Effect of Preoperative Oral Carbohydrate Intake on Perioperative Hyperglycemia in Indian Patients Undergoing Hip Fracture Fixation.

Objective: Preoperative fasting leads to a catabolic state aggravated by surgical stress. This leads to poor patient outcomes. This study aimed to determine the effect of preoperative oral carbohydrate administration on perioperative hyperglycemia and patient comfort. Methods: This prospective, randomized study was conducted on 60 adult American Society of Anesthesiologist I/II patients undergoing hip fracture fixation after obtaining institutional ethical committee clearance. Patients were randomly kept conventionally fasted before surgery (group F, n = 30) or were given oral carbohydrate 2 h before surgery (group C, n = 30). Under all aseptic precautions, a combined spinal epidural block was administered, and surgery was allowed. The primary outcome was blood glucose, and secondary outcomes included incidence of postoperative hyperglycemia, insulin level, blood urea, hunger, thirst, and anxiety. Results: Blood glucose levels were not statistically different between the two groups at baseline (T0; P=0.400), immediately after surgery (T1; P=0.399) and 24h after surgery (T2; P=0.619). The incidence of postoperative hyperglycemia was significantly higher in group F than in group C (P=0.045) at T2. Insulin levels, blood urea levels, and hunger scores were also not statistically different between the groups. The thirst and anxiety scores were lower at T0 and T1 in group C. Conclusion: Preoperative oral carbohydrate administration does not prevent perioperative increases in blood glucose levels. However, it reduces the incidence of perioperative hyperglycemia and decreases perioperative thirst and anxiety, thereby improving the quality of perioperative patient care.

Novel Asymmetric Y Design of Fascial Sling for Restoration of Oral Competence and Adequate Mouth Opening in Oral Commissure Defects Post-Malignancy Resection.

Reconstruction of through-and-through defects of cheek and commissure resulting from cancer resection are challenging. The specialized function of oral competence that the oral commissure and lip play is difficult to replicate with flap only reconstruction. Static slings play an important role in improving the functional and aesthetic outcome. The asymmetric "y" fascial sling helps in achieving the goals of oral competence along with adequate mouth opening. A total of 10 patients were operated by this technique. The results were satisfactory in terms of functional and aesthetic outcome postsurgery and were maintained 6 months postradiation.

Papillon Flap-Design Modification of ALT Flap for Circumferential Laryngopharyngeal Defect.

Anterolateral thigh (ALT) free flap is a commonly used flap for reconstruction of circumferential laryngopharyngeal defects. The flap is harvested as an ellipse and tubed along its length. We would like to present a design modification of the ALT flap where the tubing of the flap is done along the width of the flap. This design has advantages as it allows for a two-layered closure without the harvest of additional tissue and provides skin for neck coverage also. After inset, the flap resembles a butterfly, hence the name "Papillon Flap."

Non-COVID-19 Cutaneous Mucormycosis from a Plastic Surgical Perspective.

Background Cutaneous mucormycosis is a rare and fulminant infection associated with high mortality. Plastic surgeons come across this infection in the settings of road traffic accidents, surgical site infections, and as a secondary infection with underlying bacterial soft tissue infections. Due to this infection's rarity and aggressive course, it is essential to initiate prompt multidisciplinary management at the first presentation. With this study, we aim to present a protocol for managing the condition. Methods This is a retrospective observational study of patients with cutaneous mucormycosis managed at a tertiary care hospital from January 1, 2016 to November 30, 2022 excluding patients with mucormycosis who tested positive for coronavirus disease 2019. Results Of 24 patients, 22 were males, and most were in the age group of 41 to 60 years. Sixteen patients survived and five out of eight deceased had comorbidities, six presented primarily without prior debridement, and six had trunk involvement. Conclusion A high index of clinical suspicion is necessary for early diagnosis and management of patients with invasive cutaneous mucormycosis. A multidisciplinary approach with appropriate medical and surgical management can improve outcomes in cases that otherwise carry a high mortality rate.

Drug Resistance in Osteoarticular Tuberculosis: A Study From an Endemic Zone.

