The mid-term and long-term effects of tourniquet use in total knee arthroplasty: systematic review.

PURPOSE: A tourniquet is routinely used during total knee arthroplasty (TKA) to reduce intra-operative hemorrhage, though surgery without a tourniquet is becoming popular. To address concerns about the effect of blood at cement interfaces on long-term implant stability, we conducted a systematic review among patients undergoing total knee arthroplasty to determine if TKA with a tourniquet, compared to TKA without a tourniquet or with reduced tourniquet duration, is associated with better mid-term and long-term implant stability. METHODS: A literature search was conducted without language restriction in PubMed, Cochrane database and Web of Science from conception to 17th March, 2021. Prospective cohorts, randomized and observational, that compared tourniquet use with a control group, followed patients for 3 months or more and reported outcomes concerning implant stability, limb function, pain and inflammation. Article selection, quality assessment according to the Revised Cochrane risk assessment scale and Newcastle Ottawa Scale, and data extraction were conducted in duplicate. PROSPERO: CRD42020179020. RESULTS: The search yielded 4868 articles, from which 16 randomized controlled trials (RCT) and four prospective cohort studies, evaluating outcomes of 1884 knees, were included. Eleven RCTs were evaluated to be low overall risk of bias, five RCTs had some concerns and four cohort studies were good quality. Few studies showed benefits of tourniquet use in mid-term implant stability (1/6), pain (1/11) and limb inflammation (1/5), and long-term implant stability (1/1). One study reported a significantly improved range of motion (1/14) while another reported significantly reduced quadriceps strength (1/6) in the tourniquet group. The remaining studies reported non-significant effect of tourniquet use. CONCLUSION: Although few studies indicated benefits of tourniquet use in mid-term pain, limb inflammation, implant loosening and function, and long-term implant loosening, the majority of studies report no significant advantage of tourniquet use in total knee arthroplasty.

Burnout, Job Dissatisfaction, and Mental Health Outcomes Among Medical Students and Health Care Professionals at a Tertiary Care Hospital in Pakistan: Protocol for a Multi-Center Cross-Sectional Study.

Burnout, a state of vital exhaustion, has frequently been related to work-related stress and job dissatisfaction. Given the emotionally and physically challenging nature of their work, high rates of burnout have been reported among health care professionals. This may put them at a higher risk for of suffering from adverse mental health outcomes, including depression, anxiety and stress. In our study, we aim to assess the prevalence i of and associations among burnout and job dissatisfaction and adverse mental health outcomes in a developing country, where the challenges faced by the health care system are unique. Facilities are over-burdened and there is a sharp contrast between doctor to patient ratios in developing and developed countries. We plan to conduct a cross sectional study at the largest tertiary care hospital in Pakistan and its peripheral affiliated health centers. A proportionate sampling technique will be employed to include medical and nursing students, interns, residents and consultants. Previously validated questionnaires, including the Maslach Burnout tool, DASS 21, and Job Satisfaction Survey will be disseminated through Survey Monkey. Statistical analysis will be conducted using IBM SPSS Statistics Version 23 to study the association among burnout, job dissatisfaction, adverse health outcomes and demographic and work-related factors This study may begin laying the foundation for prioritizing the novel concept of physician mental health in the developing world. Further research building on to the results of this study will generate evidence to make recommendations about routine screening for mental illness and policy changes in the health care system.

Does surgeon experience influence the amount of radiation exposure during orthopedic procedures? A systematic review.

