Developing and piloting an online course on osteoporosis using a multidisciplinary multi-institute approach- a cross-sectional qualitative study.

INTRODUCTION: Postgraduate medical trainees (PGs) in developing nations face various educational hurdles due to limited access to quality resources and training facilities. This study aimed to assess the effectiveness of e-learning, particularly Massive Open Online Courses (MOOCs), within postgraduate medical education. It involved the development of a customized online course focused on osteoporosis for PGs and an examination of their perspectives and preferences concerning online learning methods like Virtual Learning Environment (VLE) platforms. METHODS: The study was conducted from January 2018 to December 2020. A multi-institutional, multidisciplinary team was assembled to design an osteoporosis course on the VLE platform. PGs (n = 9) from diverse disciplines and institutions were selected with informed consent. Focus group discussions (FGDs) among these PGs identified their preferences for the online course, which subsequently guided the development of the MOOC. The modular MOOC comprised recorded micro-lectures, flashcards, videos, case challenges, and expert interviews. The educational impact of the VLE was assessed using pre- and post-module tests among the participants, and their perceptions of the PGs and course facilitators were gathered via an online survey. RESULTS: The study identified the involvement of PGs in the course design process as beneficial, as it allowed for content customization and boosted their motivation for peer-to-peer learning. During the FGDs, PGs expressed a strong preference for flexible learning formats, particularly short downloadable presentations, and micro-lectures. They also identified challenges related to technology, institutional support, and internet connectivity. In the subsequently customized MOOC course, 66% of PGs (n = 6) attempted the pre-test, achieving a mean score of 43.8%. Following the VLE module, all PGs (n = 9) successfully passed the end-of-module test, averaging a score of 96%, highlighting its impact on learning. The majority (n = 8, 88.9%) agreed that the course content could be applied in clinical practice, and 66.7% (n = 6) expressed extreme satisfaction with the learning objectives and content. Participants favoured end-of-module assessments and the use of best-choice questions for evaluation. CONCLUSION: This study highlights the importance of virtual learning, particularly MOOCs, in addressing the educational challenges faced by developing nations. It emphasizes the need for tailored online courses that cater to the preferences and requirements of PGs. The findings suggest that MOOCs can foster collaboration, networking, and opportunities for professional development, and interdisciplinary collaboration among faculty members can be a key strength in course development. This research provides valuable insights for educators, institutions, and e-learning developers seeking to enhance their teaching methodologies and establish accessible educational environments in the digital age.

Assessment of pediatric surgical needs, health-seeking behaviors, and health systems in a rural district of Pakistan.

Surgical conditions are responsible for up to 15% of total Disability-Adjusted Life Years (DALY) lost globally. Approximately 4.8 billion people have no access to surgical care and this studies aim is to assess the surgical disease burden in children under the age of five years. We used Surgeons OverSeas Assessment of Surgical Need (SOSAS) and Pediatric Personnel, Infrastructure, Procedures, Equipment, and Supplies (PediPIPES) survey tools in Tando Mohammad Khan (TMK). A set of photographs of lesions were also taken for review by experts. All the data was recorded electronically via an android application. The current surgical need was defined as the caregiver's reported surgical problems in their children and the unmet surgical need was defined as a surgical problem for which the respondent did not access care. Descriptive analysis was performed. Information of 6,371 children was collected. The study identified 1,794 children with 3,072 surgical lesions. Categorization of the lesions by the six body regions suggested that head and neck accounted for the greatest number of lesions (55.2%) and the most significant unmet surgical need (16.6%). The chest region had the least unmet surgical need of 5.9%. A large percentage of the lesions were managed at a health care facility, but the treatment essentially consisted of mainly medical management (87%), and surgical treatment was provided for only 11% of lesions. The health facility assessment suggested that trained personnel including surgeons, anesthetic, or trained nurses were only available at one hospital. Basic procedures such as suturing and wound debridement were only performed frequently. This study suggests a high rate of unmet surgical need and a paucity of trained health staff and resources in this rural setting of Pakistan. The government needs to make policies and ensure funding so that proper trained staff and supplies can be ensured at district level.

Frequency of angular malalignment after intramedullary nailing for femur shaft fractures - A cross-sectional study.

