Iskandar Tamimi

Background: This study aimed at investigating the prolonged effects of glucocorticoids and bisphosphonates on bone. Methods: Six-to-eight-month-old skeletally mature male Sprague Dawley rats were randomized to receive a cancer therapy combination of zoledronic acid (ZA = 0.13 mg/kg) and dexamethasone (DX = 3.8 mg/kg) (treatment group, n = 10) or sterile phosphate buffer saline solution (control group, n = 10). The rats received weekly intraperitoneal injections for 8 weeks, which were stopped 6 weeks before euthanasia. Mineralized bone samples were characterized by three-point bending tests, micro-CT imaging, X-ray diffraction (XRD), thermogravimetric analysis (TGA), and differential scanning calorimetry (DSC). Bone collagen was assessed using tensile tests on the demineralized bones and attenuated total reflectance Fourier transform infrared (ATR-FTIR) spectroscopy on mineralized and demineralized bones. Results: The samples in the treatment group showed increased tibial cortical thickness, mineral crystal size, and toughness. Analyses of demineralized tibiae revealed decreased collagen tensile strength in the experimental group. The spectroscopic and TGA/DSC analyses showed that the ZA + DX treatment increased the collagen amide I 1660/1690 cm⁻¹ area ratio and collagen denaturalization temperature, indicating a higher level of collagen cross-linking. Conclusions: Bisphosphonates and glucocorticoids led to prolonged changes in the mechanical properties of bone as a result of increased cortical thickness, increased crystal size, and the deterioration of collagen quality.

The concept of brain concussion is still controversial among researchers and clinicians who address this type of head injury from different perspectives. Some clinicians prefer the term “concussion,” while others favor the term “mild traumatic brain injury” (mTBI). Brain concussion, or mild head injury, affects temporary brain function with clinical symptoms that may include loss of consciousness, memory loss, blurred vision, and confusion. The main etiology includes road traffic accidents, falls, and sports injuries. Brain concussion, or mTBI, is the most common type of head injury. The definition and pathophysiology of this condition are still controversial since research on this topic has been mainly based on animal experimentation. However, recent advances, including neuroimages and neurophysiology, have improved the understanding of brain concussion. This chapter will address the history, background, definition, classification, diagnosis, symptoms, complications, outcome, treatment, prevention, and challenges related to this condition.

Background: Meniscal repair in bucket-handle tears has proven to be effective. However, when such lesions are chronically displaced and adhered to intercondylar soft tissues, their repair may be considered unfeasible. Accordingly, the objective of this study is to show the surgical technique for the reduction and repair of this type of injury and to evaluate the long-term outcomes of such repairs. Materials and Methods: We conducted a retrospective case series of eight patients who were identified between 2006 and 2015 and presented with chronically displaced, medial meniscus bucket-handle tears. The bucket-handle tears were reduced, and the medial meniscus was repaired in all cases. The knee was immobilized in full extension and maintained nonweight bearing for 2 weeks. Then, the range of movement was limited from 0° to 90° and kept partially weight bearing for 4 more weeks. Results: The mean age of the patients was 27.2 years. The mean time to surgery was 7.12 ± 4.4 months, and the mean follow-up time was 10.0 ± 3.4 years. The average preoperative and postoperative Lysholm score was 58.0 ± 16.2 and 95.9 ± 3.4, respectively (P = 0.008). The mean preoperative and postoperative Tegner was 5.5 ± 1.1 and 5.1 ± 1.1, respectively (P = 0.109). The average KT-1000 of the participants was 1.2 ± 1.2, and the mean International Knee Documentation Committee was 92.9 ± 5.0. The average Ählback score at follow-up was 0.83 ± 0.4. Conclusions: The treatment of chronically dislocated bucket-handle tears can be successfully achieved by the sequential release and suture of the torn meniscus. Good outcomes and low rates of osteoarthritis were observed at 10-year follow-up. Level of Evidence: IV