With an increasing use of intraoperative fluoroscopy in operating rooms worldwide, the topic of radiation exposure has become a major concern among hospital staff, doctors and patients alike. Since fluoroscopy has become an integral part in orthopedic intraoperative management, we sought to identify whether surgeon grade or experience plays a role in the amount of radiation used and consequently exposed. We performed a systematic review examining the association between surgeon experience and radiation exposure using primary outcome measures (radiation dose and total screening time/fluoroscopy time). To be included in the review, the study population had to compare varying surgeon experience levels and their effect on the primary outcomes. A total of eighteen studies were included in the review. The studies were a mix of prospective and retrospective studies with low to moderate quality as evaluated by the MINORs criteria. Studies were variable in defining surgeon experience levels and in the type of operations being performed. Majority of the studies showed that inexperienced surgeons/trainees had a higher total fluoroscopy time and a higher mean radiation exposure as compared to experienced surgeons. We conclude that higher surgeon experience significantly reduces usage of fluoroscopy and the consequent radiation exposure in orthopedic procedures. Introduction of strict radiation guidelines involving limited usage of fluoroscopy and supervision of trainees may be beneficial in controlling radiation exposure in the future.

Inheritance patterns, challenges, and outcomes of fracture management in osteopetrosis patients. CASE series and review of pertinent literature.

BACKGROUND: Osteopetrosis (OP) is a group of rare inheritable genetic disorders which show increased bone radiodensity on radiography. As no cure exists, careful symptomatic treatment is the mainstay in management due to brittle bone and frequent complications. We would like to present a case series of OP patients, their management, a review of literature about this rare disease and its genetic and inheritance patterns. MATERIALS AND METHODS: Retrospective case series of 6 patients with OP seen at our institution from 2010 to January 2018. We searched PubMed and Google Scholar for articles using the following keywords: Osteopetrosis, Radiology, Fracture and Management to review literature. CASES PRESENTATION: We present 6 cases of OP each showing diverse history of frequent fractures and describe the challenges faced during management and the long-term follow-up results. RESULTS: Abnormal osteoclast activity in OP results in defective bone resorption with patients having varied clinical presentations. Bones are brittle, increasing risk of fractures. Osteosynthesis is the recommended first-choice treatment for osteopetrotic fractures despite the risk of failure. Good preoperative planning is critical. Genetic studies showed multiple genes to be involved and varied patterns of inheritance in different types of OP. Conservative management could including varied therapies has also been proposed. CONCLUSION: With all-inclusive preoperative planning and careful postoperative care surgical treatment of fractures in OP is effective. The cases presented showed that plate osteosynthesis and intramedullary nailing are suitable options. Genetic factors and inheritance pattern should be discussed with patients.

Bone graft donor site infection with a rare organism, Aeromonas Hydrophila. A typical location, presentation and organism with 2 years follow-up. Case report.

INTRODUCTION: Aeromonas are Gram-negative bacilli often causing necrotizing fasciitis or sepsis in immunocompromised patients. Aeromonas Hydrophila is most often found in immunocompromised patients or those with burns or aquatic trauma. When patients present with a discharge and infection on bone graft donor site and progressive sepsis, an Aeromonas hydrophila infection should be considered in the differential diagnosis. PRESENTATION OF CASE: We report here a rare case of Aeromonas hydrophila with surgical site sepsis/infection in an immunocompromised 69 years old female, with several comorbids. Here we are reporting infection on donor surgical graft site, sparing major surgical site with the implant. After getting culture report of exudates from the wound that grew A. hydrophila, immediate wound debridement and antibiotic beads insertion was performed with appropriate antimicrobial therapy and regular wound dressing. She was followed for around 2 years. DISCUSSION: This is the first report to our knowledge of A. Hydrophila infection in bone graft donor site. Aeromonas most often cause gastrointestinal and soft tissue infections, and bacteremia in immunocompromised patients. Early surgical intervention is essential to reducing mortality in deep soft tissue infections caused by this organism. Aeromonas have shown resistance to penicillin but are sensitive to other broad-spectrum antibiotics. CONCLUSION: Early suspicion, diagnosis, and treatment with potent antibiotics are needed to prevent any further complications resulting from infection by this emerging aggressive pathogen.

The effect of tranexamic acid in unilateral and bilateral total knee arthroplasty in the South Asian population: A retrospective cohort study.

