Skin Numbness after Total Knee Arthroplasty: Complication or Side-Effect?

BACKGROUND: Peri-incisional numbness occurs frequently after Total Knee Arthroplasty (TKA), yet its impact on clinical outcomes remains controversial. With some studies reporting 100% incidence and patients often perceiving it as a minor inconvenience, its categorisation as a complication is controversial. This study investigates the prevalence and temporal changes of numbness post-TKA to refine the informed consent process and improve patient satisfaction. MATERIAL AND METHODS: A convenience sample of patients who underwent primary cemented TKA was studied. Demographic data, scar length, tourniquet time, and WOMAC scores were collected. Patients were grouped based on time from surgery, and areas of numbness for light touch and pinprick sensations measured. RESULTS: The study included 49 patients with a mean age of 68.9 years. While all patients reported numbness, the area decreased for both pinprick and light touch sensations over time. No significant correlation was found between WOMAC scores and the area of numbness. DISCUSSION: Numbness post-TKA is common, and the affected area contracts over time, implying a natural healing process. The study's findings challenge the perception of numbness as a complication and emphasise the importance of informed consent in managing patient expectations. CONCLUSIONS: 1. Postoperative numbness around the incision site following TKA is a common occurrence with minimal clinical impact on patients. 2. It is important to inform patients that this numbness will improve, although some residual numbness may remain.

Acute Acetabular Protrusion: the Hardinge Approach for Implant Removal and One-stage Hip Reconstruction.

Acute penetration of a total hip arthroplasty into the pelvic cavity is a grave and potentially catastrophic scenario. Fortunately, this complication is uncommon and rarely encountered during a surgical career. Currently, a two-stage procedure is favoured by most surgeons, but the evidence for this is unconvincing and may expose the patient to unnecessary risks. Furthermore, a two-stage approach may be more suitable for the more common chronic migration of a loose acetabular shell, which fundamentally differs from acute pelvic penetration. We present the case of a 76-year-old man referred to our institution for reconstructive surgery following acute pelvic penetration of the acetabular shell during total hip arthroplasty. We used a single-stage Hardinge approach to retrieve the shell and successfully reconstruct the acetabulum. Specific indications for using this method are proposed. In carefully selected cases of intrapelvic implants, a single-stage method can improve patient outcomes while minimising unnecessary risks associated with the conventional two-stage approach.

Bilateral Posterior Fracture-Dislocation of the Shoulders Secondary to Uremic Encephalopathy.

Bilateral posterior fracture-dislocation of the shoulder is an uncommon injury pattern usually caused by epileptic seizures. The cause of the seizure activity remains unknown in most cases, although the injury has been associated with several conditions. A 59-year-old man with uncontrolled hypertension presented with new-onset generalized tonic-clonic seizures. He was diagnosed with uremic encephalopathy and bilateral posterior fracture-dislocation of his shoulders. His medical condition required stabilization leading to a delay in definitive surgery and a subsequent poor outcome. This case highlights the previously unknown association between bilateral fracture-dislocation of the shoulders and seizures caused by uremic encephalopathy. In these complex situations with competing clinical priorities, it is important to initiate prompt treatment of the cause in any new-onset seizures, to facilitate expedient surgical management of the orthopaedic injury.

Intramedullary reamer failure in orthopaedic surgery: Two case reports and practical recommendations for prevention.

Intramedullary reaming has been proven to be a safe and effective method for enhancing the union rates of long bone fractures. However, there is a risk of equipment failure, which can lead to severe complications. We present two cases of reamer failure during femoral nailing which illustrate the rare occurrence of intraoperative instrument failure. Our report also underscores the importance of routinely inspecting reaming equipment and provides technical insights to reduce the risk of failure.

Conversion hip arthroplasty for failed internal fixation of ipsilateral femoral neck and shaft fractures: a case report.

BACKGROUND: Ipsilateral femoral neck and hip fractures are uncommon high energy injuries. In the literature no single method of treatment has emerged as superior to the others. A recent publication has documented the successful application of the rendezvous technique using dual-implants for treating these injuries. However in some cases, this technique may fail and revision surgery is required. CASE PRESENTATION: A 67-year old man sustained ipsilateral fractures of his femur and femoral neck in a road traffic accident. His injuries were treated by a dual construct consisting of a retrograde femoral nail and dynamic hip screw. Three months after surgery the hip screw cut out of the femoral head necessitating revision to a total hip arthroplasty. Surgery was carried out using a single stage two part procedure on a standard operating table without having to reposition or redrape the patient. There were no postoperative complications and at 1 year from surgery the patient is satisfied with the result and has returned to work. CONCLUSION: Conversion hip arthroplasty in the presence of dual implants is a technically challenging and unpredictable procedure, with an increased risk of complications. Our surgical approach provides a framework for orthopedic surgeons to safely perform this complex procedure.

