Thoracolumbar Sacral Orthosis for Spinal Fractures: What's the Evidence and Do Patients Use Them?

Introduction The general consensus regarding the non-operative management of thoracolumbar (TL) spine fractures revolves around the use of thoracolumbar spine orthosis (TLSO). The efficacy of TLSO bracing remains controversial within the current literature, with several studies showing that prolonged brace use is associated with diminished lung capacity, skin breakdown, and paraspinal muscular atrophy, with no significant difference in pain and functional outcomes between patients treated with or without TLSO. Aims The aim of this study was to identify the number of braces issued over the duration of the study and understand the cost implication, added length of stay, and patient satisfaction based on a questionnaire and reflect on whether we need to change our practice on the use of TLSO. Methods Data was collected retrospectively over an 18-month period with 75 patients being initially identified for the study. A total of 42 records were included in the final study after the application of inclusion/exclusion criteria. Patient-related outcomes were recorded through a questionnaire. Results Of the patients, 60% report not receiving adequate advice regarding the duration of treatment, 43% reported that the brace interfered with their activities of daily living (ADLs), and 73% came off the brace earlier than advised, with 60% of patients reporting that they would rather be without the brace if given the option. The average increase in length of stay waiting for bracing was three days, with the estimated cost incurred being approximately £114,000. Conclusion With equivalence between treatment with or without a brace, there is a need to rethink current practice and move toward a case-by-case, patient-centered approach to minimize costs and improve patient satisfaction.

Floating proximal interphalangeal joint (PIPJ) injury of the little finger in a child: A case report.

We present a floating PIPJ injury of the non-dominant hand little finger in a skeletally immature boy following a hyperextension injury while playing football. The injury was managed non-operatively with a successful outcome. This injury pattern can happen with trivial trauma in a child and could be easily missed. It is important to be aware of this pattern of injury and good functional outcomes are possible with non-operative treatment.

Perspectives and Consensus among International Orthopaedic Surgeons during Initial and Mid-lockdown Phases of Coronavirus Disease.

With a lot of uncertainty, unclear, and frequently changing management protocols, COVID-19 has significantly impacted the orthopaedic surgical practice during this pandemic crisis. Surgeons around the world needed closed introspection, contemplation, and prospective consensual recommendations for safe surgical practice and prevention of viral contamination. One hundred orthopaedic surgeons from 50 countries were sent a Google online form with a questionnaire explicating protocols for admission, surgeries, discharge, follow-up, relevant information affecting their surgical practices, difficulties faced, and many more important issues that happened during and after the lockdown. Ten surgeons critically construed and interpreted the data to form rationale guidelines and recommendations. Of the total, hand and microsurgery surgeons (52%), trauma surgeons (32%), joint replacement surgeons (20%), and arthroscopy surgeons (14%) actively participated in the survey. Surgeons from national public health care/government college hospitals (44%) and private/semiprivate practitioners (54%) were involved in the study. Countries had lockdown started as early as January 3, 2020 with the implementation of partial or complete lifting of lockdown in few countries while writing this article. Surgeons (58%) did not stop their surgical practice or clinics but preferred only emergency cases during the lockdown. Most of the surgeons (49%) had three-fourths reduction in their total patients turn-up and the remaining cases were managed by conservative (54%) methods. There was a 50 to 75% reduction in the number of surgeries. Surgeons did perform emergency procedures without COVID-19 tests but preferred reverse transcription polymerase chain reaction (RT-PCR; 77%) and computed tomography (CT) scan chest (12%) tests for all elective surgical cases. Open fracture and emergency procedures (60%) and distal radius (55%) fractures were the most commonly performed surgeries. Surgeons preferred full personal protection equipment kits (69%) with a respirator (N95/FFP3), but in the case of unavailability, they used surgical masks and normal gowns. Regional/local anesthesia (70%) remained their choice for surgery to prevent the aerosolized risk of contaminations. Essential surgical follow-up with limited persons and visits was encouraged by 70% of the surgeons, whereas teleconsultation and telerehabilitation by 30% of the surgeons. Despite the protective equipment, one-third of the surgeons were afraid of getting infected and 56% feared of infecting their near and dear ones. Orthopaedic surgeons in private practice did face 50 to 75% financial loss and have to furlough 25% staff and 50% paramedical persons. Orthopaedics meetings were cancelled, and virtual meetings have become the preferred mode of sharing the knowledge and experiences avoiding human contacts. Staying at home, reading, and writing manuscripts became more interesting and an interesting lifestyle change is seen among the surgeons. Unanimously and without any doubt all accepted the fact that COVID-19 pandemic has reached an unprecedented level where personal hygiene, hand washing, social distancing, and safe surgical practices are the viable antidotes, and they have all slowly integrated these practices into their lives. Strict adherence to local authority recommendations and guidelines, uniform and standardized norms for admission, inpatient, and discharge, mandatory RT-PCR tests before surgery and in selective cases with CT scan chest, optimizing and regularizing the surgeries, avoiding and delaying nonemergency surgeries and follow-up protocols, use of teleconsultations cautiously, and working in close association with the World Health Organization and national health care systems will provide a conducive and safe working environment for orthopaedic surgeons and their fraternity and also will prevent the resurgence of COVID-19.

