Gluteal fibrosis, post-injection paralysis, and related injection practices in Uganda: a qualitative analysis.

BACKGROUND: Iatrogenic injection injury is a major cause of disability in Ugandan children. Two injuries thought to result from injection of medications into the gluteal region include post-injection paralysis (PIP) and gluteal fibrosis (GF). This study aimed to describe perceptions of local health care workers regarding risk factors, particularly injections, for development of GF and PIP. Specifically, we examine the role of injection practices in the development of these injuries by interviewing a diverse cohort of individuals working in the health sector. METHODS: We conducted a qualitative study in the Kumi and Wakiso Districts of Uganda in November 2017, utilizing 68 key informant interviews with individuals working in healthcare related fields. Interviews were structured utilizing a moderator guide focusing on injection practices, gluteal fibrosis and post-injection paralysis. RESULTS: We identified six themes regarding perceptions of the cause of GF and PIP and organized these themes into a theoretical framework. There was a consensus among the individuals working in healthcare that inadequacies of the health care delivery system may lead to inappropriate intramuscular injection practices, which are presumed to contribute to the development of GF and PIP. Poor access to medications and qualified personnel has led to the proliferation of private clinics, which are often staffed by under-trained practitioners. Misaligned economic incentives and a lack of training may also motivate practitioners to administer frequent intramuscular injections, which cost more than oral medications. A lack of regulatory enforcement enables these practices to persist. However, due to limited community awareness, patients often perceive these practitioners as appropriately trained, and the patients frequently prefer injections over alternative treatment modalities. CONCLUSION: This qualitative study suggests that inappropriate intramuscular injections, may arise from problems in the health care delivery system. To prevent the disability of GF and PIP, it is important to not only address the intramuscular injections practices in Uganda, but also to examine upstream deficits in access, education, and policy enforcement.

Burden of gluteal fibrosis and post-injection paralysis in the children of Kumi District in Uganda.

BACKGROUND: The purpose of this study was to estimate the prevalence of postinjection paralysis (PIP) and gluteal fibrosis (GF) among children treated in a rural Ugandan Hospital. METHODS: We conducted a retrospective cohort study by reviewing the musculoskeletal clinic and community outreach logs for children (age < 18 yrs) diagnosed with either PIP or GF from Kumi Hospital in Kumi, Uganda between 2013 and 2015. We estimated the prevalence as a ratio of the number of children seen with each disorder over the total population of children seen for any musculoskeletal complaint in musculoskeletal clinic and total population of children seen for any medical complaint in the outreach clinic. RESULTS: Of 1513 children seen in the musculoskeletal clinic, 331 (21.9% (95% CI 19.8-24.1%)) had PIP and another 258 (17.1% (95% CI 15.2-19.0%)) had GF as their diagnosis. Of 3339 children seen during outreach for any medical complaint, 283 (8.5% (95% CI 7.6-9.5%)) had PIP and another 1114 (33.4% (95% CI 31.8-35.0%)) had GF. Of patients with GF, 53.9% were male with a median age of 10 years (50% between 7 and 12 years old). Of patients with PIP, 56.7% were male with a median age of 5 years (50% between 2 and 8 years old). CONCLUSION: PIP and GF comprise over 30% of clinical visits for musculoskeletal conditions and 40% of outreach visits for any medical complaint in this area of Uganda. The high estimated prevalence in these populations suggest a critical need for research, treatment, and prevention.

Early Outcomes of Vein Grafting for Reconstruction of Brachial Arterial Injuries in Children.

