Surgical management of metastatic lesions of proximal femur and the hip

Metastatic bony lesions involving proximal femur and hip joint pose a challenge to orthopedic surgeons. Lesions in this important weight-bearing zone of the femur weaken its ability to sustain load causing pain and impending pathologic fracture. These Patients warrant multidisciplinary approach including orthopedic surgeons, oncologist and medical specialties. Management of these lesions has evolved over the last 60 years from benign neglect to internal fixation and recently to prosthetic reconstruction for optimum function. Decision for surgical approach requires consideration for location of the lesion, presence of a fracture, tumor type, cortical destruction, patient\u27s life expectancy, patient preferences and the expected outcome. We aim to present a narrative review of the options and results of surgical management of these lesions in the light of literature

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

Preliminary radiological result after establishment of hospital-based trauma registry in level-1 trauma hospital in developing country setting, prospective cohort study

Introduction: Injuries are the second most common cause of disability, the fifth most common cause of healthy years of life lost per 1000 people and unfortunately 90% of mortality takes place in low-to middle-income countries. Trauma registries guide policymakers and health care providers in decision making in terms of resource allocation as well as enhancing trauma care outcomes. Furthermore data from these registries inform policy makers to decrease the rate of death and disability occurring as a result of injuries. We present our experience in setting up an orthopedic trauma registry and the first short term follow-up of radiological outcomes.Materials and Methodology: Our study is a non-funded, non-commercial, prospective cohort study that was registered at Research Registry. The primary objectives of our study included assessing pattern of injuries in patients with upper and lower limb skeletal trauma presenting to our tertiary care academic university hospital and their respective outcomes. Data was collected by the musculoskeletal service line team members supervised by an experienced research associate and trauma consultants. The work has been reported in line with the STROCSS criteria.Results: A total of 177 patients were included in this analysis, of whom 101 (57.1%) patients had lower limb fractures, 64(36.1%) patients ad upper limb fractures and 12 (6.8%) patients had both upper and lower limbs involved. A total of 189 upper and lower limb fracture cases were recorded. 176 patients (93.1%) underwent surgeries and 13(6.9%) were managed nonoperatively. Roentgenographic outcomes were assessed using radiological criteria for each bone fractured.Conclusion: Establishing a trauma registry assists in identification of the pattern of injuries presenting to the hospital which helps in priority setting, care management and planning. This continuous audit of outcomes in turn, plays a significant role in quality improvement

Functional outcome of crossed Kirschner wire fixation in pediatric supracondylar humerus fracture

Background: Distal humeral fractures are one of the most common types of fractures in children, most of them being supracondylar. Supracondylar fractures are usually caused by trauma, most likely falls. It is an emergency, requiring rapid diagnosis and management to avoid serious complications. Recommended treatment modalities vary from no reduction and immobilization to open reduction and internal fixation. Kirschner wire (K-wire) fixation of displaced supracondylar fractures after closed reduction is a preferred method and is being performed for over 50 years now. This study was conducted to determine the functional outcome of crossed K-wire fixation in pediatric supracondylar fracture.Methods: This prospective study was conducted from May-November 2018 at the department of Orthopedics, Abbasi Shaheed Hospital, Karachi, Pakistan. It was inferred that functional outcome of pediatric displaced supracondylar humeral fractures is satisfactory when managed with percutaneous crossed K-wire fixation. It included 83 children with supracondylar fractures. They were treated with percutaneous crossed K-wire fixation. Patients were then followed up to determine satisfactory functional outcome according to Flynn’s criteria. Data entry and analysis was done using SPSS 21.0.Results: Eight-three patients were included. The mean±standard deviation age of this study population was 7.03±3.39 years. Out of the study participants, 47 (56.6%) were males and 36 (43.4%) were females. 71.1% of the patients were of Gartland class II fractures and 28.9% were of Gartland class III. 43.4% had an injury due to fall while playing while 19.3% had fallen from height. 80.7% were found to have a satisfactory functional outcome.Conclusions: It was inferred that the functional outcome of pediatric displaced supracondylar humeral fractures is satisfactory when managed with percutaneous crossed K-wire fixation

