Evaluation of the Outcome of Osteoarthritis among Patients Undergoing Total Knee Replacement.

Background: To assess the outcome of osteoarthritis among patients undergoing total knee replacement (TKR). Materials and Methods: One hundred and four subjects with one hundred and fifty-two cemented total knee arthroplasties have been analyzed in the current research. Functional assessment was carried out using the preoperative and postoperative Knee Injury and Osteoarthritis Outcome Score (KOOS) score and its five subscales: pain, other symptoms, function in activity of daily living (ADL), function in sport and recreation (Sport/Rec), and knee-related quality of life (QOL). Results: A significant improvement in the KOOS symptom score was seen with score grade changing to excellent from poor. The average postoperative KOOS symptom score occurred to be 89.9198, whereas the mean preoperative KOOS score was 30.7960 with a mean difference of 59.02385. The mean postoperative KOOS pain score was 94.6304 and the mean preoperative KOOS score was 18.4831 with a mean difference of 76.14731. A significant improvement in the KOOS pain score was seen with score grade changing to excellent from poor. Sixty patients of 104 (57.7%) had an excellent satisfaction level with a postoperative range of motion, twenty-eight patients (26.9%) had a good, eleven patients (10.6%) had a fair, and five patients (4.8%) had a poor satisfaction level with a postoperative range of motion. Conclusion: Surgery for a TKR is successful in reducing individuals' pain and restoring their functional ability. Preoperative expectations and KOOS subscale scores are factors in patients' satisfaction, which is determined a year following surgery.

Neonatal sutureless pericardial marsupialization for isolated iatrogenic pulmonary vein stenosis.

A 12-day-old girl underwent extended end-to-end aortic arch reconstruction with proximal pulmonary autograft patch augmentation on moderately hypothermic cardiopulmonary bypass. At the end of the procedure, the right superior pulmonary vein developed a severe stenosis at the insertion site of the left atrial vent, as a consequence of multiple hemostatic sutures. We report the successful intraoperative ad hoc application of the sutureless pericardial marsupialization technique for the herewith described severe, isolated, iatrogenic pulmonary vein stenosis in a neonate.

Fast tracking after repair of congenital heart defects.

Fast tracking after repair of congenital heart defects (CHD) is a process involving the reduction of perioperative period by timely admission, early extubation after surgery, short intensive care unit (ICU) stay, early mobilisation, and faster hospital discharge. It requires a coordinated multidisciplinary team involvement. In the last 2 decades, many centres have adopted the fast tracking strategy in paediatric cardiac population, safely and successfully extubating patients in the OR with reported benefits in terms of reduced morbidity and ICU/hospital stay. In this manuscript, we will review the literature available on early extubation after repair of CHD and share our experience with this approach.

Implementation of On-table Extubation After Pediatric Cardiac Surgery in the Developing World.

In the recent years there has been increasing trend towards the practice of on-table extubation after pediatric cardiac surgery among practitioner in European and non-European countries. In this article we share our experience with on-table extubation among children after cardiac surgery in the developing world supported with the currently available literature.

Functional outcome of open distal femoral fractures managed with lateral locking plates.

PURPOSE: This prospective study evaluated the functional outcome and union rates of open distal femoral fractures managed with anatomic lateral locking plates. METHODS: Thirty-four patients with open distal femur fractures with mean age of 40.8 years (range 20-65 years) were included in the study. Patients with Gustilo-Anderson grade IIIC fractures and those managed with non-locking modalities were excluded. In total, 70.6% (n = 24) of the fractures were Type IIIA and 55.9% (n = 19) were AO/OTA Type C3 fractures. In 23.5% (n = 8) patients, knee spanning external fixator was applied initially before definitive fixation. Patients were followed up for a mean period of 11.6 months (range 8-22.5 months). Functional outcome was evaluated using Sanders Score. RESULTS: In the primary plating group, 69.2% (n = 18) fractures united at an average of 27 weeks (range 21-40 weeks), while eight patients had non-union and required bone grafting. All eight patients with external fixator underwent lateral locked plating with bone grafting and united at an average time of 39.6 weeks (range 31-50 weeks). There were two cases each of infection and screw failure. The final mean Sanders Score was 30.1 (range19-40) with 73.5% (n = 25) patients having good to excellent functional outcomes. CONCLUSIONS: Lateral locking plates offer excellent stability to allow fracture union in open distal femoral fractures. A proactive approach to identify and manage potential healing difficulties is advisable to promote bone healing.

