Managing the soft tissue defects over the dorsum of hand: Our experience with Posterior Interosseous Artery (PIA) flap

Objective: To determine the outcome of posterior interosseous artery (PIA) flap in terms of coverage of the defects and survival of the flap in patients with complex defects over the dorsum of hand and distal forearm.

Methods: This descriptive study was conducted in Hand and Upper Limb Surgery (HULS) CMH Lahore Medical College, Lahore, Pakistan from 15th July 2017 to 15th August 2019.All patients with complex defects of the dorsum of the hand and distal forearm were treated with posterior interosseous artery (PIA) flap. Post operatively the grafts were observed for coverage of the defects and graft survival.

Results: The total number of patients were 24 with 19(79.1%) males and 05(20.8%) females. The mean age was 37±7SD(range 21 to 56 years). Right hand was involved in 17(70.8%) patients and left in 7(29.1%) patients. Complete coverage of the defects were achieved in all cases. Successful graft survival and uptake was seen in 20(83.3%) flaps. Partial loss was seen in 03 (12.5%) flaps which required debridement and subsequent Split Thickness Skin Grafting. Complete graft loss was seen in 01 (4.1%) flap

Conclusion: Posterior interosseous artery flap (PIA) had higher survival rates and larger area of the dorsum of the hand and distal forearm were entirely covered with this graft. We recommend posterior interosseous artery flap as first line surgical technique to treat complex tissue defects of the dorsum of the hand and distal forearm

Functional and clinical outcomes of open versus closed radius and ulna shaft fractures in adults: A prospective cohort study

Objective: To compare functional and clinical outcomes of open versus closed radius ulna shaft fractures in adults treated by internal fixation.

Methods: A prospective cohort study was conducted on patients presenting with traumatic radius and ulna shaft fractures to Aga Khan University and undergoing internal fixation between July 2015 to June 2019. Data was extracted from an ongoing orthopaedic trauma registry. Functional and clinical outcomes were assessed by Price et al. criteria at 6 weeks, 3, 6 and 12 months follow-up. Outcome scores of open versus closed fractures were compared.

Results: Twenty-nine adult patients with isolated radius and ulna shaft fracture were identified. Cause of injury was road traffic accident in 18 (62%) and fall in 11 (38%) patients. Seventeen (59%) were closed and 12 (41%) were open fractures. At 6week follow-up, better outcomes were observed in closed fracture group (p=0.01) with near-full range of motion and activity in 10(83%) patients as compared to 3(27%) in the open fracture group. No significant difference in outcomes was observed at 3 months and thereafter.

Conclusions: Earlier recovery of function at 6 weeks was observed in majority of patients in the closed fracture group. Our data shows that good-excellent functional and clinical results are achievable by internal fixation in both open as well as closed fractures of the shaft of radius and ulna in adults.

Postoperative analgesic effect of intrathecal dexmedetomidine on bupivacaine subarachnoid block for open reduction and internal fixation of femoral fractures

One of the drawbacks of subarachnoid block is the short duration of analgesia particularly when adjuvants are not added to local anesthetics agent used. However, dexmedetomidine an α2-adrenergic agent has been found to possess analgesic effect.
This study seeks to determine the analgesic efficacy of intrathecal 7.5 μg of dexmedetomidine and its side effects when used for open reduction and internal fixation (ORIF) of femoral fractures.
It is a prospective randomized, double-blinded study that was carried out in a Nnamdi Azikiwe University Teaching Hospital, Nnewi in Nigeria. Seventy American Society of Anesthesiologists I or II patients were randomized into two groups of 35 each to receive 3 ml of 0.5% hyperbaric bupivacaine combined with either 7.5 μg of dexmedetomidine in 0.3 ml of normal saline (Group D) or 0.3 ml of normal saline alone (Group S). Patient’s outcome measures noted (time to first request of analgesia, proportion of patients with pain score <4 postoperatively using numerical rating scale [NRS], and total analgesic consumed in 24 h.).
The patients in Group D had a longer time to first request of analgesia, larger proportion of patients with pain score 0.05). However, the patient satisfaction was better in Group D.
The addition of 7.5 μg of dexmedetomidine to bupivacaine for subarachnoid block in the management of femoral fractures using ORIF provided better anesthetic profile, particularly prolonged duration of postoperative analgesia without significant side effects.

