Does the WHO Surgical Safety Checklist Need Modification for Orthopaedic Surgery Practices? A Cross-Sectional Survey Among Indian Orthopaedic Surgeons.

Background: It is well known that the implementation of the WHO surgical safety checklist (SSC) leads to improved operating room team coordination and reduced perioperative complication and mortality rates. Although it is proven to be beneficial worldwide, its awareness and usage need to be evaluated in a diverse country like India. As orthopaedic surgeries involve implants and tourniquet usage, it is important to evaluate the applicability of WHO SSC specifically to orthopaedic surgeries, and whether any modifications are needed. Materials and Methods: A web-based cross-sectional survey was conducted among Indian Orthopaedic Surgeons with a pre-defined questionnaire regarding awareness, usage and suggestions to modify the existing WHO SSC (2009) for orthopaedic surgeries. Results: 513 responses were included for final analysis. 90.3% of surgeons were aware of the surgical safety checklist; however, only 55.8% used it routinely in their practice. The awareness of SSC availability was 1.85 times more among younger surgeons (< 20 years of experience) than among those with > 20 years of experience. 17% of surgeons thought the usage of SSC was time-consuming and 52.4% of participants felt a need to modify the existing WHO SSC (2009) for orthopaedic surgeries. 34.5% recommended the inclusion of the patient blood group in the "Sign-in" section, 62.77% proposed the inclusion of details about the tourniquet, whereas only 6.63% suggested adding about surgical implant readiness in the "Time-out" section and 72.7% suggested including a check to make sure the tourniquet was deflated, removed and also recording of the total usage time during the "Sign-out" section. Conclusion: Despite high (90%) awareness among Indian Orthopaedic surgeons, they have limited usage of the WHO SSC in their practice. Identifying barriers and considering modifications for orthopaedic surgeries, like details about tourniquet usage during the "Time-out" section and a check to ensure it was removed during the "Sign-out" section, will improve patient safety and outcomes. Supplementary Information: The online version contains supplementary material available at 10.1007/s43465-024-01096-5.

Paediatric bilateral 'floating elbow'.

A child sustained an ipsilateral supracondylar humerus (SCH) and distal both-bone forearm fractures bilaterally, in addition to facial injuries, following a fall from height. He was managed surgically by closed reduction and pinning for both SCH and distal end radius fractures bilaterally. At the final follow-up, all the fractures had united uneventfully, and he had no functional limitations or cosmetic concerns. We conclude that a floating elbow in the paediatric population is an uncommon injury, and the bilateral scenario is even rarer. One should be vigilant for compartment syndrome; early surgical fixation may give better results.

Quadriceps tendon autograft is promising with lower graft rupture rates and better functional Lysholm scores than hamstring tendon autograft in pediatric ACL reconstruction. A systematic review and meta-analysis.

Purpose: Graft rupture is the most prevalent complication following pediatric anterior cruciate ligament reconstruction (ACLR). The hamstring tendon (HT) autograft is frequently employed, while the quadriceps tendon (QT) autograft has garnered increased attention recently. This study aims to perform a systematic review to assess the complication rates and functional outcomes associated with these two widely used autografts in skeletally immature patients - comparing HT versus QT autografts. Research question: Is QT autograft better than HT autograft for ACLR in skeletally immature cohorts? Methodology: Three electronic databases (PubMed/Medline, Scopus, and Ovid) were comprehensively searched to identify pertinent articles reporting the outcomes of HT and QT autografts in pediatric ACLR with a minimum 2-year follow-up. Data on the outcome parameters, such as graft rupture rates, contralateral ACL injury rates, functional outcomes, and growth disturbances rates, were extracted. Meta-analysis was performed using OpenMeta Analyst software. Results: Twelve studies were included for meta-analysis (pooled analysis) with 659 patients (QT: 205; HT: 454). The analysis showed that QT autografts had a significantly lesser graft rupture rate than HT autografts (3.5 % [95 % CI 0.2, 6.8] and 12.4 % [95 % CI 6.1, 18.7] respectively, p < 0.001). The graft rupture rates between QT with bone and without bone block showed no statistically significant difference (4.6 % [95 % CI 0.8, 1.0] and 3.5 % [95 % CI 2.0, 8.9] respectively, p = 0.181). The overall contralateral ACL injury rate was 10.2 %, and the subgroup analysis revealed no statistically significant difference between the QT and HT groups (p = 0.7). Regarding functional outcome scores at the final follow-up, the mean Lysholm score demonstrated a significant increase in the QT group compared to the HT group (p < 0.001). There were no significant differences between the two groups concerning growth disturbances at the final follow-up. Return to sports (RTS) varied between 6 and 13.5 months after surgery. Conclusion: QT autografts demonstrate encouraging outcomes, showcasing lower graft rupture rates, better functional outcomes, and comparable contralateral ACL injury rates and growth disturbances relative to the commonly used HT autograft in skeletally immature patients undergoing ACLR.

