Optimal primary surgical management of infected pseudoaneurysm in intravenous drug abusers: ligation or reconstruction?

Objective: To find out the optimal primary surgical treatment options for infected pseudoaneurysm in intravenous drug abusers. Study Design: Cross sectional descriptive study. Place and Duration of Study: Department of Vascular Surgery, Combined Military Hospital Lahore, from Jan 2010 to Jun 2015

Material and Methods: A total of 31 consecutive patients with a history of intravenous drug abuse and an infected pseudoaneurysm in the groin or elbow, presenting in emergency department; were included in this study. All patients were primarily treated with ligation of the artery, excision of infected pseudoaneurysm and debridement of necrotic tissues. Only one patient underwent additional revascularization procedure

Results: All patients who underwent ligation and excision procedures did well initially. One [3.2%] patient developed severe distal ischemia after ligation of femoral artery within first 24 hours, so extra anatomic revascularization procedure was performed. Five [16.1%] patients required revascularization procedure after 16 weeks due to disabling distal ischemia. No amputation was needed and mortality rate was zero

Conclusion: Primary ligation of the artery with excision of infected pseudoaneurysm and necrotic material was found the optimal initial management for infected pseudoaneurysm in intravenous drug addicts. Ischemic complications if develop should be treated with early or late revascularization

Comparison of low-dose meglumine antimoniate/ allopurinol combination therapy with full dose meglumine antimoniate alone in the treatment of cutaneous leishmaniasis - a randomized controlled trial

Objective: To compare the efficacy and safety of meglumine antimoniate 20 mg/kg/day with combination of meglumine antimoniate 10 mg/kg/day and allopurinol 20 mg/kg/day

Methods: A multi-center single blind randomized controlled trial was conducted. Soldiers over 18 years of age having parasitologically proven cutaneous leishmaniasis requiring systemic therapy, willing for admission to hospital for the study and regular follow up visits in outdoor, and consenting not to use any other treatment for cutaneous leishmaniasis while in study were included. On entry into the study patients were randomly assigned to either group A or group B using a random number table. Group A patients were given meglumine antimoniate 20 mg/kg/day/intramuscular till clinical resolution or for 28 days maximum. Group B patients were given intramuscular meglumine antimoniate 10mg/kg/day along with allopurinol 20 mg/kg/day/per oral till clinical resolution or for a maximum of 28 days. The ulcer and induration areas were recorded separately for each patient. Time to healing was recorded and compared among the two groups

Results: A total of 324 patients were included in the study. Group A had 151 [46.6%] patients while 173 [53.4%] were in group B. Three hundred and six patients completed the study and 18 dropped out due to various complications, 9 belonging to each group. Lesion size at baseline in group A was 29.7+16.4 mm, while in group B it was 28+15.8 mm [p=0.35]. Lesion size at the end of treatment period was 1.5+3.4 mm in group A and 0.9+2.6 mm in group B [p=0.07]. Lesion size at the end of follow-up period was 0.1+0.9 mm in group A and 0.03+0.4 mm in group B [p=0.40]. A total of 109 adverse effects were seen, 60 in group A and 49 in group B [p=0.05]

Conclusion: Low-dose meglumine antimoniate/allopurinol combination is equally effective and safe as compared to full dose meglumine antimoniate treatment

Intramedullary nailing for open fractures of the tibial shaft

Interlocking intramedullary nailing has become a popular method of fixation for closed tibial fractures, and a series of reports has confirmed excellent results with this technique. However, the use of intramedullary nails for open tibial fractures is controversial. The standard treatment for these injuries has been external fixation, particularly for fractures associated with more severe soft-tissue injuries

Objective: The purpose of the present study was to compare the clinical and radiographic results of intramedullary nailing of open fractures of the tibial shaft after reaming with those of nailing without reaming

Material and Method: This was follow-up comparative study. Thirty patients who had thirty-four open fractures of the tibial shaft were randomized into two treatment groups. Sixteen fractures [nine typeI, three type-II, two type-IIIA, and two type-IIIB fractures, according to the classification of Gustilo et al.] were treated with nailing after reaming, and eighteen fractures [ten type-I, four type-II, two type-IIIA, and two type-IIIB fractures] were treated with nailing without reaming

