Perioperative mortality and morbidity of hip fractures among COVID-19 infected and non-infected patients: A systematic review and meta-analysis.

PURPOSE: Hip fractures among elderly patients are surgical emergencies. During COVID-19 pandemic time, many such patients could not be operated at early time because of the limitation of the medical resources, the risk of infection and redirection of medical attention to a severe infective health problem. METHODS: A search of electronic databases (PubMed, Medline, CINAHL, EMBASE and the Cochrane Central Register of Controlled Trials) with the keywords "COVID", "COVID-19″, "SARS-COV-2", "Corona", "pandemic", "hip fracture", "trochanteric fracture" and "neck femur fracture" revealed 64 studies evaluating treatment of hip fracture in elderly patients during COVID-19 pandemic time. The 30-day mortality rate, inpatient mortality rate, critical care/special care need, readmission rate and complications rate in both groups were evaluated. Data were analyzed using Review Manager (RevMan) V.5.3. RESULTS: After screening, 7 studies were identified that described the mortality and morbidity in hip fractures in both COVID-19 infected (COVID-19 +) and non-infected (COVID-19 -) patients. There were significantly increased risks of 30-day mortality (32.23% COVID-19 + death vs. 8.85% COVID-19 - death) and inpatient mortality (29.33% vs. 2.62%) among COVID-19 + patients with odds ratio (OR) of 4.84 (95% CI: 3.13 - 7.47, p < 0.001) and 15.12 (95% CI: 6.12 - 37.37, p < 0.001), respectively. The COVID-19 + patients needed more critical care admission (OR = 5.08, 95% CI: 1.49 - 17.30, p < 0.009) and they remain admitted for a longer time in hospital (mean difference = 3.6, 95% CI: 1.74 - 5.45, p < 0.001); but there was no difference in readmission rate between these 2 groups. The risks of overall complications (OR = 17.22), development of pneumonia (OR = 22.25), and acute respiratory distress syndrome/acute respiratory failure (OR = 32.96) were significantly high among COVID-19 + patients compared to COVID-19 - patients. CONCLUSIONS: There are increased risks of the 30-day mortality, inpatient mortality and critical care admission among hip fracture patients who are COVID-19 +. The chances of developing pneumonia and acute respiratory failure are more in COVID-19 + patients than in COVID-19 ‒ patients.

Solitary fibrous tumour of lacrimal sac masquerading as lacrimal sac mucocele: a diagnostic and surgical dilemma.

Swellings in medial canthal area in eye most often involve the lacrimal sac, the commonest aetiology being chronic dacryocystitis. Very rarely, there is a deviation in the routine diagnosis when the pathology comes out to be a lacrimal sac tumour. We report the case of a young man who presented with a medial canthal mass not extending above the medial canthal ligament. The clinical presentation was typical for a lacrimal sac mucocele, however on histopathological evaluation was diagnosed as a rare case of solitary fibrous tumour of lacrimal sac. We recommend radiological investigation in medial canthal masses where there is negative regurgitation on pressure over lacrimal sac area to avoid misdiagnoses.

External fixation versus open reduction and internal fixation in the treatment of Complex Tibial Plateau Fractures: A systematic review and meta-analysis.

OBJECTIVE: The aim of this meta-analysis was to compare the functional outcomes and complications of external fixation (EF) versus open reduction and internal fixation (ORIF) in the treatment of complex tibial plateau fractures. METHODS: Based on a comprehensive search of major databases through PubMed, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL), 19 studies comparing EF versus ORIF in treatment of complex tibial plateau fractures (Schatzker V-VI/ OTA C1, C2, and C3) were included in the studies. There was one randomized controlled trial, two prospective comparative studies, 14 retrospective comparative studies, and two conference papers. From these studies, the data regarding functional and surgical outcomes as well as complications were obtained and pooled to conduct a comparison between the two methods of treatment. RESULTS: 1191 tibial plateau fractures were determined by the systematic review. Of those fractures, 543 were treated using EF, and 648 were treated using ORIF with plate and screws. All the studies included the young patients with traumatic tibial plateau fractures with mean ages from 40 to 60 years. The analysis of pooled data revealed significantly better functional outcome in patients operated with EF (standard mean difference [SMD] = 0.29, 95% confidence interval [CI] = 0.04-0.55, P = 0.02, I2= 0%). However, according to categorical functional outcomes, no significant differences were found (OR 0.80, 95%CI: 0.47, 1.34, P=0.39, I2= 31%). The range of movement at the knee joint was significantly better in patients treated by EF (mean difference [MD] = 7.86, 95%CI = 3.56 -12.17, P = 0.0003). The surgical time in the EF group was significantly shorter compared to the ORIF group (MD = -52.11, 95%CI = -99.62-(-4.60), P = 0.03). Similarly, the intraoperative blood loss was significantly lesser in the EF group (MD = -341.53, 95%CI = -528.18- (-154.88), P = 0.0003). Although the superficial infection was more frequent in the EF group (odds ratio [OR] = 3.22, P = 0.0002), there were no differences in the deep infection and overall infection rates. Also, there were no differences in reoperation rate, knee stiffness, compartment syndrome, and venous thromboembolism. The radiographic osteoarthritis was more common in the EF group (OR = 1.56, P = 0.04); however, there was no difference in the need for total knee arthroplasty between the two treatment modalities. CONCLUSION: EF provides better functional outcomes and range of motion compared to ORIF in the treatment of complex tibial plateau fractures. With shorter surgical time and lesser intraoperative blood loss, EF can be considered as a definite treatment method in open injuries, polytrauma patients, and chronically morbid patients who cannot withstand prolonged surgery. LEVEL OF EVIDENCE: Level III, Therapeutic Study.