BACKGROUND: The present study was undertaken to determine the incidence of drug resistance against anti-tubercular drugs among patients from an endemic zone.  Methodology: Forty consecutive clinico-radiologically diagnosed patients of osteoarticular tuberculosis (29: spine, 11: extraspinal) were enrolled. Pus from needle aspiration was taken in 31 cases, tissue following spinal decompression in seven, synovial in one, and sinus edge biopsy in one. The pus/tissue was subjected to acid-fast bacilli (AFB) staining and liquid culture, sensitivity to 13 anti-tubercular drugs (Isoniazid (INH), rifampicin (RIF), kanamycin (KAN), amikacin (AMK,) capreomycin (CAP), ethionamide (ETH), levofloxacin (LEV), moxifloxacin (MOX), linezolid (LNZ), para-amino-salicylic acid (PAS), bedaquiline (BDQ), delamanid (DLM), and clofazimine (CFO)) were checked, and histopathological/cytopathological examination and molecular tests were performed.   Results: The mean age of patients was 29.07(9-65) years; 21 were female and 19 were male. The diagnostic accuracy for tuberculosis was 20% by AFB smear, 65% by liquid culture, 82.5% by histopathology, and 90% by cartridge-based nucleic acid amplification testing (CBNAAT). All culture-positive isolates were identified as Mycobacterium tuberculosis with no non-tubercular Mycobacterium. The drug resistance detected on CBNAAT was 11.1%, line probe assay (LPA) first line was 15.4%, LPA second line was 4%, and liquid drug susceptibility testing (DST) 11.5%. We detected 15.4% INH resistance, 11.1% RIF, 7.6% LEV, 3.8% MOX and PAS. No resistance was detected against second-line injectable drugs (SLID), ETH, LNZ, BDQ, DLM, and CFO.    Conclusions: No single laboratory modality can ascertain the diagnosis in all cases; hence, samples should be sent for all tests in tandem. In the presence of insufficient samples, tissue may be subjected to CBNAAT and histopathology to arrive at tissue diagnosis. In this subset, overall drug resistance incidence was 12.5% (5/40) with one patient each of isolated INH and RIF resistance, one of multidrug-resistance (MDR), and two of pre-extensively drug-resistant (pre-XDR). Primary drug resistance came out to be 11.1% (4/36) with one patient each of isolated INH and RIF resistance, one of MDR, and one Pre-XDR.

Effect of COVID-19 on the Burden and Profile of Orthopaedic Patients Admitted Post-Resumption of Routine Services in a Tertiary Care Hospital in Delhi.

Purpose On resumption of routine services post-lockdown during coronavirus disease 2019 (COVID-19), we expected a backlog of orthopaedic patients who could not get appropriate and timely care and would now present with complications due to missed or delayed treatment. This study aimed to quantify the effect of COVID-19 on the burden and profile of orthopaedic patients admitted post-resumption of routine services. Materials and methods Data on all the patients admitted to the orthopaedic department were collected using an interviewer-administered schedule for a complete one-year period after the resumption of routine orthopaedic services in a tertiary care hospital in Delhi. For comparison of the burden of trauma patients with that during the pre-COVID-19 period, data were obtained from a similar study done on trauma patients in 2017 at the same institution. For patients with non-traumatic conditions, previous hospital records were used. Results A total of 1585 patients were admitted during the one-year period post-resumption of routine services following COVID-19 restrictions, which was 41% less than that compared to the corresponding pre-COVID-19 data. The proportion of patients from other neighbouring states showed a decline from 52% in the pre-COVID-19 period to 41.55% when healthcare services resumed during the COVID-19 period. Out of all admitted trauma patients in 2021, 12.7% presented with a missed or complication of treatment as compared to 3.1% in the pre-COVID period. Around half of them (52.5%) attributed their complications to a COVID-19-related lockdown. Conclusion There was a significant decline in the number of patients post-resumption of routine orthopaedic care services. Converting whole tertiary care teaching hospitals to COVID-19-dedicated hospitals must not be done as it leads to an increase in missed or complication of orthopaedic treatment.