International quality improvement initiatives.

Across the globe, the implementation of quality improvement science and collaborative learning has positively affected the care and outcomes for children born with CHD. These efforts have advanced the collective expertise and performance of inter-professional healthcare teams. In this review, we highlight selected quality improvement initiatives and strategies impacting the field of cardiovascular care and describe implications for future practice and research. The continued leveraging of technology, commitment to data transparency, focus on team-based practice, and recognition of cultural norms and preferences ensure the success of sustainable models of global collaboration.

Synovial Hemangioma of the Knee Management and Excellent Outcome 2 Years after Arthroscopic Synovectomy in a 25-year-old Male with a 20-year History.

INTRODUCTION: Synovial hemangioma is a rare condition with <200 published case reports in world literature and is frequently misdiagnosed, leading to diagnostic delay of many years. This delay is even more significant if the patient comes from a rural background with a dearth of medical facilities in the area. This case had a lag of nearly 20 years from the time of onset of symptoms and the required management which is the maximum reported for any synovial hemangioma since most of them have been found and treated in adolescents. CASE REPORT: We present a case of an atypical synovial hemangioma in a 25-year-old Indian male from a poor socioeconomic background with a delay of 20 years who had both recurrent knee effusions and long-standing knee pain but kept ignoring his symptoms. It was managed by arthroscopic synovectomy. The patient reported to us after 2 years after the surgery with a painless knee and full range of movement. CONCLUSION: Synovial hemangioma mostly affects the knee joint, showing recurrent bloody effusions without a history of trauma. If there are no intermittent effusions, the diagnosis will be even more difficult. In cases of non-specific symptoms and long-standing knee pain of many years, the diagnosis of a synovial hemangioma should also be considered. In this particular case, magnetic resonance imaging was used to evaluate the patient after the plain radiographs and showed characteristic lace-like or linear patterns. Diagnostic arthroscopy and surgical excision were done in the same sitting, and biopsy was sent to the histopathology laboratory which confirmed our diagnosis. Although this patient had the disease since 20 years and presented late, he had little degeneration of cartilage at the time of arthroscopy. The functional outcome at 2-year follow-up was excellent, and he had no disability, effusion and was pain free.

Outcome of anatomic locking plate in extraarticular distal humeral shaft fractures.

BACKGROUND: Extraarticular fractures of distal humerus are challenging injuries to treat because of complex anatomy and fracture patterns. Functional bracing may not provide adequate stability in these injuries and operative treatment with intramedullary nails or conventional plates also has the limitation of inadequate fixation in the short distal fragment. The 3.5 mm precontoured single column locking plate (extraarticular distal humerus plate [EADHP]) has been introduced to overcome this problem. We evaluated the clinical and functional outcomes of treating these fractures with the EADHP. MATERIALS AND METHODS: 26 patients with extraarticular fractures of distal humerus presenting within 3 weeks of injury between January 2012 and June 2015, were included in this prospective study. Open IIIB and IIIC fractures, nonunions, or those with a history of previous infection in the arm were excluded. Operative fixation was done using the EADHP in all the cases. The time for union, range of motion at shoulder and elbow and secondary procedures were recorded in followup. The shoulder and elbow function was assessed using the University of California Los Angeles (UCLA) shoulder scale and Mayo Elbow Performance Score (MEPS) respectively. RESULTS: There were 21 males and 5 females with mean age of 37.3 years (range 18-72 years). Twenty two (84.6%) cases had complex fracture patterns (AO/OTA Type 12-B and C). The mean time to fracture union was 22.4 weeks (range 16-28 weeks). The mean followup time was 11.6 months, (range 4-24 months). Four patients (15.4%) had failure of cortical screws in the proximal fracture fragment, of which two required revision fixation with bone grafting. Another nonunion was seen following a surgical site infection, which healed after wound lavage and bone grafting. The MEPS (average: 96.1; range 80-100) was excellent in 81% cases (n = 21) and good in 19% cases (n = 5). UCLA score (average: 33.5; range 25-35) was good/excellent in 88.5% cases (n = 23) and fair in 11.5% cases (n = 3). CONCLUSION: EADHP is a reliable option in treating extraarticular distal humeral fractures as it provides stable fixation with an early return to function.

