No Effect of Oral Mecobalamin on Skin Numbness at 3 Months After Total Knee Arthroplasty: A Randomized, Double-Blinded, Placebo-Controlled Superiority Trial.

Background: An area of skin numbness (AON) around an incision commonly occurs following total knee arthroplasty (TKA). Mecobalamin has been shown to facilitate peripheral nerve recovery in various conditions; accordingly, the present study aimed to investigate the ameliorative effect of mecobalamin on AON following TKA, as compared with a placebo. Methods: This superiority study was a double-blinded, randomized controlled trial. All patients undergoing primary TKA were assessed for eligibility. Included patients were randomized to receive either mecobalamin (500 µg, twice daily) or placebo (corn starch powder; 500 µg, twice daily) for 3 months. The primary outcome was the change in the AON around the surgical site from 2 weeks to 3 months after TKA. Secondary outcomes included the rates of different adverse events, functional outcomes, and visual analogue scale patient satisfaction scores. Results: A total of 154 patients were enrolled, with 77 patients each in the mecobalamin and placebo groups. The mean AON among patients in the mecobalamin group was 61.6 cm2 at baseline (2 weeks) and 29.1 cm2 at 3 months, compared with 55.9 cm2 and 33.2 cm2 among patients in the placebo group, respectively. Intention-to-treat analysis showed no significant difference in the change in AON around the surgical site between the 2 groups (mean difference, 7.5; 95% confidence interval, -4.2 to 25.3; p = 0.159). The rates of adverse events, functional outcomes, and visual analogue scale patient satisfaction score were also not significantly different between groups. Conclusions: Mecobalamin did not demonstrate superiority over a placebo in reducing the AON around the surgical site at 3 months after primary TKA. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Pigmented epithelioid melanocytoma (PEM) of the spine with compression fracture: case report.

BACKGROUND: Pigmented epithelioid melanocytoma (PEM) is a sporadic type of pigmented melanocytic tumor with uncertain malignant potential. PEM arises as a solitary neoplasm that predominantly occurs spontaneously in otherwise healthy patients. Due to its rarity, a gold standard treatment regimen does not exist; however, symptomatic cases should be managed with radiotherapy and surgery. CASE PRESENTATION: A 28-year-old Thai female presented with a sudden onset of back pain and weakness of the lower extremities during the postpartum period. Magnetic resonance imaging demonstrated abnormal soft tissue formation from T4 to T7; it extended to the vertebral bodies, left neural foramina, and posterior columns of T6 and T7. The patient underwent complete tumor debulking, decompressive laminectomy from T4 to T8, and posterior instrumentation from T3 to T10. The histopathology and immunohistochemistry suggested PEM. The patient fully resolved back pain after surgery. Nevertheless, as the patient re-presented with a neurological deficit a few months after the operative intervention, it was decided to perform a surgical resection via an en bloc vertebrectomy. At the one-year follow-up, although the patient reported continued improvement of her back pain, there was no motor power improvement. CONCLUSIONS: Spinal cord compression due to PEM is uncommon, especially in adults. Early diagnosis and treatment provide a good prognosis and help to regain lost neurological functions. Complete tumor removal and decompression of the spinal cord must be considered as a treatment strategy. Perioperative radiotherapy and chemotherapy have also been highlighted as treatment modalities for spinal tumors. With our reported case, early operative intervention coupled with radiotherapy produced satisfying outcomes.

Stress Fracture of the Femoral Shaft in Paget's Disease of Bone: A Case Report.

Paget's disease of bone (PDB) is a progressive bone disorder characterized by increased osteoclast-mediated bone resorption and abnormal bone formation. Incomplete atypical femoral fracture, appearing radiographically as a stress fracture at the lateral aspect of the femur, is an uncommon low-trauma fracture frequently seen in association with long-term bisphosphonate therapy. We describe the case of a 61-year-old female patient with PDB who developed a stress fracture at the lateral femoral cortex after 5 doses of intravenous bisphosphonate. The conservative treatment plan included discontinuation of bisphosphonate, a continuation of calcium and vitamin D supplementation, and limited weight-bearing for 3 months. The patient's pain level gradually improved after switching to the new treatment plan. At the latest follow-up, approximately 5 years after the initiation of conservative treatment, the patient remained pain-free, and her PDB was well-controlled. However, the fracture line was still visible on the most recent radiograph. Although it remains unclear whether a stress fracture at the lateral femoral cortex occurred due to bisphosphonate therapy or PDB, this case highlights the importance of careful evaluation of any lesion that appears in PDB patients receiving bisphosphonate therapy.