Comparison of Outcomes of Long Versus Short Cephalomedullary Nails for the Fixation of Intertrochanteric Femur Fractures: A Systematic Review and Meta-analysis of 14,547 Patients.

Purpose: Intertrochanteric Femur Fractures (IFF) fixation could be done with short or long Cephalomedullary Nails (CMNs). Nevertheless, despite several studies in the literature, there has been a continued lack of consensus on which design of CMN is better than the other. Hence, the current review aimed to evaluate the evidence about short versus long CMNs for the fixation of IFF. Methodology: PRISMA guidelines were followed, and the protocol for the study was registered to PROSPERO. Four databases, Medline/PubMed, Embase, Scopus, and Cochrane Library, were searched. A total of 31 studies with 6 randomized trials (RCTs) and 25 non-randomized studies were included. Demographic data, follow-up period, and primary and secondary outcomes were extracted and evaluated from each of the included studies; statistical analysis was done by Review Manager Software version 5.4.1. Results: Fourteen thousand five hundred forty-seven patients were included in this review. Primary Outcomes: Long CMNs showed statistically significant lower rates of ipsilateral shaft femur refracture (OR 1.60, 95% CI 1.14, 2.24, p = 0.007); however, the difference was not statistically significant between the two groups for mortality at 30 days and within 1 year. Secondary Outcomes: Statistically significant shorter duration of surgery (MD-17.83 (95% CI - 22.03, - 13.63, p < 0.05), less intra-operative blood loss (MD - 62.65, 95% CI - 97.13 to - 28.17, p = < 0.05), and lower blood transfusion rates (OR 0.71, 95% CI 0.62, 0.83, p < 0.05) for short CMNs; no statistically significant difference for the length of hospital stay, implant-related complications, overall complications, re-operation rates, fluoroscopy time, and functional outcome between two groups of CMNs was seen. Conclusion: With shorter operative time, lesser intra-operative blood loss, and lower postoperative transfusion rates for short CMNs, they have certain benefits over longer CMNs. However, more distal shaft femur fractures were seen in the shorter version of nail, which should be considered before offering these nails to a patient; careful and individualized postoperative weight-bearing protocol could minimize the same. Supplementary Information: The online version contains supplementary material available at 10.1007/s43465-023-00915-5.

Wound Assessment Using Bates Jensen Wound Assessment Tool in Acute Musculoskeletal Injury Following Low-Cost Wall-Mounted Negative-Pressure Wound Therapy Application.

Background: Negative-pressure wound therapy (NPWT) is an alternative method of wound management for spontaneous healing. However, availability and high cost of a conventional NPWT system remain a challenge. Bates Jensen wound assessment tool (BWAT) has been used to assess wound healing in diverse wound treatments. Although there have been studies evaluating change in BWAT score following application of commercially available NPWT device, there is no literature evaluating change in BWAT score following use of wall-mounted low-cost NPWT device. Materials and Methods: Twenty patients above the age of 18 years with acute musculoskeletal wounds who underwent surgical debridement and required subsequent wound coverage were included in the study. Wound dressings were carried out using low-cost wall-mounted negative-pressure device utilizing a constant pressure of 125 mmHg for 48 h. Wound scoring was done using the Bates Jensen wound assessment tool (BWAT). The wound scores before and after application of NPWT were compared and analyzed using Wilcoxon signed-rank test. Results: Twenty patients fulfilling the inclusion criteria with a mean age of 37.10 ± 14.37 were included in the study. The average BWAT score before and after NPWT application was 31.2 ± 4.63 and 27.8 ± 3.68, respectively. The mean reduction in total BWAT score following NPWT application was 3.4. The granulation profile improved in 90% (n = 18/20) cases with a mean reduction of 1.5 ± 0.4 in the granulation tissue score. Exudation decreased in 60% (n = 12/20) patients with a mean reduction of 0.5 ± 0.23 in exudation type score and 0.35 ± 0.13 in exudation amount score. The necrotic tissue domain improved in 45% (n = 9/20) of the cases with a mean reduction of 0.45 ± 0.31 in necrotic tissue type score and 0.20 ± 0.12 in necrotic tissue amount score. Conclusion: There was a statistically significant reduction in the total BWAT score (p = 0.001) and an increase in granulation tissue (p = 0.001). The decrease in wound exudation (p = 0.004) and necrotic tissue coverage of the wound (p = 0.007) was also significant. However, there was no statistically significant change in wound depth, size, edges, undermining, tissue edema, tissue induration, and wound epithelialization after 48 h of continuous low-cost wall-mounted negative suction application in these patients.

