Limitations and Complications in Treating Femoral Neck Fractures with the Femoral Neck System: A Case Report.

Introduction: The femoral neck system (FNS) represents an emerging fixation system designed for the management of femoral neck fractures. This innovative system combines the mechanical benefits of compression and anti-rotation properties in internal fixation. Biomechanical studies have demonstrated the superior axial and rotational stability of the FNS implant when compared to traditional cannulated screws and dynamic hip screw. Despite these promising mechanical advantages, there is currently a limited body of literature addressing the factors contributing to FNS failure. A thorough assessment of the safety and outcomes associated with this novel implant is essential. Case Report: In this context, we present three cases wherein FNS failure occurred, aiming to elucidate the potential causes behind these failures, and had to undergo either an implant removal or bipolar hemiarthroplasty. Conclusion: While considering the femoral neck system as the implant of choice, we should consider the age, injury to surgery time, and the location of the fracture line. However, we cannot conclusively ascertain whether age contributes independently to the risk of failure.

Creating a Palliative Care Clinic for Patients with Cancer Pain and Substance Use Disorder.

BACKGROUND: Opioids are a first-line treatment for severe cancer pain. However, clinicians may be reluctant to prescribe opioids for patients with concurrent substance use disorders (SUD) or clinical concerns about non-prescribed substance use. MEASURES: Patient volume, 60-day retention rate, and use of sublingual buprenorphine to treat opioid use disorder. INTERVENTION: We created the Palliative Harm Reduction and Resiliency Clinic, a palliative care clinic founded on harm reduction principles and including formal collaboration with addiction psychiatry. OUTCOMES: During the first 18 months, patient volume increased steadily; 70% of patients had at least one subsequent visit within 60 days of the initial appointment; and buprenorphine was prescribed for 55% of patients with opioid use disorder. CONCLUSIONS/LESSONS LEARNED: The formal collaboration with addiction psychiatry and the integration of harm reduction principles and practices into ambulatory palliative care improved our ability to provide treatment to a previously underserved patient population with high symptom burden.

Trifocal Injury of the Patellar Tendon- An Exceedingly Rare Case Report.

Introduction: Distal pole of patella avulsion fracture with tibial tuberosity avulsion has been frequently reported as a bifocal patellar tendon injury. However, an osteochondral lateral patella facet fracture with a longitudinal split in the patella tendon in addition to these avulsion fractures has never been documented previously. Hence, we now report this trifocal patellar tendon injury. Case Report: An adolescent with a trifocal patella tendon injury underwent a fixation with a combination of transosseous pull- through sutures, suture tape, and knotless anchor. The patient was rehabilitated with gradual increase in 30° of knee flexion weekly and has now attained full knee range of motion. Conclusion: Fixation of the small avulsion fracture can be challenging using conventional methods such as cannulated cancellous screws especially in an immature skeleton as it can crush the fragments. Suture tape, transosseous tunnels, and knotless suture anchors have more flexibility, they avoid the physis and provide adequate strength in such situations compared to metallic implants.

Case of Infected Non-Union of Distal Femur Treated with Ilizarov Fixator Assisted Knee Arthrodesis and Limb Lengthening Surgery.

Introduction: Femoral fractures in adults are around 3-6% and 0.4% of all the fractures are usually distal femoral fractures, frequently consisting of high-energy injuries which are associated with compound trauma. Conventionally, femoral-tibial fusion remains one of the last treatment choices for the recurrent septic failure. Case Report: We report a unique case where a 52-year-old male had presented with a post-operative infected non-union of distal femur and patella with discharging sinus and distal femur plate in situ. The patient presented to our outpatient department with complaints of pain and swelling over right knee with discharging sinus with fixed flexion deformity of 20° for 1-year post trauma and post-surgery. The discharging sinus was over lateral aspect of knee with purulent discharge. His blood parameters were suggestive of high erythrocyte sedimentation rate, and C-reactive protein levels and a Gram staining were suggestive of Gram-negative bacilli. X-ray showed non-union of distal femur and osteomyelitic changes and knee subluxation with distal femur plate and encirclage with K-wire for patella in situ. The patient underwents three-stage procedure of debridement with implant removal, followed by knee arthrodesis and ultimately limb lengthening surgery. Conclusion: Our case report is unique and distinctive as it shows that, when a case of infected non-union of distal femur comes with stiff and non-salvageable knee with severe arthritic changes and financial constraints, we should consider for knee arthrodesis with ilizarov ring fixator and limb lengthening surgery. Although it yielded stiff knee but with functioning limb without limb length discrepancy.