Thirty-day mortality of patients with hip fracture during COVID-19 pandemic and pre-pandemic periods: A systematic review and meta-analysis.

BACKGROUND: Timely intervention in hip fracture is essential to decrease the risks of perioperative morbidity and mortality. However, limitations of the resources, risk of disease transmission and redirection of medical attention to a more severe infective health problem during coronavirus disease 2019 (COVID-19) pandemic period have affected the quality of care even in a surgical emergency. AIM: To compare the 30-d mortality rate and complications of hip fracture patients treated during COVID-19 pandemic and pre-pandemic times. METHODS: The search of electronic databases on 1st August 2020 revealed 45 studies related to mortality of hip fracture during the COVID-19 pandemic and pre-pandemic times. After careful screening, eight studies were eligible for quantitative and qualitative analysis of data. RESULTS: The pooled data of eight studies (n = 1586) revealed no significant difference in 30-d mortality rate between the hip fracture patients treated during the pandemic and pre-pandemic periods [9.63% vs 6.33%; odds ratio (OR), 0.62; 95%CI, 0.33, 1.17; P = 0.14]. Even the 30-d mortality rate was not different between COVID-19 non-infected patients who were treated during the pandemic time, and all hip fracture patients treated during the pre-pandemic period (OR, 1.03; 95%CI, 0.61, 1.75; P = 0.91). A significant difference in mortality rate was observed between COVID-19 positive and COVID-19 negative patients (OR, 6.99; 95%CI, 3.45, 14.16; P < 0.00001). There was no difference in the duration of hospital stay (OR, -1.52, 95%CI, -3.85, 0.81; P = 0.20), overall complications (OR, 1.62; P = 0.15) and incidence of pulmonary complications (OR, 1.46; P = 0.38) in these two-time frames. Nevertheless, the preoperative morbidity was more severe, and there was less use of general anesthesia during the pandemic time. CONCLUSION: There was no difference in 30-d mortality rate between hip fracture patients treated during the pandemic and pre-pandemic periods. However, the mortality risk was higher in COVID-19 positive patients compared to COVID-19 negative patients. There was no difference in time to surgery, complications and hospitalization time between these two time periods.

Limb length discrepancy after total knee arthroplasty: A systematic review and meta-analysis.

BACKGROUND: Limb length discrepancy (LLD) after total knee arthroplasty (TKA) has been considered as one of the reasons for the unsatisfactory outcome. However, there is no consensus about the extent of LLD that can be considered as clinically relevant. AIM: To evaluate the incidence of radiographic LLD and its impact on functional outcome following TKA. METHODS: All randomized-controlled trial and observational studies on LLD in TKA, published till 22nd June 2020, were systematically searched and reviewed. The primary outcome was "limb lengthening or LLD after TKA". The secondary outcomes included "assessment of LLD in varus/valgus deformity" and "impact of LLD on the functional outcome". RESULTS: Of 45 retrieved studies, qualitative and quantitative assessment of data was performed from eight studies and six studies, respectively. Five studies (n = 1551) reported the average limb lengthening of 5.98 mm. The LLD after TKA was ranging from 0.4 ± 10 mm to 15.3 ± 2.88 mm. The incidence of postoperative radiographic LLD was reported in 44% to 83.3% of patients. There was no difference in the preoperative and postoperative LLD (MD -1.23; 95%CI: -3.72, 1.27; P = 0.34). Pooled data of two studies (n = 219) revealed significant limb lengthening in valgus deformity than varus (MD -2.69; 95%CI: -5.11, 0.27; P = 0.03). The pooled data of three studies (n = 611) showed significantly worse functional outcome in patients with LLD of ≥ 10 mm compared to < 10 mm (standard MD 0.58; 95%CI: 0.06, 1.10; P = 0.03). CONCLUSION: Limb lengthening after TKA is common, and it is significantly more in valgus than varus deformity. Significant LLD (≥ 10 mm) is associated with suboptimal functional outcome.

