Osteosynthesis of Neck of Femur Fracture below 65 years of Age: does timing of surgery influence osteonecrosis, nonunion and functional outcome?

Background Influence of timing of injury surgery interval in outcome of osteosynthesis of neck of femur has always been a matter of debate. Patients in our set up have been surgically treated for neck of femur fracture with wide range of injury surgery interval which could have resulted in varied functional outcome and radiological outcome. Objective To evaluate the difference in functional outcome, femoral head osteonecrosis and non-union in fracture neck of femur fixed within and after twenty-four hours. Method All patients, who had undergone osteosynthesis for the neck of femur fractures via open or closed technique from 2010 to 2018 were analyzed retrospectively. The cases were examined and evaluated in terms of injury surgery interval, fracture union, functional status using Modified Harris Hip Score, complications like femoral head osteonecrosis and non-union. Result Fifty patients with an average injury surgery interval of 34±28 hours were evaluated. Twenty three (46%) cases were included in early surgery group (< 24 hours) and 27 (54%) patients were included in delayed (> 24 hours) surgery group. Incidence of femoral head osteonecrosis was reported in two (4%) cases, both being in delayed fixation group (p=0.49). Non-union was reported in four (8%) patients, one in early fixation group and three in delayed fixation group (p=0.61). The average Modified Harris Hip Score in early fixation group was 87 and in delayed fixation group was 84 (p=0.1). Forty two (84%) cases had a good quality of reduction and eight (16%) had a poor reduction. Non-union and functional outcome significantly differed between the good and poor reduction group (p=0.001 and 0.004 respectively). Conclusion There is no significant difference in the functional and radiological outcome of cases operated before and after 24 hours for osteosynthesis of neck of femur fractures in patients 16 to 65 years age group. However, poor reduction is significantly associated with the increased rate of non-union and poor functional outcome.

The Ponseti method in the treatment of children with idiopathic clubfoot presenting between five and ten years of age.

Our goal was to evaluate the use of Ponseti's method, with minor adaptations, in the treatment of idiopathic clubfeet presenting in children between five and ten years of age. A retrospective review was performed in 36 children (55 feet) with a mean age of 7.4 years (5 to 10), supplemented by digital images and video recordings of gait. There were 19 males and 17 females. The mean follow-up was 31.5 months (24 to 40). The mean number of casts was 9.5 (6 to 11), and all children required surgery, including a percutaneous tenotomy or open tendo Achillis lengthening (49%), posterior release (34.5%), posterior medial soft-tissue release (14.5%), or soft-tissue release combined with an osteotomy (2%). The mean dorsiflexion of the ankle was 9° (0° to 15°). Forefoot alignment was neutral in 28 feet (51%) or adducted (< 10°) in 20 feet (36%), > 10° in seven feet (13%). Hindfoot alignment was neutral or mild valgus in 26 feet (47%), mild varus (< 10°) in 19 feet (35%), and varus (> 10°) in ten feet (18%). Heel-toe gait was present in 38 feet (86%), and 12 (28%) exhibited weight-bearing on the lateral border (out of a total of 44 feet with gait videos available for analysis). Overt relapse was identified in nine feet (16%, six children). The parents of 27 children (75%) were completely satisfied. A plantigrade foot was achieved in 46 feet (84%) without an extensive soft-tissue release or bony procedure, although under-correction was common, and longer-term follow-up will be required to assess the outcome.

SU-D-BRA-03: Simultaneous MV-KV Imaging for Intra-Fractional Motion Management during Volume Modulated Arc Therapy (VMAT) Delivery on the Varian TrueBeam.

