Задача о рюкзаке с выпуклыми монотонными сепарабельными функциями

Рассмотрена модельная задача о рюкзаке. Предложена схема решения задачи о рюкзаке с выпуклыми монотонными сепарабельными функциями

Management of resistant distal femur non-unions with allograft strut and autografts combined with osteosynthesis in a series of 22 patients

Introduction and Purpose: Challenges to the surgeon in managing cases of resistant non-union of the distal femur include poor bone stock, disuse osteopenia and joint contractures. Procedures varying from simple bone grafting to megaprosthesis revision have been described. We successfully managed such cases using our technique of combining cortical allograft struts to augment the defect in the femoral condyle coupled with autogenous iliac crest bone grafting and locking plate osteosynthesis. Materials and Methods: Between April 2012 and May 2014, 22 patients who presented with resistant nonunions of the distal femur following initial surgery were managed using this technique. Cortical allograft struts were taken from the tissue bank of our institution. All patients were followed up post operatively and their time to union was noted. Functional outcome was calculated using LEFS (Lower extremity functional score). The average follow up of all our patients was 24 months. Results: All patients went on to achieve complete bony union. The average union time was 6.2 months (5 to 8 months). One patient who was a diabetic had superficial infection post operatively which was treated successfully with IV antibiotics. Average knee flexion was 110 degrees (80 to 130 degrees). The mean LEFS score was 72 (59 to 79). Conclusion: Combing a locking plate fixation with the bone grafting technique of using an allograft strut to support the metaphyseal medial bone defect and autografts gives a good union and a good functional outcome in the management of resistant non-unions of the distal femur by enhancing the biology and providing a good structural support to the distal femur.</p

The effects of diabetes medications on post-operative long bone fracture healing

Purpose: Diabetes has long been known to have an impact on bone repair. More recently, however, most diabetic patients receive medications to normalise this hyperglycaemic environment. To date, no studies have investigated the effects of diabetic medications on fracture healing in humans. Method: Patients were identified from two tertiary trauma centres. Inclusion criteria were adult patients having sustained a closed diaphyseal femoral or tibial fracture, treated surgically. Exclusion criteria were open, pathological or peri-prosthetic fractures, and patients having sustained polytrauma. Matched non-diabetic controls were identified, matched for age, sex, fracture classification and osteosynthesis. Output measures were: time to callus first appearance, bridging of involved cortices and time to union, along with the eventual outcome: union/non-union. Results: A total of 36 (25 males) eligible patients were identified with a control group of 166 patients (138 males). ANOVA demonstrated class of medication to have a significant effect at two of the three time points and on the eventual outcome. Multiple regression analysis also demonstrated significant impact (p = 0.02). Conclusion: All classes of medication demonstrated anti-osteogenic effects compared to the control cohort. Biguanides demonstrated this in contrast to the in vitro evidence to date. Sulphonylureas demonstrated this to a greater extent; however, no in vitro evidence is available for comparison within this class. Clinicians should be aware of these delays in bone healing when treating diabetic patients and aim for optimal blood glucose control until such time as further research can be undertaken

Modified Capanna’s technique (vascularized free fibula combined with allograft) as a single-stage procedure in post-traumatic long-segment defects of the lower end of the femur: Outcome analysis of a series of 19 patients with an average gap of 14 cm

Objectives: Salvage and reconstruction of posttraumatic defects of the long bone are complex due to the multiple procedures involved and increased chances of poor outcomes. We present the outcomes of the modified Capanna’s technique—a reliable single-stage procedure of combining allograft and free vascularized fibular graft—in treating large posttraumatic bone defects in the distal third of the femur. Study Design: This is a retrospective analysis. Materials and Methods: Between April 2012 and September 2016, 19 patients with an average age of 33.8 years (range: 18–49 years) and an average defect of 14.5 cm (range: 9.5–20 cm) in the distal femur were managed by the modified Capanna’s technique. Bone union time and functional outcome using lower extremity functional score (LEFS) after union were noted. Outcomes and Results: Eighteen grafts went onto achieve bony union at an average of 6.6 months (range: 5–9), with an average knee flexion of 80 degrees (range: 45–110 degrees) and an average LEFS of 63 (range: 46–72). One patient had a nonunion with graft resorption at 8 months following persistent infection and was revised with debridement and augmenting the vascularized fibula from the other leg which went on to achieve union. Three patients had superficial infection, and three patients had delayed union. Conclusion: The modified Capanna’s technique provided increased biology and enhanced structural stability and therefore is a good single-stage procedure in the reconstruction of posttraumatic long-segment defects of the distal femur. Level of Evidence: Level 4. Level of Clinical Care: Level I tertiary trauma center.</p