Assessment of inter and intra-observer variation of Leonetti and Tigani CT bases classification of tibial pilon fractures.

INTRODUCTION: tibial pilon fracture constitutes 5-7% of all tibial fractures. The treatment of choice is an open reduction with anatomical articular reconstruction and stable fixation. A relievable fracture classification is needed for the preoperative planning the surgical management of these fractures. Hence, we assessed the inter- and intra-observer variation of Leonetti and Tigani CT bases classification of tibial pilon fractures. MATERIALS AND METHODS: In this prospective study, 37 patients aged between 18-65 years with an ankle fracture were included. All these patients underwent a CT scan for the ankle fracture, and the CT scan was further evaluated by 5 independent observers (Orthopaedic surgeon). A kappa value was determined for inter and intra-observer variation. RESULTS: Leonetti and Tigani's CT-based classification of the kappa values was 0.657 to 0.751, with a mean value of 0.700. The range of values for the intra-observer variation using Leonetti and Tigani CT-based classification on the kappa values was 0.658 to 0.875 with a mean value of 0.755. The P-value < 0.001 states that there was a significant agreement between the inter-observer and intra-observer classification. CONCLUSION: Leonetti and Tigani Classification have shown substantial inter- and intra-observer agreement, and the "4B" subclass of Leonetti and Tigani CT-based classification showed a predominance in the present study.

Comparison between reliability of Schatzker's classification and CT based four quadrant classification for tibial plateau fractures.

Introduction: Conventionally used Schatzker and AO/OTA classification, do not identify posterior column injuries in tibial plateau fractures. CT based Four quadrant classification, has been proposed to identify fractures of tibial plateau and help in surgical planning of treatment. However, to assess its validity, there is scanty literature about its reliability (inter and intra-observer variation) and comparison of its reliability with that of the more popular Schatzker classification in classifying tibial plateau fracture. Material and methods: X-rays and CT scans of 35 patients (18-65 years) of closed tibial plateau fractures were assessed by 5 Orthopaedic surgeons and classified by both Schatzker's and Four Quadrant Classification. A similar observation was recorded after 2 months. All observers were blinded for the demographic and clinical details of the patients. Their responses were noted and interobserver and Intraobserver variation was calculated. Kappa Test of Cohen was used to determine the level of agreement, as per Landis and Koch's criteria. The reliability of four quadrant classification was also compared with that of Schatzker's classification. Results: There was a moderate agreement in interobserver variation in observations for Schatzker's classification (on X-rays) which improved to substantial agreement when the observations were recorded after showing both CT and X-rays. The intraobserver variation had substantial agreement. On the other hand, there was a perfect agreement in both intra- and interobserver variation for Four Quadrant Classification. This difference between the reliability of both classifications was statistically significant (p < 0.001). Conclusions: Four Quadrant classification is a more reliable classification having a better agreement on interobserver and intraobserver variation.

Efficacy of Single Injection of Platelet-Rich Plasma in Shoulder Impingement Syndrome.