PURPOSE: To evaluate a MV-kV intra-fractional imaging technique for use during volume modulated arc therapy (VMAT) with the Varian TrueBeam. METHODS: MV-kV image pairs were acquired intra-fractionally during VMAT delivery. kV images (11 fps) were acquired throughout delivery using a standard pre-programmed imaging template. MV images (9.5 fps) were acquired simultaneously by deploying the EPID and passively collecting the resulting images using Varian proprietary software, iTools Capture. Localization accuracy was evaluated by imaging a Rando phantom implanted with 3 fiducials while moving the couch according to XML- programmed trajectories simulating typical prostate and respiratory motion. VMAT delivery was done using a single 360 degree arc in TrueBeam Developer mode. The effect on accuracy of total MU and gantry speed was studied. To improve image quality, MV frame averaging was performed and the MV and kV images were then registered to their corresponding DRRs using in-house registration software. From these 2D registrations, the 3D position at each MV-kV acquisition point was determined. RESULTS: Between 130 and 390 MV-kV pairs were acquired for each delivery. The mean difference between planned couch and measured fiducial 3D positions with prostate motion was less than 0.03 cm in each direction (SD 0.03 cm). Neither gantry speed nor MU significantly impacted accuracy. for respiratory motion, the mean difference between planned and measured position was less than 0.04 cm. Standard deviation averaged 0.06 cm but increased to 0.12 cm with large instantaneous motion and less MV dose per frame. MV frame averaging and inaccuracies in MV image gantry angle determination also affected accuracy, particularly with significant motion. CONCLUSIONS: With high quality MV imaging, MV-kV localization techniques can be highly accurate, even in the presence of significant motion. As clinical MV-kV methods become available, such techniques can provide an efficient and accurate method for monitoring intra-fractional motion. This work was partially supported through a research agreement with Varian Medical Systems, Palo Alto, CA.

Transthoracic echocardiography may be useful for preoperative cardiac evaluation of gynaecological patients undergoing routine surgery.

Echocardiography has been an integral noninvasive tool for [preoperative] cardiac evaluation that provides with echocardiographic details which may also be useful to perioperative clinicians to tailor their anesthetic deliberation while dealing with preoperative patients. The objective of this study is preoperative evaluation of routine gynecological patients echocardiographically after being referred from respective internists or anesthesiologists. This was a prospective, nonrandomized study of elective 68 cases who underwent echocardiographic evaluation preoperatively from 15th July 2009 to 14th July 2012. The mean age of the patients was 52.1 +/- 10.3 years with the age range of 30-79 years. Valvular heart disease was the most common echocardiographic finding (129.4%) followed by left ventricular diastolic dysfunction, LVDD (48.5%) and left ventricular hypertrophy (22.1%). Systolic dysfunction was detected in 2.9% of patients and pulmonary arterial hypertension in 2.9% patients. Amongst patients referred after preoperative anaesthetic evaluation, patients had different cardiac lesions echocardiographically. Preoperative echocardiographic evaluation may provide important cardiac informations and values which might be employed by perioperative physicians to tailor their treatment.

Health problems and social consequences in teenage pregnancy in rural Kathmandu Valley.

Early marriage, less awareness of family life education, low socio economic condition and burden of large families in rural area are the contributory factors to high teenage pregnancy and its complications. A rural health centre based cross sectionals study was under taken over six month period among teenage (10-19 years) in the rural Kathmandu Valley. The study sample comprises (15-19 years old) 180 subjects. Data includes demographical variables as anemia, preterm delivery, abortion and hemoglobin. Preterm delivery cases within 37 weeks of gestation. Below 10 gm. of Hb was considered as anemia. The prevalence of anemia was quite high (56.66%) in teenage pregnancy. However severe (<7.9 gm) anemia was observed in 55.67% cases.

Conservative treatment in acute appendicitis.

INTRODUCTION: Acute appendicitis is one of the commonest surgical problems and appendectomy is one of the most commonly done operations in the emergency world wide. Though there have been occasional reports with conservative treatment in acute appendicitis, it is not being practiced as a routine. METHODS: All patients between ten to sixty years of age admitted at BPKIHS with the diagnosis of acute appendicitis over a period of one year were enrolled in the study. After taking informed consent the patients were managed conservatively. Those who did not respond to antibiotics within 24 hours were operated. Total hospital stay and complications were recorded and they were followed up at first week, sixth week and sixth month. The success rate, conversion rate, recurrence rate and morbidity and mortality pattern were assessed as the final outcome of conservative treatment of acute appendicitis. RESULTS: A total of 96 patients (48 males and 48 females) underwent conservative treatment. The conservative treatment was successful in 79 (82.3%) cases and failed in 11 (11.4%) cases, which included: conversion to appendectomy during conservative treatment period 4 (4.2%) cases, recurrence 7 (7.3%) cases. There was no mortality in this study. CONCLUSION: Acute appendicitis can be treated successfully with conservative (antibiotics) treatment with a short hospital stay. Though there is a risk of recurrence in some cases, all the complications after appendectomy can be eliminated with the conservative treatment.