OBJECTIVE: To determine the frequency of angular malalignment of femur in patients undergoing Intra Medullary nailing for femur shaft fracture by measuring axis on immediate postoperative plain radiographs. METHODS: A cross-sectional study was conducted at the Section of Orthopaedics, Department of Surgery, Aga Khan University Hospital, Karachi from 1st January 2019 till 30th June 2019. All patients between the ages of 15 to 80 years who underwent IM nailing for femur shaft fractures were included. Angulation was measured on immediate post-operative X-ray films and an angle of ≥5° on AP and/or lateral views was defined as malalignment. RESULTS: A total of 65 patients were enrolled in the study with a mean age of 39.9 ± 16.5 years. Majority of the patients,49 (75.4) were males and road traffic accidents were found to be the most common mechanism of injury. Malalignment after surgery was encountered in 6(9.2%) patients. Proximal femur fractures were noted to be significantly associated with malalignment with a p-value of 0.014. CONCLUSIONS: This shows that frequency rate of malalignment after IM nail for femoral shaft fractures in a developing country like Pakistan is comparable to internationally reported literature and proximal femur fracture is a risk factor for malalignment.

Functional and radiological outcomes of atypical femur fractures among elderly in Karachi, Pakistan.

OBJECTIVE: To assess the functional and radiological outcomes in a unique class of fractures i.e. atypical femur fractures and to assess the effects of osteoblastic agents in healing. METHODS: It is a retrospective observational study conducted at Aga Khan University Hospital, Karachi, Pakistan. All patients with atypical femur fractures who were surgically managed with intramedullary nailing from January, 2013 to June, 2017 and with a follow-up till December 2019, were included in the study. Radiological outcomes were expressed as mean healing time and functional outcomes were recorded as mean Short Musculoskeletal Functional Assessment (SMFA) score. RESULTS: A total of twenty-four patients were included in this study. Mean age of patients was 65.8 ± 8 years. Mean healing time was 10 ±3.2 months post operatively. Two patients underwent redo procedures. No other complications like paresthesia or weakness was observed in any patients. All the patients reported a good score on SMFA ranging from 19% to 31%. CONCLUSION: Intra-medullary nailing shows a promising result in treatment of atypical femur fractures. Use of post-operative osteoblastic supplements showed statistically significant results with early healing time (p=0.008 [95% CI]).

Mobile phones in the orthopedic operating room: Microbial colonization and antimicrobial resistance.

BACKGROUND: Surgical site infections are a major cause of morbidity and mortality following orthopedic surgery. Recent efforts to identify sources of contamination in the operating rooms have implicated mobile phones. AIM: To investigate microbial colonization on the mobile phones of health care professionals in the orthopedic operating room. METHODS: We conducted a cross-sectional study involving culture and sensitivity analysis of swabs taken from the mobile phones of orthopedic and anesthesia attendings, residents, technicians and nurses working in the orthopedic operating rooms over a period of two months. Demographic and cell phone related factors were recorded using a questionnaire and the factors associated with contamination were analyzed. RESULTS: Ninety-three of 100 mobile phones were contaminated. Species isolated were Coagulase-negative Staphylococcus (62%), Micrococcus (41%) and Bacillus (26%). The risk of contamination was increased with mobile covers and cracked screens and decreased by cell phone cleaning. CONCLUSION: Mobile phones belonging to health care workers are frequently contaminated with pathogenic bacteria with the potential of transferring drug resistance to nosocomial pathogens. Studies investigating the relationship to surgical site infections need to be conducted. The concept of "mobile hygiene" involving the change of mobile covers, replacement of cracked screens or even wiping the phone with an alcohol swab could yield the cost-effective balance that contaminated cell phones deserve until they are established as a direct cause of surgical site infections.

Does surgical approach affect outcome after fixation of intra-articular fractures of distal humerus? Retrospective cohort study from a level-1 trauma centre in a metropolitan city.

