Salvage of infected proximal tibial tumour prosthesis using vacuum assisted closure (VAC) in seven patients

Background: Proximal tibia is the second most common site for both benign and malignant bone tumours. The treatment protocols of such tumours have seen a paradigm shift from amputation towards limb salvage. Limb salvage has been possible with resection and reconstruction using custom modular prosthesis but the risk of tumour recurrence and infection still looms large.Methods: Here we present our series of seven patients with infected proximal tibial tumour prosthesis which were salvaged using vacuum assisted closure (VAC) dressing. The indications for surgery were recurrent giant cell tumour (4 cases), chondrosarcoma (2 cases) and osteosarcoma (one patient). The prosthesis used was the limb preservation system (LPS) [Depuy-Synthes, US]. There were 6 males (M:F 6:1) with average age of 34.23 years. The predominant organism cultured was Staph aureus. We proceeded with radical wound debridement and VAC dressing with continuous negative pressure drainage for an average of 18 days (range 12-24 days). The patients then underwent secondary suturing and delayed suture removal (18-21 days).Results: All 7 patients were well at 8 months follow-up with no recurrent or persistent infection with good functional outcome. The average knee society score (KSS) was 73 (good). Conclusions: We conclude that with early thorough radical debridement and with select bacteriological culture profile, VAC is a valuable tool in the salvage of infected tumour prosthesis. This may reduce the need for amputations of such infected limbs by a significant margin while still retaining good functional outcome

Functional and radiological outcome following operative skeletal stabilisation with bone grafting in distal femur non-unions: a study of 21 patients

Background: The study was done to assess the functional and radiological outcome after operative skeletal stabilisation with bone grafting in 21 patients who presented to us with distal femur non-unions.Methods: Between August 2008 and October 2015, 21 patients (M:F- 14:7)  with established non-unions of the distal femur were included. All patients presented to us with established non-union following treatment with a native bone setter using splints.  There were 16 patients with AO Type A, 4 with AO Type B and one patient with Type C. All patients underwent open reduction, internal fixation with plate and screws and bone grafting. Serial follow-ups were done at 4, 8, 12, 16, 20, 24 weeks and 6 monthly thereafter.Results: All 21 patients had complete fracture healing at average of 19 weeks (Range 16-24). Knee flexion (ROM) improved from an average 16® pre-op to 66® post-operatively. There were no implant failure, infection or non-unions in our study. The Knee Society score improved from 54 pre-operatively to 74 post-operatively at last follow-up. Conclusions: Even in established non-unions, good results can be expected if good surgical technique is followed and with bone grafting satisfactory union rated can be achieved. Knee ROM also improves with dedicated postoperative rehabilitation

Locking Compression Plating for Osteoporotic and Peri-Articular Fractures: A Short Term Outcome Analysis