Preoperative echocardiography for patients with hip fractures undergoing surgery in a low-resource setting: Asset or obstacle?

The aim of this study was to determine the rate of preoperative transthoracic echocardiography in hip fracture patients and to evaluate its effects on time to surgery and length of stay. We conducted a retrospective review of all patients with hip fractures treated at a tertiary referral hospital. Data examined included age, sex, comorbidities, time to surgery, length of stay, fracture type and transthoracic echocardiography findings. Forty-eight patients with hip fractures underwent surgery (men 41.7%; mean age 77.2 (49-95)). Nine patients (18.7%) had a preoperative transthoracic echocardiography. Preoperative transthoracic echocardiography was associated with a significantly longer time to surgery an abbreviation for days e.g dys should be added after the values to indicate what time frame is being measured (14.7 versus 6.8, p = 0.0051) and length of stay (23.6 versus 10.4, p = 0.0002). This study demonstrates a high rate of preoperative transthoracic echocardiography in hip fracture patients. The role of transthoracic echocardiography should be reassessed in view of its association with significant surgical delays.

Successful Outcome Following Limb Conservation Surgery for a Recurrent Malignant Peripheral Nerve Sheath Tumour: A Case Report.

Introduction: A malignant peripheral nerve sheath tumor (MPNST) is a rare soft-tissue sarcoma with a high recurrence rate and poor prognosis. Early diagnosis and complete surgical excision are the fundamental principles of treatment. A benign presentation and low clinical suspicion often delay definitive diagnosis, and en bloc excision may not be feasible depending on the size and location of the tumor. We describe a rare case of a recurrent MPNST successfully treated by surgical excision. Case Report: A 35-year-old woman presented with a rapidly growing painful mass 3 months following incomplete removal of a MPNST from her forearm. Staging investigations showed no evidence of metastasis. The patient underwent en-bloc surgical excision, split skin grafting, and adjuvant radiation therapy. Histology and immunohistochemical analysis confirmed a MPNST. Five years after having surgery, the patient shows no evidence of recurrence and has excellent function. Conclusion: MPNST are rare soft tissue sarcomas that can masquerade as benign lumps. There is a paucity of literature on the outcome of surgically-treated recurrent disease. Notwithstanding local recurrence of the tumor, complete surgical excision can yield excellent clinical results.

Hip Fracture Surgery in Trinidad and Tobago During the COVID-19 Pandemic: An Analysis of Two Patients Treated in the Parallel Healthcare System.

The rapid spread of the deadly coronavirus disease 2019 (COVID-19) pandemic has fundamentally affected healthcare delivery globally. As governments struggled to preserve life, several approaches to healthcare delivery have emerged. Central to limiting viral transmission is the separation of patients based on their COVID-19 status. Studies have shown that a geographically separate dual-site service is preferable, contingent upon the local infrastructure and circumstances. Despite the restrictions on free movement, most studies indicate that low-energy hip fractures in elderly patients have remained relatively constant throughout the pandemic. Arguably these patients represent the most vulnerable subgroup in society and are susceptible to developing severe COVID-19 respiratory disease. In keeping with global recommendations, the government of Trinidad and Tobago devised a parallel healthcare system to limit the spread of disease. All regional health authorities under the Ministry of Health were at liberty to implement the system in a manner best suited for their particular infrastructure leading to highly variable practices among institutions. This report describes the clinical course of two hip fracture patients treated within the parallel healthcare system at different regional health authorities. Analysis of these cases provides an understanding of the potential risks to patients entering the parallel healthcare system and an insight into preventative measures to improve clinical outcomes.

Removing a bent femoral nail - man versus metal: A case report.