Result: The average diameter of the nail was 10 millimeters [range, nine to eleven millimeters] in the group treated with reaming and 9 millimeters [range, eight to ten millimeters] in the group treated without reaming. No clinically important differences were found between the two groups with regard to the technical aspects of the procedure or the rate of early postoperative complications. The average time to union was 30 weeks [range, thirteen to seventy-two weeks] in the group treated with reaming and 29 weeks [range, thirteen to fifty weeks] in the group treated without reaming. Two of the fractures treated with reaming and three of the fractures treated without reaming did not unite. There were two infections in the group treated with reaming and one in the group treated without reaming. More screws broke in the group treated without reaming four, per cent] than in the group treated with reaming [Three; 9 per cent]. The functional outcome, in terms of pain in the knee, range of motion, return to work, and recreational activity, did not differ significantly between the groups

Conclusion: We concluded that the clinical and radiographic results of nailing after reaming are similar to those of nailing without reaming for fixation of open fractures of the tibial shaft, although more screws broke when reaming had not been done

Outcome of open reduction and cross k-wires fixation in displaced supracondylar fratures of humerus in children

Objective: to determine the outcome of open reduction and cross k-wires fixation in supracondylar fractures of humerus in terms of functional and cosmetic outcome by using Flynn's grading system

Study design: this was a descriptive and cross-sectional study

Patients and method: a sample of sixty consecutive patients with displaced supracondylar fracture of humerus [Gartland Type II and III] assessed on anteroposterior and lateral radiograph between ages of 2 to 12 years [both sex] were included in this study from Orthopedic Department, Services Hospital Lahore. This was a follow-up study

Results: the mean age was 7.7 years, the youngest patient being 2 years of age and the oldest 12 years. Functional outcome for 46 [76.7%] patients was excellent, 10 [10%] patients were good, 03 [5 %] patients was fair and 1 [1.7%] patient was poor. Cosmetic outcome of 47 [78.3%] patients was excellent, 09 [15%] patients was good, 03 [5%] patients was fair and 01 [1.7%] patient was poor

Conclusion: open reduction and internal fixation with cross k-wires is a good and safe method of treatment in displaced supracondylar fractures of humerus in children

Perforated duodenal ulcer; frequency during the holy month of Ramadan

Objective: To compare the frequency of patients presenting with perforated duodenal ulcer during holy month of Ramadan with those presenting during the rest of the year. To assess the risk factors such as smoking, non-steroidal anti inflammatory drugs usage and a history of acid peptic disease. To assess the age groups and gender of patients. Study Design: It was a descriptive study. Period: Three years from Jan 2001 to Dec 2003

Setting: Surgical units of Holy Family and Rawalpindi General Hospitals

Materials and Methods: A total of 133 patients presenting during this three years period were managed surgically after resuscitation in the emergency rooms of both the hospitals. History findings were recorded on a specially designed proforma for this study

Results: 36% of all the patients presented during the holy month of Ramadan alone as compared to 64% during the rest of the year. 46% of all the patients were smokers, whereas 64% of the patients had a previous history of acid peptic disease. 54% of the patients were in the 20 to 40 years age group and the male to female ratio was 5:1

Conclusions: This study clearly showed the increased frequency of perforated duodenal ulcers during the holy month of Ramadan and stresses on the need of precautions specially for smokers, non-steroidal anti inflammatory drugs users and patients with the history of acid peptic disease during this month

Empyema thoracis; evaluation of different treatment options

Thirty patients suffering from empyema thoracis have been included in this study: [26 males and 4 females]. 17 patients were in chronic phase of the disease while 13 were in transitional [sub acute] phase. 16 patients suffered from empyema thoracis due to tuberculosis while rest of the patients suffered from other nonspecific infections. Rib resection and closed drainage showed good results in transitional phase of the disease while decortication produced good results in chronic phase. In those patients who were in chronic phase of the disease and were toxic, rib resection prior to decortication proved beneficial. The most difficult patients to manage were those suffering from tuberculosis