INTRODUCTION: Fractures around the distal humerus fractures make up to 2% of all fractures. Complex intra-articular distal humerus fractures present as challenge to restore of painless, stable and mobile elbow joint. Surgical exposure to all critical structures is of paramount importance to achieve anatomic reduction. Conflict still persists regarding the choice of ideal approach. In this study we compare the effect of surgical approach triceps lifting vs olecranon osteotomy on the functional outcome after fixation of distal humerus fractures. METHODS: Non-funded, non-commercial, retrospective cohort study was conducted on patients with closed distal humerus intra-articular fractures between 2010 and 2015 at our tertiary care level-1 trauma and university hospital. Patients >18 years of age with closed complex intra-articular distal humerus fracture were operated using one of the two surgical approaches, either triceps lifting approach (Group1) or with olecranon osteotomy (Group 2). Functional evaluation using quick DASH scores at 1 year of follow-up. Study is registered with ID:NCT03833414 and work has been reported in line with the STROCSS criteria. RESULTS: Out of 43 patients 16 were treated with triceps lifting approach and 27 with olecranon osteotomy. The difference between the mean quick DASH score for both groups was not statistically significant (p = 0.52) although higher for group 1. Complications were comparable for both groups but 2 patients suffered delayed union of osteotomy site in group 2. CONCLUSION: Triceps lifting approach can be used equally efficiently for exposure of these complex distal humerus injuries with no comprise in visibility of articular fragments.

Ilizarov hip reconstruction osteotomy - A review.

Hip joint instability can be secondary to congenital hip pathologies like developmental dysplasia (DDH) or acquired such as sequel of infective or neoplastic process. An unstable hip is usually associated with loss of bone from the proximal femur, shortening, abnormal gait, and pain. Many authors have suggested proximal femoral valgus osteotomy for the treatment of unstable hip joints. Ilizarov modified this technique and performed a double-level osteotomy. In addition to proximal femoral valgus extension osteotomy, he introduced a distal femoral varus osteotomy which would lead to limb lengthening and correction of mechanical axis of the leg. This effectively reduces the limp, improves the abductor lurch and leg length, and provides stability to the destroyed joint.

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.

Proximal Femur Locking Plate for Sub-Trochanteric Femur Fractures: Factors Associated with Failure.

INTRODUCTION: Proximal femur locking compression plates (PF-LCP) have gained popularity since their inception due to superior biomechanical stability and durability but clinical experience has shown conflicting results including implant failure. OBJECTIVE: To study the incidence of implant failure in patients with sub-trochanteric fractures managed with proximal femoral locking compression plate and identify potential risk factors associated with the failure. MATERIALS & METHODS: Fifty patients with sub-trochanteric fractures, operated upon with titanium PF-LCP were included in the study from January 2012 to December 2014. These plates were of two designs including one five 5.0 mm proximal locking screws (implant A) and other with three 6.5 mm proximal locking screws (implant B). Fractures were classified according to AO/OTA and Seinsheimer classification. Patients had regular follow-up visits for at least a year, allowing for clinical and radiological assessment of union and implant-related complications. RESULTS: A total of 13 out of 50 (26%) plates failed of which 7 were implant fractures, 3 screw breakage and 3 screw cut outs. 70% of the failures occurred in elderly females. Overall implant failure was significantly more common in patients >50 years (p 0.04). Comparing the two different designs of implants used, implant A was more likely to fail at a plate screw density of 0.8 or more (p 0.02), whereas implant B was associated with significant failure when less than 4 proximal screws were used (p 0.03). CONCLUSION: This study revealed a high failure rate (26%) of this implant. Attention to the neck shaft angle difference, number of proximal screws and plate screw density may help reduce failure rates, particularly in elderly osteoporotic females.

Outcome of Judet's quadricepsplasty for knee contractures and the effect of local infiltration of epinephrine on reducing blood loss.

OBJECTIVE: To evaluate the effectiveness of Judet's quadricepsplasty for treatment of knee contractures and to identify the effect of local infiltration of epinephrine on blood loss associated with this procedure. METHODS: A retrospective cohort study was conducted in which all cases of knee contractures managed with Judet's quadricepsplasty from 1st January 2009 to 31st December 2013 were included and were divided into two groups. The epinephrine group included patients who were infiltrated with diluted epinephrine (1:400,000) along with xylocaine, around the operative field 15 min prior to the incision time, while the control group did not receive any infiltration. Judet's outcome, blood loss, drop in hemoglobin and required blood transfusion were noted for all patients and compared between both groups. RESULTS: Most common preceding pathology identified for the development of knee contractures was periarticular fracture while ilizarov application was the most common etiology. Both groups were found similar in all preoperative characteristics except preoperative flexion contracture (p = 0.02). All functional outcome measures including Judet's outcome were similar in both groups. In contrast, duration of surgery (p = 0.01), blood loss (p = 0.02), drop in hemoglobin (p = 0.01) and number of transfusions (p = 0.03) were significantly reduced in epinephrine group. CONCLUSION: Judet's quadricepsplasty is a useful procedure to increase the range of motion of rigid knees and local infiltration of epinephrine is effective in decreasing the amount of subsequent blood loss and transfusion requirements.

