Long-term clinical and functional outcomes of distally based sural artery flap: A retrospective case series

Background: Reconstruction of soft tissue defects around the lower leg, foot and ankle is a challenge for orthopedic surgeons. These defects commonly occur as a result of trauma, infection and tumor excision. Sural artery neurovascular island flap is a relatively thin, pliable and insensate flap with minimum donor-site morbidity and acceptable aesthetic outcome.Methods: A retrospective analysis of a case series was conducted, all operated by a single surgeon over a period of 25 years from July 1996 to February 2020. Data were collected through a structured proforma; the variables included were as follows: demographic data, mechanism of injury, defect site and size, size of flap, hospital stay, complications, outcome of flap and functional status of limb. Data analysis was performed by using SPSS version 25.0.Results: We included 89 patients out of 106, with 92 distally based sural artery flaps. The flap coverage was divided in two groups: group I for leg (n=41) and group II for foot (n=51). The mean flap dimension in leg was 9.98 ± 2.2 cm and 12.15 ± 3 cm in foot. Postoperatively functional outcomes were assessed using a self-designed tool and graded as excellent in 79 cases (leg=38; foot=41), good in 10 cases (leg=2; foot=8), fair in 3 cases (leg=1; foot=2) and poor in zero cases. All flaps survived uneventfully.Conclusion: The reverse sural artery flap is versatile and reliable, and can be performed easily with good knowledge and using a microsurgical technique. It is useful for the reconstruction of soft tissue defects around the lower third of the leg, dorsum of the foot, malleoli and hind foot. The functional range of motion of the ankle is not compromised because of the flap\u27s supple and pliable nature. The reverse sural artery flap is ideal for the coverage of the foot, ankle and lower one third of the leg. This flap is insensate and not suitable for the weight-bearing area of the heel

Functional and radiological outcomes of atypical femur fractures among elderly in Karachi, Pakistan

Objective: To assess the functional and radiological outcomes in a unique class of fractures i.e. atypical femur fractures and to assess the effects of osteoblastic agents in healing.Methods: It is a retrospective observational study conducted at Aga Khan University Hospital, Karachi, Pakistan. All patients with atypical femur fractures who were surgically managed with intramedullary nailing from January, 2013 to June, 2017 and with a follow-up till December 2019, were included in the study. Radiological outcomes were expressed as mean healing time and functional outcomes were recorded as mean Short Musculoskeletal Functional Assessment (SMFA) score.Results: A total of twenty-four patients were included in this study. Mean age of patients was 65.8 ± 8 years. Mean healing time was 10 ±3.2 months post operatively. Two patients underwent redo procedures. No other complications like paresthesia or weakness was observed in any patients. All the patients reported a good score on SMFA ranging from 19% to 31%.Conclusion: Intra-medullary nailing shows a promising result in treatment of atypical femur fractures. Use of post-operative osteoblastic supplements showed statistically significant results with early healing time (p=0.008 [95% CI])

Proximal femur locking plate for sub-trochanteric femur fractures: Factors associated with failure

Introduction: Proximal femur locking compression plates (PF-LCP) have gained popularity since their inception due to superior biomechanical stability and durability but clinical experience has shown conflicting results including implant failure.Objective: To study the incidence of implant failure in patients with sub-trochanteric fractures managed with proximal femoral locking compression plate and identify potential risk factors associated with the failure.Materials & Methods: Fifty patients with sub-trochanteric fractures, operated upon with titanium PF-LCP were included in the study from January 2012 to December 2014. These plates were of two designs including one five 5.0 mm proximal locking screws (implant A) and other with three 6.5 mm proximal locking screws (implant B). Fractures were classified according to AO/OTA and Seinsheimer classification. Patients had regular follow-up visits for at least a year, allowing for clinical and radiological assessment of union and implant-related complications.Results: A total of 13 out of 50 (26%) plates failed of which 7 were implant fractures, 3 screw breakage and 3 screw cut outs. 70% of the failures occurred in elderly females. Overall implant failure was significantly more common in patients \u3e50 years (p 0.04). Comparing the two different designs of implants used, implant A was more likely to fail at a plate screw density of 0.8 or more (p 0.02), whereas implant B was associated with significant failure when less than 4 proximal screws were used (p 0.03).Conclusion: This study revealed a high failure rate (26%) of this implant. Attention to the neck shaft angle difference, number of proximal screws and plate screw density may help reduce failure rates, particularly in elderly osteoporotic females

Early experience of dynamic hip screw with spiral blade and locking side plate for the stabilization of trochanteric fractures.