INTRODUCTION: Intramedullary nailing is the treatment of choice for femoral shaft fractures in adults with excellent clinical results and low complication rates reported in the literature. However, in situ bending of a femoral nail is a rare complication that merits special attention. While there are several extraction techniques and algorithms the scientific evidence to support these decision-making tools is unconvincing. PRESENTATION OF CASE: A 26-year old man presented to the Accident and Emergency Department with a deformed thigh following a low-energy injury. Radiographs showed a bent femoral nail in situ and the patient disclosed that he had surgery four weeks earlier for a fractured femur sustained in a motor vehicle accident. A treatment algorithm was followed in planning the surgical strategy, but ultimately a simple hacksaw blade was used to cut and remove the nail. The fracture which was stabilised by exchange nailing went on to uncomplicated union and the patient recovered fully. DISCUSSION: Non-invasive methods of removing a bent femoral nail are often unsuccessful and may result in iatrogenic injuries. Surgeons should assess the available local resources and first consider using simple open methods when attempting to remove a bent femoral nail. CONCLUSION: Open extraction methods often disregard the low-resource environment in which many surgeons work. We describe a simple and economical technique that uses a regular hacksaw blade to cut and remove a bent femoral nail.

Greater Gender Diversity Observed at Orthopaedic Conferences in the Caribbean Than in the United States or England.

Introduction Women are underrepresented in orthopaedics. Recent studies have shown that women comprise only a very small proportion of all practising orthopaedic surgeons in the United States. One theory that seeks to explain this disparity is the lack of female mentors in orthopaedic surgery. Women are particularly influenced by same-sex mentors, and the paucity of mentors sets up a negative feedback loop that further reduces applications to residency programs. Presentation of scholarly work at conferences increases the visibility of women and represents important opportunities to encourage young female doctors to the speciality. The annual meeting of The Caribbean Association of Orthopaedic Surgeons (TCOS) is a forum that allows regional exposure to young doctors. In the present work, we aim to analyse the gender diversity among presenters at the annual TCOS meetings. Methods A retrospective analysis of the final programs of TCOS meetings over five years was conducted to determine the sex of the presenter, their roles, and topics. The first author listed on the program was taken as the presenter unless it was otherwise stated. Gender was determined using conventional naming taxonomy. Presenters were classified as podium presenters or moderators and presentations as clinical or non-clinical. We subdivided clinical presentations into seven subspecialty areas. A Chi-squared test was used to calculate differences between groups, with a p-value of < 0.05 representing significance. Statistical tests were performed using Analyse-it for Microsoft Excel 5.40 (Analyse-it Software Ltd). Results There was a total of 195 podium presentations over the study period. During this time, there was a steady increase in the number of presentations by women, with a mean value of 19.5%. Compared with men, women presented fewer clinical papers (52.6%vs 73.9%, p=0.037), presented on more general topics (63.2% vs 31.2%, p=0.007) and were less likely to moderate a session (2.7% vs 97.3%, p=0.014). Presentations by female residents were marginally higher than the mean rate for women overall and were representative of the gender distribution in the resident pool. Conclusions There are significantly fewer presentations by women than men at the annual TCOS meetings. Encouragingly, however, there is a positive trend towards greater female presentations over the study period. Our results show that despite being underrepresented, more women are presenting at orthopaedic conferences in the Caribbean than in the United States or England.

Complex pediatric "Spin Dryer" injuries - An uncommon mechanism and pattern of synchronous upper limb fractures.

Ipsilateral humerus and forearm fractures, or 'floating elbow,' are high-energy injuries, uncommon in children and usually due to falls or motor vehicle accidents. Early models of washing machines were associated with various reports of upper extremity injuries in children, mostly occurring when the child attempted to remove clothes from a spinning machine. Some of these accidents resulted in serious injuries, including amputation, but have become considerably less common with the introduction of improved safety features in modern appliances. We describe the successful management of a child with multiple complex upper limb fractures caused by a modern washing machine.

Extensor mechanism reconstruction and joint preservation surgery following a tibial tuberosity fracture in giant cell tumor of bone: A case report.

