Disseminated intravascular coagulation following femoral nailing in a metastatic prostate carcinoma patient - A case report.

INTRODUCTION: Disseminated intravascular coagulation (DIC) is a rare condition that is known to affect patients with metastatic prostate adenocarcinoma. In an unsuspecting orthopaedic surgeon, DIC could lead to significant morbidity and mortality. This article highlights another such case and discusses management strategies to help improve clinical outcomes for these patients. CASE: A 70-year-old male with metastatic prostate adenocarcinoma underwent prophylactic intramedullary nailing of an impending right femur pathological fracture. Surgery was uneventful, however postoperatively he was haemodynamically unstable with heavily soaked dressings. Laboratory investigations revealed DIC. Supportive treatment and correction of coagulopathy were undertaken. Ketoconazole was also initiated by Urology Services to treat the underlying condition of metastatic prostate carcinoma. Unfortunately, the patient responded poorly and passed away. CONCLUSION: DIC is rarely encountered in orthopaedic surgery, but carries significant morbidity and mortality risks. Patients with risk factors, in particular metastatic cancer, should be screened for non-overt pre-DIC state and coagulopathies corrected preoperatively. Initiating treatment of underlying condition can be considered preoperatively in established non-overt DIC. Operative technique can also be modified to minimise risk of fat or tumour emboli. Early recognition, prompt resuscitation and timely treatment of underlying condition may be able to improve the outcomes in these patients.

Effect of Severity of Deformity on Clinical Outcomes of Scarf Osteotomies.

BACKGROUND: Literature is sparse on whether severity of hallux valgus affects outcomes of surgery. We thus aimed to evaluate the impact of hallux valgus severity on the clinical outcomes of surgery. METHODS: 83 consecutive scarf osteotomies performed by a single surgeon for symptomatic hallux valgus between 2007 and 2011 were divided into 3 groups (mild, moderate, and severe) based on severity of their preoperative hallux valgus using the hallux valgus and intermetatarsal angles. Outcomes were assessed using the visual analog scale (VAS) for pain, 36-Item Short Form Health Survey physical functioning (SFPF) and mental health (SFMH) subscales, and American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scores. These were assessed preoperatively and at 6 months and 2 years postoperatively. Patient satisfaction was assessed at 6 months and 2 years postoperatively. Eleven (13.2%), 54 (65.1%), and 18 (21.7%) feet were in the mild, moderate, and severe groups, respectively. RESULTS: There was no difference in preoperative VAS, SFPF, SFMH and AOFAS scores between the groups except for AOFAS scores for the second toe, which were poorer with increasing hallux valgus. Postoperatively, there was improvement across all outcome scores. VAS and AOFAS showed excellent scores, and patient satisfaction was high across all 3 groups (88.9%, 89.4%, and 86.7%). The severe group had slightly lower SFPF scores at 6 months (mild, 81.1; moderate, 84.0; severe, 74.3; P = .031) and 2 years postoperatively (mild, 93.4; moderate, 89.7; severe, 76.4; P = .005), and slightly poorer second toe scores for VAS (mild, 0.0; moderate, 0.1; severe, 1.2; P = .017) and AOFAS (mild, 94.7; moderate, 93.5; severe, 83.4; P = .043) at 2 years postoperatively. All other scores including patient satisfaction showed no between-group differences. Complication and revision rates between the groups were similar. CONCLUSION: Surgery for symptomatic hallux valgus lead to excellent outcomes and high patient satisfaction regardless of severity of deformity. LEVEL OF EVIDENCE: Level III, comparative series.

Arthroscopic debridement of the degenerative knee - Is there still a role?

OBJECTIVES: The role of arthroscopic debridement in the painful degenerative knee is controversial. Studies have shown that arthroscopic surgery for knee osteoarthritis provides no additional benefit to optimized physical and medical therapy. There are however, limited studies on the management of the subgroup of significantly symptomatic patients who remain refractory to maximal conservative treatment and are poor candidates for knee replacement surgery.We propose that with careful patient selection, arthroscopic debridement can provide good symptomatic relief with sustained benefits in the degenerative knee. METHODS: We performed a retrospective, single-surgeon study of 180 consecutive knee arthroscopies performed in 169 patients, aged 40 years and above, who had mechanical symptoms affecting their daily lives and underwent arthroscopic debridement after failure of a minimum 2 months of optimized medical and physical therapy. Severity of the knee osteoarthritis on plain radiographs was assessed using the Kellgren-Lawrence classification.Functional and satisfaction scores were assessed using Oxford Knee Score, Koos Knee Survey, Short Form-36, Numeric Pain Rating Scale, and questions adapted from the North American Spine Society Questionnaire. RESULTS: Excellent functional outcomes and patient satisfaction were reported in the majority of patients over the follow-up timeframe of 2-8 years. The mean pre-operative Kellgren-Lawrence score was 2.02 (SD 0.580). Significant improvements compared to pre-operative scores were seen across all scoring systems tested. 90% of patients reported good to excellent results. CONCLUSION: Arthroscopic knee debridement can provide good symptomatic relief and sustained benefits in significantly symptomatic patients with early degenerative knees who have failed conservative management. This is most useful in patients with mechanical symptoms secondary to degenerative meniscal tears or chondral flaps, and those with symptomatic patellofemoral osteoarthritis.