Oculomotor Nerve Palsy as a Rare Presentation and First Sign of Multiple Myeloma.

Acquired oculomotor nerve palsy has varied aetiologies like vascular (diabetes, heart disease, atherosclerosis and posterior communicating artery aneurysm), space occupying lesions or tumours, inflammation, infection, trauma, demyelinating disease like Multiple sclerosis, autoimmune disorders such as Myasthenia gravis, postoperatively as a complication of neurosurgery, cavernous sinus thrombosis etc. Cranial Nerve palsies as one of the first symptoms of multiple myeloma have been reported sparsely in literature. We report a case of a 60-year-old woman who developed sudden onset right-sided pupil sparing oculomotor nerve palsy along with a tender swelling at right sternoclavicular joint. Cranial and orbital magnetic resonance imaging and cerebrospinal fluid examination demonstrated no abnormalities. Immunological investigations and histopathological analysis of sternoclavicular joint swelling confirmed the diagnosis of IgG type multiple myeloma. After confirmation of diagnosis we started her with appropriate chemotherapy, after which the palsy resolved within one month. The cause of the palsy was probably due to nerve ischemia due to hyper viscosity of the serum.

Sebaceous Gland Carcinoma of Eyelid- A Tarnished Masquerade.

Malignant tumours of the face are usually seen in the periocular region, mainly on eyelids most commonly in the inferior eyelid, medial canthus and superior eyelid, respectively. The prime treatment for eyelid malignant tumours is the total excision of the lesion with frozen section control or by Mohs Micrographic surgery. The postoperative defects should be reconstructed judicially taking care that the near normal anatomical and functional recovery is achieved. The Cutler-Beard flap procedure, a good alternative in the reconstruction of superior near-total eyelid defects resulted in good restoration of anatomy and function in our patient. We report a case of an eyelid growth persisting for 2 year duration mimicking a chalazion. Clinically the eyelid mass had malignant features and hence was planned for wide excision with frozen section of margins. After confirming the tumour free margins, we performed reconstruction of the eyelid defect with Cutler Beard flap procedure. She was followed up for one year which showed no local recurrence or regional/distant metastases.

Adie's Tonic Pupil in Systemic Sclerosis: A Rare Association.

We report a rare association of Adie's tonic pupil in a patient with systemic sclerosis who was otherwise systemically stable. This paper is an effort to unravel whether the tonic pupil and systemic sclerosis are an association by chance (which may be the case) or systemic sclerosis is the source of the tonic pupil.

Cortical blindness following spinal surgery: very rare cause of perioperative vision loss.

A 38-year-old man was operated with posterior spinal decompression and pedicle screw instrumentation for his L2 fracture with incomplete neurological deficit. In the recovery, he complained of blindness in both eyes after twelve hours. Computed tomographic scan and magnetic resonance angiography revealed bilateral occipital lobe infarcts. He remained permanently blind even after three years follow-up. Though rare, perioperative vision loss is a potential complication following spine surgery in prone position. We report a rare occurrence of cortical blindness following lumbar spine surgery.

Ewing's sarcoma as second malignancy following a short latency in unilateral retinoblastoma.

Second malignancies, mostly in the form of bone sarcomas, are known to occur in hereditary retinoblastomas, which usually present with bilateral disease. Only 2 cases of Ewing's sarcoma have been reported in the literature following sporadic unilateral retinoblastoma. A 5-year-old boy presented to our hospital with Ewing's sarcoma of the right humerus (proven by biopsy and immunohistochemistry) following successful treatment of retinoblastoma of the left eye with enucleation and chemotherapy 2 years previously. He was treated with 2 cycles of chemotherapy followed by radiation therapy. At 15 months follow-up, the tumor had reduced in size and the child had a good functional outcome. The cumulative risk of second malignancies in retinoblastoma survivors is 32%. Ninety-eight percent of second malignancies occur in patients with bilateral retinoblastoma. Germ line mutations have been considered in sporadic tumors occurring bilaterally and multifocal unilateral sporadic tumors. Bone and soft tissue sarcomas are the most common second malignancies. Radiation therapy increases the risk of developing a second malignancy in the irradiated field. Unilateral retinoblastomas, which comprise the majority of retinoblastomas, are not immune from the development of second malignancies. Close follow-up of all retinoblastomas--even in the early period--can improve the outcome by facilitating the early detection and aggressive treatment of second malignancies.