INTRODUCTION: Peri-articular and osteoporotic fractures of long bones are becoming more common and are very challenging injuries to treat even for a veteran orthopaedician. Peri-articular fractures occur in two different age groups -due to different types of injuries. In young patients peri-articular fractures occur due to high velocity injury such as road traffic accidents, fire arm injuries and sport’s injuries while in elderly patients with osteoporosis it occurs usually due to low velocity injury like fall during walking. Also these conditions do result from fractures in the young treated by conservative methods and which in the long term end up in non-unions and further more these conditions are compounded by disuse osteoporosis. Because of the proximity of peri-articular fractures to the corresponding joints, regaining full motion and function may be difficult. Also achieving full union rates are increasingly difficult because of the lack of availability of good bone stock which is very common in periarticular fractures because of the cancellous nature of the metaphyseal fragment. The incidences of malunion, nonunion, and infection are relatively high in many reported series. In older patients, treatment may be complicated by coexisting osteoporosis. AIM: The aim of the study is to analyze the short term results in terms of union and functional outcome for osteoporotic and periarticular fractures treated with locking compression plating. MATERIALS AND METHODS: This is a study conducted in the Department of Orthopaedics, Madras Medical College, Government General Hospital, Chennai. This study is a prospective study Conducted in the Department of Orthopaedics from September 2007 to September 2009 with a sample size of 21 cases. Patients were randomly selected from among the admissions to the Orthopaedic ward in the Department of Orthopaedics, Government General Hospital, Chennai and recruited into the study prospectively based on the following criteria: Inclusion criteria - 1. Age more than 16 years. 2. Osteoporotic bones either disuse or pathological bones. 3. Fractures occurring at or near joints namely distal femur, proximal humerus, distal radius, distal tibia, proximal tibia. 4. Osteoporotic non-unions. 5. Patients who consents to be included in the study. Exclusion criteria - 1. Exclusion criteria were skeletal immaturity 2. Patients with tumourous conditions. 3. Severe articular comminution not possible to be reconstructed with internal fixation. 4. Undisplaced fracture patterns needing only conservative management. 5. Patients not willing for internal fixation. RESULTS: There were a total of 3 complications in two patients, two were infections( one case of superficial and one case of deep infection) the infection rate which was 0.01% and is similar to other reported series [11,14].They were treated with thorough wound debridement and i.v antibiotics for six weeks which soon resolved. There was one case of non-union which was due to the infection. Solid union was observed in 21 out of the 24 cases ( 88 %) which are similar to other studies[4,5,8,11,14]. The range of movements attained at an average follow-up of 15.5 months was 87 % of which 17 had excellent results, 4 had good outcome, 2 had fair outcome and 1 case had poor functional results according to the respective scoring systems like DASH, Harris hip score and HSS (Hospital Severity Score) knee score. CONCLUSION: This study highlights the role of locking compression plating in complex osteoporotic and peri-articular fractures in which conventional dynamic compression plates and reconstruction plates would fail prematurely. The correct application of locking compression plates requires a long learning curve and spurious use will negate the advantages of the locking plates. The results of our study have confirmed earlier reports that locking compression plates provide better fixation in osteoporotic fractures. The chances of implant failure are less as the screws are firmly position inside the bone. Also since these plates are limited contact plates there is less contact between plate and the bone and hence there is minimal disruption of sub-periosteal blood supply to the fracture ends and this aids in fracture union. The locked nuts prevent further tightening of the screws and hence reduction is maintained and secondary angular deformities are prevented

Passive flow control in wind turbine blade by geometrical optimization of vortex generator

A wind turbine is a device that converts mechanical energy into electrical energy by its rotary action. In this paper, a wind turbine’s lift and power characteristics are improved by employing a vortex generator as a passive flow control device on the surface of the wind turbine. A triangular vortex generator is used for this study for its simplicity in design and effective results. NACA 4418 airfoil is selected for the conceptual design by BEM (Blade Element Momentum theory), and geometrical modeling is carried out using SOLIDWORKS. Computational analysis of the blade with vortex generators is done using ANSYS CFX, and analysis on a clean blade is verified using Q Blade. The geometrical parameters considered for optimization are chordwise position (xvg), Height (hvg), and Inclination from the baseline(βvg), keeping fixed spacing (svg). By optimizing the design parameters, the lift and power increment is observed alongside a delay in the flow separation point, which agrees with the experimental results. This investigation can be extended to future unconventional shapes such as ogive, vane, and wishbone generators through wind tunnel and field tests

Optimization of the Printing Parameters to Improve the Surface Roughness in Fused Deposition Modeling

A better surface finish is an essential requirement of any component in particular medical components. The recent development in additive manufacturing technology produces components with a good surface finish. However, the optimization of process parameters helps to achieve a better surface finish. This paper focuses on the optimization of printing parameters of the surface roughness of a flat object developed from an FDM printer. FDM (Fused Deposition Modeling) is a layer-by-layer deposition process to develop 3D objects. It uses solid-state material (Filament) to print the product by melting and depositing the material on the printing bed. Several factors in the FDM process can affect the product’s quality. The parameters such as printing temperature, bed temperature, printing speed, fill density, layer thickness, and air gap influence the quality of the printed products. This investigation has considered printing temperature, layer height, and printing as process parameters. In addition, the parameter affecting the printed object’s surface finish is determined using ANOVA optimization and S/N ratios. PLA (Polylactic Acid) is taken as study material which is one of the feedstocks used in polymer filament and finds its applications in implant printing and medical tools

The impact of immediate breast reconstruction on the time to delivery of adjuvant therapy: the iBRA-2 study

