Pre-treatment delay and out of pocket expenses by notified new tuberculosis patients in an Indian mega city.

BACKGROUND: Study was carried out to find out delay from onset of symptoms and out of pocket expenditure (OOPE) until initiation of anti-TB treatment (ATT) by new Tuberculosis (TB) patients registered in public health facilities in Bengaluru. METHODS: Notified patients (N = 228) selected purposively were interviewed at initiation of ATT regarding number and type of facilities visited and delay in initiating ATT. OOPE was elicited separately for in- and out-patient visits, towards consultation, purchase of medicines, diagnostic tests, transportation, hospitalization and food. Dissaving or money borrowed was ascertained. RESULTS: Two-thirds of participants were 15-44 years of age and 56% were males, mean annual household income was $4357. About 75% first visited a private health facility; 68% and 87% respectively were diagnosed and started on ATT in public sector after visiting an average of three facilities and after a mean delay of 68 days; the median delay was 44 days. Of mean OOPE of $402, 54% was direct medical expenditure, 5% non-medical direct and 41% indirect. OOPE was higher for Extra-pulmonary TB compared to PTB and when number of health facilities visited before initiating treatment was >3 compared to those who visited ≤3 and when the time interval between onset of symptoms and treatment initiation (total delay) was >28 days compared to when this interval was ≤28 days. About 20% suffered catastrophic expenditure; 34% borrowed money and 37% sold assets. CONCLUSION: Concerted efforts are needed to reduce delay and OOPE in pre-treatment period and social protection to account for indirect expenditure.

The effect of COVID-19 on a Major Trauma Network. An analysis of mechanism of injury pattern, referral load and operative case-mix.

PURPOSE: The aim of this study was to evaluate changes in both mechanism and diagnoses of injuries presenting to the orthopaedic department during this lockdown period, as well as to observe any changes in operative case-mix during this time. METHODS: A study period of twelve weeks following the introduction of the nationwide "lockdown period", March 23rd - June 14th, 2020 was identified and compared to the same time period in 2019 as a "baseline period". A retrospective analysis of all emergency orthopaedic referrals and surgical procedures performed during these time frames was undertaken. All data was collected and screened using the 'eTrauma' management platform (Open Medical, UK). The study included data from a five NHS Foundation Trusts within North West London. A total of 6695 referrals were included for analysis. RESULTS: The total number of referrals received during the lockdown period fell by 35.3% (n=2631) compared to the same period in 2019 (n=4064). Falls remained proportionally the most common mechanism of injury across all age groups in both time periods. The proportion sports related injuries compared to the overall number of injuries fell significantly during the lockdown period (p<0.001), however, the proportion of pushbike related accidents increased significantly (p<0.001). The total number of operations performed during the lockdown period fell by 38.8% (n=1046) during lockdown (n=1732). The proportion of patients undergoing operative intervention for Neck of Femur (NOF) and ankle fractures remained similar during both study periods. A more non-operative approach was seen in the management of wrist fractures, with 41.4% of injuries undergoing an operation during the lockdown period compared to 58.6% at baseline (p<0.001). CONCLUSION: In conclusion, the nationwide lockdown has led to a decrease in emergency orthopaedic referrals and procedure numbers. There has been a change in mechanism of injuries, with fewer sporting injuries, conversely, there has been an increase in the number of pushbike or scooter related injuries during the lockdown period. NOF fractures remained at similar levels to the previous year. There was a change in strategy for managing distal radius fractures with more fractures being treated non-operatively.

Proof-of-concept prototype drill-guide for use in medial patello-femoral ligament (MPFL) reconstruction surgery.

For surgical reconstruction of the medial patello-femoral ligament (MPFL) a variety of techniques are used for fixation of the graft to the medial border of the patella. The bone bridge or V-shaped tunnel technique utilises two tunnels drilled from the medial aspect of the patella that converge centrally creating a tunnel through which the graft is threaded. This technique has advantages: it avoids hardware (bone anchors) and their associated complications, creates a broad attachment of the ligament approximating normal anatomy and the tunnel does not breach the lateral cortex of the patella reducing the risk of patella fracture. In current practice the bony tunnels are created using freehand techniques. These rely on estimation of the patella centre by the surgeon and is subject to wide variation. Additionally this technique can be inefficient, inaccurate and time consuming. To address these disadvantages a new drill-guide device was developed. A prototype drill-guide was constructed using CAD and 3D printing methods. The device was designed to allow the surgeon to accurately and efficiently drill the required v-shaped bone tunnel. To assess the efficacy of the prototype drill guide, an experiment designed to assess a group of ten surgeons with an average of 4.2 years experience performing the task of creating a v-shaped bone tunnel using a free-hand technique and the drill-guide. To determine the accuracy of the tunnel placement, the angle between drill holes, distance from centre of the patella and the amount of over-drill were measured. Procedure duration was also compared. The results revealed that the prototype drill-guide created a more accurate bone bridge than the traditional free hand method. The root mean square error for the distance from centre was 0.50 mm vs 2.12 mm and the angle between tunnels was 2.6O vs 15.9O for the prototype and traditional methods respectively. There was a mean of 8.9 mm over-drill with the traditional method, which was negated when using the guide. Surgeons using the guide were approximately 25% faster than using the traditional free-hand technique. The prototype drill-guide improved the accuracy, reduced the variability, and reduced procedure duration compared to the traditional free-hand technique.

Preservation vs. resection of the infrapatellar fat pad during total knee arthroplasty Part I: A survey of current practice in the UK.