Introduction To analyze the change in Visual Analog Scale (VAS), QuickDASH score, and the range of motion at the shoulder joint following a single injection of platelet-rich plasma (PRP) in shoulder impingement syndrome. Methods Twenty patients (21 shoulders) of either sex above the age of 18 years with a clinical diagnosis of shoulder impingement having a positive shoulder impingement test (positive Hawkins-Kennedy impingement test and/or positive Neer's impingement sign), ultrasonographic confirmation of shoulder impingement, and a failure to respond to standard non-operative methods for a minimum period of four weeks were included in this prospective interventional study. PRP was injected at the proposed site. At three months after the injection, the changes in the VAS, QuickDASH score, and the range of motion at the shoulder joint were analyzed. Results There were significant changes in the VAS, QuickDASH score, and range of motion at the shoulder joint following a single injection of PRP. Conclusions Platelet-rich plasma (PRP) injection results in a significant decrease in pain and improvement in the range of motion and an overall excellent functional outcome in shoulder impingement syndrome. However, future studies with a bigger sample size and longer follow-up are needed.

Assessment of Usefulness of CT Scan in AO Classification of Intertrochanteric Fractures: A Prospective Observational Study.

OBJECTIVE: The sliding hip screw (SHS) is the gold standard for the management of stable intertrochanteric (IT) fractures. However, intramedullary implants are now being increasingly used for management of unstable IT fractures especially those with a compromised or vulnerable lateral wall. Therefore, accurate classification of fracture is important to ensure proper surgical planning and choice of implant. The AO classification for IT fractures is based on plain radiographs alone and many authors have reported it to have poor inter- and intra-observer agreement. Therefore, the objectives of the study were to assess the improvement in inter- and intra-observer agreement of the AO classification after addition of CT scan to plain radiographs, to assess the change in pattern of AO classification on addition of CT scan to plain radiographs and to assess percentage of times, stable lateral wall seen on plain radiographs is classified as unstable or broken on CT scans. METHOD: Fifty-four patients of intertrochanteric fracture were included in study. Plain radiographs of patients were shown to three orthopedic surgeons. They were asked to document the AO classification of the fracture, and comment on the integrity of the lateral wall. Then, CT scans with 3D reconstructions of the same patients were provided along with the radiographs and they were asked to classify the fracture again. Inter- and intra-observer agreement of the AO classification based on plain radiographs alone and once CT scan with 3D reconstruction was added to the plain radiographs was determined using Kappa coefficients. Pattern of change in classification on addition of CT scan to plain radiographs was also assessed. RESULT: The mean kappa value for inter- and intra-observer agreement for AO classification on plain radiographs alone were 0.58 (moderate) and 0.66 (substantial), respectively. Upon addition of CT scan to plain radiographs, both improved to 0.70 (substantial) and 0.77 (substantial), respectively. The AO classification of the fracture changed 28.70% times (93 of 324 observations) upon addition of CT scan to plain radiographs. 96.77% times (90 of 93 observations) the classification was upgraded to higher group, while it was downgraded in only 3.22% times (3 of 93). 55.91% times this change was observed in AO 31 A 2 group (52 of 93 observations). In 17.59% cases (57 of 324 observations), fractures which were classified as stable (A1.1-A2.1) on radiographs alone, were reclassified as unstable (A2.2-3.3) upon addition of CT scan to plain radiographs. In 11.4% cases (37 of 324 observations), the lateral wall was classified as vulnerable or broken on CT scans where it was classified intact on plain radiographs. CONCLUSION: Addition of CT scans with 3D reconstructions to plain radiographs improves the intra- and inter-observer agreement of the AO classification. Addition of CT scan results in change in classification of the fracture in about one out of three cases. This most commonly happens in the AO 31 A 2 group. Most of the times, this results in the classification of fracture being upgraded. Many fractures which are initially classified as stable (A1.1-A2.1) on radiographs are reclassified as unstable (A2.2-3.3) on addition of CT scans. The lateral wall is also classified as vulnerable or broken more number of times on CT scans than plain radiographs alone. Therefore, we conclude that CT scan with 3 D reconstructions definitely helps in better pre-operative classification of intertrochanteric fractures especially in select group of fractures (AO 31 A 2) where stability and integrity of lateral wall is difficult to assess.

Outcomes of Displaced, Comminuted, Intracapsular Neck Femur Fracture in Young Adults Managed with Three Screw Inverted Triangle Versus Four Screw Diamond Configuration: A Comparative Pilot Study.