Two incision mini open carpal tunnel release- a minimally invasive alternative to endoscopic release.

Surgical techniques for carpal tunnel release are constantly evolving to reduce complications. This retrospective study was planned to identify the outcome and complications associated with a new operating technique for release of carpal tunnel using two incisions. It was conducted at the Aga Khan University Hospital, Karachi, and comprised patients undergoing surgical release of carpal tunnel syndrome (CTS) between January 2011 and December 2014. Of the 54 patients,38(70.4%) cases were of right-sided CTS. The mean operating time was 12.5±4.9 minutes. Complete relief from symptoms was observed in all the patients and the only complication noted was superficial infection in 2(3.7%) patients.The outcomes and complications associated with this technique were comparable with other standard techniques. No major complication (e.g. neurovascular injury) was reported, which showed that this technique was safe and had no additional risks. Therefore, it can be used as an alternative to endoscopic release which is expensive and requires special training and equipment.

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.

Rotational Mal-Alignment after Reamed Intramedullary Nailing for tibial shaft fracture.

Intra-medullary (IM) nailing is standard of care for unstable tibial shaft fractures. Malrotation is very common but it is under-recognised, inpart because of variation in normal anatomy and partly due to difficulty in accurately assessing rotation. This study was planned to evaluate the frequency of rotational mal-alignment after reamed tibia IMnailing. This cross-sectional study was conducted at Aga khan University Hospital, Karachi, and comprised patients with tibia shaft fractures managed with IMnailing from January to December 2014. All the patients were assessed intra-operatively for rotational alignment using the knee and ankle fluoroscopic images. There were 81 patients with a mean age of 38±16.9 years. There were 64(79%) male patients. Overall the incidence of malrotation was in 20(24.7%) cases. Rotational mal-alignment is one of the preventable complications after IMnailing which can be assesed intra-operatively under fluoroscope.

Does tranexamic acid reduce blood transfusion following surgery for inter-trochanteric fracture? A randomized control trial.

OBJECTIVE: To compare the frequency of blood transfusion after surgery for fixation of inter-trochanteric fractures in patients given tranexamic acid versus placebo. METHODS: The randomised control trial was conducted at the Aga khan university hospital from May 1 to October 31, 2014, and comprised patients diagnosed with Inter-trochanteric fracture based on X-ray imaging. The patients were randomised into two equal groups based on a computer-generated random number table. The Intervention group received two doses of 10mg/kg body weight of tranexamic acid just before surgery and three hours later intravenously. The Control group received two doses of 10mg/kg body weight of normal saline at similar intervals. Numbers of blood transfusions required postoperatively were noted based on the postoperative haemoglobin readings. RESULTS: There were 100 patients who were divided into groups of 50(50%) each. Mean post-op haemoglobin for the intervention group was 10.2±2.4 g/dl and for the control group it was 8.9±2.4 g/dl (p=0.007). Nine (18%) patients in intervention group required blood transfusion compared to 21(42%) in control group (p=0.009). CONCLUSIONS: Administering tranexamic acid was a useful and safe option for reducing requirement of blood transfusion postoperatively after inter-trochanteric hip fractures.

Clinic-based biopsy with a small curette: is it a reliable and safe option in extremity tumours?

OBJECTIVE: To establish the diagnostic accuracy and safety of clinic-based biopsy done with a small curette. METHODS: The retrospective study was conducted at Aga Khan University Hospital Karachi and comprised data of patients who underwent biopsy procedure of extremity tumours in clinic under local anaesthesia from July 2009 to June 2012. Patients who underwent the procedure in operating room under general anaesthesia were excluded and so were those with insufficient or missing information, or those who had the final procedure done elsewhere. Clinical parameters were evaluated and histo-pathology was compared with the final resected specimen. RESULTS: The mean age of the 51 patients in the study was 32±19.6 years. Lower extremity was involved in 37(73%) cases, and the most common tumour was osteosarcoma in 9(17%).Biopsy was inconclusive in 2(4%) patients, leaving the clinical accuracy to be 94%. The cost of clinic-based biopsy was at least seven times less than those done in the operating room under general anaesthesia. CONCLUSIONS: Biopsy done in a clinic with a small curette is accurate, safe and cost-effective method.

