Modified Frailty Index as a Predictor of Adverse Outcomes in Elective Primary Hip and Knee Replacement Surgery Patients at a Tertiary Care Hospital in Pakistan: A Cross-Sectional Study.

Objective The objective was to evaluate the modified frailty index as a predictor of early (within 30 days) postoperative complications in total joint arthroplasty patients, in a low middle-income country. Material and methods A cross-sectional study was carried out which included patients with ages ranging from 23 to 86 years, who underwent elective primary Total Hip or Knee Arthroplasties (TKA or THA) between December 2021 and February 2023. Modified frailty index (mFI-5) was calculated and 30-day morbidity and mortality were recorded. Post-operative complications were categorized as either surgical or medical and recorded. Results A total of 175 patients were included, amongst whom the majority were females (68.6%, n=120) and the mean age was 60.5 ± 13.2 years. 85 patients (48.6%) had a mFI-5 score of one while 48 patients (27.4%) had a score of two. Superficial surgical site infection was the most common complication overall in 6 patients (3.4%); however, no case of prosthetic joint infection was noted. Deep vein thrombosis (DVT) was the most common medical complication (1.7%, n=3). 5 patients (2.9%) required re-admission and two mortalities were recorded within the 30-day interval. A significant association was noted between post-operative surgical complications and mFI-5 score (p-value = < 0.001), with the risk of complications increasing with a higher mFI-5 score. Smoking was noted to be a risk factor for post-operative medical complications as well as 30-day mortality. Conclusion The current study shows that the mFI-5 index can effectively be used as a predictor of postoperative complications in the South Asian region such as Pakistan. This should be calculated routinely and can be used as a tool for pre-operative assessment and counseling.

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.

Comparison of Surgical Site Infection After Skin Closure by Prolene or Staples in Bilateral Simultaneous Knee Arthroplasty Patients: A Parallel Design Randomized Controlled Trial Protocol.

INTRODUCTION: Knee arthroplasty also known as the total knee replacement is an orthopedic surgical procedure done to resurface the knee that has been severely damaged by arthritis. After the completion of the surgical procedure, the skin closure is done. The optimal goal of skin closure after the procedure is to promote rapid healing and an acceptable cosmetic result while minimizing the risk of infection. Skin closure after knee arthroplasty is done by using either of the two widely used sutures i.e., polypropylene (Prolene) sutures or the skin staple sutures. There are no standard guidelines as which type of the suture should be used. The present study aims to compare the incidence of surgical site infections (superficial and deep) for Prolene vs staple sutures in the bilateral knee arthroplasty patients within 6 weeks for superficial and within 90 days for deep infection. METHODS: This study will be conducted as an open blinded, parallel design, equivalence randomized controlled trial. The patients would be selected and randomized in 1:1 ratio to receive either of the two interventions i.e., Prolene or Staples. Patients undergoing unilateral or staged total knee replacement (TKR) were excluded. ANALYSIS: The normality assessment will be done using Shapiro Wilk test. Cox proportional hazard regression will be used to check the univariate and multi-variable associations of independent variables with the outcome. Both intention to treat analysis and per protocol analysis would be performed. ETHICS AND DISSEMINATION: All the required approvals will be taken from the ethical review committee. Informed consent will be taken form the patient to enroll him/her in the study. Results of the study will be disseminated to the study participants, public health and clinical professionals and would also be published in a reputable international journal.The trial is registered at clinicaltrials.gov and UIN of the registry is NCT04492852. HIGHLIGHTS: Post-operative surgical site infections and complications are a major concern nowadays.Skin staples are not widely used as compared to Prolene because they are expensive and not easily available in every hospital.There are no standard guidelines as which type of the suture should be used.The type of sutures is being selected on the orders and wishes of the surgeon at the time of skin closure.

Gum Chewing, Added to Conventional Feeding, Reduces Risk of Post-Operative Ileus after Elective Hip and Knee Arthroplasty Procedures in Elderly Population: A Protocol for a Parallel Design, Open-Label, Randomized Controlled Trial.

INTRODUCTION: Postoperative ileus (poi) is defined as a temporary cessation of bowel movement after a surgical procedure. Cessation of bowel movement not only leads to disturbing constipation but also may lead to nausea, loss of appetite, and food intolerance. Literature reports "sham feeding" (gum-chewing) effect as an increase in chewing and saliva which enhances the gastric emptying and overall motility of gut as a cephalic phase of digestion. Therefore, we aim to assess the effect of adding gum-chewing to the conventional postoperative feeding regimen on restoring postoperative bowel function and length of stay in hospital of patients undergoing elective hip arthroplasty. METHODS AND ANALYSIS: This is a single-center, open-label, parallel design, superiority randomized-controlled trial with 2 treatment arms. The primary and secondary outcomes will be the time interval in hours from the end of surgery until the passage of flatus and the time interval in hours from the end of surgery until the passage of stool. Statistical analysis will be done using STATA software. Length of stay will be calculated by Kaplan-Meier analysis, with unadjusted comparison of groups by Mantel-Cox log rank test. Risk ratios for the time-to-become ileus free and time-to-discharge from hospital will be calculated by Cox regression modeling. P value as 0.05 or less will be taken as significant. ETHICS AND DISSEMINATION: This protocol is exempted from Ethical review at this stage however all the required approvals will be taken from the ethical review committee before starting the study. Informed consent will be taken form the patient to enroll him/her in the study. Results of the study will be disseminated to the study participants, public health, and clinical professionals. The results would also be published in a reputable international journal. TRIAL REGISTRATION: This trial is registered on clinicaltrials.gov with ID: NCT04489875. HIGHLIGHTS: Cessation of bowel movement not only leads to disturbing constipation but also may lead to nausea, loss of appetite, and food intolerance.These patients tend to have more pain scores and dissatisfaction with the surgical management and team.The "sham feeding" (gum-chewing) effect causes an increase in chewing and saliva formation and therefore enhances the gastric emptying and overall motility of gut as a cephalic phase of digestion even in non-gastro or colorectal surgeries.We hypothesize that there is an association between gum chewing and the relief from postoperative ileus in hip arthroplasty patients.