Background: Three cannulated cancellous screws (CCS) inverted triangle configuration is considered to be the gold standard for management of displaced intracapsular neck femur (ICNF) fractures in young adults. However, some authors have recommended four CCS in diamond configuration in the presence of comminution. However, there are no comparative studies to assess the superiority of one over the other. Therefore, the aim of the present study was to compare the radiological and functional outcomes of displaced, comminuted, ICNF fracture in young adults managed with three screw inverted triangle versus four screw diamond configuration CCS fixation. Material and Methods: Twenty-three patients (group I) with displaced comminuted ICNF fractures were managed with three CCS fixation in inverted triangle fashion between October 2014 and October 2015 and were followed up for a mean duration of 33.5 months (range 25-38 months). Twenty-five patients (group II) with the same inclusion and exclusion criteria were managed with four CCS in diamond configuration between October 2013 and October 2014 and followed up for a mean duration of 33.3 months (range 25-38 months). Radiological outcomes of these patients were compared in terms of union rates and avascular necrosis, while functional outcome was measured by Harris Hip Score (HHS) at a minimum of 24 months. Results: Nineteen patients of group I and 20 patients of group II were available for final follow-up. Mean union time in group I was 15 weeks (12-24 weeks), while in group II, it was 14 weeks (12-24 weeks). There was total of four (4/19) cases of non-union in group I, while it was two (2/20) cases in group II. One patient (1/19) developed avascular necrosis in group I, while two (2/20) developed the same in group II. In group I, the mean HHS was 87.3 (range 84-94) points, while in group II, mean HHS was 93.5 (range 78-96) points. Conclusion: There is no difference in the clinical and radiological outcomes following three screw inverted triangle or four screw diamond configuration CCS fixation of displaced comminuted ICNF fracture in young adults. Thus, we conclude that both three screw inverted triangle or four screw diamond configuration CCS fixation are effective treatment modalities for fracture neck femur with comminution and in the absence of larger studies and long-term follow-up the superiority of one over the other cannot be recommended.

Senescent chondrogenic progenitor cells derived from articular cartilage of knee osteoarthritis patients contributes to senescence-associated secretory phenotype via release of IL-6 and IL-8.

OBJECTIVES: Despite the presence of chondrogenic progenitor cells (CPCs) in knee osteoarthritis patients they are unable to repair the damaged cartilage. This study aimed to evaluate the oxidative stress, cellular senescence, and senescence-associated secretory phenotype (SASP) in the CPCs derived from osteoarthritic cartilage and compare with the CPCs of healthy articular cartilage. METHODS: Isolated CPCs were characterized based on phenotypic expression of stem cell markers, clonogenicity, and tri-lineage differentiation assay. Production of ROS was measured using DCFDA assay. Cellular senescence in CPCs was assessed by senescence-associated beta-galactosidase assay and expression of senescence markers at the gene level using real-time PCR. Morphological features associated with senescent OA-CPCs were studied using scanning electron microscopy. To study SASP, the production of inflammatory cytokines was assessed in the culture supernatant using a flow-cytometer based cytometric bead array. RESULTS: OA-CPCs exhibited elevated ROS levels along with a relatively high percentage of senescent cells compared to non-OA CPCs, and a positive correlation exists between ROS production and senescence. The morphological assessment of senescent CPCs revealed increased cell size and multiple nuclei in senescent OA-CPCs. These results were further validated by elevated expression of senescence genes p16, p21, and p53. Additionally, culture supernatant of senescent OA-CPCs expressed IL-6 and IL-8 cytokines indicative of SASP. CONCLUSIONS: Despite exhibiting similar expression of stem cell markers and clonogenicity, CPCs undergo oxidative stress in diseased knee joint leading to increased production of intracellular ROS in chondrogenic progenitor cells that support cellular senescence. Further, senescence in OA-CPCs is mediated via the release of pro-inflammatory cytokines, IL-6 and IL-8.