INTRODUCTION AND IMPORTANCE: Pathologic fractures of the tibial tuberosity secondary to giant cell tumor of bone are rare injuries. While there are several well-described methods in the literature to reattach the tibial tuberosity, these techniques rely on good quality bone. However, in the presence of diseased and weak bone, additional factors have to be considered. CASE PRESENTATION: A 47-year-old man with a Giant Cell Tumor of bone affecting the proximal tibia presented with a displaced avulsion fracture of the tibial tuberosity. The patient underwent surgical curettage, bone grafting and osteosynthesis with reattachment of the tibial tuberosity. Eighteen months after surgery there is no evidence of tumor recurrence, and despite mild knee pain and a limited range of movement, the patient has returned to work. CLINICAL DISCUSSION: The extensor mechanism was repaired by first reinforcing the tuberosity fragment with an autograft before reattaching it using a tension band FibreWire ® suture. Without access to a tumor endoprosthesis we used a joint sparing approach to treat the Giant Cell Tumor. CONCLUSION: Patients with dual-pathology present technical challenges in repairing the extensor mechanism and treating the underlying condition. Surgeons must address competing priorities in a holistic, patient-centred approach consistent with their working environment.

Reasons for day of surgery cancellation of orthopaedic cases following a major earthquake in Trinidad and Tobago.

An earthquake in 2018 resulted in irreparable damage to the Port of Spain General Hospital, Trinidad and Tobago, and severely affected orthopaedic services. This study investigates the rate and reasons for cancellation on the day of surgery of orthopaedic cases during the post-earthquake period. We prospectively collected data on all cases scheduled to undergo surgery during the study period. Information was gathered on patient demographics, the number and reasons for cancellation. Data were analysed using Analyse-it for Microsoft Excel 5.40 (Analyse-it Software Ltd). Our results show that 43 patients were cancelled, resulting in a 44.3% cancellation rate. Patients who had their surgery cancelled were older, with a higher American Society of Anesthesiologists class compared with patients whose surgery was not cancelled. Hospital-related factors were found to be responsible for the majority of cancellations. Placed in context, our findings suggest that limited operating time due to the earthquake-induced hospital damage was the principal reason for the high rate of surgery cancellations.

Magnification assessment of radiographs for knee replacement (MARKeR) - A pilot study in a low-resource setting.

Background: Selecting the correct size of implants to be used in total knee arthroplasty is critical for a successful outcome. Marker-less templating systems use an institutionally derived magnification factor for all radiographs. Purpose: To determine the institutional magnification of knee radiographs for patients awaiting total knee arthroplasty. Material and Methods: Eighty patients awaiting total knee arthroplasty underwent preoperative knee radiographs using a standardized protocol. A marker attached to the patients' knees at the level of the knee joint was used to calculate the magnification factor on both anteroposterior (AP) and lateral (LAT) views. Two independent observers estimated the magnification to determine the intra and inter-observer reliability. Results: The mean magnification of the AP (15.3%) radiograph was significantly greater than the LAT (12.1%) radiograph (p< 0.0001). Patients with absent markers on their radiographs were heavier than patients in whom the marker was visible (84.7 kgs vs. 76.6 kgs, p=0.01). No marker was visible on the radiographs in 56.3% (45/80) of patients. There was excellent inter and intra-observer reliability of both the AP and LAT measurements. Conclusion: After standardizing the protocol for preoperative knee radiographs, our results show significantly greater institutional magnification of the anteroposterior compared with the lateral images. Accurate templating in knee arthroplasty requires both radiographic images. To reduce errors in implant sizing, we recommend surgeons use different institutional magnification factors for the anteroposterior and lateral radiographs.

En bloc Surgical Excision of an Arteriovenous Malformation in the Foot: A Case Report and Review of the Literature.

Introduction: Arteriovenous malformations (AVM) are developmental vascular malformations consisting of abnormal arteriovenous shunts surrounding a central nidus. These lesions are relatively uncommon, comprising just 7% of all benign soft-tissue masses. Most AVMs occur in the brain, neck, pelvis, and lower extremity and rarely manifest in the foot. When they do form in the foot, non-specific pain and the absence of clinical features contribute to the high rate of misdiagnosis on initial presentation. Although surgical excision combined with embolotherapy has emerged as the preferred treatment for large AVM, controversy exists over the best treatment for small lesions in the foot. Case Presentation: A 36-year-old Afro-Caribbean man was referred to the clinic with a 2-year history of increasing pain in his forefoot, affecting his ability to stand or walk comfortably. There was no history of trauma, and despite changing his footwear, the patient continued to have significant pain. Clinical examination was unremarkable except for mild tenderness over the dorsum of his forefoot, and radiographs were normal. A magnetic resonance scan reported an intermetatarsal vascular mass but could not exclude malignancy. Surgical exploration and en bloc excision confirmed the mass to be an AVM. One year post-surgery, the patient remains pain-free with no evidence of recurrence. Conclusions: The rarity of AVM in the foot, combined with normal radiographs and non-specific clinical signs, contributes to the long delay in diagnosing and treating these lesions. Surgeons should have a low threshold for obtaining magnetic resonance imaging in cases of diagnostic uncertainty. En bloc surgical excision is an option for treating small suitably located lesions in the foot.