PURPOSE: We postulated that, with microsurgical technique, vascular reconstruction with interpositional vein grafts in the pediatric population is safe and results in sustained vascular patency and excellent midterm outcomes. METHODS: Twenty children with brachial artery injuries were treated with interpositional vein grafting at a tertiary pediatric hospital from 1995 to 2013. Medical records were evaluated for demographic, clinical, and radiographic data. Ten patients were available for longer-term follow-up. Pain at rest, pain with exercise, and temperature intolerance were assessed with visual analog scale (VAS) (range, 0-5). Functional outcomes were assessed using the Pediatric Outcomes Data Collection Instrument (PODCI) and Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaires. Graft patency and flow were characterized via duplex sonography. Peak flow velocity and resistive index (RI) were compared with the contralateral extremity. Median patient age at the time of injury was 7.75 years (range, 4.6-11.5 years) and median follow-up was 1.75 years (range, 0.3-6.3 years). RESULTS: All patients had perfused hands with palpable radial pulses at follow-up. There were no clinically meaningful differences in motion, sensibility, or strength between affected and unaffected limbs. Mean VAS scores for pain at rest, pain with exercise, and temperature intolerance were 0.4, 0.4, and 0.6, respectively. Mean global PODCI and DASH scores were 98.0 and 5.1, respectively. Nine of 10 patients had patent arteries with normal flow patterns. In the patient with graft occlusion, there was collateralization around the elbow with normal reconstitution of the distal vessels. Mean peak flow velocity proximal and distal to the graft were 77.7 cm/s and 66.5 cm/s, respectively. Mean RI of the graft were 0.84 and 0.77, respectively. CONCLUSIONS: Brachial artery reconstruction using interpositional vein graft and microsurgical technique is safe and effective and results in excellent functional outcomes in children. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

Paediatric musculoskeletal disease in Kumi District, Uganda: a cross-sectional survey.

PURPOSE: The purpose of this study is to estimate the burden of musculoskeletal disease among children treated in Kumi District, Uganda, to inform training, capacity-building efforts, and resource allocation. METHODS: We conducted a retrospective cohort study by reviewing the musculoskeletal (MSK) clinic and community outreach logs for children (age < 18 years) seen at Kumi Hospital in Kumi, Uganda, between January 2013 and December 2015. For each patient, we recorded the age, sex, diagnosis, and treatment recommendation. RESULTS: Of the 4852 children, the most common diagnoses were gluteal and quadriceps contractures (29.4% (95% CI 28.1-30.7%), 96% of which were gluteal fibrosis), post-injection paralysis (12.7% (95% CI 11.8-13.6%)), infection (10.5% (95% CI 9.7-11.4%)), trauma (6.9% (95% CI 6.2-7.6%)), cerebral palsy (6.9% (95% CI 6.2-7.7%)), and clubfoot (4.3% (95% CI 3.8-4.9%)). Gluteal fibrosis, musculoskeletal infections, and angular knee deformities create a large surgical burden with 88.1%, 59.1%, and 54.1% of patients seen with these diagnoses referred for surgery, respectively. Post-injection paralysis, clubfoot, and cerebral palsy were treated non-operatively in over 75% of cases. CONCLUSION: While population-based estimates of disease burden and resource utilization are needed, this data offers insight into burden of musculoskeletal disease for this region of Sub-Saharan Africa. We estimate that 50% of the surgical conditions could be prevented with policy changes and education regarding injection practices and early care for traumatic injuries, clubfeet, and infection. This study highlights a need to increase capacity to care for specific musculoskeletal conditions, including gluteal fibrosis, post-injection paralysis, infection, and trauma in the paediatric population of Uganda.

Papillary endothelial hyperplasia in association with vascular malformation of the hand.

Vascular malformations are uncommonly encountered in the hand. This case report involves the unique case of a rapidly enlarging mass associated with a known vascular malformation. Final pathology revealed dense reactive fibrous tissue, with prominent blood vessels, consistent with a venous malformation and associated papillary endothelial hyperplasia. The intraoperative finding of two separately identifiable masses, one fibrotic and one vascular, has not previously been reported.

Surgical Implant Generation Network Implant Follow-up: Assessment of Squat and Smile and Fracture Healing.

OBJECTIVES: To evaluate the reliability, sensitivity, and specificity of the Squat and Smile (S&S) test, a clinical photographic follow-up, in determination of fracture healing and to assess the extent of continued fracture healing beyond 1-year postoperation. DESIGN: Retrospective review of the Surgical Implant Generation Network (SIGN) database. SETTING: The S&S test is utilized in low-resource settings where the SIGN intramedullary nail is used due to unavailability of intraoperative fluoroscopy. PATIENTS/PARTICIPANTS: One hundred fifty patients undergoing fracture fixation utilizing SIGN intramedullary nails with data available at least 1 year (9-16 months) after surgery. INTERVENTION: None. MAIN OUTCOME MEASURES: We extracted clinical data and calculated scores for the S&S photographs and radiographs at the 1-year (9-16 month postoperative) follow-up and last follow-up available beyond that. We analyzed the sensitivity of S&S scoring, using Radiographic Union Scale for Tibia fracture scores as the gold standard for fracture union. RESULTS: Of the 126 patients analyzed, 21% were found to have incomplete healing at 1 year, whereas 17% of the 64 patients with further follow-up past 1 year had incomplete healing. We found that both S&S and radiographic fracture healing scores had good interrater reliability (k = 0.73-0.78 for S&S and 0.94 for radiographs). The S&S test had poor sensitivity (0.11) and specificity (0.85) in determining fracture healing at the 1-year follow-up. CONCLUSIONS: The S&S scoring method was reliable but neither sensitive nor specific for determining fracture healing at 1 year. Fractures deemed incompletely healed by radiographic evaluation at 1 year after SIGN implant may still have the potential to heal over time. LEVEL OF EVIDENCE: Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Gluteal Fibrosis and Its Surgical Treatment.

