Challenges of evidence based medicine in clinical practice

Evidence-based medicine (EBM) is an approach by clinicians that involves conscientious, explicit, and judicious use of available evidence in deciding on the care of individual patients. With the digital revolution and easy access to the available literature, EBM, which was not very practical a few decades ago due to the difficulty in assessing the resources, has been practiced with increasing success nowadays, even in the developing world. The revolution brought about by EBM with regard to the practice of medicine over the past few decades has been remarkable. Because of the individualized treatment based on external evidence, EBM leans towards justifying the action with accountability; hence being labeled as the fourth revolution in American Medicine

Knowledge, attitude and perception of COVID-19 among Orthopaedic surgeons

Introduction: COVID-19 has a long incubation period, is highly contagious but lacks definite cure. It has evolved into a pandemic resulting in global outcry. Preventive measures include hand washing or sanitization, maintaining social distance, face mask, quarantine etc. Orthopaedic surgeons are considered a high-risk group, due to the aerosol generating procedures (AGPs) they need to perform. A good knowledge and attitude are essential to prevent the contraction and spread of the virus. Method: This is a cross-sectional descriptive study done in the form of online survey via e-mail among the registered Orthopaedic surgeons of Nepal. A four-point Likert scale was used for single option answer. Ethical approval was obtained. Descriptive analysis of data was performed by Microsoft Excel. Result: Out of 123 responses, on the main issues regarding hand washing, social distancing and face masks, majority (>85%) of the Orthopaedicians had a good knowledge and attitude. Around 14% disagreed on Orthopaedic surgeries being AGPs. Majority (>90%) had a positive perception about implementation of preventive measures. More than 90% of the respondents believed that hospital meetings/teaching learning activities/presentations can be effectively conducted through virtual platforms. Conclusion: Study found that most Orthopaedic surgeons have good knowledge and attitude regarding COVID-19. Importance of hand hygiene, social distancing, surgical mask, and well-ventilated rooms were well understood. Most perceived AGPs is a high risk procedure. Study found need of awareness on doffing of PPE. Online platforms were felt effective for most meetings and clinical consultations

Should research and publication be included in the undergraduate medical curriculum?

Scientific papers are the key to advancements that humans have leaped through in different fields of science. Members of the scientific community use research to explore, discover and accumulate knowledge/skills to contribute to society which makes humans stand out among all the existing species on the planet. The publication has been used as a tool to document the findings/discoveries, and also to build up the foundation of the knowledge which has kept growing over time for humans to have the ability to develop complex and advanced stuff, which in other words is termed ‘development’

External rotation method for reduction of acute anterior dislocation of shoulder

Introductions: Many different techniques of reduction of acute anterior shoulder dislocation have been described. The aim of this study was to evaluate the effectiveness of external rotation method for reduction of acute anterior shoulder dislocation. Methods: Fifty-one patients with acute anterior shoulder dislocations with or without greater tuberosity fracture were reduced during a period from January 2013 to January 2015. The external rotation method was used as an initial reduction method performed by orthopaedic surgeon on call or residents. Data sheets completed by the orthopaedic surgeon on call or residents were evaluated with regard to the type of dislocation, the effectiveness of the procedure in achieving reduction, the need for premedication, the ease of performing the reduction, and complications, if any. Results: There were 42 male and nine female patients between 18 to 78 years. Among 51 patients, 49 had successful reduction. No premedication was required in 33 patients who had a successful reduction, and the average time required for reduction in 23 patients was within two minutes whereas 20 patients reduced within five minutes. Only four patients reported severe pain during the process of reduction. The method was not successful in two patients with subcoracoid dislocation associated with displaced fracture of the greater tuberosity. Conclusions: External rotation method is reliable, safe, simple and relatively painless method for reduction of acute anterior shoulder dislocation. Keywords: acute anterior shoulder dislocation, external rotation method, painless reductionÂ

Three lateral divergent pinning for displaced supracondylar humerus fractures in children