The functional outcome of direct lateral approach for fixation of proximal humeral fractures: A case series from a tertiary care hospital

Displaced proximal humeral fractures warrant surgical fixation for early rehabilitation and better functional outcome. These fractures are traditionally fixed by delto pectoral surgical approach. Direct lateral approach has recently gained interest as it involves less soft tissue dissection and is particularly helpful in certain fracture patterns. However, there have been concerns of axillary nerve damage with this approach. We report a case series of proximal humerus fractures fixed by direct lateral approach from our institution. All displaced Type 2 and 3 fractures were included in our study. Pathological and comminuted Type 4 fractures and fractures with ipsilateral clavicle or elbow fractures were excluded. Oxford Shoulder Score was done at regular intervals for assessment of functional outcome. We did not observe any axillary nerve damage in our case series and the outcomes of 70.5% of our patients were excellent while in 29.5% it was good. We recommend direct lateral approach for specific pattern of proximal humerus fractures

Regular post dinner walk; can be a useful lifestyle modification for gastroesophageal reflux

OBJECTIVES: To evaluate the correlation of gastroesophageal reflux disease (GERD) symptoms with routine post dinner physical activity and time interval before going to bed, in multiethnic South Asian population. METHODS: Prospective, cross sectional analytical, multicenter study was conducted from February 2009 to March 2010. Patient\u27s relative sitting in outpatient clinics with no comorbids, nonsmoker and non alcoholic were included. They were asked to fill a validated GERD questionnaire and were also inquired about routine post dinner physical activity (lying, sitting, walking) and dinner-bed time interval. Odds Ratios (OR) and their 95% Confidence Intervals (CI) were estimated using Logistic Regression, with gastroesophageal reflux (GER) symptoms as an outcome. RESULTS: Subjects analyzed were 1875. Mean age was 35.37 +/- 12.69 years of which 689 (36.74%) had GERD symptoms. GERD symptoms were 42.08% in routine post dinner recumbency position. While 35.17% and 30.52% had the symptoms in post dinner sitting and walking before going to bed [OR for walking 0.66 (95% CI 0.5-0.88) when compared with lying posture]. GERD symptoms were 45.86% among those with dinner-bed time of one hour, progressively decreasing to 41.68%, 31.45% and 29.88% in the second, third and forth hour respectively. Odds ratio was significant only at 3rd [0.55 (0.41-0.74)] and \u3e or = 4th hr [0.51 (0.37-0.71)] when compared with first hour. CONCLUSION: Regular post dinner walk and \u3e 3 hour dinner-bed time interval were less associated with GERD symptoms

Establishing musculoskeletal oncology service in resource constrained country: Challenges and solutions

The burden of orthopedic tumor surgery in Pakistan is not known. Similarly the number of procedures being performed for bone and soft tissue surgery are not known. This is even becoming more challenging where the existence of rules and regulations in health care are next to minimal. Furthermore data recording in our country and case registries hardly exist. Despite the lack of information and resources, with high disease burden on community, various providers provide surgical interventions every day in our settings. A lot of tumor surgery is still being done by general surgeons and general orthopedic surgeons who have little knowledge and update about musculoskeletal oncology principles. Lack of subspecialized centers and the high cost of such centers force the patients to visit these surgeons for a highly sophisticated problem like a bone tumor which is the disease of young bones. In this article we will emphasize on the difficulty in establishing an orthopedic tumor service in our part of the world and the consequences including delay in diagnosis, faulty course of management and later decline in functionality, disease progression and increased mortality. We will highlight the principles and stepwise approach of orthopedic tumor surgery and explain the difficulty encountered if these principles are not followed

Comparison of bipolar hemiarthroplasty and total hip arthroplasty with dual mobility cup in the treatment of old active patients with displaced neck of femur fracture: A retrospective cohort study