Patient Experiences After Aborted Cancer Surgery: A Qualitative Study.

BACKGROUND: Surgical resection is a necessary component of curative-intent treatment for most solid-organ cancers but is occasionally aborted, most often due to occult metastatic disease or unanticipated unresectability. Despite its frequency, little research has been performed on the experiences, care needs, and treatment preferences of patients who experience an aborted cancer surgery. METHODS: Semistructured interviews of patients who had previously experienced an aborted cancer surgery were conducted, focusing on their recalled experiences and stated preferences. All interviews were audio recorded, transcribed, and coded by two independent researchers by using NVivo 12. An integrative approach to qualitative analysis was used-both inductive and deductive methods-and iteratively identifying themes until saturation was reached. RESULTS: Fifteen patients with an aborted cancer surgery participated in the interviews. Cancer types included pancreatic (n = 9), cholangiocarcinoma (n = 3), hepatocellular carcinoma (n = 1), gallbladder (n = 1), and neuroendocrine (n = 1). The most common reasons for aborting surgery included local tumor unresectability (n = 8) and occult metastatic disease (n = 7). Five subthemes that characterized the patient experience following an aborted cancer surgery emerged, including physical symptoms, emotional responses, impact on social and life factors, coping mechanisms, and support received. CONCLUSIONS: This qualitative study characterizes the impact of aborted cancer surgery on multiple domains of quality of life: physical, emotional, social, and existential. These results highlight the importance of developing patient-centered interventions that focus on enhancing quality of life after aborted cancer surgery.

Does preoperative 3D CT planning helps in predicting the component size determination and alignment in automatic robotic total knee arthroplasty (RA-TKA).

Purpose: Image-based Robotic Total knee Arthroplasty (RA-TKA)was developed with the purpose of enhancing the accuracy in determining the component sizes preoperatively and helping surgeons in minimizing errors and improve patient outcomes. The research aims to find the reliability of robotic-assisted TKR based on images in determining the correct component sizes using preoperative three-dimensional (3D) computer tomography. Method: After ethical approval, we conducted a prospective study from March 2022 to December 2022. A total of 100 knees underwent image-based RA-TKA having grade 4 Osteoarthritis knee (Kellegren Lawrence classification). A single senior surgeon performed on all patients. Postoperative implant sizes and fit were assessed by five radiographic markers by an independent observer. Results: In our study, we found the mean age was (64.96 ± 7.3) years, with female to male ratio of 43:22. The preoperative 3D CT accuracy is 100% for femoral component sizing and 97% for the tibial component. There was a statistically significant improvement in varus deformity from preoperative 7.370 ± 3.70° to 1.24 0 ± 0.910° after surgery., p = 0.001. Improvement in flexion deformity correction was from preoperative 6.50 ± 6.30 to postoperative 1.640 ± 1.770, p = 0.001. Conclusion: Our study concludes that the use of pre-operative 3D CT helps in predicting the component sizes, minimizes surgical time, and enhances implant position accuracy, as well as improves postoperative limb alignment in the coronal and sagittal planes.

Whether M.D. Pathology curriculum is sufficient to meet pathology practice requirements in India? A survey of newly qualified pathologists.