Cosmetic outcomes and patient satisfaction compared between staples and subcuticular suture technique for wound closure after primary total knee arthroplasty: a randomized controlled trial.

INTRODUCTION: Staples and subcuticular suture are commonly used wound closure techniques after total knee arthroplasty (TKA). To date, only a few studies have investigated the differences between these two wound closure methods in TKA. Accordingly, this study aimed to compare cosmetic outcome and patient satisfaction between staples and subcuticular suture for post-TKA wound closure. MATERIALS AND METHODS: This prospective randomized controlled trial included patients scheduled to undergo TKA at the Department of Orthopaedic Surgery of Siriraj Hospital (Bangkok, Thailand) during June 2018-March 2019. Patients were randomized into the staples or subcuticular suture groups. Hollander Wound Evaluation Scale (HWES), cosmetic-visual analogue scale (VAS), and patient satisfaction-VAS were evaluated at the 6-week and 3-month follow-ups. Functional outcome by the modified Knee Society Knee Scoring System and wound complications were also assessed. RESULTS: Sixty-two patients (31 per group) were included. There were no significant differences in the HWES, cosmetic-VAS, patient satisfaction-VAS, or wound complication rate between groups at the 6-week or 3-month follow-ups. Wound closure time was significantly shorter in the staples group (p < 0.001), but the total operative time was not significantly different between groups. Modified knee score was significantly better in the suture group at 6 weeks (p = 0.024), but there was no significant difference between groups at 3 months. Significant association was observed between patient satisfaction-VAS and cosmetic-VAS at the 6-week (p = 0.03) and 3-month (p = 0.021) follow-ups. CONCLUSION: Subcuticular suture and staples were found to be comparable wound-closure options after TKA relative to cosmetic outcome, patient satisfaction, functional outcome, and wound complication rate at 3-months post-operation.

Validity and responsiveness of Barthel index for measuring functional recovery after hemiarthroplasty for femoral neck fracture.

INTRODUCTION: To investigate the validity of Barthel Index (BI) compared with de Morton Mobility Index (DEMMI), EuroQol-visual analog scale (EQ-VAS), 2-min walk test (2MWT), and timed get-up-and-go test (TUG), and to evaluate the responsiveness of all outcome measures for assessing functional recovery in older patients who underwent hemiarthroplasty after femoral neck fracture. MATERIAL AND METHOD: Eighty-one femoral neck fracture patients who were enrolled in a study evaluating functional recovery after bisphosphonate therapy during 2013 to 2015, and who had data available at both baseline and 12 months after surgery were included in this study. RESULTS: All scores improved significantly from baseline to the 1-year follow-up. BI had moderate to strong correlation with DEMMI, 2MWT, and TUG (r-value: 0.490-0.843), and mild to moderate correlation with EQ-VAS (r-value: 0.278-0.323). All outcome measurements had high effect estimates. The minimal clinically important difference (MCID) of BI at 12 months was 9.8 points. CONCLUSION: Since BI was shown to have good validity (moderate to strong correlation with DEMMI and performance-based tests, and mild to moderate correlation with EQ-VAS), BI can be used to accurately assess functional recovery in patients who undergo hemiarthroplasty after femoral neck fracture.

Estimation of 10-Year Risk of Coronary Heart Disease in Nepalese Patients with Type 2 Diabetes: Framingham Versus United Kingdom Prospective Diabetes Study.

BACKGROUND: Predicting future coronary heart disease (CHD) risk with the help of a validated risk prediction function helps clinicians identify diabetic patients at high risk and provide them with appropriate preventive medicine. AIM: The aim of this study is to estimate and compare 10-year CHD risks of Nepalese diabetic patients using two most common risk prediction functions: The Framingham risk equation and United Kingdom Prospective Diabetes Study (UKPDS) risk engine that are yet to be validated for Nepalese population. PATIENTS AND METHODS: We conducted a hospital-based, cross-sectional study on 524 patients with type 2 diabetes. Baseline and biochemical variables of individual patients were recorded and CHD risks were estimated by the Framingham and UKPDS risk prediction functions. Estimated risks were categorized as low, medium, and high. The estimated CHD risks were compared using kappa statistics, Pearson's bivariate correlation, Bland-Altman plots, and multiple regression analysis. RESULTS: The mean 10-year CHD risks estimated by the Framingham and UKPDS risk functions were 17.7 ± 12.1 and 16.8 ± 15 (bias: 0.88, P > 0.05), respectively, and were always higher in males and older age groups (P < 0.001). The two risk functions showed moderate convergent validity in predicting CHD risks, but differed in stratifying them and explaining the patients' risk profile. The Framingham equation predicted higher risk for patients usually below 70 years and showed better association with their current risk profile than the UKPDS risk engine. CONCLUSIONS: Based on the predicted risk, Nepalese diabetic patients, particularly those associated with increased numbers of risk factors, bear higher risk of future CHDs. Since this study is a cross-sectional one and uses externally validated risk functions, Nepalese clinicians should use them with caution, and preferably in combination with other guidelines, while making important medical decisions in preventive therapy of CHD.