Background: The standard treatment of displaced femoral neck fracture is arthroplasty. THA is reportedly superior to BHA in terms of hip pain, function and reoperation rate. On the other hand THA has a higher rate of dislocation. Total hip replacement with dual mobility cup increases the range of motion and reduces the chances of dislocation. The aim of this study is to compare the functional outcome, rate of dislocation, complications and mortality between BHA and THA with dual mobility cuff for the treatment of displaced neck of femur fracture.Patients and method: This is a non-commercialized retrospective cohort study conducted at our tertiary care level 1 trauma centre. Patients of age group 60 years and above who underwent hip arthroplasty (BHA or THA with dual mobility implant) between 2015 and 2017 for displaced neck of femur fracture with a complete follow up for one year were included. Both groups were assessed for postoperative surgical complications including dislocation, fracture, surgical site infection, and medical complications, one-year mortality and functional outcome were analysed via Harris Hip Score (HHS) at the latest follow up.Results: Overall 104 patients were included in the study out of which 77 patients underwent BHA while 27 underwent THA with dual mobility cup. Baseline characteristics were found to be similar in both groups. Mean pre-op HHS for bipolar group was found to be 71.01 while for THA with dual mobility cup group it was 73.52 with the difference being statistically insignificant (P = 0.12). Mean post-op HHS for bipolar group was noted to be 68.82 whereas for THA with dual mobility cup group it was 76.81. The difference was found to be statistically significant with a P-value of Conclusion: In relatively young and active elderly patients with displaced neck of femur fracture, a THA with dual mobility cuff provides better hip functional outcome, does not increase mortality or morbidity as compared to BHA and can be considered as primary treatment modality

THE ROLE OF MICRO-CREDENTIALS IN PROFESSIONAL DEVELOPMENT OF SKILLS IN EMPLOYEES: A QUALITATIVE STUDY FROM AN EMERGING ECONOMY

<p>To investigate the role of micro-credentials in professional development of skills in employees working in academia and industry. In-depth qualitative interviews with teachers, instructors, directors, industrial experts and government representatives were taken from across the city. The authors conducted 12 interviews and it was found out that micro-credentials play a pivotal role in developing skillful workforce. Due to the changing trends in post-COVID world, learning skills and keeping up to-date with new technology has become very important. Higher education commission (HEC) of Pakistan has taken several initiatives, however still a lot of work has to be done to acknowledge and cope with the upcoming challenges. It is also observed that employers prefer practical skills over theoretical knowledge because they want employees to be prepared to take up the tasks and fulfill them in the most effective manner. The major point of discussion in this paper is that micro-credentials are needed to prepare skillful workforce in the emerging economy of a developing country. Instead of making fixes for conventional education, micro-credentials are providing basic skills by blurring the line in higher education between public and private sectors. Micro-credentials can contribute towards division and coherence of skills and knowledge required in industry. The broader spectrum sees an employ as not only a part of the organization, also a person who has stake in and who can contribute towards society.</p&gt

THE USE OF DISCOURSE MARKERS BY PAKISTANI ESL LEARNERS IN THEIR EXPLANATORY AND REFLECTIVE ESSAYS

Discourse markers are expressions which are equipped “with the primary function of bringing to the reader's attention a particular kind of linkage of the upcoming utterance with the immediately preceding discourse context. The researchers, keeping the importance of relevance and coherence in the text in mind, conducted this study to explore the use of discourse markers in the reflective and explanatory essays written by the undergraduates of The Islamia University of Bahawalpur, Punjab, Pakistan. The results revealed the type of discourse markers used in both reflective and explanatory essays. After data analysis the results showedthe most frequent and the least frequent use of discourse markers in ESL learners’ writing compositions. From the results, it is evident that the learners used the discourse markers in explanatoryessays like “and”, “because”, and “for example” most frequentlywhile “despite”, “on the other hand”, and “contrary” were used least frequently. The highest percentages were 10.76, 9.88, and 7.85 and the lowest percentages were 0.58, 0.87, and 1.16 respectively. In reflective essays they used “also”, “there”, “therefore” most frequently while “finished”, “at the beginning”, and “at that time” were least frequently used.The highest percentages were 10.03, 9.34, and 6.92 and the lowest percentages were 0.69, 1.38, and 2.42 respectively. In both types of essays, the most frequently used discourse markers were: ‘and’, ‘because’, ‘also’ and ‘there’ with percentages 10.76, 9.88, 10.03 and 9.34 respectively