Type III monteggia injury with ipsilateral type II Salter Harris injury of the distal radius and ulna in a child: a case report.

BACKGROUND: Although previously reported, ipsilateral Monteggia fracture dislocation and distal radius fracture in a child is still a rare occurrence. A full clinical examination may be difficult but should not be ignored. Full length forearm radiographs are ideal but proper limb positioning may be difficult. The injury pattern can be easily missed. CASE PRESENTATION: A five-year-old right hand dominant Caucasian male presented with a history of fall on outstretched hand. Clinical examination was difficult and X-rays confirmed type III Monteggia fracture with an ipsilateral Type II Salter Harris injury of the distal radius and ulna. CONCLUSION: This report highlights the need for relevant examination of the wrist and elbow in young children. Appropriate radiographs must also be performed to prevent missing these injuries.

Deep vein thrombosis in shoulder arthroplasty - a prospective study.

BACKGROUND: Shoulder arthritis of varied aetiology is often disabling and patients seek treatment for pain relief and restricted movements. Though non operative measures in the form of analgesics, physiotherapy and joint injections offer satisfactory results in the early stages; operative treatment in the form of joint replacements becomes necessary in late and advanced stages. The above operations are being performed more frequently in the recent years across the National Health Service [NHS] in the UK with increasing success in specialised units and the outcome of the operation is often rewarding. In addition to the other complications, risks of Deep vein thrombosis [DVT] and pulmonary embolism [PE] exists. Available evidence suggests a low incidence but the true risk has only been partially addressed. The final decision to consider thromboprophylaxis rests with the operating surgeon. It is important to carefully balance the clinical decision of thromboprophylaxis and bleeding with wound complications, which add considerable morbidity and mortality. To define the risk of DVT in this subgroup of patients is the initial step to enable better use of resources and achieve cost effectiveness. This we believe will provide robust evidence to help formulate guidelines for thromboprophylaxis in shoulder arthroplasty. METHODS/DESIGN: The aim will be to determine whether shoulder arthroplasties carry a risk of DVT. A cohort of 100 consecutive patients being considered for shoulder arthroplasty for degenerative arthritis, rotator cuff arthropathy, inflammatory arthropathy including rheumatoid arthritis will be prospectively included for the study. All eligible patients will be assessed clinically and screened for DVT in all 4 limbs both pre and postoperative with Doppler scans within a 6 week perioperative period. We aim to include the reasons for non inclusion of eligible patients and patient's perspective of their general well being in relation to DVT. DISCUSSION: We present the risk of DVT associated with shoulder arthroplasties to establish a good quality evidence for thromboprophylaxis. The study is underway and we would further be able to define whether the general risk factors for DVT are relevant to shoulder replacements.

Pituitary apoplexy following shoulder arthroplasty: a case report.

INTRODUCTION: Pituitary apoplexy following a major surgical procedure is a catastrophic event and the diagnosis can be delayed in a previously asymptomatic patient. The decision on thromboprophylaxis in shoulder replacements in the absence of definite guidelines, rests on a careful clinical judgment. CASE PRESENTATION: A previously healthy 62-year-old Caucasian male patient who underwent shoulder arthroplasty developed hyponatremia resistant to correction with saline replacement. The patient had a positive family history of deep vein thrombosis and pulmonary embolism and heparin thromboprophylaxis was considered on clinical grounds. The patient developed hyponatremia resistant to conventional treatment and later developed ocular localizing signs with oculomotor nerve palsy. The diagnosis was delayed due to other confounding factors in the immediate post-operative period. Subsequent workup confirmed a pituitary adenoma with features of pituitary insufficiency. The patient was managed successfully on conservative lines with a multidisciplinary approach. CONCLUSIONS: A high index of suspicion is required in the presence of isolated post-operative hyponatremia resistant to medical correction. A central cause, in particular pituitary adenoma, should be suspected early. Thromboprophylaxis in shoulder replacements needs careful consideration as it may be a contributory factor in precipitating this life-threatening condition.