Background and Objectives: Pathology is a broad subject consisting of various branches, such as hematology, clinical pathology, biochemistry, histopathology, cytology, blood banking, and others. All the subspecialties are difficult to cover in depth in a 3-year MD Pathology course and curriculum. Hence, it was decided to investigate whether the MD Pathology curriculum is able to meet the challenges of today's laboratory medicine practice. So, a survey was conducted among newly qualified pathologists who have passed their exam within last 5 years. Purpose was to know their views about MD Pathology curriculum with special emphasis on challenges they face during their day-to-day practice. Materials and Methods: Study is designed as cross-sectional survey conducted via web-based Google forms questionnaire. Study population is pathologists qualified within last 5 years. A convenience sample of eligible pathologists was taken by sending a web-based Google form to various pathology groups on social media apps. Data were collected in the Google spreadsheet software and various responses were summarized as percentages, graphs, and pie-charts as necessary. Chi square test was used to find the significance of difference in responses from government, private, and deemed university respondents. Results: Different numbers of responses were received to different survey questions. Out of 187 respondents, 65 (34.8%) worked in a hospital-based laboratory, 61 (32.6%) did jobs in a private laboratory, 49 (26.2%) worked in a medical college, and 37 (19.8%) worked in their own private laboratories. Out of 193 respondents, 158 (81.9%) were working in hematology, 149 (77.2%) in clinical pathology, 139 (72%) in cytopathology, 118 (61.7%) in histopathology, whereas 103 (53.4%) worked in clinical biochemistry, and least number of respondents, i.e., 38 (19.7%) were working in blood bank. Almost all the respondents had overlapping work in hematology and other areas. The level of confidence rated by the respondents was best in hematology, followed by clinical pathology; it was least for clinical biochemistry and blood bank. Out of 192 respondents, 64.1% (123) felt that the curriculum does not equip them for lab management and administration, 21.9% (42) felt that the curriculum somewhat equipped them; whereas only 14.1% (27) felt that curriculum equips them for this task. There were 191 responses to the question regarding satisfaction with MD Pathology curriculum; out of which, 51.8% (99) were not satisfied, 24.6% (47) said they may be satisfied, whereas 23.6% (45) were satisfied with the curriculum. There was no significant difference in responses from government, private, and deemed university respondents. Conclusions: The graduating MD Pathology students expressed confidence in reporting routine cases of hematology, clinical pathology, routine cytology, and histopathology. However, there is difficulty in clinical biochemistry, blood banking, and reporting of malignancies. The laboratory management and administration, communication skills, and quality assurance are also other areas of weakness. MD Pathology program needs more focus on these weaknesses, so that newly qualified graduate would feel confident in day-to-day laboratory working.

Defining the psychiatric and financial burden of mental and substance use disorders in cancer patients.

PURPOSE: To identify the proportion of Emergency Department (ED) visits in cancer patients associated with a mental and substance use disorder (MSUD) and the subsequent healthcare costs. METHODS: Nationally representative data on ED visits from 2009 to 2018 was obtained from the Nationwide Emergency Department Sample (NEDS). We identified cancer-related visits with or without a MSUD using the Clinical Classifications Software diagnoses documented during the ED visit. Survey-adjusted frequencies and proportions of ED visits among adult cancer patients with or without a MSUD was evaluated. Survey-adjusted multivariable logistic regression models were used to examine demographic and clinical predictors of the presence of an MSUD and the likelihood of hospital admission for patients with a primary MSUD. RESULTS: Among 54,004,462 ED visits with a cancer diagnosis between 2009 and 2018, 11,803,966 (22%) were associated with a MSUD. Compared to a primary diagnosis of cancer, patients who presented to the ED with a chief complaint of MSUD were more likely to be female (54% vs. 49%), younger (median: 58 vs. 66), more likely to have Medicaid insurance, and more likely to be discharged home. The three most common MSUD diagnoses among cancer patients were alcohol-related disorders, anxiety disorders, and depressive disorders. The total costs associated with a primary MSUD from 2009 to 2018 was $3,133,432,103, of which alcohol-related disorders claimed the largest majority. Younger age (OR per 10-year increase: 0.86, 95% CI: 0.85, 0.86) and female sex (OR: 1.34, 95% CI: 1.33-1.35) were associated with higher odds of having an MSUD. CONCLUSIONS: Our findings demonstrate a high burden of psychiatric and substance use illness in the cancer population and provide the rationale for early psychosocial intervention to support these patients.

Top Ten Tips Palliative Care Clinicians Should Know About Buprenorphine.