Introductions: Cross or two lateral pinnings are the most commonly doneprocedures for displaced supracondylar humerus fractures in children. Acrossed pin is biomechanically stable than lateral pins, but associated withrisk of iatrogenic ulnar nerve injury. Recent studies have shown stable fixationwith three lateral pin construct. The purpose of this study was to evaluate theefficacy of three lateral divergent pinning for displaced supracondylar humerusfractures.Methods: Thirty five children with Gartland types III were treated betweenNovember 2012 and November 2013. Closed reduction and three lateraldivergent pinning was done with image intensifier guidance. Patients werefollowed up for minimum 6 months. Radiological assessment was done to seeunion, proper pin placement and loss of reduction. Clinically, patients wereassessed by using Flynn criteria.Results: There were 24 (68.6%) male and 11 (31.4%) female children between2 to 13 years of age with displaced supracondylar fractures, left side 26 (74.3%) and right nine (25.7%) cases. All were successfully managed with closed reduction and three lateral divergent pins within 2-6 days of injury. One radial and one median nerve palsies sustained at injury recovered spontaneously. No iatrogenic nerve injuries occurred. A comparison of perioperative and final radiographs revealed no loss of reduction. Twenty-seven excellent, five good, two fair and one poor results on Flynn’s grading. One patient had a superficial pin-tract infection.Conclusions: Closed reduction with three lateral divergent pins is safe for stablefixation of displaced supracondylar humeral fractures in children.Keywords: children, humerus, percutaneous pinning, supracondylar fractur

Outcome of anterior cruciate ligament reconstruction using bone-patellar tendon-bone auto graft

Introductions: A rupture of the Anterior Cruciate Ligament (ACL) is the most common ligament injury resulting in instability of the knee which can cause secondary articular injury and early osteoarthritis (OA). Aim of this study was to evaluate the short term outcomes of ACL reconstruction using Bone Patellar Tendon Bone Auto Graft (BPTB) auto graft and factors that might contribute to poor results. Methods: Patients with Anterior Cruciate Ligament injury during the period of July 2013 to May 2014 were enrolled to observe the outcome of the ACL reconstruction using BPTB without arthroscopy. Lysholm Knee Scoring Scale was used to determine the clinical outcome. Outcome parameters were evaluated using Statistical Package for Social Science Version 20 (SPSS). Results: Total 30 normal or near normal function outcome of knee was reported in 29 (97%) patients after ACL reconstruction using BPTB without arthroscopy. There was no failure of grafts. Good static knee stability achieved with increased patient’s satisfaction. Lysholm Score was excellent in 27 (90%) and good in 3 (10 %) cases. Anterior knee pain persisted in 6 cases (20%). Conclusions: Excellent functional outcome with BPTB auto graft in Anterior Cruciate Ligament injury was achieved. Keywords: ACL reconstruction, bone-patellar tendon-bone auto graft, clinical outcom

Minimally Invasive-Closed Reduction and Percutaneous Pinning for Supracondylar Fractures of the Humerus in Children

Introductions: Although Closed Reduction and Percutaneous Pinning is the goldstandard of treatment for Supracondylar fractures (SC) in children, reductionis not always easy. Minimally Invasive, Closed Reduction and PercutaneousPinning (MI-CRPP) reduces the soft tissue trauma and provides easy reduction.We have reviewed the success rate of minimally invasive reduction techniqueand its outcome.Methods: We reviewed the charts of 155 children (97 male, 58 female) ageranging from 2 to 14 years with SC fractures of the humerus who were operatedwith minimally invasive closed reduction and precutaneous pinning fromNovember 2008 to June 2014 at Patan Hospital and Om Hospital. They werefollowed up for a mean of eight (4 to 24) weeks. The K-wires were removed at4 to 6 (average 4.28) weeks.Results: Male children were affected more than female with the ratio being 97to 58. Right side was affected more than left (ratio 89 to 66). Post-operatively,there were six (3.87%) ulnar nerve injury and eight (5.16%) patients came withsuperficial pin tract infection. One hundred and thirteen (72.9%) had excellent,35 (22.58%) good, five (3.23%) fair and two (1.3%) poor results at the eightweek follow-up which was improved to 144 (92.9%) excellent, seven (4.5%)good, three (1.9%) fair and one (0.65%) poor results at the 14 week follow-up.Conclusions: Closed reduction of supracondylar fractures of the humerus inchildren with minimally invasive technique prior to K-wire fixation is a relativelysimple, safe and effective method of achieving satisfactory reduction and goodfunctional outcome.Keywords: cubitus varus deformity, K wire fixation,minimally invasive closedreduction and precutaneous pinning, supracondylar fracture