Prophylactic surgical drainage is associated with increased infection following intramedullary nailing of diaphyseal long bone fractures: A prospective cohort study in Nigeria

Introduction: Prophylactic surgical drains are commonly used in Nigeria following intramedullary nailing (IMN) of long bone diaphyseal fractures. However, evidence in the literature suggests that drains do not confer any benefit and predispose clean wounds to infection. This study compares outcomes between patients treated with and without prophylactic surgical drainage following diaphyseal long bone fractures treated with IMN. Methods: A prospective cohort study with randomization was conducted at a tertiary referral center in Enugu, Nigeria. Investigators included skeletally mature patients with diaphyseal long bone (femur, tibia, humerus) fractures treated with SIGN IMN. Patients followed-up at 5, 14, and 30 days post-operatively. The primary outcome was surgical site infection (SSI) rate. Secondary outcomes included post-operative pain at 6 and 12 h, need for blood transfusion, wound characteristics (swelling, ecchymosis, and gaping), need for dressing changes, and length of hospital stay. Results: Of the enrolled patients, 76 (96%) of 79 completed 30-day follow-up. SSI rate was associated with patients who received a prophylactic drain versus those who did not (23.7% vs. 10.5%, p = 0.007). There were no significant differences in transfusion need (p = 0.22), wound swelling (p = 0.74), wound ecchymosis (p = 1.00), wound gaping (p = 1.00), dressing change need (p = 0.31), post-operative pain at 6 h (p = 0.25) or 12 h (p = 0.57), or length of stay (p = 0.95). Discussion: Surgical drain placement following IMN of diaphyseal long bone fractures is associated with a significantly higher risk of SSI. Reducing surgical drain use following orthopaedic injuries in lower resource settings may translate to reduced infection rates.

The Hidden Risk of Ionizing Radiation in the Operating Room: A Survey Among 258 Orthopaedic Surgeons in Brazil

Background: This study aims to assess orthopaedic surgeon knowledge in Brazil about ionizing radiation and its health implications on surgical teams and patients.
Methods: A 15-question survey on theoretical and practical concepts of ionizing radiation was administered during the 23rd Brazilian Orthopaedic Trauma Association annual meeting. The survey addressed issues within orthopedic surgery, such as radiation safety concepts, protection, exposure, as well as the participant gender. Participants were either orthopedic surgeons or orthopedic surgery residents working at institutions in Brazil.
Results: One thousand surveys were distributed at the moment of the meeting registration, and 258 were answered completely (25.8% response rate). Only 5.8% of participants used basic radiation protection equipment; 47.3% used a dosimeter; 2.7% reached the annual maximum permissible radiation dose; 10.5% knew the period of increased risk to fetal gestation; 5.8% knew the maximum permissible radiation dose during pregnancy; 58.5% knew that the hands, eyes, and thyroid are the most exposed areas and at greater risk of radiation-related lesions; 25.2% knew the safe distance from a radiation-emitting tube is 3 m or more; 44.2% knew the safest positioning of the radiation-emitting tube; 25.2% knew that smaller tubes emit greater radiation at the entrance dose to magnify the image; and 55.4% knew that the surgery team receives more scattered radiation in surgical procedures performed on obese patients.
Conclusion: This study revealed inadequate theoretical and practical knowledge about radiation exposure among orthopaedic surgeons in Brazil. Only a minority of orthopaedic surgeons used basic radiation protection equipment. No significant differences in knowledge were found when comparing all orthopedic surgery specialties. Our findings indicate an urgent need for education to increase knowledge among orthopaedic surgeons about the hazards of ionizing radiation. Personal protection and implementation of the ALARA (as low as reasonably achievable) protocol in daily practice are important behaviors to prevent the harmful effects of ionizing radiation.

Total Hip Arthroplasty for Femur Neck Fractures in Elderly Patients. A Multi-Centre Study from Pakistan

Introduction: The burden of hip fractures on health care systems and professionals is increasing with increase in life expectancy of patients. There is an increasing global trend for total hip replacement rather than Hemiarthroplasty for femur neck fractures in elderly patients. This is based on large series reported from various countries showing efficacy, safety and better functional outcome associated with this procedure. The concerns with Total hip replacement procedure include increased risk of dislocation, infection and anaesthetic complications. The adoption of this practice in developing countries pose additional challenges including access to medical facility, availability of equipped operating room, financial burden and the surgical expertise required for Total Hip Replacement for this unique group of patients.

Objectives: To evaluate the effectiveness and associated complications of total hip arthroplasty for femur neck fractures in elderly patients from various centres in Pakistan.

Materials and Methods: Retrospective cohort of patients from 3 different hospitals in the country was included. Data was obtained from prospectively held databases and patients with at least 12 months follow up were included in the study.

Results: A total of 63 patients were included in the study, including 27 males and 36 females with an average age of approximately 62 years. The commonest implant type used was cemented hip replacement with commonest head size being 32 mm. Only two patients had superficial wound infection, 1 patient had pulmonary embolism and 1 patient had dislocation at 2 months. No mortalities were reported during the study period.