Pain management in palliative care (PC) is becoming more complex as patients survive longer with life-limiting illnesses and population-wide trends involving opioid misuse become more common in serious illness. Buprenorphine, a generally safe partial mu-opioid receptor agonist, has been shown to be effective for both pain management and opioid use disorder. It is critical that PC clinicians become comfortable with indications for its use, strategies for initiation while understanding risks and benefits. This article, written by a team of PC and addiction-trained specialists, including physicians, nurse practitioners, social workers, and a pharmacist, offers 10 tips to demystify buprenorphine use in serious illness.

Psychological Distress in Young Adults with Acute Myeloid Leukemia Undergoing Induction Chemotherapy.

Young adults (YAs), aged 18-39 years, with acute myeloid leukemia (AML) navigate life disruptions amid an unpredictable illness trajectory. We conducted a secondary analysis of patient-reported outcomes for hospitalized YAs with high-risk AML receiving intensive chemotherapy, collected during a multisite randomized clinical trial. Of the 160 patients, 14 (8.8%) were YAs. At week 2 of hospitalization, YAs demonstrated significant worse quality of life (ß = -18.27; p = 0.036), higher anxiety (ß = 2.72; p = 0.048), and higher post-traumatic stress disorder (PTSD; ß = 10.34; p = 0.007) compared with older adults. Our analysis demonstrated a longitudinal presence of anxiety and PTSD, suggesting persistent unmet psychological needs for YAs with AML.

A Unique Case of Recurrent Osteochondroma Enclosing Brachial Artery in a 13-Year-Old Female.

Introduction: Osteochondromas (OCEs) are benign chondrogenic lesions arising on the external surface of the bone with aberrant cartilage (exostosis) from the perichondral ring that may contain a marrow cavity also. In few cases, depending on the anatomical site affected, different degrees of edema, redness, paresthesia, or paresis can take place due to simple contact or friction. Furthermore, depending on their closeness to neurovascular structures, the procedure of excision becomes crucial to avoid recurrence. We report a unique case of recurrent OCE of the proximal humerus enclosing the brachial artery which makes for an important case and procedure to ensure that no relapse occurs. Case Report: We report a unique case of a 13-year-old female who had presented with a history of pain and recurrent swelling for 5 years. The swelling size was 4.4 cm × 3.7 cm × 4 cm with a previous history of swelling at the same site operated in 2018. Conclusion: This case report demonstrates that when presented with a case of recurrent OCE of the proximal humerus, doing proper excision of the tumor is crucial to prevent its relapse.

Ilizarov Ankle Arthrodesis: A Simple Salvage Solution for Failed and Neglected Ankle Fractures.

Background: Infection around the ankle joint after fracture fixation, or septic arthritis with active discharging sinuses is often challenging to manage with conventional procedures of arthrodesis. The Ilizarov method of arthrodesis gives a better alternative for salvage in such cases. Methods: This was a retrospective study including 20 patients who were subjected to tibiotalar arthrodesis with Ilizarov method. The major pathologies included internal fixation of ankle fractures complicated by infection, posttraumatic infected ankle arthritis, and osteomyelitis. The patients were evaluated on the basis of Association for the Study and Application of the Method of Ilizarov (ASAMI) criteria. The aim of the surgery was to achieve plantigrade, stable, and painless foot with no signs of infection. Results: A total of 20 patients were operated and reviewed at our institute. The study comprised of 15 male and 5 female patients with a mean age of 43.9 years (range 33-55 years). Out of 20 patients, 4 patients had complications of pin-tract infection and one had wire breakage of the forefoot ring. According to the ASAMI criteria, 17 patients had excellent bone scores and 18 patients had good functional scores. Union was achieved in all patients with resolution of infection and the mean limb length discrepancy was 1.92 cm (range 1-2.5 cm). Conclusions: The Ilizarov fixator for ankle arthrodesis provides an excellent way for strong bone fusion, infection eradication, early weight-bearing, and the added benefits of compression at the arthrodesis site post-operatively.

Arthroscopic meniscus repair and augmentation with autologous fibrin clot in Indian population: A 2-year prospective study.