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.

Inflammatory arthritis and Mycobacterium Tuberculosis infection: a diagnostic and management challenge for Knee arthroplasty in endemic areas.

Tuberculosis continues to be one of the most challenging health problems more prevalent in developing countries. Pakistan ranks 5th in tuberculosis prevalence among the high-burden countries. Prosthetic joint infection of the knee by acid fast bacilli is a rare and distressing complication, occurring in nearly 1% of primary joint arthroplasties requiring prolonged medical treatment and multiple surgeries. A recent publication extensively reviewed English literature from 1952 to 2016, and repor ted only 64 prosthetic joint infec tion with tuberculosis, of which 27 cases involved the knee. Tuberculosis is a global health problem adding to the challenges that arthroplasty surgeons face in our resource-constrained setting. Furthermore, it presents as other inflammatory arthritis with almost same laboratory and radiological findings. The current paper was planned to highlight the preoperative and postoperative challenges that the arthroplasty surgeon may have in diagnosis and management of this rare infection. We included studies from 1996 to date which reported knee tuberculosis prosthetic joint infection that were managed by medication alone or with surgical intervention in patients who had undergone arthroplasty.

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.

Osteoid osteoma: Contemporary management.

Osteoid osteoma is a benign bone-forming tumor with hallmark of tumor cells directly forming mature bone. Osteoid osteoma accounts for around 5% of all bone tumors and 11% of benign bone tumors with a male predilection. It occurs predominantly in long bones of the appendicular skeleton. According to Musculoskeletal Tumor Society staging system for benign tumors, osteoid osteoma is a stage-2 lesion. It is classified based on location as cortical, cancellous, or subperiosteal. Nocturnal pain is the most common symptom that usually responds to salicyclates and non-steroidal anti-inflammatory medications. CT is the modality of choice not only for diagnosis but also for specifying location of the lesion, i.e. cortical vs sub periosteal or medullary. Non-operative treatment can be considered as an option since the natural history of osteoid osteoma is that of spontaneous healing. Surgical treatment is an option for patients with severe pain and those not responding to NSAIDs. Available surgical procedures include radiofrequency (RF) ablation, CT-guided percutaneous excision and en bloc resection.

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.

Primary total hip arthroplasty: Staying out of trouble intraoperatively.

Total hip Arthroplasty is one of the most successful and commonly performed procedures in Orthopaedic Surgery. Meticulous preoperative planning allows to surgeon anticipate potential problems to reduce postoperative complications and optimize patient outcomes. Currently, the posterior approach is the most common approach utilized in the United States. In order to prevent errors in stem version, especially with cementless fixation, the entry point should be posterior, and the initial entry point should be aligned in the correct anteversion as this will determine the ultimate version of the stem. Preoperative evaluation should asses for true and apparent lengths. For successful osseointegration of cementless components, bone ingrowth occurs when there is less than 40 µm of motion between the implant and bone. Certain socket conformations such as elliptical versus hemispherical are more prone to generate fractures at the time of impaction.

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.

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.

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.

Giant cell tumour of the sacrum: function-preserving surgery with extended curettage and ilio-lumbar fusion.

Giant cell tumours of the sacrum pose a unique therapeutic challenge due to the inaccessibility of the tumour, significant intra-operative blood loss from extensive vascularity, high rate of local recurrence with conservative surgery, and loss of neurological function and mechanical instability with en-bloc excision. We present a case where successful outcome was achieved by tailoring treatment in consideration of the above issues. A 28 year old male diagnosed on biopsy to have giant cell tumour of the sacrum presented to us with low-back pain, left-sided S1 radiculopathy, ankle weakness and urinary incontinence. MRI showed a tumour involving the S1 and S2 vertebral segments, breaching the posterior cortex and compressing the neural elements. An angiographic tumour embolization was performed followed by surgery through a posterior approach whereby an extended curettage was done, carefully freeing the sacral nerve roots and abrading the bone using high-speed burr. An ilio-sacro-lumbar fusion was done employing iliolumbar instrumentation and bone grafting. Post-operatively, within a week the patient was ambulated with a lumbar corset. At 9 months follow-up, the patient was completely pain free, had no ankle weakness, and had normal continence. This treatment approach resulted in preservation of neurologic function and maintenance of spinal stability, thus the patient returned to full function.

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.