Abstract OBJECTIVE: To evaluate early experience with helical hip system in osteoporotic elderly patients with per-trochanteric fractures. METHODS: The retrospective study was conducted at Aga Khan University Hospital, Karachi, and comprised records of patients having low-velocity pertrochanteric fractures who were fixed with spiral blade Dynamic Helical Hip Systemfrom July to December 2014 and were followed up for a minimum of 3 months. Demographic variables and clinical outcomes were noted from the medical records whereas operative details were recorded from the operative note. Radiological variables and outcomes were assessed by viewing appropriate pre-operative, post-operative and follow-up radiographs. RESULTS: Of the 32 patients in the study, 14(44%) were men and 18(56%) were women, with an overall mean age of 77.81±7.04 years and mean body mass index of 25.99±4.13 kg/m2. Of the total, 1(3.13%) patient had implant cut-out, 1(3.13%) had myocardial infarctionand 2(6.2) expired. CONCLUSIONS: The introduction of spiral blade dynamic hip screw manifested favourable results and good clinical and radiological outcomes with low cut-out rates

Change in the spectrum of orthopedic trauma: Effects of COVID-19 pandemic in a developing nation during the upsurge; a cross-sectional study

Background: The COVID-19 pandemic has caused a great impact on orthopedic surgery with a significant curtailment in elective surgeries which is the major bread and butter for orthopedic surgeons. It was also observed that the spectrum of orthopedic trauma injuries has shifted from more severe and frequent road traffic accidents (high energy trauma) to general, low energy house-hold injuries like low energy fractures in the elderly, pediatric fractures, house-hold sharp cut injuries and nail bed lacerations. The aim of this study is to appraise the effect of the COVID-19 pandemic on orthopedic surgical practice, both inpatient and outpatient facility.Materials and methods: This is a retrospective cross sectional study conducted in a tertiary care teaching hospital. We collected data of patients admitted from February 1, 2020 to 30th April 2020 in the orthopedic service line using non-probability consecutive sampling. This study population was divided into pre-COVID and COVID eras (6 weeks each). The data included patient demographic parameters like age, gender and site of injury, mechanism of injury, diagnosis and procedure performed and carrying out of COVID-19 Polymerase Chain Reaction (PCR) test in the COVID-era.Results: We observed that outpatient clinical volume decreased by 75% in COVID era. Fifty percent of surgical procedures decreased in COVID era as compared to pre-COVID era. Trauma procedures reduced by 40% in COVID era. Most common mechanism of injury was household injuries like low energy falls. A significant reduction in elective surgeries by 67% was observed in the COVID era.Conclusion: The impact of COVID-19 pandemic has significantly changed the spectrum of orthopedic injury. More household injuries have occurred and are anticipated due to the ongoing effects of lockdown

Outpatient percutaneous release of trigger finger: A cost effective and safe procedure

Introduction: Trigger finger is a common cause of pain and disability of the hand. Percutaneous release results in earlier functional recovery and patient satisfaction. This is a rapid and cost-effective method which saves a surgical procedure and results in better functional outcome.Materials and Methods: This is a prospective observational study conducted on fifty-two fingers and thumbs in 52 patients treated from 1st July 2014 till 31st December 2014, in the Orthopaedic Section, Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan. All the baseline characteristics of the patients, like demographics, symptoms, Quinell\u27s criteria and functional outcome were recorded. The patients were treated at our hospital with trigger finger, managed with percutaneous release using an 18 gauge needle and followed up for a minimum period of three months. The follow-up information included range of motion scoring, patient satisfaction and overall outcome of the procedure in terms of patient acceptance. The data was analyzed to determine the functional outcome at three months.Results: There was complete release of A1 pulleys in 52 out of 52 digits (100%) in the patients undergoing percutaneous release and significant patient satisfaction. No recurrence was observed.Conclusion: Percutaneous release of trigger finger with needle was not only associated with excellent functional outcome and recovery in terms of patient satisfaction and range of finger motion three months post-procedure but also was found to be cost effective

Covid-19 pandemic: Economic burden on patients with musculoskeletal injuries in a tertiary care hospital of LMIC; retrospective cross sectional study

Covid-19 has adversely impacted the health care organizations by over burdening with Covid patients and suspending the elective surgeries and clinics. Hospitalization during pandemic may increase health cost of patients for elective and emergency procedure due to extra cost of covid testing and isolation. A single center retrospective study was conducted to quantify losses due to postponement of elective surgeries and extra cost for procurement of PPEs. The secondary objective was to see the effect of Covid -19 on the total costs of inpatient care during Covid era.Patient and method: We included all the patients admitted in orthopedic section for operative intervention of fractures and elective procedures from January 1, 2020 to May 31, 2020. We divided this period into two halves; the first half was from January first to March 15 named as PreCovid Era and second half was from March 16, to May 31, 2020, termed as Covid Era. The total number of trauma procedures and elective procedures were compared in both eras. We compared six procedures each from upper and lower limit for cost analysis and length of stay. We also analyzed the extra cost for procurement of PPEs.Results: A total 625 patients were admitted during study period; 417 in precovid and 208 in covid era. There was 50% reduction in patients admissions during Covid era. There was no statistically significant difference in age and gender of both groups. A total of 840 (591in preCovid era and 251 in Covid era) procedures were performed on these 625 patients. Elective and emergency procedures were significantly reduced in Covid era. There was 55.7% drop in the collective revenue generated in covid era as compared to that of Precovid era. The average length of stay was decreased in Covid era. No statistically significance difference was found in inpatient hospital charges of both groups except for two procedures ankle and proximal humeral fractures; that was significantly reduced in Covid era. There was significantly increase in use of PPE in covid era.Conclusion: The financial income of our service decreased more than 55% due to postponement of elective work. The number of elective and procedures related to musculoskeletal trauma also decreased. The cost for inpatient care did not increase during covid era. There was significant reduction in inpatient hospital stay during covid era. The hospital management had to spent additional expenses on procurement of PPEs