Introduction: This study was proposed to evaluate the efficacy of fibrin clot augmentation in meniscal tear using inside-out meniscal repair. Methods: A total of 35 patients with meniscus tears were operated on with inside-out meniscus repair and fibrin clot augmentation. Patients were evaluated preoperatively and postoperatively with clinical criteria, Lysholm knee scoring system, and MRI. Results: Out of the total 35 cases, 5 cases were lost to follow-up. Clinical improvement was observed in 29 out of 30 patients (96.6%). The mean Lysholm score improved significantly from 67.63 ± 6.55 points preoperatively to 92.0 ± 2.9 points postoperatively (P < 0.05) in 3 years follow-up. Follow-up MRI in all patients revealed complete healing except in 1 case where the patient presented with recurrence of symptoms such as pain and locking which resolved with partial meniscectomy. Paraesthesia in the anterior part of the knee was observed in 2 cases. (6.6%). Conclusion: We conclude that fibrin clot augmentation is a good cost-effective modality of treatment for repairable meniscus tears to preserve the meniscus and decrease the point contact pressure on the condyles which may prevent the early occurrence of osteoarthritis.

Multiple Cantilever K-wiring Technique for Severely Comminuted Articular Fragments in Neglected Distal Humerus Fracture with Anterior Elbow Dislocation: A Case Report.

Introduction: Anterior dislocation of the elbow is comparatively less frequent and is often associated with fractures of the distal humerus. Such injuries require surgical intervention at the earliest but with the surge of COVID-19 pandemic and different protocols being followed by surgeons, such cases are getting neglected. We present a 5-week-old neglected anterior dislocation of the right elbow joint with lateral condyle and medial epicondyle humerus fracture and a unique cantilever K-wiring technique used for its treatment. Case Presentation: A 30-year-old man presented with pain, deformity, and limited range of movement of his right elbow joint and a non-healing wound over the olecranon after he had a road traffic accident 5 weeks back. The patient had been initially treated in a local hospital where he tested positive for COVID-19 and was managed conservatively. Radiographs revealed lateral condyle and medial epicondyle humerus fracture and an unreduced anterior dislocation of the right elbow joint. Conclusion: Neglected fracture-dislocation of the elbow is challenging and is further complicated by comminuted fragments with loss of bone stock. A unique use of multiple Kirschner wires in a cantilever fashion provides a good fixation alternative for such cases.

Survey of semen analysis practices in India and need for standardization and improvement.

BACKGROUND AND OBJECTIVES: Infertility is a sensitive subject carrying with it economic, social, and psychological implications. Work up of male infertility is often hampered by a lack of infrastructure and facilities, as well as inadequate training of pathology residents. The purpose of this research survey was to evaluate the current status of semen analysis practices and compare them to the standards laid down by the World Health Organization (WHO). MATERIALS AND METHODS: A web-based questionnaire was designed consisting of questions related to semen analysis practices and procedures being followed currently by pathologists in India. A total of 194 pathologists responded. Questions regarding the procedures followed for semen collection, sperm count, volume, normal range, lower normal limit of sperm count, morphology, etc., were included in the survey. These data were recorded. The differences and gaps in the practice with respect to the WHO standards were analyzed. RESULTS: The survey revealed that the printed instructions for semen analysis were available with 38.7% of the respondents; 58.8% of the respondents had a separate room for semen collection; 95.9% performed the analysis manually, and; only 4.1% used automated analyzers. Only 53.6 and 52.6% of the respondents were correctly reporting the normal range of semen volume and sperm counts, respectively. Only 19.6% stated as having read the WHO manual and were also practicing its guidelines, while 14.4% had not read the WHO manual even once. CONCLUSION: The present study showed a large gap between the practice of semen analysis by respondents from various parts of India and standard procedures as laid down by the WHO. Many laboratories do not follow the standard instructions. There is a need to improve the quality of practice related to semen analysis in this country through appropriate teaching and training in medical institutions as well as through Continuing Medical Education (CMEs) or regular update programs.

Closed Reduction of Chronically Subluxated knee with Deftix (Made in India Hexapod).

Introduction: The aim of the study was to study results of (made in India) hexapod external fixator (HEF) (deft fix)-assisted correction in a case of knee subluxation with malunited medial tibial condyle fracture. Methodology: A subject with knee subluxation was selected for application of hexapod and Ilizarov ring fixator for staged correction of subluxation using deft fix-assisted correction. Result: The study shows anatomical reduction of the subluxated knee using HEF with deft fix-assisted correction. Conclusion: The HEF does not require frame transformation and is easier to use and is known to have the ability to correct complex multiplanar deformities better and much faster than the traditional Ilizarov ring fixator which requires multiple changes in hardware while correcting complex deformities. Software-assisted hexapod correction provides more faster and accurate correction with the ability to do fine adjustments at any stage of correction.