Study of Cell Viability and Etiology of Contamination in Decalcified Bone Allograft: A Pilot Study.

BACKGROUND: Bone allografts can elicit immune responses which is correlated with the presence of Human Leukocyte Antigen (HLA) and cellular DNA. It also has risk of causing occult infection arising out of contamination during its processing and storage. The presence of immunogenic materials like cells, cellular remnants and DNA in a decalcified bone allograft during different phases of processing has never been studied. Present study was conducted to explore- the cell viability using routine Hematoxylin and Eosin, presence of DNA using Feulgen staining and etiology of contamination in decalcified bone allograft during procurement, demineralization and ethanol preservation. METHODS: The harvested bones from patients undergoing hemireplacement/THR/TKR were processed to prepare decalcified bone allografts. The samples during procurement (A), HCL treatment (B) and ethanol preservation (C) were sent for histopathological analysis (number of osteocytes in the maximum density field under 40x and the cells demonstrating presence of DNA on feulgen stain) and microbiological assessment (aerobic/anaerobic/fungal cultures). RESULTS: Histopathological study demonstrated the presence of osteocytes and other cells like bone marrow, adipocytes, endothelial cells in the decal bone allograft. The average number of osteocytes gradually decreased from 55.47, 9.6, 0.86 in sample A, B, C, respectively. Feulgen staining confirmed the presence of DNA in osteocytes and other cells which decreased both qualitatively and quantitatively in subsequent stages of processing. Rate of contamination demonstrated at the procurement was 6.67% (Staphylococcus aureus). After treatment with HCl (demineralisation), 7.14% of non-contaminated allografts were found contaminated (Staphylococcus epidermidis). None of the remaining 13 non-contaminated allografts showed contamination after storage in ethanol. Overall 13% of the patients had positive cultures on microbiological assessment. CONCLUSION: The population of osteocytes in the harvested bone reduced significantly after processing with HCl and ethanol preservation. Presence of DNA, demonstrated by using Feulgen staining, was observed in bone marrow cells, adipocytes along with osteocytes which showed quantitative reduction on processing. Hence, antigenicity, conferred by cells and their DNA, reduced significantly after processing of decal bone. Contamination rate of banked decalcified allograft was 13%. Thus, culture and sensitivity tests should be carried out at each step of processing of decal bone allograft.

Change in granulation tissue coverage and bacteriological load using Low Cost Negative Pressure Wound Therapy in acute musculoskeletal wounds.

BACKGROUND: Low cost Negative Pressure Wound Therapy (NPWT) dressings have been considered as an alternative to traditional daily dressings. There is scanty literature evaluating the change in the percentage area of wound covered by granulation tissue following application of low-cost NPWT. The change in the bacteriological flora following application of low-cost NPWT devices has also not been evaluated. METHODS: Patients above the age of 18 years with acute musculoskeletal injuries of <3 weeks duration which underwent a surgical debridement and required subsequent wound coverage were included in the study. Area of the wound and the area covered by the granulation tissue as well as the bacteriological count were measured before and after application of NPWT. A low cost NPWT using wall mounted vacuum device was put on the patient giving a constant negative pressure of 125 mm of Hg for 2 days. The findings before and after application of NPWT were compared and analyzed using Wilcoxin Signed-rank test. RESULTS: 21 patients with mean age of 35.52±15.075 were included. The pre-NPWT granulation tissue area ranged from 122 mm2 to 8483 mm2 with a mean of 1648.38 mm2 (SD = 1933.866). The post-NPWT granulation tissue area ranged from 234 mm2 to 7847 mm2 with a mean of 2364.48 mm2 (SD = 1857.716). The mean increase in granulation tissue was 716.1 mm2.The pre-NPWT wound area ranged from 422 mm2 to 10847 mm2 with a mean of 4009.62 mm2 (SD = 3026.209). The post-NPWT wound area ranged from 326 mm2 to 9143 mm2 with a mean of 3410.33 mm2 (SD = 2636.206). The mean reduction in wound size was 599.29 mm2.The pre-NPWT bacteriological count ranged from 3000/ml to 130000000/ml with a mean of 12616761.90/ml (SD = 29664589.37). The post-NPWT bacteriological count ranged from 1000/ml to 380000000/ml with a mean of 26401523.81/ml. The mean increase in bacteriological count was 13784761.91/ml. CONCLUSION: There was a statistically significant decrease in wound size (p = 0.001) and statistically significant increase in percentage area of granulation tissue coverage (p = 0.000) following low cost NPWT application. However there was no statistically significant increase in bacteriological clearance in these patients.