Medial versus anterior approach for open reduction of hip in children with DDH under two years - A meta-analysis of comparative studies.

Purpose: Open reduction (OR) is usually required in developmental dysplasia of hip (DDH) for children below 24 months of age, those who failed to achieve a satisfactory reduction by the closed method. OR in this age group can be performed either through a medial or anterior approach. However, there is a paucity of literature and a lack of more substantial evidence regarding which approach (medial versus anterior) is superior for performing OR in this age group with minimal complications. Methods: Four databases (PubMed, Embase, Scopus, and Cochrane Library) were searched for relevant articles reporting outcomes and complication rates of DDH children less than 24 months undergone OR either through medial or anterior approach using pre-defined keywords. Data on avascular necrosis (AVN) rates, further corrective surgery (FCS) rates, and clinical and radiological grading using McKay clinical criteria and Severin radiological criteria were assessed. Meta-analysis was carried out using RevMan (Review Manager 5.4) software. Results: Five comparative studies, having a minimum of two-year follow-up, were included for final analysis. According to the MINORS tool assessment, all five studies were of good to high quality. Of 257 hips, 151 and 106 underwent OR through medial and anterior approaches, respectively. Our meta-analysis showed a statistically significant (p = 0.01) number of AVN cases with the anterior approach compared to the medial approach. The overall random effect showed the odds of having AVN with an anterior approach to be 2.27 (95% CI: 1.18,4.38) times more than the same with a medial approach. Regarding FCS rates, the meta-analysis depicted no significant difference between the two groups (p = 0.63). The two groups had no statistically significant difference regarding clinical and radiological outcomes using McKay and Severin criteria, respectively. Following surgery, improvement in the acetabular index from pre-operative value showed no statistically significant difference between the two groups (p = 0.48). Conclusions: Medial approach is safe and effective for OR of the hip in DDH up to 24 months of age. Our analysis showed that AVN rates are lower with a medial approach than the anterior approach, with similar clinical and radiological outcomes and rates of FCS. However, one should consider the surgeon's expertise while choosing between these approaches.

Subtrochanteric Pathological Femur Fracture in an HIV-Positive Patient on Tenofovir-based antiretroviral therapy: A Case Report and Review of the Literature.

Introduction: The population of people living with human immunodeficiency virus (HIV) and AIDS has increased and so is the incidence of fragility fractures in these patients. Multiple contributory factors are responsible for osteomalacia or osteoporosis in such patients such as a chronic inflammatory response to the HIV, highly active antiretroviral therapy (HAART) itself, and associated comorbidities. Tenofovir has also been reported to disrupt bone metabolism and causes fragility fractures. Case Report: A 40-year-old HIV-positive female came to us with pain in her left hip and was unable to bear weight. She had a history of trivial fall. The patient has been taking tenofovir-associated HAART regimen for the past 6 years and has been compliant. She was diagnosed with a left-side transverse subtrochanteric closed femur fracture. Closed reduction and internal fixation was done using a proximal femur intramedullary nail (PFNA). The latest follow-up shows fracture union and good functional outcomes after treating osteomalacia, and HAART changed to a non-tenofovir regimen later. Conclusion: Patients with HIV infection are prone to fragility fractures and periodic monitoring of their BMD, serum calcium, and vitamin D3 levels should be done for prevention and early diagnosis. More vigilance in patients receiving a tenofovir-associated HAART regimen is needed. Appropriate medical treatment needs to be started once any abnormality in the bone metabolic parameters is detected, and drugs like tenofovir need to be changed as it causes osteomalacia.