INTRODUCTION: Together with evidence of higher bleeding tendencies, the vulnerability of the South-Asian population to anemia secondary to a higher prevalence of hemoglobinopathies and micronutrient deficiencies merits further exploration of the effects of tranexamic acid on this population. Additionally, limited access to self-care facilities and certain sociocultural beliefs and practices may not be conducive to a speedy recovery from surgical complications. The aim of this study is to investigate the effects of intraoperative administration of tranexamic acid during total knee arthroplasty when considering the South-Asian population. METHODOLOGY: Medical record files of 355 patients who underwent total knee arthroplasty (2007-2015) were reviewed to collect data regarding patient characteristics, surgical variables and post-operative complications. Unilateral and Bilateral total knee arthroplasty were studied separately. Analysis was done using t-test, Mann-Whitney U test, chi-square and Fisher's exact square where appropriate. The threshold for significance was p < 0.05. RESULTS: The study showed that for unilateral surgery, tranexamic acid caused a significant reduction in estimated blood loss (p-value=0.011), total operative time, calculated blood loss, and hemoglobin change (p-value<0.001) whereas in bilateral surgery, tranexamic acid only caused a significant reduction in calculated blood loss (p-value < 0.001) and hemoglobin change (p-value=0.001). Interestingly, in those who received tranexamic acid vs. those who did not, there was a significant increase in length of hospital stay (p<0.001) and special care unit admissions (p-value=0.033) in unilateral and bilateral surgery respectively. CONCLUSIONS: Although tranexamic acid effectively reduces intraoperative blood loss, it does not have an effect on the need for post-operative blood transfusions. The increased length of stay and special care unit admissions associated with tranexamic acid use should be explored further to reveal the complete safety profile of tranexamic acid administration in the South-Asian population during total knee arthroplasty.

Management of stress fractures of the proximal tibia in patients with advance knee osteoarthritis. A case series.

To evaluate the outcome of one stage long stem total knee arthroplasty (TKA) of patients with stress fracture of the proximal tibia of the knee joint. Record of 15 patients, 14 females and one male who underwent one stage long stem TKAfrom the year January 2008 till December 2014 were reviewed retrospectively. Outcome variable was fracture healing which was seen clinically (pain free and postop ambulation) as well as radiologically (union of three out of four cortices). Mean age of the patients were 65 years and the mean BMI was 31. Of the 15 knees 13 had varus malalignment and 2 had valgus malalignment. The mean duration of fracture healing was four and a half months and the mean duration of follow-up was 26 months. All the patients were ambulated full weight bearing with walker. One patient had non-union at fracture site which required bone grafting. Long stem TKA is an effective method of treating tibial stress fractures associated with advance osteoarthritis as it not only restores the normal mechanical alignment but also facilitates fracture healing.

Does obesity affects early infection after total knee arthroplasty. A comparison of obese vs non obese patients.

Surgical site infection (SSI) is a disastrous complication after total knee arthroplasty (TKA) which can cause prosthesis loosening and may end up in septicaemia. The incidence of infection reported to be in the range of 0.3-12.4% for primary TKA. Significantly higher infection rate is found in the morbidly obese patients. The current study compared the immediate rate of post-total knee replacement wound infection in the obese versus non-obese population. The cross-sectional study was conducted at Aga Khan University Hospital (AKUH) and comprised patients undergoing TKA for primary knee osteoarthritis. Surgical outcome was measured by the Southampton wound infection score at 1-month follow-up. Out of 142 enrolled patients with a mean age of 67.8±56 years, infection was confirmed in 3(2.11%) patients who needed surgical management. All the patients who developed SSIs were females.

Lower red cell transfusion rates with use of tranexamic acid in single-stage bilateral total knee arthroplasty: A retrospective audit.