Perioperative intravenous lidocaine infusion on postoperative pain relief in patients undergoing upper abdominal surgery.

Due to unpleasant nature and physiological consequences of postoperative pain, search of safe and effective modalities for its management has remained a subject of interest to clinical researchers. Analgesic action of lidocaine infusion in patients with chronic neuropathic pain is well known but its place in relieving postoperative pain is yet to be established. The study aimed to assess the effectiveness of perioperative intravenous lidocaine infusion on postoperative pain intensity and analgesic requirement. Sixty patients undergoing major upper abdominal surgery were recruited in this randomized double blinded study. Thirty patients received lidocaine 2.0% (intravenous bolus 1.5 mg/kg followed by an infusion of 1.5 mg/kg/h), and 30 patients received normal saline according to randomization. The infusion started 30 min before skin incision and stopped 1 h after the end of surgery. Postoperative pain intensity and analgesic (diclofenac) requirement were assessed at the interval 15 minutes for 1 hour then 4 hourly up to 24 hours. The pain intensity at rest and movement as well as the total postoperative analgesic (diclofenac) requirement were significantly lower (142.50 +/- 37.80 mg vs.185.00 +/- 41.31 mg, P<0.001) in lidocaine group. The extubation time was significantly longer in lidocaine group (14.43 +/- 3.50 minutes vs. 6.73 +/- 1.76 minutes, P<0.001). The time for the first dose of analgesic requirement was longer in lidocaine group (60.97 +/- 18.05 minutes vs.15.73 +/- 7.46 minutes, P<0.001). It can be concluded that perioperative infusion of low dose of lidocaine decreases the intensity of postoperative pain, reduces the postoperative analgesic consumption, without causing significant adverse effects in patients undergoing upper abdominal surgery.

Pediatric femoral hernia.

Pediatric femoral hernias account for less than 1% of all groin hernias. Pediatric femoral hernias are rather uncommon more so in males, often overlooked, misdiagnosed and treated as inguinal hernia. Femoral hernia masquerading as inguinal hernia in a seven year old male is reported along with review of relevant literature.

Splenic epidermoid cyst.

Splenic epidermoid cyst is a rare cystic disease affecting the spleen. We report a young male who presented with a painless abdominal lump. Ultrasonography and CT scan of abdomen showed a huge cystic lesion of obscure origin. At laparotomy a huge cyst was found to be arising from the superior pole of the spleen, and its removal necessitated splenectomy. Histopathological findings were consistent with splenic epidermoid cyst. The aetiopathology and different treatment modalities of splenic cysts are discussed.

Iliopsoas abscess: analysis and perspectives from an endemic region of Eastern Nepal.

OBJECTIVE: To evaluate the clinical profile and outcome in patients with iliopsoas abscess. METHODS: A descriptive study was carried out in B.P. Koirala Institute of Health Science, Dharan, Nepal from February 2005 to March 2006. The medical records of all thirty six patients admitted in surgery ward with diagnosis of iliopsoas abscess during the study period were analyzed. RESULTS: Thirty six patients were included the study. There were 22 (61.1%) males and 14 (38.9%) females with a mean age of 24.33 +/-19.19 years. Demographic distribution of the patients revealed the highest number 13 (36.1%) from Sunsari district, eastern part of the country. Right sided unilateral involvement was the most common presentation and only 2 cases had bilateral involvement. In none of our patients the dorsolumbar spine radiograph revealed any involvement of the bone. The most common complaints were pain in lower abdomen and lump in iliac fossa with flexion deformity at hip joint. All the patients underwent open surgical drainage and their outcomes were analyzed in term of cure, morbidity and mortality. Staphylococcus aureus was the most common organism 24 (61.5%) isolated. Twenty two (91.66%) of Staphylococcus aureus samples were sensitive to ciprofloxacin. There was one mortality in the group who died of septicaemia secondary to necrotizing fascitis. Six patients had wound infection, which were cured by regular dressing. CONCLUSION: On the basis of our experience and review of available relevant literature, we can conclude that a high index of suspicion and awareness of the varying clinical picture are required to diagnose this condition properly. Ultrasonography should still be the preferred imaging modality as it is cheap, safe, cost effective and readily available. Ciprofloxacin should be used as a first line drug. Image guided aspiration may be practical in selected cases having little pus and traditional open drainage should be considered without hesitation.