Giant cell tumor of soft tissue: GCT arising from periosteum of tibia.

Primary Giant Cell Tumor of Soft Tissue (GCT-ST) is a rare disease, a neoplasm with low potential for malignancy. It belongs to the group of Fibrohistiocytic tumors with borderline malignancy. Most commonly it presents as a painless, slow-growing mass in a superficial location. It is associated with lower local recurrence rate as compared to GCT of bone but has a higher rate for metastasis and mortality. A case of rare GCT-ST with suspicion of lung metastasis is being reported here. The lesion per-operatively appeared to be growing from the periosteum of the bone (tibia in our case). After excisional biopsy it proved to be GCT-ST which has never been reported previously in literature.

Diagnostic accuracy of C-reactive protein to rule out infectious complications following hip fracture surgery.

Background and Objective: Knowledge of the C-reactive protein trend and deviation from the expected value may give an early indication of a possible postoperative infection. According to previous studies, CRP appears to be a more sensitive and specific marker of postoperative infections than ESR and white cell count. This study was conducted to determine the diagnostic accuracy of C-reactive protein to rule out surgical site infection in patients undergoing hip fracture surgery. Methods: This cross-sectional study was conducted at The Indus Hospital and Health Network, Karachi from July 1, 2018 to February 24, 2020. All operative hip fracture patients aged 11-90 years were included. CRP was done on admission, days 3, 14 and 28. Wound assessment was done using the criteria of the Center of Disease Control and prevention on postoperative days 3, 14 and 28. Data was analyzed using STATA version 16. Results: Out of 152 patients, 11(7.2%) developed infection. One patient (0.7%) presented with the infection on day three post-surgery, eight (5.3%) and two (1.3%) patients on days 14 and 28 respectively. CRP levels at admission had poor diagnostic accuracy for diagnosing infection at 14th and 28th day post-surgery respectively (AUC=0.490 and 0.447). CRP levels measured on post-op Day-3 (cutoff value 230mg/dl) had good diagnostic accuracy for diagnosing infection at 14th and 28th day post-surgery respectively (AUC=0.819 and 0.818). Conclusion: CRP level at post-operative day three is a sensitive indicator of infection after hip fracture surgery.

Inter-observer variation of the Schatzker and Khan classification of Tibial plateau fractures: Cohort study.

OBJECTIVE: To compare the inter-observer reliability of Shatzker classification and Khan Classification of Tibial plateau fractures. METHODS: This retrospective cohort study was conducted at The Indus Hospital, Karachi, Pakistan. Radiographs of 50 patients who presented with tibial plateau fractures from March 2015 to November 2016 were collected. Two observers classified these cases independently according to Shatzker and Khan Classification. Gwet's AC1 statistics applied to assess inter-observer reliability of both the classification systems. RESULTS: Moderate inter-observer agreement for Schatzker classification (p<0.001) and slight inter-observer agreement on Khan Classification (p=0.738) was observed. CONCLUSIONS: Khan Classification is more comprehensive in classifying tibial plateau fractures and can be used for clinical research purpose, while Shatzker classification with better inter-observer reliability is applicable for routine clinical practice.

Role of platelet rich plasma in fracture non-union of scaphoid - Case series.

This case series of 4 patients was studied at Queen Mary Hospital, Hong Kong from 2007 to 2011 to evaluate the clinical and radiological outcome of scaphoid fracture non-union treated with Open reduction and internal fixation ORIF supplemented with Bone Graft (BG) from iliac crest and Platelet Rich Plasma PRP. The purpose was to achieve union with pain free adequate range of movement. Patients presenting with scaphoid fracture non-union were included in our study. Total 4 patients with an average age of 35±7.7 years (range 31 to 47 years) and mean follow-up of 21.75±14.97 months, (range 05 months to 3.5 years) were included. All patients achieved union with pain free Range of motion of wrist as well as thumb. We recommend open reduction and internal fixation with bone graft along with platelets rich plasma for non-union of scaphoid.

Nottingham Hip Fracture Score as a predictor of 3 months postoperative mortality in patients undergoing surgical fixation of hip fractures: A prospective study.