The role of a trauma review system and development of intra-operative checklists in improving the quality of fracture fixations in a high volume tertiary centre

Introduction In high volume centres, audits are essential to ensure good surgical techniques and fracture fixations to avoid complications, revision surgeries and poor outcomes. A method to assess fixations for fractures of different regions employing different implants and surgical demands is a challenge. We present here a simple method of review and follow-up work flow of more than 6000 fixations every year that helped in improving outcomes and also provide training for residents and junior staff. Materials and methods The results of 6348 fracture fixations in 2014, led to a trauma review system in January 2015 to classify all fracture fixations by senior consultants into three categories: category A (good fixations); category B (acceptable fixations; need further follow-up); category C (poor/unacceptable fixations needing revision) combined with a teaching program. A strategy was evolved that included the following practices: (1) identifying ‘red flag’ fractures that led to frequent failures, (2) routine senior surgeons’ involvement in such fractures, (3) evolving ‘intra-operative checklists’, (4) requirement of senior surgeons’ intervention if there was a ‘fiddle time’ of more than 20 min, and (5) approval of post-fixation c-arm image by a senior person before closure. The impact of these rules on the fixations for 2015, 2016 and 2017 were prospectively analysed. Results In the years 2015, 2016 and 2017 the number of fracture fixations performed were 6579, 6978 and 7012, respectively. There was a significant increase (p  Conclusion We present here a very effective, tested, simple and easily reproducible method of audit and follow-up work flow that can be used in all high turnover trauma centres to improve outcomes and can also serve as a teaching resource for junior staff. Study design Prospective study. Level of evidence Level II.</p

Retinopathy of prematurity: Incidence, prevalence, risk factors, and outcomes at a tertiary care center in Telangana

Aims: To evaluate the incidence of retinopathy of prematurity (ROP), prevalence of pre-and postnatal risk factors for development of ROP, and treatment outcomes among preterm infants admitted to the Neonatal Intensive Care Unit (NICU) of a tertiary care hospital located in Hyderabad. Materials and Methods: Retrospective chart review of all infants admitted to the NICU between 2008 and 2013, who met the criteria for ROP screening: (a) ≤34 weeks of gestation, (b) ≤1750 g of birth weight, (c) infants with significant risk factors including sepsis, respiratory distress syndrome, or long-term oxygen use. Treatment was offered to infants with Stage III ROP disease or Stage II in Zone II with plus disease. Qualified infants were treated with argon laser photocoagulation within 48 h of diagnosis. They were followed until the disease was successfully treated. Results: A total of 2910 infants were admitted to the NICU. Incidence of ROP was found to be 2.3% (n = 66), the majority of whom (71%) had Stage I ROP. Seventeen percent of the infants weighed <1000 g. The most prevalent prenatal risk factor was multiple gestations (17%). Prevalent postnatal risk factors included oxygen treatment (71%) and respiratory distress syndrome (58%). Twelve percent (8/66) of infants met the treatment threshold. Following argon laser, regression was observed in 100% of infants, with no recurrence with follow-up between 1 and 4 years after treatment. Conclusions: This is the first study to evaluate the incidence of ROP in Telangana. Argon laser photocoagulation appears to be effective in the treatment of infants in this population. We recommend screening infants ≤32 weeks of gestation and infants born ≤1700 g birth weight

A surgical algorithm for the management of recalcitrant distal femur nonunions based on distal femoral bone stock, fracture alignment, medial void, and stability of fixation