Extubation in the operating room after cardiac surgery in children: a prospective observational study with multidisciplinary coordinated approach.

OBJECTIVE: This prospective observational study was undertaken to determine the feasibility of extubation of children in the operating room after cardiac surgery. DESIGN: A prospective observational study compared with historic controls. SETTING: A single tertiary care referral hospital. PARTICIPANTS: One thousand consecutive pediatric patients requiring cardiac surgery aged 1 day to 18 years. Patients with spinal deformity, neurologic problems, coagulopathy as diagnosed by high international normalized ratio (INR) more than 1.5, and patients preoperatively on mechanical ventilation were excluded from the study. Data were also reviewed for another 1,000 patients operated before the beginning of this study, which constituted historic controls. INTERVENTIONS: All 1,000 patients were considered as potential candidates for extubation in the operating room after cardiac surgery and managed by a combination of general anesthesia and neuraxial analgesia with a mixture of caudal morphine and dexmedetomidine, and extubation in the operating room was attempted after completion of the surgical procedure. These comprised the study group (SG). Data also were reviewed for another 1,000 patients before the beginning of this study when extubation in the operating room was not attempted and compared with this group to study the impact of extubation in the operating room on intensive care unit (ICU) stay and resource utilization. This data comprised the before-study group (BSG). MEASUREMENTS AND MAIN RESULTS: Eight hundred seventy-one (87.1%) patients were extubated in the operating room. This included 40% of neonates and 70%, 85%, and 91% of patients aged between 1 and 3 months, 3 months to 1 year, and more than 1 year, respectively. Forty-five patients (4.5%) required re-intubation within 24 hours, and 9 patients died among those extubated in the OR, but for reasons thought not to be related to extubation. The ICU stay was significantly less in the study group (2.56±1.84 v 5.4±2.32 days, p<0.0001) as compared to before-study group (BSG). The number of patients in the ICU (34.76±3.19 v 59.98±4.92, p<0.0001) and the number of patients on a ventilator (5.1±1.24 v 24.5±2.88, p<0.0001) on a daily basis were significantly less in the study group, reflecting positive impact on resource utilization. CONCLUSION: Extubation in the operating room was successful in 87.1% of the patients without any increase in mortality and morbidity, but with a decrease in ICU length of stay and less use of hospital resources.

Thrombocytopenia in children with vivax malaria: a study from north India.

OBJECTIVES: To study incidence, severity and clinical significance of thrombocytopenia and to study recovery pattern of platelet counts in children with vivax malaria. METHODS: This was a retrospective hospital based descriptive case series. Cases of confirmed vivax malaria were studied and their Total Platelet Counts (TPC) evaluated daily till recovery and again after 1 wk on follow up visit. RESULTS: In this study out of 39 children of confirmed vivax malaria 22 had thrombocytopenia, having mean platelet count 48 × 10(9)/L on admission which showed a very quick recovery on treatment and by day 3 of treatment it rose to 126.5 × 10(9)/L without platelet transfusion. In untreated cases the lowest platelet counts was observed on day 5-6 and on treatment, platelet counts returned to normal without any platelet transfusion by 9th day. Even among children there are variations in different age groups and younger ones show more quicker recovery than older peers. CONCLUSIONS: Vivax malaria is associated with transient thrombocytopenia which does not lead to significant bleeding in children.

Utility of intra-operative capnogram to detect branch pulmonary artery obstruction following total correction of tetralogy of Fallot.