Bilateral total knee arthroplasty (BTKA) patients may require blood transfusion which has its risks. Anti-fibrinolytic drugs such as aprotinin, aminocaproic acid and tranexamic acid (TXA) have reduced transfusion requirements in major surgery. This retrospective audit was performed to assess effectiveness of TXA in reducing blood transfusion rate in single-stage sequential BTKA cases operated by a single surgeon. Records of 91 patients given TXA and 80 controls who were operated before 2012 and not given TXA were reviewed. TXA was given 15mg/kg intravenously (IV) before tourniquet deflation and 3 hours postoperatively.Blood transfusion was done in 9(10%) patients in the TXA group compared to 20(25%)in the control group (p<0.01). One (1.25%) patient in the control group had non-fatal pulmonary embolism.TXA appeared to be effective in decreasing post-operative blood loss and requirement for blood transfusion after single-stage BTKA.

Effect of continuous passive motion on knee flexion range of motion after total knee arthroplasty.

OBJECTIVE: To compare mean knee flexion in patients on continuous passive motion and those without it after total knee arthroplasty. METHODS: The randomised controlled study was conducted at Aga Khan University Hospital, from July 2013 to June 2014, and comprised patients who underwent total knee arthroplasty. Patients were randomly assigned to either group, with Group A receiving standardised physiotherapy from 1st postoperative day, and Group B receiving physiotherapy and one hour of continuous passive motion twice a day from 1st postoperative day until discharge. Outcome assessment was done on the day of discharge. RESULTS: Of the 76 patients, there were 38(50%) in each group. There were 61(80%) women and 15(20%) men, with a mean age of 65.5±7.9 years in Group A and 61.6±9.1 years in Group B. The mean preoperative knee flexion in Group A was 90.3±13.2° and in Group B it was 96.9±11.5°. Mean maximum flexion at the time of discharge was 96.3±5.7° in Group A and 94.3±8.4° in Group B (p=0.22). The mean length of stay in Group A was 6.1±1.4 days and in Group B it was 8.6±2.4 days (p=0.01). CONCLUSIONS: Continuous passive motion had no influence on knee range of motion after total knee arthroplasty at the time of discharge.

Conservative surgery for osteoid osteoma of the lumbar vertebrae.

BACKGROUND: We present two patients with osteoid osteomas of the lumbar spine to highlight the delay in diagnosis and the utility of precise radiological localization enabling tumor resection without jeopardizing spinal stability. CASE DESCRIPTION: Two young patients with refractory back pain presented after having undergone a year of conservative treatment for presumed mechanical back pain. The presence of "red-flag" symptoms (e.g. rest and night pain, and transient pain relief with aspirin) led to the performance of an isotope bone scan, and subsequent computed tomography (CT), which were both consistent with the diagnosis of an osteoid osteoma. After accurate CT-based preoperative planning for tumor excision, a customized conservative surgical technique was utilized that included marginal en-bloc surgical resection of the tumors. As the intervertebral facet joints were also carefully preserved along with stability, no accompanying instrumented fusion was warranted. Both patients returned to full function with complete resolution of their long-standing back pain of more than 2 years. CONCLUSIONS: The diagnosis of osteoid osteoma of the spine requires a high index of clinical suspicion. Diagnostic evaluations should include thin-slice CT scan to assist in planning the most restricted/conservative en-bloc surgical resection while preserving vertebral stability with facet preservation, and thus avoiding instrumented fusions. Without the availability of percutaneous radiofrequency ablation, such restricted/conservative approaches to osteoid osteomas are viable options in countries with developing economies.

Operative management of unstable thoracolumbar burst fractures.

Operative management of unstable burst vertebral fractures is challenging and debatable. This study of such cases was conducted at the Aga Khan Hospital, Karachi from January 1998 to April 2003. All surgically managed spine injuries were reviewed from case notes and operative records. Clinical outcome was assessed by Hanover spine score and correction of kyphosis was measured for radiological assessment. The results were analyzed by Wilcoxon sign rank test for two related samples and p-value < 0.05 was considered significant. Ten patients were identified by inclusion criteria. There was statistically significant difference between mean pre-and postoperative Hanover spine score (p=0.008). Likewise, there was significant difference between mean immediate postoperative and final follow-up kyphosis. (p=0.006). Critical assessment of neurologic and structural extent of injury, proper pre-operative planning and surgical expertise can optimize the outcome of patients.