Burden of road traffic injuries in Nepal: results of a countrywide population-based survey.

BACKGROUND: Road traffic injury has emerged as a leading cause of mortality, contributing to 2·1% of deaths globally and is predicted to be the third highest contributor to the global burden of mortality by 2020. This major public health problem disproportionately affects low-income and middle-income countries, where such incidents are too often underreported. Our study aims to explore the epidemiology of road traffic injurys in Nepal at a population level via a countrywide study. METHODS: The Surgeons OverSeas Assessment of Surgical Need (SOSAS) tool, a cluster randomised, cross-sectional nationwide survey, was conducted in Nepal between May 25, and June 12, 2014. Two-stage cluster sampling was performed: 15 of 75 districts were chosen randomly proportional to population; within each district, after stratification for urban and rural, and three clusters were randomly chosen. Questions were structured anatomically and designed around a representative spectrum of surgical conditions. Road traffic injury-related results were reported. FINDINGS: 1350 households and 2695 individuals were surveyed with a response rate of 97%. 75 road traffic injuries were reported in 72 individuals (2·67% [95% CI 2·10-3·35] of the study population), with a mean age of 33·2 years (SD 1·85). The most commonly affected age group was 30-44 years, with females showing significantly lower odds of sustaining a road traffic injury than men (crude odds ratio 0·29 [95% CI 0·16-0·52]). Road traffic injuries composed 19·8% of the injuries reported. Motorcycle crashes were the most common road traffic injuries (48·0%), followed by car, truck, or bus crashes (26·7%), and pedestrian or bicycle crashes (25·3%). The extremity was the most common anatomic site injured (74·7%). Of the 80 deaths reported in the previous year, 7·5% (n=6) were due to road traffic injuries. INTERPRETATION: This study provides the epidemiology of road traffic injuries at a population-based level in the first countrywide surgical needs assessment in Nepal. WHO reported that mortality due to road traffic injuries in Nepal in 2011 was 1·7%, whereas our study reported 7·5%, consistent with the concept of underreporting of deaths in police and hospital level data noted in previous literature. Road traffic injuries continue to be a significant problem in Nepal, probably greater than previously reported; future efforts should focus on addressing this growing epidemic through preventive and mitigating strategies. FUNDING: The Association for Academic Surgery and Surgeons OverSeas.

Injury prevalence and causality in developing nations: Results from a countrywide population-based survey in Nepal.

BACKGROUND: Traumatic injury affects nearly 5.8 million people annually and causes 10% of the world's deaths. In this study we aimed to estimate injury prevalence, to describe risk-factors and mechanisms of injury, and to estimate the number of injury-related deaths in Nepal, a low-income South Asian country. METHODS: A cluster randomized, cross-sectional nationwide survey using the Surgeons OverSeas Assessment of Surgical Need tool was conducted in Nepal in 2014. Questions were structured anatomically and designed around a representative spectrum of operative conditions. Two-stage cluster sampling was performed: 15 of 75 districts were chosen randomly proportional to population; within each district, after stratification for urban and rural populations, 3 clusters were randomly chosen. Injury-related results were analyzed. RESULTS: A total of 1,350 households and 2,695 individuals were surveyed verbally, with a response rate of 97%. A total of 379 injuries were reported in 354 individuals (13.1%, 95% confidence interval 11.9-14.5%), mean age of 32.6. The most common mechanism of injury was falls (37.5%), road traffic injuries (19.8%), and burns (14.2%). The most commonly affected anatomic site was the upper extremity (42.0%). Of the deaths reported in the previous year, 16.3% were injury-related; 10% of total deaths may have been averted with access to operative care. CONCLUSION: This study provides baseline data on the epidemiology of traumatic injuries in Nepal and is the first household-based countrywide assessment of injuries in Nepal. These data provide valuable information to help advise policymakers and government officials for allocation of resources toward trauma care.