OBJECTIVE: Nottingham Hip Fracture Score was utilized to evaluate its efficacy to identify high risk pateints interms of 3 months postoperative mortality.NHFS comprises of seven independent predictors that were incorporated into a risk score to identify patients who were high risk for post-operative mortality with hip fracture.. METHODS: NHFS was prospectively calculated for 88 patients who underwent surgeries for hip fracture from 25th December 2014 to 25th June 2015 at the Indus Hospital Karachi. Both neck of femur and Intertrochanteric fracture were included. NHFS of ≤4 was considered as low risk and a score of ≥5 as high risk for mortality. RESULTS: The 3 months post-operative mortality was 22%. Increase in number of mortality was observed in patients who belonged to the high risk (NHFS ≥5) group, with statistically significant relationship when compared with the low risk (NHFS ≤4) group (p=0.01). CONCLUSIONS: NHFS can be used to predict the risk of 3 months postoperative mortality in patients undergoing hip fracture surgery.

The frequency of Deep Vein Thrombosis in patients with hip fractures.

OBJECTIVE: To find out the frequency of deep vein thrombosis in hip fracture patients. Methods: The prospective, cross-sectional study Was conducted at Indus Hospital, Karachi, from November 2016 to September 2017, and comprised patients with hip fractures who were scanned for the presence of deep vein thrombosis on both lower limbs preoperatively at the time of presentation and postoperatively on post-op day 3 and day 28. No thrombo-prophylaxis was provided to the patients. Risk factors for deep vein thrombosis were also assessed. Data was analysed using SPSS 21.. Results: Of the 109 patients, 50(46%) were male and 59(64%) were females. The overall mean age was 64.59 ± 9.82 years. Deep vein thrombosis was found in 4(3.66%) patients; 2(50%) preoperatively and 2(50%) in the early postoperative period. No deep vein thrombosis was found in any patient on postop day 28.. Conclusion: The frequency of deep vein thrombosis in Pakistani geriatric patients with hip fractures was found to be low compared to the western population.

Intra-operative implantation errors during Austin Moore Hemiarthroplasty.

Austin Moore hemiarthroplasty is an established treatment in elderly patients with neck of femur fractures. Being commonly performed, it is also associated with several technical errors of implantation which results in complications and failure requiring revision surgery. This retrospective pre- and post-operative radiographic study to determine the frequency of technical errors was conducted at the Indus Hospital, Karachi, and comprised data of 50 patients who underwent Austin Moore hemiarthroplasty between January and November 2016. Of the total, 29(58%%) patients had no error of implantation. Overhanging of prosthesis was observed in 21(42%) patients, followed by inadequate length of the neck remnant in 18(36%). Moreover, 8(16%) patients sustained intra-operative periprosthetic fractures managed with cerclage wire. Also, 33(66%) patients had a Dorr type-Afemur morphologic pattern. Hemiarthroplasty was found to be a technically demanding procedure associated with avoidable intra-operative implantation errors by proper preoperative planning, careful patient selection, proper training of surgeons, hence avoiding failure.

New technique: tendon interposition arthroplasty in Distal Interphalangeal Joint arthritis in Chinese population - New horizon for treatment.

OBJECTIVE: To evaluate the clinical outcome of managing distal inter-phalangeal joint arthritis by using excisional arthroplasties with soft-tissue interposition to provide pain-free joint with adequate range of motion and preserving the bone stock. METHODS: The case series was conducted at Queen Mary Hospital, Hong Kong from 2013 to 2015 and comprised patients with distal inter-phalangeal joint arthritis. Excisional arthroplasty was performed for all patients. Interposition was performed using extensor retinaculum/ palmaris longus. An axial K wire for 3-4 weeks was applied to maintain the reconstructed part in satisfactory alignment. Mallet splint was applied for another 3 weeks. Free active mobilisation was allowed afterward. Clinical assessment was done at least at 3, 6 and 12 months. RESULTS: There were three patients in the series, and all the 5 fingers, including one thumb, achieved good range of motion with no complication except in 1(33.3%) patient who needed re-exploration of index finger for retained suture with no documentary infection. All patients (100%) had significant pain relieved with mean visual analogue scale score of 3/10±SD at 3 months and 0/10 at 1-year follow-up. All achieved good range of motion. All (100%) were satisfied with postoperative surgical outcome. CONCLUSIONS: Interposition arthroplasty gave the patients adequate range of motion with preservation of bone stock.