Orthopaedic services during COVID-19 lockdown at Patan Hospital, Nepal

Introduction: The COVID-19 pandemic has paralyzed the world, including elective health care services. To prevent the spread of infection, most countries have gone into lockdown and adjustments have been made to provide urgent medical care, including Orthopaedic services. In accordance with the guidelines from worst affected countries and neighboring India, Patan Hospital followed instructions from Ministry of Health and Population to provide only urgent and semi-urgent Orthopaedic services. This study aims to audit the patient profile during lockdown so as to have a clearer picture, which will enable us to be prepared for similar epidemic in the future. Method: All patients admitted to the Orthopaedic ward of Patan hospital from 24 March to 27 April 2020, during the lockdown, were included. Clinical profile, including cause of admission, management, hospital stay were descriptively analyzed. Ethical approval was obtained. Result: Out of 44 admissions, there were male 27 and female 17. Trauma cases were 38, and 18 were in age group 20-26 years. Admission due to infections were four. Conservative management were done in seven while 33 were treated surgically, out of which 30 accounted for trauma. Average 6.14 days hospital stay, range 1-22 days. Conclusion: Trauma comprised of major bulk of patients seeking urgent Orthopaedic care. Hospital needs to be prepared with necessary measures to ensure safety of health care workers and yet provide urgent Orthopaedic services. Keyword: COVID-19, lockdown, orthopaedic

Global surgery and global health: One size does not fit all: Global surgery and global health

Global surgery is interpreted differently and may lack an in-depth understanding which is complicated by socio-economy and culture. Global surgery and global health have become part of health care service following the report of the Lancet Commission. Sustainability, ethical principles, and decolonization are some important ongoing issues for recipient societies. Incorporating societal dimensions, socio-cultural values, patients’ needs, and affordability requires a tailored approach and not blindly pursuing the best technology. The recent COVID-19 has exposed the unethical and inequity in terms of equitable healthcare, vaccine rollout and its access, and unprecedented high mortality observed in some societies. Surgery has been a neglected stepchild of global health and in addition global surgery must not be a slave of technology for the promotion of the ‘gold standard’, especially corporate-led commercialized services because a sustainable and effective surgical service at a reduced cost is desirable for all, be resource-rich or poor. Global surgery and global health include health security and universal health coverage. Stakeholders of global surgery need to be aware that ‘one size does not fit all’ and are required to consider the diverse conditions

Flexible intramedullary nailing for femoral diaphyseal fractures in children

Background &amp; Objectives: Although various treatment options are available for the treatment of femoral diaphyesal fractures in children, the titanium flexible nailing has gained popularity because it is safe, easy procedure with rapid recovery and high success rate. The aim of this study was to evaluate the outcome of titanium elastic nails in treating paediatric femoral diaphyesal fractures at Patan Hospital.Materials &amp; Methods: There were 35 cases which were all fixed with titanium flexible intramedullary nail under image intensifier at the Patan hospital from January 2013 and December 2015. Patients were evaluated in follow-ups to observe the alignment of fracture, infection, delayed union, nonunion, limb length discrepancy, implant failure, range of movement of hip and knee joints, and time to unite the fracture. The final results were evaluated using criteria of titanium elastic nail (TEN) outcome score described by Flynn et al.Results: The mean age of the patients was 8.51 years. Among 35 patients (22 boys and 13 girls), there were 19 mid-shaft fractures, nine proximal third fractures and seven distal third fractures. Fracture patterns were transverse (22), oblique (10), spiral (2), and comminuted (2). The mean time for fracture union was 8.17 weeks radiologically whereas 9.83 weeks clinically. According to TEN outcome score, excellent and good results were in 28 cases (80%) and seven cases (20%) respectively.Conclusion: Flexible titanium nailing is a safe and satisfactory treatment for diaphyseal femoral fractures in children, because it provides rapid recovery, short rehabilitation and immobilization as well as very high union rate with few complications. </p