Clinic based biopsy vs. theatre biopsy of bone and soft tissue extremity tumours: comparable diagnostic modalities.

OBJECTIVE: To compare the diagnostic accuracy of clinic-based biopsy versus theatre biopsy against final histopathology in patients presenting with extremity tumours. METHODS: The retrospective study was conducted at Aga Khan University Hospital, Karachi, and comprised record of patients who underwent biopsy procedure of extremity tumours from January 2008 to December 2011. Data regarding socio-demographic status, disease-related and procedure-related variables were collected from the files. Histopathology report of biopsy was compared with the final histopathology after definite procedure of the tumour for concordance. RESULTS: Of the 87 patients whose records were reviewed, 42(48%) had undergone biopsy in theatre and 45(52%) in clinic. The overall median age was 29 years (Inter-quartile range: 18-58 years). As compared to final histopathology after the definite procedure, diagnostic accuracy of theatre and clinic-based biopsy was 97.7% vs. 95.5% respectively. Surgical site infection was observed in 2(5%) in theatre and in 1(2.2%) in clinic. CONCLUSIONS: Clinic-based biopsy was accurate and safe with diagnostic accuracy comparable to theatre-based biopsy. Clinic-based biopsy, being cost-efficient along with low morbidity, should be preferred in patients with extremity tumours.

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.

K Wire fixation of supra-condylar humerus fractures in children. Is ulnar nerve at risk?

OBJECTIVE: To compare iatrogenic ulnar nerve injury in lateral entry pin fixation versus medial and lateral entry pin fixation in the treatment of supracondylar fractures of the humerus in children. Measurement of clinical parameters in terms of elbow range of motion and postop radiographic alignment was also targeted. METHODS: The retrospective cohort study was conducted at Aga Khan University Hospital, Karachi, and comprised data of paediatric patients who underwent closed reduction and percutaneous pin fixation for the treatment of displaced extension type supracondylar fractures of the humerus between July 2007 and June 2012. Data regarding socio-demographic status, disease and procedure variables was collected from patient files and was analysed using SPSS 19. RESULTS: There were 71patients; 37(52%) in the lateral entry group and 34(48%) in the medial and lateral entry group. The two groups were similar in terms of mean age, gender distribution, and preoperative displacement, comminution, and associated vascular and nerve status (p> 0.05 each). There were no cases of iatrogenic ulnar nerve injury in either group and no significant differences between groups with respect to the elbow range of motion and radiological parameters (p> 0.05 each). CONCLUSIONS: With the use of the specific techniques employed, both lateral entry pin fixation and medial and lateral entry pin fixation were effective in the treatment of displaced extension type supracondylar humerus fractures in children.

Early experience of dynamic hip screw with spiral blade and locking side plate for the stabilization of trochanteric fractures.

OBJECTIVE: To evaluate early experience with helical hip system in osteoporotic elderly patients with per-trochanteric fractures. METHODS: The retrospective study was conducted at Aga Khan University Hospital, Karachi, and comprised records of patients having low-velocity pertrochanteric fractures who were fixed with spiral blade Dynamic Helical Hip Systemfrom July to December 2014 and were followed up for a minimum of 3 months. Demographic variables and clinical outcomes were noted from the medical records whereas operative details were recorded from the operative note. Radiological variables and outcomes were assessed by viewing appropriate pre-operative, post-operative and follow-up radiographs. RESULTS: Of the 32 patients in the study, 14(44%) were men and 18(56%) were women, with an overall mean age of 77.81±7.04 years and mean body mass index of 25.99±4.13 kg/m2. Of the total, 1(3.13%) patient had implant cut-out, 1(3.13%) had myocardial infarctionand 2(6.2) expired. CONCLUSIONS: The introduction of spiral blade dynamic hip screw manifested favourable results and good clinical and radiological outcomes with low cut-out rates.