Management of Acute Appendicitis During the COVID-19 Pandemic is Significantly Different: A Retrospective Single UK Hospital Study.

INTRODUCTION: The COVID-19 pandemic has led to a change in the delivery of acute and emergency surgical services. With emphasis on reducing unnecessary operative intervention and performing more CT scans, there has been a shift in managing acute appendicitis conservatively. We evaluate the impact of this shift on the management of acute appendicitis. METHODS: A single UK centre retrospective study evaluating patients with suspected acute appendicitis pre-COVID-19 rota (18 March 2020) and post-COVID rota implementation. Data including demographics, inflammatory markers, imaging, mode of management and operative findings were collected. Logistic regression with SPSS was used to determine which factors were associated with conservative management and treated with antibiotics. RESULTS: A total of 161 patients were analysed, 82 pre-COVID19 and 79 post-COVID19. Of the pre-COVID-19 patients, 67.07% underwent appendicectomy while the rest were conservatively managed; 24.3% of these patients underwent a CT scan only. Post-COVID-19, 22.78% of patients underwent appendicectomy with a higher percentage of diagnostic CT scans performed, 43/79 (54.4%, p <0.001). The proportion of histologically normal appendicectomies was significantly reduced in the post-COVID-19 era (12.78% vs 0.00%; p-value 0.001). Logistic regression analysis showed a normal WCC to be associated with greater likelihood of conservative management. No conservatively managed patients returned to theatre in the 30-day follow-up period. CONCLUSION: Due to the restrictions imposed by the post-COVID-19 rota, a greater proportion of patients were managed conservatively with comparable patient outcomes. The approach also led to fewer negative appendicectomies owing to greater reliance on imaging.

Ankle syndesmotic injury: Tightrope vs screw fixation, A clinical academic survey.

OBJECTIVE: The goal of the study is to find out the treatment of choice for ankle fractures involving syndesmotic injury based on level of experience of orthopaedic surgeons. METHODS: A survey was undertaken to analyse the management used for ankle fractures with syndesmotic injuries AO 44c in a 35-year-old patient. Surgeons attending an orthopaedic course were invited to take part in a survey sorted into groups: junior surgeons middle grades, and experienced. Pictures of an x ray were shown to the participants and treatment options were asked. RESULTS: 100 surgeons from 20 nations took part in the event. Juniors made up 39%, registrars made up 38%, and experienced doctors were 29%. Screws, were reported by 93% for syndesmosis fixation. 66% of surgeons who used screws for syndesmosis fixation favoured a single screw over two screws.3-4 cortices were virtually evenly divided in choice, with 54% preferring three and 46% preferring four cortices. Only 22% of the time did they utilise a washer with their screws. With 52% of patients, the most typical time for permitting them to weight bear was 4-6 weeks after surgery. At 1-2 months postoperatively, 34% preferred to remove the screw, and at 2-3 months postoperatively, 29% preferred to remove the screw. CONCLUSION: Data show that the majority of junior level doctors handle their patients according to AO principles. The majority prefer one 3.5 mm screw positioned between 2 and 4 cm above the ankle joint, with three cortices being somewhat preferred. Despite the lack of data to support one procedure, the majority of people remove their screws within 1-3 months.

Total knee replacement: A comparison of the subvastus and medial parapatellar approaches.

OBJECTIVE: The goal of this study is to compare the subvastus method to the usual medial parapatellar technique for total knee replacement in patients with osteoarthritis who present to a tertiary care centre, based on quadriceps function recovery in days after surgery. MATERIALS AND METHODS: We retrospectively reviewed case notes of 76 patients with osteoarthritis who had total knee replacements in a tertiary care hospital over the course of a year from August 2019 to August 2020. We divided them into two groups: group A received TKR via the subvastus approach, and group B received TKR via the medial parapatellar approach. Preoperative quadriceps strength, BMI, and baseline demographics were all recorded from their initial pre-operative workup case notes. Starting on the first postoperative day, patients recorded first unassisted straight leg raise (SLR) was kept as the main determinant for muscle function. The data were evaluated to determine the quadriceps muscle function post TKR. RESULTS: When compared to the medial parapatellar approach, the quadriceps muscle function returns sooner with the subvastus technique. Patients in their sixties showed the highest improvement. Preoperative quadriceps strength has a major impact on muscle recovery after surgery. CONCLUSION: The subvastus method to total knee replacement is linked to a faster recovery of quadriceps muscle strength, resulting in a shorter hospital stay and postoperative therapy.

Complications of interosseous infusion resulting in a diagnostic dilemma.

Successful revival of a patient with cardiac arrest need vigilant effort on behalf of whole team but sometimes missing a small thing can create disaster. Here we present a case of 58 years old obese lady who was revived from a cardiac arrest secondary to septic shock. Obstruction due to proximal ureteric stone was relieved with JJ stent insertion. She required renal replacement therapy and invasive ventilation. Fever and inflammatory blood markers improved and she woke up after 6 days in intensive care unit (ICU). She developed another episode of sepsis but this time it was her shoulder that was hurting. Initially it was thought to be an iatrogenic skeletal injury during aggressive cardiopulmonary resuscitation (CPR) but radiographs came out to be normal. Magnetic resonance imaging (MRI) created more confusion by showing septic arthritis with proximal humeral osteomyelitis and gas formation. MRI suggested that it might be the sequelae of an intraosseous line insertion. All documented records were silent regarding the intraosseous line insertion. Resuscitation team was contacted and inquired. They confirmed the insertion of intraosseous line insertion during initial resuscitation which was removed after securing peripheral vascular access and before transferring the patient to ICU but they forgot to document. Her shoulder joint was washed out and debrided arthroscopically. She made a safe recovery without any other problem.