Polyaxial screws for lumbo-iliac fixation after sacral tumor resection: experience with a new technique for an old surgical problem.

BACKGROUND: Although numerous reports have been published about various methods for reconstruction after sacrectomies, there are still biomechanical and technical dilemmas that are unaddressed. This report describes the experience at authors' institution of five cases in which polyaxial pedicle screws construct has been successfully used for lumbo-iliac fixation after sacral tumor resection. METHODS: Five cases of sacral tumors, two of Ewing's sarcoma and three of giant cell tumor (GCT) underwent surgical resection and then reconstruction was done with hardware using vertical rods placed alongside the spine bilaterally, transfixing monoaxial and polyaxial pedicle screws in lower lumbar levels and polyaxial screws into the ilium bilaterally. Cross links were also used to connect the two vertical members, thus enhancing biomechanical stability of the construct. Use of autologous bone grafts was relied upon to fill the gap created by sacral resection. RESULTS: No instrumentation failure was noted and the continuity of the spine and pelvis was well established with the instrumentation and auto grafts. In follow up of these patients (1-3 years), no complications were seen. CONCLUSION: Polyaxial pedicle screws fixation is an effective technique to transmit axial load from spine to the appendicular bone and can be used safely in patients in whom sacral integrity is compromised after surgical resection. However, the long term benefits of this technique need to be evaluated.

First successful autologous chondrocyte implantation in Pakistan.

Osteochondritis dissecans entails a hyaline cartilage defect of the articular surface causing pain and functional restriction in young adults, sometimes resulting in early degenerative arthritis. Conventional treatment methods such as abrasion chondroplasty and mosaicplasty have limitations in terms of quality of the resultant cartilage and donor site morbidity. A more recent technique, autologous chondrocyte implantation (ACI) results in hyaline cartilage formation and gives good long-term outcome, but requires a high-level cell culture facility and two surgical procedures. The patient was a young female with knee pain, intermittent locking and feeling of "joint mouse". MRI scan and arthroscopy showed a 2 x 2 cm full thickness osteochondral defect in the medial femoral condyle. A free fragment of articular cartilage was found, which was extracted arthroscopically, and chondrocytes were cultured from it in the Juma laboratory. Subsequently, patient underwent surgery whereby the chondrocytes were injected under a periosteal patch sewn over the defect. Over six months, patient's symptoms completely resolved and she returned to full function. A repeat arthroscopy after one year revealed complete filling of the previous defect with normal appearing cartilage indicating success of the procedure. This technology can be utilized for treating patients with a variety of conditions affecting hyaline cartilage of joints.

Peer review audit of trauma deaths in a developing country.

OBJECTIVES: Peer review of trauma deaths can be used to evaluate the efficacy of trauma systems. The objective of this study was to estimate teh proportion of preventable trauma deaths and the factors contributing to poor outcome using peer review in a tertiary care hospital in a developing country. METHODS: All trauma deaths during a 2-year period (1 January 1998 to 30 December 1998) were identified and registered in a computerized trauma registry, and the probability of survival was calculated for all patients. Summary data, including registry information and details of prehospital, emergency room, and definitive care, were provided to all members of the peer review committee 1 week before the committee meeting. The committee then reviewed all cases and classified each death as preventable, potentially preventable, or non-preventable. RESULTS AND CONCLUSION: A total fo 279 patients were registered in the trauma registry during the study period, including 18 trauma deaths. Peer review judged that six were preventable, seven were potentially preventable, and four were non-preventable. One patient was excluded because the record was not available for review. The proportion of preventable and potentially preventable deaths was significantly higher in our study than from developed countries. Of the multiple contributing factors identified, the most important were inadequate prehospital transfer, limited hospital resources, and an absence of integrated and organized trauma care. This study summarizes the challenges faced in trauma care in a developing country.