Background: Recalcitrant distal femur nonunions (RDFN) are a challenge in management due to factors including poor bone stock, multiple surgeries, metaphyseal bone loss, and joint contractures. There are no specific guidelines in the management of cases of RDFN. Based on our experience, we devised an algorithm and we present the results of 62 cases of RDFN managed following it. Materials and methods: Our algorithm was formulated after analyzing 34 cases of RDFN and it involved four factors which were hypothesized to influence outcomes namely: distal femoral bone stock, extent of medial void, alignment of the fracture, and stability of fixation. Each factor was addressed specifically to achieve a good outcome. Between 2012 and 2015, 62 patients with RDFN at a mean age of 47.4 years (26–73) and 2.3 prior surgeries (2–6) were managed following the algorithm. Intervention: 58 patients required revision osteosynthesis to improve alignment and achieve a stable fixation. 4 elderly patients with poor bone stock were managed with arthroplasty. Extent of medial void was found to significantly influence surgical decision making. Five patients without medial void required only cancellous autograft bone grafting, 47 patients with  2 cm were managed with medial plating. Outcomes and results: 57 patients treated with osteosynthesis achieved union at an average of 7.4 months (6–11) and the 4 patients managed with arthroplasty also had a favourable outcome. One patient who was managed with revision osteosynthesis had a nonunion with an implant failure and needed an arthroplasty procedure. The average LEFS (lower extremity functional score) of all our patients was 67 (51–76) at an average follow-up of 18.2 months (12–33). Conclusion: Our stepwise surgical algorithm would help surgeons to identify the factors that need to be addressed and guide them towards the interventions that are necessary to achieve a successful outcome while managing cases of RDFN.</p

Surgery for stage 5 retinopathy of prematurity: The learning curve and evolving technique

Purpose: To describe our experience with management of eyes with stage 5 retinopathy of prematurity (ROP) Methods: Closed vitreoretinal surgery was done on 96 eyes of patients with stage 5 ROP. Lens was sacrificed in all but one eye. Surgery involved an attempt to clear all preretinal tissue and open the peripheral trough all round. In most instances bimanual surgery under viscoelastic was performed. Results: At last follow up, anatomical success (defined as attached posterior pole) was achieved in 22.5&#x0025; cases. Significant postoperative problems included reproliferation and secondary glaucoma. Only two infants obtained mobile vision. Conclusion: Late identification of disease, lack of prior treatment such as laser or cryo, and higher incidence of narrow-narrow funnel configuration were responsible for the poor surgical results noted in this series. The poor surgical and functional results reemphasise the need for prompt screening and management of infants at risk

Variation in practice preferences in management of open injuries of extremities—an international survey by SICOT research academy

Purpose Open fractures are challenging injuries and there is a lot of variation in practice preferences which may reflect the wide variations in outcome in different units across the world. A survey was done amongst the international community of SICOT membership to document the practice preferences and variations. Methods An online questionnaire containing 23 questions which were sub-divided into three sections covering the various aspects of open injury management was sent by email to orthopaedic trauma surgeons across the world. A total of 358 responses were evaluated and presented in this manuscript. Results The SICOT study confirmed wide variation in practice protocols. About 94.7 % of orthopaedic surgeons around the world use the Gustillo Anderson scoring system for assessment of open injury and 50.6 % of surgeons prefer lavage in operation theatre. For lavage, 84.6 % of surgeons preferred normal saline and for antibiotic prophylaxis, 48.3 % used a combination of second generation cephalosporin, metronidazole and an aminoglycoside for a minimum of three to five days. In 88 % of patients, orthopaedic surgeons performed the initial debridement and 69.2 % surgeons aimed for debridement within six hours. Regarding wound management, 43.9 % units preferred and were capable of soft tissue cover within 72 hours and about 26.3 % surgeons combined definitive fixation along with plastic procedure. Conclusion Our study documented wide variations in practice preferences across the world and showed that information and awareness about current guidelines and practices will help many to update themselves in terms of basic questions about open fracture care.</p