Impact of Tibial Tubercle Osteotomy on Final Outcome in Revision Total Knee Arthroplasty:Our Experience and Technique in Pakistan

Background@#Due to extensive fibrosis during revision surgery, adequate exposure is essential and it can be achieved with several extensile approach options, such as tibial tubercle osteotomy. Information regarding surgical exposure during revision arthroplasty is limited in developing countries, such as Pakistan, due to the lack of adequate data collection and follow-up. Therefore, the purpose of this study was to evaluate the impact of tibial tubercle osteotomy on final outcome of revision total knee arthroplasty (TKA). @*Methods@#A total of 231 revision TKAs were performed between January 2008 and December 2017. Twenty-nine patients underwent tibial tubercle osteotomy for adequate exposure during revision surgery. Of these, 27 patients with complete follow-up were included in our study. Factors examined include age at the time of revision surgery, gender, comorbidities, arthroplasty site (right or left), body mass index (BMI), and primary indications for the tibial tubercle osteotomy during revision TKA. Functional outcome was measured by using Knee Society score (KSS) at 3 months and the final follow-up. All statistical analysis was done using SPSS version 20.0 with a p-value < 0.05 considered significant. @*Results@#Out of 27 patients, 6 patients (22.2%) were men and 21 patients (77.7%) were women. Right knee revision arthroplasty was performed in 15 patients (55.5%), left knee revision arthroplasty was performed in 12 patients (44.4%), and bilateral revision surgery was performed in only 1 patient (3.7%). The mean BMI was 29.2 kg/m 2 . We used a constrained condylar knee in 20 patients (74%), a rotating hinge knee in 5 patients (18.5%), and mobile bearing tray plus metaphyseal sleeves in 2 patients (7.4%).The KSS was 52.21 ± 4.05 preoperatively, and 79.42 ± 2.2 and 80.12 ± 1.33 at 3 months and 12 months, respectively. Radiological union was achieved in all patients at 3 months. Of 27 patients, only 1 patient (3.7%) had proximal migration of the osteotomy site at 6 months: the patient was asymptomatic and union was also achieved and, therefore, no surgical intervention was performed. @*Conclusions@#Tibial tubercle osteotomy during revision TKA can be a safe and reliable technique with superior outcomes and minimal complication rates.

Comparison of mean corneal endothelial cell loss after trabeculectomy with and without mitomycin C

Objective: To compare mean endothelial cell loss in patients of primary open angle glaucoma undergoing trabeculectomy with and without mitomycin C. Study Design: Randomised control study. Place and Duration of Study: Institute of Ophthalmology, Mayo Hospital, Lahore, from May 2016 to April 2017

Methodology: Patients with primary open angle glaucoma, not controlled with medication, were selected from the outpatient department. Patients with secondary glaucomas and concomitant ocular disease were excluded. Selected patients were divided into two groups of 30 each. Group A patients underwent trabeculectomy with adjunctive mitomycin C while group B patients underwent trabeculectomy alone. Pre- and post-trabeculectomy endothelial cell counts were recorded with the help of specular microsope and entered on proforma

Results: Median cell loss was 283 [66.50] when trabeculectomy was done with the use of adjunctive mitomycin C in group A while median endothelial cell loss was 72.50 [19.25] when the trabeculectomy was done without the use of adjunctive mitomycin C in group B

Conclusion: Use of mitomycin C causes more endothelial cell loss during trabeculectomy as compared to when done without it

To determine the efficacy of locking compression plating in comparison with intramedullary nailing for humeral shaft fractures at a tertiary care hospital in Karachi, Pakistan

Objective: The purpose of our study is to compare the effectiveness, surgical outcome and complications of locking compression plating as compared with intramedullary nailing for the purposes of fixation of humeral shaft fractures in the adult population

Methodology: The type of study is a prospective randomized controlled trial, which was carried out for a period of three years from Jan 2012 to December 2014, at a tertiary care hospital in Karachi Pakistan. Patients coming to the hospital via the A and E department with radiographic evidence of a humeral shaft fracture were included in the study. 50 patients were selected for the study, who were randomly divided into two groups, group A [n=25] comprised of patients who underwent intramedullary nailing procedure, while group B [n=25] patient underwent compression plating for the fixation of the humeral fracture. The surgical outcome was assessed based on the operative time, intra operative blood loss, the time of hospital stay, the time required for the union of bone, functional outcome and complications. [American shoulder and elbow surgeons score] ASES and the constant score was used to assess the functional outcome of patients