Operation notes in orthopaedics: Beliefs and practices in a developing country.

Maintaining accurate and complete operation notes is an essential metric of the quality of surgical care. While developed countries have implemented electronic health records to improve documentation, financial constraints prevent this realisation in the Caribbean. Somewhat paradoxically, previous studies in this area have focussed on 'process' while neglecting the key role of the surgeon. We conducted a 25-item Knowledge, Attitudes and Practices survey of orthopaedic doctors to identify any culturally unique health-related behaviours. Our results indicate that while most doctors understand the importance of operation notes, many are unaware of international note-keeping recommendations. Legibility was identified as a significant issue by 92% of doctors. A disturbing and previously unreported finding from the study revealed that 72% of surgeons would occasionally write the operation notes, although they were not scrubbed in for the procedure. We suggest that future studies examine this peculiar behaviour in greater detail.

Trauma surgery via distance mentoring: A model inspired by the 2020 pandemic.

When the COVID-19 pandemic unfolded in March 2020, surgical care was impacted globally. The developing nations in the Caribbean were unprepared with fragile, resource poor healthcare systems. A series of rapid policy changes in response to the pandemic radically changed surgical care and prevented the usual oversight in the operating theatre. Attending surgeons responded utilising readily available technology for distance mentoring. Using this model, postgraduate surgical residents were able to complete 96% of trauma laparotomies safely without major complications.

Are Natural Remedies Perceived To Be An Effective Treatment for Sinusitis in Trinidad and Tobago? A Cross Sectional Survey

●Sinusitis is inflammation of the mucosal lining of the nose and paranasal sinuses (air-filled cavities in the ethmoid, maxillary, sphenoid and frontal bones within the skull). ● 12% of people worldwide experience sinusitis symptoms. ● Trinidad and Tobago is plagued by Saharan dust, exacerbating symptoms. ● The symptoms of sinusitis are nasal congestion, discharge, reduction/loss of smell, facial pain/pressure, fever and tooth pain. ● Currently, there is little research on effective sinusitis treatment locally.

Successful Treatment of an Osteoporotic Posterior Fracture-Dislocation of the Hip in a Low-Resource Setting Using the Combined Hip Procedure.

The prevalence of osteoporotic acetabular fractures and fracture-dislocations of the hip is increasing worldwide. These injuries are difficult to treat, and outcomes using traditional methods of osteosynthesis have been generally disappointing. Currently, there is debate about the management strategies with no widely held consensus on which technique is best. Studies from tertiary centers in North America and Europe have reported excellent results using the "combined hip procedure" which merges osteosynthesis and acute hip arthroplasty to treat these challenging fractures. As our population ages, these injuries are likely to occur more commonly in the developing world. We describe a case of an 80-year-old man who sustained a posterior fracture-dislocation of his hip and underwent successful treatment using the combined hip procedure in a low-resource setting.

Revision Total Hip Arthroplasty in Jehovah's Witnesses at a Public Hospital: Practical Recommendations for a Low-Resource Setting.

Revision total hip arthroplasty (THA) is a major reconstructive procedure traditionally associated with significant blood loss. Jehovah's Witnesses (JW) do not accept blood or blood product transfusions because of their religious beliefs. When confronted with a JW patient requiring a complex arthroplasty procedure, surgeons face moral and ethical questions and may be reluctant to perform surgery. A successful outcome depends on several factors including surgical and anesthetic expertise, a range of revision implants, and a multimodal blood management protocol. While these resources are readily available in a developed country, in many of the developing Caribbean islands, the healthcare system is underfunded and under-resourced. Here, we describe our experience performing a revision THA on a JW patient in the Caribbean. Through this case report, we aim to illustrate our approach to blood management by exploring the fundamental elements that were employed in a low-resource setting. We believe that the extrapolation of these crucial principles to the broader category of primary arthroplasty in the general population can be used to reduce the rate of blood transfusion, increase access to surgery, and improve outcomes.