Branch pulmonary artery obstruction is one of the prime reasons for re-operation in patients who have undergone repair for tetralogy of Fallot. Branch pulmonary artery obstruction may develop over a period of time due to dilation of right ventricular outflow tract or it may be caused by residual stenosis after inadequate repair. This may lead to differential lung perfusion causing morbidity. Intra-operative capnogram monitoring reveals ventilation-perfusion relationship. We report two cases where the capnogram helped the diagnosis and management of branch pulmonary artery obstruction. We found a redundant patch in the first and an extra length of the homograft in second case which led to the obstruction. However, but for the changes in the intraoperative capnogram, this condition may by far remain undiagnosed considering the fact that it does not produce hemodynamic changes but can lead to postoperative morbidity.

Influence of colloid infusion on coagulation during off-pump coronary artery bypass grafting.

This study was conducted to determine the influence of colloid infusion on coagulation in patients undergoing off-pump coronary artery bypass grafting (OP-CABG). Thirty patients undergoing elective OP-CABG received medium molecular weight hydroxyethyl starch group I (MMW-HES 200/0.5), low molecular weight hydroxyethyl starch group II (LMW-HES 130/0.4) or gelatin group III (GEL) in a prospective randomized trial. Blood samples were assessed for hemoglobin (Hb), activated coagulation time (ACT), prothrombin time (PT), activated partial thromboplastin time (aPPT), platelet count, fibrinogen and von Willebrand factor (vWF) at specified intervals. Total volume of the colloid infused and postoperative chest-time drainage was also measured. There was a significant decrease in Hb, platelet count, fibrinogen levels in all these groups, which did not warrant blood transfusion. After the colloid infusion, vWF decreased significantly to 67% from baseline in group I as compared to 85 and 79% in group II and group III, respectively. vWF levels remained lower than the baseline value in the first 24 hours in group I, whereas this factor level increased above the baseline values in groups II and III, 6 hours postoperatively. Postoperative chest tube drainage in 24 hours was significantly higher in group I (856 +/- 131 ml) as compared to group II (550 +/- 124 ml) and group III (582 +/- 159 ml). LMW-HES 130/0.4 was superior to MMW-HES 200/0.5 and gelatin in patients undergoing OP-CABG, in terms of better preservation of coagulation associated with enhanced volume effect.

Intra-operative trans-esophageal echocardiography in congenital heart disease.

Intra-operative trans-esophageal echocardiography (TEE) is an important monitoring and diagnostic tool used during surgery for repair of congenital heart disease. In several studies,TEE has been shown to provide additional intra-cardiac anatomic information. Its ability to be used intra- operatively before and after cardiac repair makes it a unique tool. Before TEE was available for intra-operative use, significant residual abnormalities were frequently not detected. The result was often substantial post-operative morbidity and mortality and sometimes the need for re-operation. According to practice guidelines established by the Society of Cardiovascular Anesthesiologists and the American Society of Anesthesiologists, there is strong evidence for the usefulness of TEE in surgery for congenital heart disease because it significantly improves the clinical outcome of these patients. Before surgical correction, TEE helps confirm diagnosis and spot any additional lesion, while after the surgical correction, it provides baseline parameters for comparison after the surgical correction.

Anatomic repair for congenitally corrected transposition of the great arteries.

OBJECTIVE: Anatomic repair is being actively evaluated as the preferred option for congenitally corrected transposition of the great arteries. We present our 13-year experience with this approach. METHODS: Between May 1994 and September 2007, 68 patients with congenitally corrected transposition of the great arteries underwent anatomic repair. Thirty-one patients (group 1, mean age of 94.8 +/- 42.3 months) underwent a combined Rastelli and atrial switch operation. Thirty-seven patients (group 2, mean age of 36.1 +/- 46.9 months) underwent an arterial switch operation and atrial rerouting. Eight patients in group 2 had an intact ventricular septum. RESULTS: Group 1 had 5 early deaths (17%) but no late deaths. Three patients underwent conduit revision at a mean follow-up of 62 months. Group 2 had 5 early deaths (13.5%). There were 4 late reoperations (2 pulmonary baffle revisions, 1 mitral valve replacement, and 1 permanent pacemaker implantation) and 4 late deaths (1 secondary to progressive left ventricular dysfunction, 2 secondary to uncontrolled atrial tachyarrhythmia, and 1 secondary to pulmonary hypertension and right ventricular failure). In group 2, 4 patients have a left ventricular ejection fraction less than 40%, 5 patients have moderate aortic incompetence, 5 patients have symptomatic tricuspid incompetence, 1 patient has tricuspid stenosis, 1 patient has superior cava obstruction, and 3 patients are receiving antiarrhythmic therapy. CONCLUSION: The occurrence of left ventricular dysfunction indicate that anatomic repair in the arterial switch group is still fraught with imperfections. The Rastelli group required conduit revisions but has otherwise performed well.