Results: According to our study, the operative time, hospital stay and intra operative blood loss was much lower in group A [the intramedullary nail group] as compared to those in the group B [locking compression plate group]. The rate of bone union, constant and ASES score did not show any significant difference. The union time for group A was lower as compared to group B. Complications such as radial nerve palsy were observed to be associated more with the locking compression plate as compared with the group of patients who underwent intramedullary nailing

Conclusion: According to our study the intramedullary nailing technique for the repair of humeral shaft fractures is a superior technique as compared to the locking compression plate, as it has decreased incidence of blood loss during the procedure, less time required for the procedure, less time of hospital stay and union of bone. It also has a low incidence of complications

Frequency of echocardiographic complications of dilated cardiomyopathy at a tertiary care hospital

Background: Dilated cardiomyopathy can lead to a variety of complications recognisable on clinical, echocardiographic, electrocardiographic and radiographic assessment. Among this, transthoracic echocardiography has the dual advantage of being helpful in making the diagnosis of dilated cardiomyopathy as well as an effective tool in early recognition of certain complications for timely management to improve the quality of life of these patients. Methods: This descriptive [case series] study was undertaken at Departments of Medicine, Cardiology, Paediatrics and Obs/Gyn, Ayub Teaching Hospital, Abbottabad from July to December, 2008. Fifty patients of dilated cardiomyopathy without age and gender discrimination were selected by convenience sampling. Those with hypertrophic and restrictive cardiomyopathies, valvular and congenital heart disease, hypertension and ischemic heart disease were excluded. Results: Mean age was 47.12 +/- 17.9 year with male predominance [males=34, females=16]. Mean ejection fraction was 30.6 +/- 6.9%. Complications revealed on echocardiography were intracardiac thrombi [5, 10%], spontaneous echo contrast [5, 10%], pericardial effusion [6, 12%], mitral regurgitation [46, 92%], tricuspid [25, 50%], aortic [5, 10%], pulmonary [2, 4%] multi-valvular regurgitation [28, 56%], and left atrial dilatation [36, 72%]. Conclusion: LV systolic dysfunction, cardiac thrombi, spontaneous echo contrast, mitral and tricuspid regurgitation and left atrial enlargement are important complications of dilated cardiomyopathy. Echocardiography is important tool towards identification of these complications. Keywords: cardiomyopathy, dilated, cardiomyopathy, complications, cardiomyopathy, congestive, echocardiography

Frequency of metabolic syndrome in patients with type-2 diabetes

Diabetes, Hypertension, Obesity and Ischaemic Heart Disease have become a problem of public health magnitude with substantial economic burden both in the developed as well as the developing countries. Obesity is quite frequent in Type 2 diabetics and also plays a central role in causing Metabolic Syndrome [MetS]. Metabolic Syndrome significantly increases the incidence of cardiovascular complications. This study was done to determine the frequency of MetS in our Type 2 diabetic patients as most of the components of MetS can be modified and identifying/managing these at an early stage might be of considerable help in reducing cardiovascular complications. This cross-sectional study was done in Medical 'B' and Medical 'A' wards of Ayub Teaching Hospital, Abbottabad from Nov, 08 to April, 09. Type 2 Diabetic patients aged above 40 years who gave informed consent were included in the study. Data was collected through a structured proforma. Frequency of Metabolic Syndrome was estimated according to the IDF consensus worldwide definition of the MetS. Of the 100 patients enrolled in this study 56 were females and 44 were males with a mean age of 59.9 years. Out of these 100 participants seventy six [76%] were diagnosed to have metabolic syndrome. Of the 56 females, forty eight [85.71%] were having metabolic syndrome while twenty eight [63.63%] of the 44 male participants were having the syndrome. The difference was statistically significant [p<0.05]. Frequency of MetS was found to be significantly high in this study with female preponderance. All the components, except Hypertension were more frequent in females. Diabetic patients with metabolic syndrome need more aggressive approach in management so as to decrease the incidence of cardiovascular complications

Frequency of dyslipidaemia in type 2 diabetes mellitus in patients of Hazara division

Diabetes mellitus increases the risk of atherosclerotic vascular disease because of associated dyslipidaemia. Many studies advocate aggressive management of lipid disorders in Type 2 Diabetes to decrease these complications. This study was carried out to know the frequency of dyslipidaemia in our patients and also to determine that whether patients with good glycaemic control [HbA1c /= 8%] emphasizing the importance of good glycaemic control. However none of our patients had a low HDL-Cholesterol as found in some other studies. Hypertriglyceridaemia along with impaired LDL-Cholesterol is present in majority of our patients. Good glycaemic control does affect the lipid profile in Type 2 Diabetes mellitus. However to provide the benefits of lipid lowering therapy to our patients, as confirmed in many studies, we need more awareness and placebo controlled double blind studies