Background: Immediate breast reconstruction (IBR) is routinely offered to improve quality-of-life for women requiring mastectomy, but there are concerns that more complex surgery may delay adjuvant oncological treatments and compromise long-term outcomes. High-quality evidence is lacking. The iBRA-2 study aimed to investigate the impact of IBR on time to adjuvant therapy. Methods: Consecutive women undergoing mastectomy ± IBR for breast cancer July–December, 2016 were included. Patient demographics, operative, oncological and complication data were collected. Time from last definitive cancer surgery to first adjuvant treatment for patients undergoing mastectomy ± IBR were compared and risk factors associated with delays explored. Results: A total of 2540 patients were recruited from 76 centres; 1008 (39.7%) underwent IBR (implant-only [n = 675, 26.6%]; pedicled flaps [n = 105,4.1%] and free-flaps [n = 228, 8.9%]). Complications requiring re-admission or re-operation were significantly more common in patients undergoing IBR than those receiving mastectomy. Adjuvant chemotherapy or radiotherapy was required by 1235 (48.6%) patients. No clinically significant differences were seen in time to adjuvant therapy between patient groups but major complications irrespective of surgery received were significantly associated with treatment delays. Conclusions: IBR does not result in clinically significant delays to adjuvant therapy, but post-operative complications are associated with treatment delays. Strategies to minimise complications, including careful patient selection, are required to improve outcomes for patients

Minimally invasive total knee replacement : techniques and results

In this review, we outlined the definition of minimally invasive surgery (MIS) in total knee replacement (TKR) and described the different surgical approaches reported in the literature. Afterwards we went through the most recent studies assessing MIS TKR. Next, we searched for potential limitations of MIS knee replacement and tried to answer the following questions: Are there selective criteria and specific patient selection for MIS knee surgery? If there are, then what are they? After all, a discussion and conclusion completed this article. There is certainly room for MIS or at least less invasive surgery (LIS) for appropriate selected patients. Nonetheless, there are differences between approaches. Mini medial parapatellar is easy to master, quick to perform and potentially extendable, whereas mini subvastus and mini midvastus are trickier and require more caution related to risk of hematoma and VMO nerve damage. Current evidence on the safety and efficacy of mini-incision surgery for TKR does not appear fully adequate for the procedure to be used without special arrangements for consent and for audit or continuing research. There is an argument that a sudden jump from standard TKR to MIS TKR, especially without computer assistance such as navigation, patient specific instrumentation (PSI) or robotic, may breach a surgeon's duty of care toward patients because it exposes patients to unnecessary risks. As a final point, more evidence is required on the long-term safety and efficacy of this procedure which will give objective shed light on real benefits of MIS TKR

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Optimization of the Printing Parameters to Improve the Surface Roughness in Fused Deposition Modeling

A better surface finish is an essential requirement of any component in particular medical components. The recent development in additive manufacturing technology produces components with a good surface finish. However, the optimization of process parameters helps to achieve a better surface finish. This paper focuses on the optimization of printing parameters of the surface roughness of a flat object developed from an FDM printer. FDM (Fused Deposition Modeling) is a layer-by-layer deposition process to develop 3D objects. It uses solid-state material (Filament) to print the product by melting and depositing the material on the printing bed. Several factors in the FDM process can affect the product’s quality. The parameters such as printing temperature, bed temperature, printing speed, fill density, layer thickness, and air gap influence the quality of the printed products. This investigation has considered printing temperature, layer height, and printing as process parameters. In addition, the parameter affecting the printed object’s surface finish is determined using ANOVA optimization and S/N ratios. PLA (Polylactic Acid) is taken as study material which is one of the feedstocks used in polymer filament and finds its applications in implant printing and medical tools

Passive flow control in wind turbine blade by geometrical optimization of vortex generator

A wind turbine is a device that converts mechanical energy into electrical energy by its rotary action. In this paper, a wind turbine’s lift and power characteristics are improved by employing a vortex generator as a passive flow control device on the surface of the wind turbine. A triangular vortex generator is used for this study for its simplicity in design and effective results. NACA 4418 airfoil is selected for the conceptual design by BEM (Blade Element Momentum theory), and geometrical modeling is carried out using SOLIDWORKS. Computational analysis of the blade with vortex generators is done using ANSYS CFX, and analysis on a clean blade is verified using Q Blade. The geometrical parameters considered for optimization are chordwise position (xvg), Height (hvg), and Inclination from the baseline(βvg), keeping fixed spacing (svg). By optimizing the design parameters, the lift and power increment is observed alongside a delay in the flow separation point, which agrees with the experimental results. This investigation can be extended to future unconventional shapes such as ogive, vane, and wishbone generators through wind tunnel and field tests