The efficacy of aprotinin in arterial switch operations in infants.

BACKGROUND: In the present study we assessed whether aprotinin at a total dose (40,000 kallikrein inhibitor units (KIU)/kg) is effective in reducing postoperative blood loss and blood product requirement after arterial switch operations in infants. METHODS: A prospective, double-blind, randomized study, evaluated 50 infants who underwent arterial switch operations for transposition of great arteries. Patients were randomized into a placebo group, 25 patients who received normal saline and a treatment group, 25 patients who received 20,000 KIU/kg of aprotinin after induction of anesthesia, followed by 20,000 KIU/kg of aprotinin added to pump prime. Postoperative blood loss through the thoracic chest tubes and blood product requirements (mL/kg/24 h) were measured for the first 24 h in the intensive care unit. RESULTS: Postoperative blood loss in the first 24 h was significantly (P < 0.0001) higher in the placebo group (49.7 +/- 11.9 mL/kg/24 h) as compared to the aprotinin group (37.1 +/- 3.5 mL/kg/24 h). Requirements for fresh frozen plasma (mL/kg/24 h) and use of platelet concentrate transfusion (mL/kg/24 h) were significantly less in patients who received aprotinin (P < 0.0001), but did not reduce the proportion of patients transfused with blood products. The number of total donor exposures to all allogenic blood products was less in the aprotinin group [range (median) = 2-4 (3)] than the placebo group [range (median) = 7-14 (10)]. The re-exploration for excessive bleeding was significantly less with aprotinin group (16% vs 32%) (P = 0.01). CONCLUSION: Our study concludes that aprotinin decreased the postoperative blood loss and requirement of transfusion of fresh frozen plasma and platelets (mL/kg/24 h) during the early postoperative period. Further, it reduced the number of donor exposures and re-exploration for excessive bleeding in the treatment population.

Total anomalous pulmonary venous connection with intact interatrial septum.

The presence of an interatrial communication is considered an integral part of the diagnosis of total anomalous pulmonary venous connection and is believed to be essential for survival. We report a 9-month-old infant with obstructed supracardiac total anomalous pulmonary venous connection without an interatrial communication.

Ultra low dose aprotinin decreases blood loss and transfusion requirements in high risk two valve replacement surgery.

The efficacy of ultra-low-dose-aprotinin (ULDA) in 'high-risk' two valve replacement surgery, was evaluated in this prospective, randomized, double-blind study. Forty adult high-risk patients undergoing elective two valve replacement surgery, were included. The patients were divided into 2 groups of 20 each. In Group I, aprotinin in a dose of 1,000,000 KIU was administered from the end of anaesthesia induction to the time of sternotomy after a 1 ml of test dose. In Group II (control), 100 ml of normal saline was administered in a similar fashion. Coagulation parameters, blood loss, and amount of transfusion of blood / blood products were measured at specific intervals. The postoperative chest tube drainage in the first 24 hours was significantly less 203+/-35 ml (p<0.05) in Group I as compared with 490+/-104 ml in group II and consequently, Group I patients received significantly less (p<0.05) red cell concentrates and platelet transfusion. There was a significant decrease in the length of postoperative elective ventilation, intensive care unit (ICU) stay and direct costs involved in the hospital expenses with the use of ULDA. We conclude that ULDA is safe and effective in 'high-risk' two-valve replacement surgery to reduce postoperative bleeding, postoperative length of intubation and ICU stay; use of ULDA is associated with significant direct cost savings.