(1) Purpose: The incidence of anterior cruciate ligament (ACL) ruptures in children and adolescents has considerably increased during the last decades due to higher levels of competitive athletic activity, and early sport specialization and professionalization. Contemporary ACL reconstruction techniques have recently been subject to renewed interest in this population. The objective of this study is to report the short- and mid-term results of our physis-sparing ACL reconstruction technique using an “over the top” technique associated with a modified Lemaire procedure. (2) Methods: A retrospective series of 12 junior soccer players who presented to our clinic with a torn ACL between January 2019 and September 2021 was reviewed. The inclusion criteria were patients under 15 years with open tibial and femoral physes, with a stable contralateral knee, a minimum follow-up of 6 months, and a time frame from injury to surgery of <3 months. Patients with previous knee surgery, structural concomitant injuries, muscular, neurological, or vascular abnormalities, or hypersensitivity to metal alloys were excluded. The functional evaluation was performed using the International Knee Documentation Committee (IKDC) rating, Lysholm score, and Tegner activity level. Moreover, clinical and radiological assessments were also performed, including KT-1000 and knee X-rays. (3) Results: We identified 1 female and 11 male patients with ACL tears, with a mean age of 13.17 ± 0.9 months. Concomitant injuries include isolated vertical and bucket-handle tears of the medial meniscus, lateral meniscus tears, bilateral tear of both menisci. The mean follow-up time was 26 ± 12.6 months. The average IKDC, Lysholm and Tegner scores were 93.29 ± 11.04, 95.08 ± 13.2 and 9 ± 0.0 points, respectively. The average KT-1000 score of the participants was 0.96 ± 1.6 points. None of the included patients reported post-surgical complications or required additional surgeries. (4) Conclusions: Our novel ACL reconstruction with LET technique is a safe procedure that resulted in good clinical outcomes, lower failure rate and return to sports in skeletally immature patients.

Background: Research has indicated that β-blockers may downregulate various inflammatory mediators that are involved in osteoarthritis (OA). The objective of this study was to analyze the likelihood of total knee arthroplasty (TKA) among patients with OA who were being treated with β-blockers. Methods: A nested case-control study was conducted with use of clinical records from our institutional database. We included patients who attended our outpatient clinic with a history of new-onset knee pain between 2010 and 2019. The case group included individuals who had undergone primary TKA between 2018 and 2019, whereas the control group included subjects who had not undergone TKA. Controls were matched by date of birth ±2 years, sex, calendar time (first outpatient visit ±1 year), and the grade of arthritis; the control-to-case ratio was 1:1. Adherence to β-blocker use was measured with use of the proportion of days covered (PDC) (i.e.,<0.25, ≥0.25 to <0.75, ≥0.75), and the cumulative effect was measured on the basis of the total number of years of treatment with β-blockers. A binary logistic regression analysis adjusted to potential confounders was carried out to assess the risk of TKA associated with the intake of β-blockers. Results: A total of 600 patients were included (300 in the case group and 300 in the control group). Compared with non-users, any use of β-blockers during the follow-up period was associated with a reduction in the likelihood of undergoing TKA (adjusted odds ratio [OR], 0.51; 95% confidence interval [CI], 0.34-0.77). The adjusted ORs for the use of selective β1-blockers and nonselective β1-blockers were 0.69 (95% CI, 0.36 to 1.31) and 0.42 (95% CI, 0.24 to 0.70), respectively. The adjusted ORs for any recent use, PDC of <0.25, PDC of ≥0.25 to <0.75, and PDC of ≥0.75 were 0.65 (95% CI, 0.51 to 0.99), 0.62 (95% CI, 0.21 to 1.85), 0.32 (95% CI, 0.09 to 1.22), and 0.55 (95% CI, 0.34 to 0.88), respectively. Regarding the cumulative effect of β-blockers, the adjusted ORs for the use for <1 year, ≥1 to <5 years, and ≥5 years were 0.41 (95% CI, 0.20 to 0.85), 0.52 (95% CI, 0.21 to 1.33), and 0.36 (95% CI, 0.22 to 0.60), respectively. Conclusions: The use of nonselective β-blockers was associated with a lower likelihood of undergoing TKA. Patients treated for prolonged periods were at a lower likelihood for undergoing TKA. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Purpose To compare the outcomes of arthroscopic anterior Bankart repair with and without associated postero-inferior capsulolabral repair as treatment of anterior glenohumeral instabiliy at minimun 10 year follow-up. Methods A retrospective comparative study including patients who underwent arthroscopic anterior Bankart repair to treat anterior glenohumeral instability with glenoid bone-loss < 15% between January 2000 and February 2010 was performed. Outcomes were reported as recurrence rate, type of recurrence (dislocation or subluxation), need for revision surgery, range of motion, complications, and functional status. Outcomes were compared depending on whether a postero-inferior capsulolabral repair was added to the anterior Bankart repair. Results 70 shoulders [59 males, mean age 28.2 (range 14–56), mean follow-up 146.1 (range 120–208) months] were included. Recurrence occurred in 9 cases (12.8%), including 3 dislocations and 6 subluxations. Revision surgery was needed in 8 (11.4%). Mean Rowe score improved from 29.7 (11.6) preoperatively to 87.1 (12.3) postoperatively. 83.3% returned to previous sports activities. Mean forward flexion changed from 173.5° (19.2) to 168.4º(10.4) (P < 0.01), external rotation from 81.4° (18) to 75.7° (10.5) (P < 0.01), and internal rotation decreased from 66.2% reaching T12 to 14.1% (P < 0.01). Addition of postero-inferior capsulolabral repair did not influence any of the outcomes significantly. Conclusion Postero-inferior capsulolabral repair added to anterior Bankart repair as treatment of anterior glenohumeral instability in abscence of significant glenoid bone-loss did not influence the outcomes in terms of recurrence, range of motion, return to sports, or functional status, compared to isolated anterior Bankart repair at 12.2 year follow-up. Level of Evidence Level III.