What matters to children with lower limb deformities: an international qualitative study guiding the development of a new patient-reported outcome measure.

BACKGROUND: Lower limb deformities include conditions such as leg length discrepancy, lower limb deficiency and associated angular and rotational deformities of the hips, knees, ankles and feet. Children with lower limb deformities often have physical limitations due to gait irregularities and pain. The differences in the appearance and function of their lower limbs can discourage participation in social, recreational and leisure activities, which may result in behavioural, emotional, psychological and social adjustment problems. The health-related quality of life (HRQL) of these children is often impacted due to the factors discussed above, as well as by the complex surgical procedures. Surgical treatment options for limb deformities in children vary from limb lengthening and reconstruction to amputation. The lack of evidence demonstrating superiority of either treatment options and their effect on HRQL limits the ability of healthcare providers to counsel families on the best evidence-based treatment option for them. This manuscript describes the international qualitative study which guided the development of a new patient-reported outcome measure (PROM). Individual semi-structured face-to-face interviews with children with lower limb deformities and their parents were conducted at five sites: Canada (2 sites), Ethiopia, India and the USA. RESULTS: Seventy-nine interviews were conducted at five international sites. Five main themes emerged from the qualitative interviews and formed the basis of the conceptual framework. These themes were: 1) appearance, 2) physical health, 3) psychological health 4) school and 5) social health. CONCLUSIONS: Lower limb deformities have a substantial impact on the HRQL of children. The concepts of interest identified in our study were similar across children from all countries. The conceptual framework guided the development of outcome scales specific to these patients. The information about the impact of various treatment options on the HRQL of children with lower limb deformities, collected using this new PROM, could be used to inform parents and children about outcomes (physical, social, psychological) associated with specific treatment options. This information could supplement other objective outcome information (e.g., complication rates, how the leg will look, etc.) to help families to come to a more informed decision on a child's course of treatment.

Feasibility of Customised Polymethyl Methacrylate Implants Fabricated Using 3D Printed Flexible Moulds for Correction of Facial Skeletal Deformities.

INTRODUCTION: Use of patient specific Polymethyl methacrylate (PMMA) implants for the reconstruction of cranial defects has become a standard practice with excellent long-term results. However, for the reconstruction of midface and mandibular osseous defects other alloplastic materials are preferred but their use is limited due to high cost. This is a report of our experience with the use of low-cost patient specific PMMA implants fabricated using 3D printed moulds in the reconstruction of osseous defects involving different areas of the facial skeleton not limited to cranium. METHODS: The 25 consecutive patients with craniofacial osseous defects who underwent reconstruction using customized PMMA implants were analyzed. All PMMA implants were fabricated intraoperatively with the use of 3D printed flexible moulds or templates. RESULTS: A total of 34 implants were used in 25 consecutive patients. Out of 34 implants 25 were used for midface and mandibular osseous defects. Most common etiology was post-traumatic deformity (n = 19) followed by tumor (n = 3), craniofacial anomalies (n = 2) and post-craniotomy (n = 1). One patient out of 25 (n = 1) had postoperative implant exposure. The follow-up was ranged from 3 to 19 months with an average of 12 months. The aesthetic outcome was found to be good to excellent with mean visual analogue score of 4.08. CONCLUSIONS: Polymethyl methacrylate implants fabricated intraoperatively using 3D printed moulds provide accurate and precise reconstruction at an exceptionally low cost. PMMA has an excellent moulding property with low infection rates. As shown in our study its application may be easily extended to all areas of the craniofacial skeleton.