BACKGROUND: The objective of this study was to analyze the literature regarding the diagnosis, pathogenesis, and prevalence of gluteal fibrosis (GF) and the outcomes of treatment. METHODS: We searched PubMed, Embase, and Cochrane literature databases, from database inception to December 15, 2016. We used the following search terms including variants: "contracture," "fibrosis," "injections," "injections, adverse reactions,' "gluteal," and "hip." All titles and abstracts of potentially relevant studies were scanned to determine whether the subject matter was potentially related to GF, using predefined inclusion and exclusion criteria. If the abstract had subject matter involving GF, the paper was selected for review if full text was available. Only papers including ≥10 subjects who underwent surgical treatment were included in the systematic analysis. Data abstracted included the number of patients, patient age and sex, the type of surgical treatment, the method of outcome measurement, and outcomes and complications. RESULTS: The literature search yielded 2,512 titles. Of these, 82 had a focus on GF, with 50 papers meeting the inclusion criteria. Of the 50 papers reviewed, 18 addressed surgical outcomes. The surgical techniques in these papers included open, minimally invasive, and arthroscopic release and radiofrequency ablation. Of 3,733 operatively treated patients in 6 reports who were evaluated on the basis of the criteria of Liu et al., 83% were found to have excellent results. Few papers focused on the incidence, prevalence, and natural history of GF, precluding quantitative synthesis of the evidence in these domains. CONCLUSIONS: This study provided a systematic review of surgical outcomes and a summary of what has been reported on the prevalence, diagnosis, prognosis, and pathogenesis of GF. Although GF has been reported throughout the world, it requires further study to determine the exact etiology, pathogenesis, and appropriate treatment. Surgical outcomes appear satisfactory. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Does overlapping surgery result in worse surgical outcomes? A systematic review and meta-analysis.

BACKGROUND: The practice of overlapping surgery impacts patients, providers, and policy-makers. While several studies have examined the relationship between overlapping surgery and clinical outcomes, a combined analysis of all available data has not been performed. We aimed to evaluate the impact of overlapping surgery on 30-day mortality, morbidity, and length of surgery. METHODS: A systematic literature review revealed all relevant studies examining outcomes of overlapping versus non-overlapping surgery as of March 2018. A pooled meta-analysis with stratification by study quality grade was performed, and heterogeneity and publication bias were assessed. RESULTS: A total of 14 sets of analyses met inclusion and exclusion criteria. Meta-analysis revealed no significant differences in 30-day mortality (OR = 0.84; p = 0.277) or overall morbidity (OR = 0.96; p = 0.632) between patients who underwent overlapping versus non-overlapping surgery. The standardized mean difference for length of surgery between the groups indicated a small statistically significant increase in length of surgery for the overlapping surgery group (SMD = 0.079, p < 0.05). CONCLUSION: While further study is warranted, current literature suggests that overlapping surgery is not associated with increased risk of mortality or morbidity.

A technical trick which reduces the need for stab incisions when using bone tenaculums for fracture reduction.

During the reduction of fractures using a bone tenaculum, rather than making a stab incision, a frequently successful strategy can be to place a folded operative towel placed between the patient's skin and the head of the tenaculum. Using this technique, the surgeon can decrease scarring and potential stab wound complications. When the angle is too steep for the towel to allow the tenaculum to remain stable during the reduction, the surgeon can use the towel as a safe means of trial and error to determine the necessary alignment of the tenaculum to achieve reduction and consequently the best location at which to make the stab incision for the tine of the tenaculum.