who had intra-articular distal radius fractures (Frykman types 3, 4, 7, 8). Closed reduction and percutaneous pinning under guide of fluoroscopy were done for them. Fifteen cases received intra-articular autologus PRP. Patients were followed for 3 and 6 months and “patient rated wrist evaluation” (PRWE) questionnaire was completed and range of motion of the wrist was measured. Results The mean of pain score and the score of specific and usual activities at 3 months follow-up in the case group and in the control group were (8.33 versus 19.67), (10.66 versus 26.8), and (6.2 versus 13.4), respectively. The mean of pain score and score of specific and usual activities at 6 months follow-up in the case group and in the control group were (3.6 versus 12), (3 versus 15.7), and (1.2 versus 6.8), respectively. The case group was significantly different from the control group. The mean of loss of flexion and extension of the wrist at 3 months follow-up in the case group was significantly different from the control group as well. Conclusion PRP may have significant effect on reduction of pain and amount of difficulty in functions including specific and usual activities after intra-articular distal radius fractures. Level of evidence Level III, therapeutic trial.

Objectives To investigate the role of sex-hormonal changes in idiopathic carpal tunnel syndrome (CTS) among post-menopausal women through measuring estrogen receptor (ER) expression in their transverse carpal ligament (TCL) and serum estrogen level, as well as determine the correlation between these factors and electrodiagnostic parameters and Boston score. Methods Biopsy samples of TCL were collected from 12 postmenopausal women who had undergone surgery for severe idiopathic CTS; control specimens were collected from 10 postmenopausal women without CTS who had undergone surgery for the other hand pathologies. To determine the distributions of ER in TCL, histological and immunohistochemical examinations were performed. Serum estrogen level was also measured. Electrodiagnosis and Boston questionnaire were used for CTS severity and determination of the patients' function. Results ER expression in TCL and serum estrogen level were not significantly different in the case group compared to the control group (P = 0.79 and P = 0.88, respectively). Also, there was no correlation between ER expression or serum estrogen level and electrodiagnostic parameters or Boston score. Conclusions Sex hormones cannot still be considered as the etiology of idiopathic CTS in postmenopausal women. The role of other factors such as wrist ratio and narrower outlet in females compared to the males should be considered along with hormonal changes.