Recurrent Giant Cell Tumor of the Distal End of the Femur.

Introduction: The aim of the study was a case report of a right-sided recurrent giant cell tumor of the distal end of the femur. Methodology: A case of a 25-year-old male patient with a history of recurrent giant cell tumor of the right distal femur who presented with chief complaints of pain over right distal femur and stiffness in the right knee for 2 years with restricted knee movement and is unable to walk. He was diagnosed with recurrent giant cell tumor of the right of the distal femur and was treated with wide excision with mega prosthesis reconstruction. Result: Wide excision with mega prosthesis reconstruction showed a good functional range of motion with early rehabilitation, stability, and mobility of joints. Conclusion: We recommend wide excision and reconstruction with mega prosthesis is an effective method compared to sandwich technique and nailing and can be successfully done in the case of recurrent giant cell tumor of the distal femur with a good outcome, functional range of motion, stability, and mobility of the joint with early rehabilitation though it is a technically demanding surgery. The knee joint could have been salvaged and the need for more extensive surgery could have been prevented, had the diagnosis of recurrent giant cell tumor was made earlier.

A Novel technique of three-ring Ilizarov fixator frame in gap non-union of tibia.

INTRODUCTION: Gap non-union of tibia occurring mostly after trauma and many times complicated by infection, is a difficult problem to treat. The study aimed to assess the outcome of the three-ring construct of the Ilizarov fixator frame in the management of gap non-union of the tibia. METHODS: This retrospective study included 30 patients of gap non-union of tibia operated from April 2016 to March 2019 with a three-ring Ilizarov fixator frame and follow-up done till March 2021. The mean age was 39.27 (range 10-66) years. The results were assessed by the Association for the Study and Application of the Method of Ilizarov (ASAMI) criteria. MPTA, PPTA, and LDTA after removal of the frame were also measured. RESULTS: Out of the total 30 cases, all the patients showed complete union. The Ilizarov fixator was kept for an average period of 11.43 months and the mean defect size was 7.17 (range 2-12) cm. All patients were followed up for an average period of 39.36 (range 24-54) months. According to the ASAMI score bone/radiological results, 27 were classified as excellent, 2 as good, and 1 as poor. Functionally 28 were graded as excellent and the remainder as good. The normal ranges of MPTA, LDTA & PPTA were also achieved in a majority (80%) of patients. CONCLUSION: Our results after using only a three-ring Ilizarov fixator frame are almost equivalent to earlier studies and have advantages such as less weight, better patient compliance, superior radiographic visualization, easy mobilization, and reduced costs. Ilizarov ring fixator remains an excellent treatment modality for tibial non-union with a defect, regarding bone union, deformity correction, infection eradication, limb-length achievement, and limb function.

Osteochondroma Presenting Clinically with Carpal Tunnel Syndrome in a 12-Year-old Boy.

INTRODUCTION: An exostosis is a benign growth of bone, which when capped with cartilage is called osteochondroma, which can appear as solitary or multiple, mostly affecting the long bones, pelvis, and shoulder region. The prevalence of known solitary exostosis is 1-2% in the general population. They are slow growing lesions with rare malignant transformation. In patients with a solitary exostosis, the chance of developing a chondrosarcoma out of an exostosis is around 1%. CASE REPORT: A 12-year-old boy presented to our outpatient department with complaints of pain, and swelling at the right wrist since 1 year and tingling numbness on and around palmar aspect of index and middle finger since 6 months. The swelling was of size 3 cm × 2 cm, Tinel's sign was positive. His blood parameters were normal. X-ray showed exostoses. Magnetic resonance imaging was suggestive of osteochondroma. Nerve conduction study was normal. Excision biopsy confirmed the diagnosis and also relieved all symptoms. CONCLUSION: Our case report is unique in its own way as it reminds us that when presented with a case of osteochondroma of the distal radius in children, carpal tunnel syndrome can also occur.