The pulley suture: A reliable option for closure of selected soft tissue defects under tension- three years experience of a tertiary care hospital.

OBJECTIVE: To assess the outcome of closure of soft tissue defects through pulley suture in different clinical situations. METHODS: The descriptive chart review was conducted at The Indus Hospital, Karachi, and comprised data from May 2008 to November 2011. A detailed questionnaire was developed to address variables of interest. All patients with less than three months of follow-up or inadequate information were excluded. The data was collected through Health Management Information System. Data was entered and analysed by SPSS 16. RESULTS: There were 259 patients with 289 wounds in the study. The mean age was 29.2±11.9 years. At follow-up of two weeks, there was wound dehiscence in 2.07%, infection in 0.69% and partial flap necrosis in 1.03% patients. At 12 weeks, hypertrophic scar was reported in 2.07% and stretched scar in 0.3% patients. Acute pain was not reported in the first week of surgery. Type of wound was found to have significant association with complications (p value<0.005). Age and gender were not found have any significant association with complications (p value 0.372 and 0.238 respectively). None of the patients reported scar tenderness at 12-week follow-up. Cosmetic outcome was acceptable to all patients. CONCLUSIONS: Judicious use of pulley suture can lead to primary closure of selected soft tissue defects under moderate tension. The technique, however, needs to be utilised by surgeons experienced in soft tissue reconstruction.

A comparative review of three techniques of syndactyly release.

OBJECTIVE: To compare the outcome of three techniques of congenital syndactyly release; to identify factors leading to difference in outcome, and to identify the incidence of neurovascular abnormalities in various types of syndactyly. METHODS: The chart review was conducted at The Indus Hospital, Karachi, and comprised data of all patients who had undergone syndactyly release between August 2008 and December 2014. Three techniques of release were included as described in literature by Bauer, Skoog and Niranjan. The data was collected through Health Management Information System. A detailed questionnaire was designed to address variables of interest. RESULTS: The age of the 29 patients with 50 webs in the study ranged from 2.2 to 17.1 years. The male to female ratio was 21:8. The complications encountered were web creep, skin flap necrosis, flexion deformity and contracture of joint. Single neurovascular bundle was found in 04(8%)webs and 45(90%) required skin graft for resurfacing of the digits. CONCLUSIONS: Bauer technique was found to be to be superior for web formation and there was low incidence of web creep compared to Skoog technique. Inclusion of syndromic cases may lead to increased complication and dissatisfaction rate. Tight closure of flaps should be avoided and generous use of skin grafts is advocated for success.

Protection of heel flaps with Ilizarov fixator as an elevation frame: A case series and review of literature.

OBJECTIVE: To compare outcome of Ilizarov fixator for protection of heel and foot flaps with that of plaster of Paris boot technique. METHODS: The retrospective chart review was conducted at The Indus Hospital, Karachi, and comprised data of patients who underwent flap reconstruction of the heel from January 2011 to December 2014. All patients had a minimum follow-up of 3 months. The patients using Ilizarov fixator were placed in group A and those with modified plaster of Paris boot as the elevation device were placed in group B. A detailed questionnaire was developed to note down the relevant variables. RESULTS: Of the 31 patients, 21(70%) were in group A and 10(30%) in group B. The modified boot was considered heavy (70%) compared to none in the Ilizarov group. The mean time of removal was 5.9 wks in group A and 4.8 weeks in group B. The mean time for use of Foley\'s catheter was 16.8 hours in group A and 14.8 hours in group B. There was significant number of associated bony injuries (33%) in group A and none in group B. Both groups were satisfied with the outcome. CONCLUSIONS: While Ilizarov technique is recommended for patients with extensive wounds along the heel and foot, obese patients and those non-compliant to the positioning protocol, careful use of modified plaster of Paris boot technique in relatively simpler situations of heel reconstruction with flaps is also very rewarding.

A comparison between orthopedic surgeon and allied health worker in pirani score.