Mushroom poisoning in children: clinical presentation and outcome

A variable clinical picture characterizes mushroom poisoning. The Amatoxin, the main toxic component of these fungi, are responsible for gastrointestinal symptoms as well as hepatic and renal failure. As acute gastroenteritis is extremely common in our set up, so every patient presenting with these symptoms is treated as gastroenteritis of viral aetiology. The authors present the clinical picture of the phalloid syndrome, its treatment and immediate outcome. All children age less than 16 years admitted in Saidu Hospital Swat from January to December 2006 with mushroom poisoning were included in the study. Patients with doubtful history or with associated illness were not included. The diagnosis was based on the clinical picture of the patient, history and the laboratory data. In addition to maintenance of fluid and electrolyte balance and treating sepsis, oral Silymarin and intravenous penicillin was started. Liver function tests, renal functions tests, serum electrolytes and coagulation profile was done in all the patients. The severity of poisoning was graded according to hepatic transaminase elevations and prolongation of prothrombin time. Of the 18 patients, fifteen were above five years of age. Female were twice in number. Fifteen patients developed hepatic failure and three patients developed renal failure. Thirteen patients expired. To start timely management, Mushroom poisoning should be considered in the differential diagnosis in patients presenting with food poisoning particularly coming in groups. Delay in diagnosis is associated with high mortality

Type 2 diabetes mellitus: how well controlled in our patients?

Type 2 Diabetes mellitus has reached epidemic proportions worldwide and Pakistan is no exception. This study was done to see the glycaemic control of our diabetic patients by estimating Glycosylated haemoglobin and Fasting blood glucose as poor control leads to significant complications causing enormous human suffering and socioeconomic burden. This Cross-sectional study was conducted on Type 2 diabetic patients coming to medical OPD and medical B ward of Ayub Teaching Hospital between March-September 2007 fulfilling the inclusion criteria. Among 100 patients with type 2 diabetes forty two had HbA[1]c more than 7.5%, while seventy had fasting blood glucose more than 120 mg/dl. All patients with HbA[1]c more than 7.5% had increased fasting blood glucose. While thirty out of seventy patients with fasting blood glucose more than 120 mg/dl had HbA[1]c less than 7.5%. None of the patients with fasting blood glucose less than 120 mg/dl had HbA[1]c more than 7.5%. Significant number of patients [42%] had poor control of diabetes as revealed by HbA[1]c, with FBG showing poor control in even more patients, i.e., 70%. However their blood glucose estimation was not frequent enough as required. Blood glucose results can be spuriously high and may lead to frequent change/ increase in the dose of hypoglycaemic medications. This can lead to poor compliance as well as psychological trauma to patients. HbA[1]c on the other hand is easy to interpret, reflects long term glycaemic control and cost effective. We recommend its more frequent use along with blood glucose for better glycaemic control and decreased chances of complications

Significant incidence of typhoid in hepatitis C patients

Only proven way of transmission of Hepatitis C is through blood. The origin is unknown in nearly half the cases. Pollution is suspected as a cause but it is impossible to prove this relationship directly. We thought that typhoid being a proven pollution related disease, determination of its confection in Hepatitis C patients representing same Socio-economic group would be of interest. A typhoid in Hepatitis C patients can easily be overlooked because symptoms like fever and abdominal discomfort are present in both diseases. Blood samples were collected from three groups of study as mentioned in materials and methods. These samples were processed for 4[th] generation HCV ELISA. PCR for HCV, PCR for typhoid. Blood culture for typhoid and widal test as required [details are given in methodology]. Finally the data thus obtained was analysed and conclusions were drawn. Health Biotechnology Division, National Institute for Biotechnology and Genetic Engineering [NIBGE] and Millat Laboratory Faisalabad. April 2004 to Oct 2004. The parameters included were PCR, blood culture and widal test. There were three groups of study, PCR and ELISA positive patients of Hepatitis C [105] - further subdivided into two groups, with history of exposure to known causes of spread of HCV in last one year [65] and those without such history [40]; clinically diagnosed cases of typhoid [30]; and healthy controls [50]. In the three groups, PCR was positive in 9.5[7.7 and 12.5], 63.3, and 2.0% cases respectively. Figures for blood culture were 4.7[3.1 and 7.5], 33.3, and 0% in the same order, and the respective figures for widal test were 34.2[33.8 and 35.0], 56.6, and 24.0%. The increase in PCR and blood culture positivity in Hepatitis C cases as compared with normal subjects is statistically significant [P< 0.05]. These results clearly suggest that the source of infection for the two diseases is same in many cases, and therefore, provides a strong indication of a relationship between pollution and Hepatitis C