Fatal pulmonary embolism following shoulder arthroplasty: a case report.

INTRODUCTION: Fatal pulmonary embolism following a shoulder joint replacement is a rare event. The exact prevalence of shoulder arthroplasties is not clear. Unlike hip and knee joint replacements where some form of thromboprophylaxis is routinely prescribed, no such guidelines and practice exist for shoulder replacements. Other case reports have confirmed fatal and non-fatal pulmonary embolisms following shoulder replacements, but particular risk factors were identifiable in those patients. CASE PRESENTATION: We report the case of a 73-year-old Caucasian woman with fatal pulmonary embolism secondary to a calf deep vein thrombosis following a shoulder joint replacement procedure. The patient was otherwise healthy; there were no other risk factors directly contributing to deep vein thrombosis and pulmonary embolism except for a body mass index of 34. Post-mortem examination confirmed that the patient had a thrombus in the calf and a pulmonary embolus. CONCLUSIONS: Fatal deep vein thrombosis and pulmonary embolism can occur following shoulder joint replacements in otherwise normal patients. A high degree of suspicion should therefore be maintained in susceptible individuals. Thromboprophylaxis needs careful consideration in shoulder replacements in susceptible individuals.

Outcomes of Ilizarov ring fixation in recalcitrant infected tibial non-unions - a prospective study.

BACKGROUND: Infected non-union of long bones is a problem in the developing countries. Persistent infection, deformity, shortening, bone loss, joint stiffness and disability complicate the non-union. Secondary procedures are often required for correction of bone defects and deformity. Ilizarov method addresses all the above problems simultaneously and offers a panacea for infected non-unions. The stability of the fixation and provision for bone transport allows bridging of bone defects, limb lengthening, early weight bearing ambulation and joint mobilisation. AIM OF THE STUDY: To know the suitability of this procedure in recalcitrant infected tibial non-unions in the Indian population and the influence of socio-economic factors in the functional outcome. METHOD OF STUDY: This was a 3-year prospective study in 22 consecutive patients with an average follow up of 13 months following fracture union. The results were analysed using the ASAMI scoring system. RESULTS: Of 22 patients in the study, 13 patients who underwent external bone transport, had an average bone gap of 4 cms [2-11 cms] with an average duration of fixation of 9.3 months [6.5-13 months]. There were 4 excellent, 3 good, 4 fair and 2 poor bony results and 1 excellent, 3 good, 6 fair and 2 poor results. 1 patient was lost for follow up at final functional analysis. 9 patients who underwent internal bone transport had an average bone gap of 5.4 cms [1.5-9 cms] with an average duration of fixation of 8.5 months [4-11 months]. There were 3 good 4 fair and 2 poor bony results and 1 good, 3 fair, and 2 poor functional results. Good to excellent results were witnessed in well-motivated patients with adequate social and financial support. Patients with fair to poor results preferred amputation to limb salvage despite the fact that they retained their limbs. CONCLUSION: Treatment of infected non-unions of Tibia with Ilizarov ring fixation is effective but for optimal results the treatment needs to be individualised by the treating surgeon with due consideration of the socio-economic factors.

Report of the case of a rare pattern of Maisonneuve fracture.

UNLABELLED: The classic Maisonneuve fracture is localized to the proximal portion of the fibula, in association with disruption of the ankle that involves tibiofibular diastasis. This report, however, describes a case involving a Maisonneuve fracture in the presence of intact deltoid and tibiofibular syndesmotic ligaments. When this injury is suspected, further diagnostic imaging and intraoperative assessment may be useful, and operative repair does not require the use of trans-syndesmotic fixation. LEVEL OF CLINICAL EVIDENCE: 4.

Surviving streptococcal toxic shock syndrome: a case report.

Streptococcal toxic shock syndrome and associated myositis caused by group A beta-hemolytic streptococcus pyogenes generally have a poor outcome despite aggressive operative treatment. Frequently the diagnosis is missed initially as the clinical features are non-specific. The progression to a toxic state is rapid and unless definitive treatment measures are initiated early, the end result can be catastrophic. We report a previously healthy patient who had features of toxic shock syndrome due to alpha haemolytic (viridans) streptococcus mitis which was treated successfully with antibiotics, aggressive intensive care support including the use of a 'sepsis care bundle', monitoring and continuous multidisciplinary review. Life and limb threatening emergencies due to streptococcus mitis in an immune-competent person are rare and to our knowledge, have not previously been described in the English scientific literature. Successful outcome is possible provided a high degree of suspicion is maintained and the patient is intensively monitored.