OBJECTIVE: To assess the strength of agreement for each of the Pirani assessment categories between an orthopaedic surgeon and allied health worker on scoring clubfeet. METHODS: The descriptive cross-sectional study was conducted at the Indus Hospital, Karachi, from November 2012 to June 2013, comprised children below 12 months of age with untreated unilateral or bilateral clubfoot deformity an allied health worker, who was a plaster technician, was given 1-week training in the Pirani Scoring method. The feet were scored by the surgeon and the paramedic independently. SPSS 21 was used for statistical analysis. RESULTS: The study had 57 patients, and 92 feet were assessed. The difference between the means of score of each parameter, including the hind foot score and total score, was less than 0.09. The means of total score were found to be identical. Total Hind Foot Score was 0.48 and Total Score was 0.354. The statistical inter-observer reliability for all components was rated as substantial to moderate agreement except Equinus Rigidityand Total Score, which showed fair agreement. CONCLUSIONS: Pirani scoring method for clubfoot assessment was found to be a reliable tool for use by plaster technicians for independent assessment of clubfoot. However, prior training and supervision in the early phase is necessary.

Perception about braces in parents of children with clubfoot.

OBJECTIVE: To access the acceptability of Steenbeek brace by children undergoing clubfoot correction and their parents to ensure long-term compliance. METHODS: The cross-sectional study was conducted at the Indus Hospital, Karachi from October 2013 to March 2014. A trained researcher interviewed the person primarily responsible for bracing the child using a pre-coded questionnaire. Modified Orthotics Prosthetics User Survey for satisfaction with either the Mitchell brace of the Steenbeek brace was used. It included 11 questions in the Parent Bracing Satisfaction Survey. SPSS 21 was used for statistical analysis. RESULTS: Interviews were completed with 110 primary caregivers among whom 90(81.8%) were mothers. Overall, 32(29.1%) children were using the Mitchell brace, 30(27.3%) the Steenbeek brace, 46(41.8%) had shifted from Mitchell to Steenbeek brace, and 2(1.8%) had shifted from Steenbeek to Mitchell brace. Median duration of current brace usage was 4 and 3.5 months for Steenbeek and Mitchell braces respectively. The mean age of the child was 1.4 ±0.7 years, and the mean of 4-point Likerts cale score of parent bracing satisfaction was 28.7±2.2 in children on the Mitchell brace versus 28.5±1.9 for those on Steenbeek brace (p=0.505). Overall, 82(74.5%) parents had favourable attitude towards braces in general, but there were no significant differences in the items except "brace is easy to put on" (p=0.040) and "durability between Mitchell and Steenbeek groups" (p=0.017). CONCLUSIONS: There were no differences in satisfaction levels between the two types of brace users.

Significance of strontium ranelate in healing of surgically fixed tibial diapyseal fractures treated with strontium ranelate vs placebo; a randomised double blind controlled trial.

OBJECTIVE: To determine the surgical outcome of patients with axial cervical spine fractures. METHODS: The randomised double-blinded placebo-controlled clinical study was conducted at the Indus Hospital, Karachi, from August 2011 to August 2013. Patients were randomised to receive placebo or strontium ranelate postoperatively after surgical fixation of tibial diaphyseal fractures. Assessment of fracture healing was done clinically and radiologically at 30, 60 and 90 days. SPSS 21 was used for statistical analysis. RESULTS: Initially, 76 patients were enrolled, but 63(82.9%) completed the study. Out of 63 patients, 32(50.8%) were randomly assigned to group A and 31(49.2%) to group B, which was administered the placebo. Overall enhancement of fracture healing efficacy of strontium ranelate group was 20(62.5%) versus 9(29%) of the placebo group. CONCLUSIONS: Strontium ranelate was effective in enhancing fracture healing based on clinical and radiological assessment. Hence, it can be considered an effective therapeutic agent for accelerating fracture healing.

Anthropomorphic mismatch between distal femurs and a standard total knee replacement system in Pakistani population.