Polymicrobial infection presenting as non-clostridial gas gangrene in a non-diabetic trauma patient. A case report and review of literature.

BACKGROUND: Clostridium species are known to be the primary causative organism of gas gangrene. Non-clostridial gas gangrene (NCGG) is another rare necrotizing entity often associated with an underlying disease, particularly diabetes mellitus, and has a high mortality rate. CASE REPORT: A 16-year-old, immunocompetent male was referred to us after four days, following a roadside accident, with a degloving injury over the thigh and knee along with fractures around the knee. Although clinico-radiologically suspicious of gas gangrene, the initial smear report was negative for any Gram-positive bacilli. On the same day, he underwent aggressive debridement with an external fixator spanning the knee to salvage the limb. On post-operative day one, due to deteriorating general clinical condition and a strong clinical suspicion of gas gangrene, he underwent above-knee amputation (open stump) after discussion with microbiologists and physicians. RESULTS: Polymicrobial non-clostridial infection was seen in culture reports taken serially at different stages of management. The latest follow-up showed a healed amputation stump following split skin grafting. CONCLUSION: Although rare, polymicrobial infections can present as non-clostridial gas gangrene even in an immunocompetent patient. A high index of clinical suspicion with a multi-disciplinary approach helps in early decision-making to avoid a devastating outcome.

Efficacy of antifibrinolytics in reducing blood loss during hip reconstruction surgery in cerebral palsy children. A systematic review and meta-analysis.

BACKGROUND: Cerebral palsy (CP) children undergoing hip reconstruction are more prone to blood loss during surgery due to poor nutritional status, antiepileptic medication intake, depletion of clotting factors, and the extent of surgery involved. We conducted this present review to analyze whether antifibrinolytics during hip surgery in CP children would reduce surgical blood loss and transfusion requirements. METHODS: Three databases (PubMed, EMBASE, and Cochrane library) were searched independently for publications mentioning the use of antifibrinolytics during hip reconstruction surgery in CP children. The primary outcome was to compare the surgical blood loss with and without antifibrinolytics use. Secondary outcomes were transfusion requirements, drop in hemoglobin level, length of hospital stay, and complication rates. RESULTS: All five studies (reporting 478 patients) published on this topic were found eligible based on inclusion criteria and were included for final analysis. Primary outcome: In three of the included studies, antifibrinolytics use resulted in a significant reduction in total blood loss with a mean difference (MD) of -151.05 mL (95% CI -272.30 to -29.80, p = 0.01). In the other two studies although statistically not significant, antifibrinolytics use reduces estimated blood loss (MD: 3.27, 95% CI -21.44 to 14.91, p = 0.72). Secondary outcomes: We observed that in the antifibrinolytics group, there was a reduction in total blood transfusion requirements (OD: 0.70, 95% CI 0.35 to 1.37, p = 0.29), and a drop in haemoglobin level (MD: 0.16, 95% CI -0.62 to 0.30, p = 0.49) but statistically not significant. No adverse effects related directly to antifibrinolytics were noticed in all five studies. CONCLUSION: Only two out of five included studies favored the use of antifibrinolytics in CP children undergoing hip reconstruction. The evidence synthesized on this meta-analysis is also not sufficient enough to support its routine use in this cohort of children for hip reconstruction surgery. High-quality studies with adequate sample size to determine the effective and safe dosage, timing, and cost involved of different antifibrinolytics are the need of the hour. LEVEL OF EVIDENCE: Ⅲ.