Conclusion: THA is a safe option for carefully selected patients with neck of femur fractures. In a developing country, despite numerous constraints we are still able to reproduce the same results as published in the international literatur

Diagnostic Accuracy of Core Needle Biopsy in Bone Tumors. Results of 100 Consecutive Cases from a Sarcoma Unit in Pakistan

Background: Histological diagnosis is the main step towards management of bone tumors. Although open biopsy is considered as gold standard but core needle biopsy is advantageous because of its low cost, low morbidity rates and less time consumption. The aim of this study was to determine the diagnostic yield of core needle biopsy.

Methods: From January 2016 to December 2018, 100 consecutive patients with suspected bone tumors underwent core needle biopsy in a single unit. Patients between 5 to 90 years of age were included in the study. Informed consent was obtained from all patients. Core needle biopsy was performed under Local or General anesthesia depending of the location of tumor and age. Multiple cores were obtained and were sent to a single histopathological lab.

Results: Out of 100 patients, 61 were male and 39 were females. The age range was from 5 to 73 years with a mean of 39 years. Diagnosis was made in 91% of cases with approximately 4% of them being negative and 5% of the patients had inconclusive results. Only 3 patients required repeat biopsy. None of our patients had any complications.

Conclusion: Core needle biopsy for diagnosis of bone tumors has high diagnostic and accuracy rates with minimal associated complications.

International Collaboration in Total Joint Arthroplasty: A Framework for Establishing Meaningful International Alliances

Despite the increase in utilization of total joint arthroplasty (TJA) throughout high-income countries, there is a lack of access to basic surgical care, including TJA, in low- and middle-income countries (LMICs). Multiple strategies, including short-term surgical trips, establishment of local TJA centers, and education-based international academic collaborations, have been used to bridge the gap in access to quality TJA. The authors review the obstacles to providing TJA in LMICs, the outcomes of the 3 strategies in use to bridge gaps, and a framework for the establishment and maintenance of meaningful international collaborations.

Frequency of Vertebral Fractures in Patients presenting with Hip Fractures

Objective:To determine the frequency of vertebral fractures in patients presenting with hip fractures. Methods:This prospective study was conducted at The Indus Hospital, Karachi, from May 2018 to November 2018. All patients above 40 years presenting with hip fractures were enrolled and a dorsal lumbar lateral view radiograph was obtained to investigate for vertebral fractures. Data was entered and analyzed using SPSS. Post-stratification, Chi-square/Fisher exact test was applied as appropriate to assess the significant association. P value of ≤0.05 was considered significant. Results:Three hundred thirty five patients were enrolled. Of these, 189 (56.4%) were females and 165 (49.3%) presented with neck of femur fractures. Out of 335 hip fractures patients, 77 (23%) were found to have concomitant vertebral fractures, with 73 (96.1%) having a compression fracture. T12 was the most common vertebra involved and 68.8% of patients were asymptomatic. Co-morbid conditions were statistically significantly associated with vertebral fractures. Conclusion:There is a high prevalence of asymptomatic vertebral fractures in our population, but low compared to studies from western countries. There is a need to evaluate these fractures separately for the prevention of morbidity and mortality.

Operative Treatment of Traumatic Spinal Injuries in Tanzania: Surgical Management, Neurologic Outcomes, and Time to Surgery

Little is known about operative management of traumatic spinal injuries (TSI) in low- and middle-income countries (LMIC). In patients undergoing surgery for TSI in Tanzania, we sought to (1) determine factors involved in the operative decision-making process, specifically implant availability and surgical judgment; (2) report neurologic outcomes; and (3) evaluate time to surgery.

All patients from October 2016 to June 2019 who presented with TSI and underwent surgical stabilization. Fracture type, operation, neurologic status, and time-to-care was collected.

Ninety-seven patients underwent operative stabilization, 23 (24%) cervical and 74 (77%) thoracic/lumbar. Cervical operations included 4 (17%) anterior cervical discectomy and fusion with plate, 7 (30%) anterior cervical corpectomy with tricortical iliac crest graft and plate, and 12 (52%) posterior cervical laminectomy and fusion with lateral mass screws. All 74 (100%) of thoracic/lumbar fractures were treated with posterolateral pedicle screws. Short-segment fixation was used in 86%, and constructs often ended at an injured (61%) or junctional (62%) level. Sixteen (17%) patients improved at least 1 ASIA grade. The sole predictor of neurologic improvement was faster time from admission to surgery (odds ratio = 1.04, P = .011, 95%CI = 1.01-1.07). Median (range) time in days included: injury to admission 2 (0-29), admission to operating room 23 (0-81), and operating room to discharge 8 (2-31).

In a cohort of LMIC patients with TSI undergoing stabilization, the principle driver of operative decision making was cost of implants. Faster time from admission to surgery was associated with neurologic improvement, yet significant delays to surgery were seen due to patients’ inability to pay for implants. Several themes for improvement emerged: early surgery, implant availability, prehospital transfer, and long-term follow-up.