AIMS: To compare the measurements of distal femurs of a Pakistani population and with the implants used. METHODS: The single-centre prospective cross-sectional study was conducted at the Indus Hospital, Karachi, from 01-06-2011 to 31-10-2011, and comprised total knee replacement patients. Surgeries were performed by the same team. Each measurement was taken after the resection of the trochlea (flush to the anterior femoral cortex), the distal cut and the anterior chamfer cuts. Measurements were taken intraoperatively with a sterile vernier calliper. SPSS 17was used to analyse the data. RESULTS: The mean age of the 33 patients in the study was 59.3±7years. There were 4(12.1%) males and 29(87.9%) females. A mismatch was found in per-operative measurements with the mean aspect ratio being 0.79±0.05and the standardised aspect ratio of the implants being 0.90 (SD±0.0). CONCLUSIONS: There are differences between anthropomorphometry of our skeleton and Caucasian designed implants. This could have implications in the long term.

Prophylactic Antibiotics in Hip Fracture Surgery: A Randomized Prospective Study.

Introduction Hip fracture surgeries constitute a large portion of orthopedic surgeries, and infective complications are one of the most severe and devastating sequels following fixations or replacements. Preoperative antibiotic prophylaxis is an important means to control SSI. Thus, we set out to assess the impact of a single dose versus three doses of antibiotics on surgical site infections in patients undergoing hip surgery. Materials and methods A randomized controlled trial was conducted at the Department of Orthopaedics, The Indus Hospital, Karachi, Pakistan. All patients admitted for hip fracture surgery who met the inclusion criteria were enrolled and divided into two groups. One group (Group A) was given a single dose of antibiotics preoperatively, and the other (Group B) was given three doses, one preoperatively and two postoperatively. Patients were assessed for wound condition and signs of infection. Data were entered and analyzed using SPSS version 21.0. The chi-square test was applied to assess the significant association between both the groups and SSI. A significant statistical association was noted when the P value was found to be <0.05. Results The study included 62 patients, with the majority of them being females (n=33; 53.2%). The mean age of the patients was 60.5±15.1 years. Only three (4.8%) patients developed SSI. No statistically significant association was detected between surgical site infections and the two antibiotic regimens being administered after controlling for the confounders. Conclusion There was no statistical relationship between surgical site infections with a single dose versus three doses of antibiotics in patients undergoing hip surgery.

Histopathological Features Of Denosumab Treated Giant Cell Tumours Of Bone "A Single Institutional Experience" At A Tertiary Care Center, Karachi.

BACKGROUND: Giant cell tumour (GCT) is a primary benign, locally aggressive bone tumour. Treatment is surgical however, denosumab has been increasingly used as a treatment in recurrent or unresectable locally advanced GCT because of its effect in reducing tumour size. Denosumab treated GCT can exhibit a wide array of histopathological features resulting in diagnostic problems for pathologists. Our study aimed at identifying these histopathological features to aid pathologists in reaching a correct diagnosis. METHODS: Our study included 20 patients of biopsy-proven GCT cases treated with denosumab. We received specimens for histopathological examination in our institution from January 2018 to March 2020. The demographic and clinical data of these patients were retrieved from the Health Management Information System (HMIS). The slides were retrieved and studied for histopathological changes. RESULTS: The mean age of patients in our study was 29.5 years. There were 11 males and 9 females. Distal radius was most commonly involved bone. On histopathological examination, ovoid to spindle mononuclear stromal cells were seen. Total absence of osteoclast like giant cells was seen in 10 (50%) cases, whereas 3 (15%) cases showed a marked reduction in osteoclast like giant cells. CONCLUSIONS: Denosumab treated GCT of bone can exhibit a wide spectrum of histopathological features. Pathologists need to be mindful of these features. Correlation of histopathological findings with clinical history and radiological features is important to prevent erroneous diagnosis. Treatment history of patients with denosumab is essential as incorrect diagnosis can be made if the history of denosumab treatment is not provided.

Significance Of Pirani Score at Bracing-Implications for Recognizing A Corrected Clubfoot.