Insight into the molecular pathophysiology of myelodysplastic syndromes: targets for novel therapy

Myelodysplastic syndromes (MDS) are clonal hematopoietic stem cell disorders characterized by abnormal cellular differentiation and maturation with variable progression to acute leukemia. Over the last decade, scientific discoveries have unraveled specific pathways involved in the complex pathophysiology of MDS. Prominent examples include aberrations in cytokines and their signaling pathways (such as tumor necrosis factor-alpha, interferon-gamma, SMAD proteins), mutations in genes encoding the RNA splicing machinery (SF3B1, SRSF2, ZRSR2, and U2AF1 genes), mutations in genes disrupting the epigenetic machinery (TET2, DNMT3A, DNMT3B, EZH2, ASXL1). In addition, abnormalities in regulatory T-cell dynamics and atypical interactions between the bone marrow microenvironment, stroma and progenitor cells, and abnormal maintenance of telomeres are also notable contributors to the complex pathogenesis of MDS. These pathways represent potential targets for novel therapies. Specific therapies include drugs targeting aberrant DNA methylation and chromatin remodeling, modulating/activating the immune system to enhance tumor-specific cellular immune responses and reduce anomalous cytokine signaling, and blocking abnormal interaction between hematopoietic progenitors and stromal cells

Biopsy Proven Renal Morphology Cognizance into its Four-Year Evolving Pattern; A Pakistani Perspective

Objective: To determine the pattern of Biopsy Proven Renal Diseases (BPRD) in a single tertiary care centre in Islamabad, Pakistan. Study Design: Cross-sectional study. Place and Duration of Study: Department of Nephrology, KRL Hospital, Islamabad Pakistan, from Mar 2016 to Nov 2020. Methodology: The archival records of all native renal biopsies performed in adults (>18 years) were retrospectively analyzed.The biopsies were performed according to standard indications and evaluated by light microscopy and immunofluorescence. Results: A total of 134 renal biopsies were studied. Among these, 85(61.1 %) were males, and 49(36.5 %) were females. The mean age was 44.70±14.63 years. Primary glomerulonephritis’s were the predominant group of diseases found in 93(69.4%) cases. Membranous nephropathy (MN) was the most common lesion in 52(38.8%), followed by focal segmental Glomerulosclerosis (FSGS) in 22(16.4%) cases. Chronic tubulointerstitial nephritis (Ch. TIN) 12(9.0%) was the third most common lesion among all biopsies. Other diagnoses included lupus nephritis (LN) 10(7.5%) and IgA nephropathy (IgAN) 9(6.7%). One sample one-sided t-test was used to estimate the minimum proportion of occurrence of different biopsies in our concerned population. The estimated minimum proportion of membranous nephropathy (MN) was 0.31, with a p-value of 0.034. Conclusion: We concluded that primary Glomerulonephritis (PGN) is the most common renal disease, and membranous nephropathy is the most common biopsy-proven Glomerulopathy in our concerned population

Venous thromboembolism following hematopoietic stem cell transplantation-a systematic review and meta-analysis

Venous thromboembolism (VTE) is a common complication of hematopoietic stem cell transplantation (HSCT). Graft-versus-host disease (GVHD) is another complication of HSCT that may modify the risk of VTE. Our objective was to explore the incidence of VTE (deep venous thrombosis and pulmonary embolism) following HSCT and to evaluate its association with GVHD. A comprehensive search of Medline In-Process & Other Non-Indexed Citations, MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Scopus was conducted to search for both retrospective and prospective HSCT studies which had reported VTE. Random-effects meta-analysis was used to pool incidence rates. We included 17 studies reporting on allogeneic- and 10 on autologous-HSCT; enrolling 6693 patients; of which 5 were randomized. The overall incidence of VTE after HSCT was 5%(4-7%). Incidence in allogeneic-HSCT was 4%(2-6%) and in autologous-HSCT was 4%(1-15%). Eleven and nine studies reported data on acute and chronic GVHD, respectively. The incidence of VTE in chronic GVHD was 35%(20-54%), whereas in acute GVHD it was 47%(32-62%). Based on the results of this meta-analysis, VTE is a fairly common complication after HSCT, emphasizing the importance of assimilating guidelines for both treatment and prophylaxis in this patient population