Introduction: The use of proton pump inhibitors (PPIs) has been associated with a higher risk of osteoporotic fractures and non-unions rates. However, the relation between the use of PPIs and the development of aseptic loosening in arthroplasty procedures has not been studied. The objective of this study is to analyze the relation between the use of PPIs, and the risk of early aseptic loosening in total knee arthroplasty (TKA) and total hip arthroplasty (THA). Materials and methods: A nested case-control study was conducted on patients who were subjected THA or TKA in our center between 2010 and 2014. Cases were patients subjected to revision surgery due to early aseptic loosening during the study period. Cases were matched with controls who did not require any type of revision surgery by type of joint replacement (THA/TKA), gender, age (+/− 2 years), and follow-up time (±6 months). Odds Ratios were adjusted to potential confounders. Results: The crude and adjusted ORs (95% CI) of undergoing revision surgery for aseptic loosening following primary total knee arthroplasty or total hip arthroplasty, were 6.25 (2.04–19.23) and 6.10 (1.71–21.73), respectively, for any use PPIs compared with non-users. Crude and adjusted ORs, were 11.6 (2.93–45.88) and 17.1 (2.41–121.66), respectively, for patients with a Proportion of Days Covered (PDC) for PPIs <.5 (Table 2). In addition, the crude and adjusted ORs of undergoing revision surgery, were 5.05 (1.59–16.02) and 5.01 (1.36–18.44), respectively, for patients with a PDC for PPIs ≥.5. Discussion: These results suggest that PPIs should be used with caution in patients with TKA and THA, and that the use of these drugs should not be prolonged unless there was a justifiable indication. Conclusions: The use of PPIs and was associated with a higher risk of early aseptic loosening in patients subjected to THA and TKA.

Background Proton pump inhibitors (PPIs) are one of the most frequently used drugs worldwide. Previous research has shown that they could increase the risk of fracture and interfere with the fracture healing process. In this study, we analyzed the effect of PPIs on the risk of fracture non-union in patients with femoral and tibial shaft fractures. Methods A case–control study was conducted at our institution, including a total of 254 patients who underwent fixation surgery for a femoral or tibial shaft fracture between January 2012 and December 2017. We defined cases as patients who experienced a delayed union (case group A; n = 44), or non-union (cases group B; n = 12). Cases were matched by age, sex, and fractured bone, to 144 controls who did not experience delayed fracture union and did not require further procedures. A conditional logistic regression analysis was performed adjusted to potential confounders, and to the proportion of days covered (PDC) with PPIs. Results Adjusted ORs (95% CI) for undergoing a nail dynamization following a tibial or femoral shaft fracture were 1.38 (0.70–2.65) for any use PPIs. Patients with a longer PPI treatment courses (PDC ≥ 0.5) had an adjusted OR of 1.86 (0.70–4.76) for undergoing nail dynamization when compared with controls. Contrastingly, patients with a PDC < 0.5 had an adjusted OR of 1.03 (0.43–2.48). The adjusted OR (95% CI) for undergoing additional surgical procedures due to non-union was 4.5 (0.62–32.8) for any use of PPIs, and 12.3 (1.9–81.0) in patients with a PDC ≥ 0.5. Conclusions A prolonged use of PPIs use was associated with a higher risk of fracture non-union in tibial and femoral shaft fractures.