BACKGROUND: The aim of clubfoot treatment by Ponseti method is to achieve a corrected foot, with at least 15° dorsiflexion and 70° abduction, and fit comfortably into a brace at the recommended setting. This study aimed to acknowledge the validity and reliability of the Pirani scoring system, while investigating if a corrected clubfoot has a Pirani score of zero. The study hypothesized that a corrected clubfoot may or may not have a Pirani score of zero. METHODS: 706 patients with clubfoot were treated by Ponseti's method of weekly manipulations and casting, from November 2011 to May 2016, at a tertiary care hospital, making a total of 1055 feet. All data was entered into the International Clubfoot Network Database, along with Pirani scoring. Tenotomy was performed in eligible patients. RESULTS: The mean Pirani score at the end of treatment phase of casting and initiation of the maintenance phase of bracing for the right foot was 1.1 (SD=0.55) and left foot was 1.2 (SD=0.58). These feet not only fit the criteria of a corrected clubfoot, 70° abduction and 15° dorsiflexion, but also fit well in a foot abduction brace. Of the 1055 diagnosed Clubfeet, 643 required tenotomy (60.9%). CONCLUSION: The study shows that the affected foot does not need to have a Pirani score of zero to be considered a corrected foot. Pirani score is an excellent tool used over the years to evaluate clubfoot. Pirani score does not assess adequately the transition from the treatment phase of casting to the maintenance phase of bracing. The use of the International Clubfoot Database-Treatment visit form, including all components of clubfoot and the Pirani score, provides a clear understanding of whether the patient has achieved foot correction or not. Level of Evidence: Level IV.

Restoration of glenohumeral motion in Erb's palsy by tendon transfers.

BACKGROUND: Children with erb's palsy have significant functional disability, mainly related to the shoulder. The objective of this study was to analyze the functional outcome of tendon transfers performed for restoration of shoulder motion in patients with Erb's palsy. METHODS: This descriptive case series was conducted at Aga Khan University Hospital from May 1999 to December 2003. Ten patients who had functional deficit of shoulder elevation were operated by a single surgeon. The surgical procedure; modified Sever L'Episcopo procedure was uniform in all cases. The data was collected through patient interviewing and medical records maintained through Health Information Management System (HIMS). Mallet class was recorded preoperatively and postoperatively. RESULTS: Ten patients; seven females (70%) and three males (30%), with average age of 75 months at operation were included in this series. Right shoulder was affected in seven cases (70%) while left in three cases (30%). Preoperative mallet class for global abduction improved from 3 to 4; for global external rotation from 2 to 4 and for ability to bring the hand to mouth and neck from 1 to 3. Post operatively mallet class improved in all aspects to 4 and 5; statistically significant on paired t-test with p value of less than 0.005. There was a significant improvement in abduction, forward flexion and external rotation as compared to -preoperative values; statistically significant on paired t-test with p value of less than 0.005. CONCLUSION: Tendon transfer improves the functional status of shoulder in late cases of Erb's Palsy with significant improvement in mallet class, cosmesis and patient satisfaction. A motivated patient, compliance and aggressive rehabilitation are important outcome parameters.

Delayed supramalleolar flap--an innovative technique for enhanced viability.

BACKGROUND: Delaying flap rotation for 48 to 72 hours leads to opening of choke anastomotic vessels linking adjacent vascular territories. This mechanism enhances flap circulation. Lateral supramalleolar flap with larger dimensions or vascular variations can potentially have survival problems. The purpose of this study is to assess the outcome of delayed lateral supramalleolar flap. METHODS: This descriptive case series was conducted at Aga Khan University Hospital, Karachi from May 1999 to December 2004. Eight cases of delayed lateral supramalleolar flap were identified through medical records maintained through Health Information Management Systems (HIMS). A detailed questionnaire was developed addressing variables of interest. RESULTS: Eight patients required flap delay for 48 hours out of 25 patients, who underwent lateral supramalleolar flap for coverage of foot and ankle soft tissue defects. There were six male (75%) and two female (25%) patients with average age of 31.25 years ranging from 5-52. The reasons for delaying lateral supramalleolar flap were larger flap dimension in four (50%), absent peroneal artery perforator in three (37.5%) and one patient (12.5%) had poor circulation in immediate postoperative period. All the patients required two stage procedure and had excellent coverage of defects. No flap failure occurred subsequent to the delay procedure. CONCLUSIONS: Flap delay enhanced survival and extended the viable dimensions of lateral supramalleolar flap. Compromised circulation in larger flaps and flaps with vascular variations can be improved by delaying flap transfer to the recipient site for 48 hours following its elevation.