BACKGROUND: The management of the infrapatellar fat pad (IPFP) during total knee arthroplasty (TKA) is the subject of ongoing debate. In part 1 of this two-part series, we present an overview of current practice regarding the management of the IPFP in elective TKA among surgeons in the UK. METHODS: A web-based survey was offered to 269 delegates of the BASK 2017 annual conference. RESULTS: The survey showed a large variation in practice. Of the 173 responders, 86.7% were consultants; 62.4% partially resected the IPFP; 23.1% totally resected the IPFP, and 9.8% preserved it. Forty percent felt that resection made a difference. Only 23% stated that they were aware of guidelines/evidence. CONCLUSION: There is wide variation in practice with regard to the IPFP in TKA. The available literature with regard to resection or preservation of the IPFP is not conclusive. IMPLICATIONS: There are no definitive guidelines available for the management of the IPFP in TKA resulting in a wide variation in practice amongst surgeons.

Preservation vs. resection of the infrapatellar fat pad during total knee arthroplasty part II: A systematic review of published evidence.

BACKGROUND: The management of the infrapatellar fat pad (IPFP) during total knee arthroplasty (TKA) is the subject of ongoing debate. In part 2 of this two part series the authors aimed to investigate if resection of the IPFP affects clinical outcomes. METHODS: A systematic search of CENTRAL Cochrane library, Medline, Embase and Web-of-science databases for the past 10 years was performed. Studies of patients undergoing primary TKA comparing outcomes between IPFP resection and preservation were included. The meta-analysis was performed with Review Manager 5.3. RESULTS: Seven studies, involving 2815 patients (3312 knees) were included in the systematic review, of which two were RCTs. Outcome measures included patellar tendon length (PTL), post-operative pain, Knee Society Scores (KSS) and Functional Scores. Meta-analysis identified a trend toward shortening of the patellar tendon with IPFP resection. Resection correlated with a lower incidence of post-operative pain at one to two months, however at three to six months pain scores were higher in this group. No statistical difference was found in KSS and Functional Scores. CONCLUSION: There is wide variation in practice with regard to the IPFP in TKA. The available literature with regard to resection or preservation of the IPFP is not conclusive. IMPLICATIONS: There is no clear consensus in the literature on the resection or preservation of the IPFP indicating a clear need for high quality studies in the future to provide meaningful answers.

Role of pre-Xpert® screening using chest X-ray in early diagnosis of smear-negative pulmonary tuberculosis.

In a sub-district level hospital in South India, the proportion of patients with abnormal chest X-ray (CXR) was evaluated among smear-negative, Xpert® MTB/RIF (Xpert) positive individuals with pulmonary tuberculosis (PTB) symptoms; 384 smear-negative PTB individuals with PTB symptoms and without a history of anti-tuberculosis treatment underwent CXR and Xpert testing of one sputum specimen. Of 378 individuals with both Xpert and CXR results available, 14 were positive for Mycobacterium tuberculosis. Of these, 13 (92.9%) had an abnormal CXR and one was normal. This study highlights the usefulness of CXR before Xpert testing, which needs further validation.

Clinical outcomes of bilateral single-stage unicompartmental knee arthroplasty.

BACKGROUND: Deciding whether to treat patients with bilateral arthritis with two-stage or bilateral single-stage arthroplasties is a cause of considerable debate in orthopaedic surgery. METHODS: A total of 394 cemented Unicompartmental Knee Arthroplasties (UKA) were performed in this unit between 2006 and 2010. A retrospective review identified 38 patients (76 knees) who underwent bilateral Single-Stage Sequential UKA, performed by a single surgeon. RESULTS: The mean BMI was 29.8 and the majority of patients were ASA grade 2. The mean duration of follow-up was 30 months. The mean total tourniquet time was 83 min. The mean post-operative haemoglobin was 11.8 and no patient required blood transfusion. The mean time to mobilisation was 18 h and the average length of stay was 3.5 days. This compares favourably with an institutional average length of stay of two days for a single UKA. There was a significant improvement in the mean pre- to post-operative OKS (from 14 to 34, p<0.0001). One patient required operative fixation of a tibial plateau fracture after sustaining a mechanical fall two months following surgery. There were no other major complications, including thrombo-embolic events or deep infections. Two patients required excision of a superficial suture granuloma. CONCLUSIONS: Bilateral Single-Stage Sequential UKAs provide significant improvement in patient function and can be performed safely with a low complication rate. Patients can benefit from a single hospital admission and anaesthetic whilst the shorter total in-patient stay reduces costs incurred by the hospital. LEVEL OF EVIDENCE: IV.

Lipoma Arborescens of both Knees - Case report and Literature Review.

INTRODUCTION: Lipoma arborescens (LA) is a rare, benign intra-articular lesion most commonly found in the knee, characterised by villous proliferation of the synovium. It generally presents as a longstanding, slowly progressive swelling of one or more joints associated which may or may not be associated with pain. MRI is the investigation of choice, with images clearest on fat-supressed or STIR sequences. CASE REPORT: We present a 35 year old male patient, who presented with a three year history of bilateral knee pain and swelling. Magnetic resonance imaging (MRI) scans of his knee showed the characteristic features of lipoma arborescens. A 99technetium bone scan revealed increased uptake in both knees. The patient underwent bilateral arthroscopic synovectomies and made an uneventful recovery. The samples sent for histology were reported as being characteristic of lipoma arborescens. CONCLUSIONS: Lipoma arborescens is a rare, benign intra-articular tumour which may mimic a number of other diagnoses. MRI should be considered to exclude this pathology as well as other uncommon intra-articular pathology. Treatment with synovectomy is frequently curative.