Hybrid approach in sacral sore management with maggot debridement therapy and flap reconstruction

Sacral sore is a common problem in patients with spinal cord injury. It leads to prolonged hospitalization and recurrent infections which might require repeated surgery to treat. Flap reconstruction allows soft tissue coverage of sacral sore under the premise of infection-free wound base. Maggot debridement therapy (MDT) has been described as an alternative non-surgical management as opposed to the traditional surgical debridement in case of infected sore, reducing number of surgeries under anaesthesia. However, MDT and surgery are not mutually exclusive. In this article we describe a hybrid approach combining MDT and flap reconstruction with multi-disciplinary effort in management of sacral sore, which accelerates wound healing and prevents morbidities, while lowering the risks associated with repeated surgical debridement at the same time.

Adult presentation of locked 'congenital' trigger thumb: A case report

INTRODUCTION AND IMPORTANCE

Although 'congenital' or paediatric trigger thumb is commonly seen in the paediatric age group, adult presentation is very rare. However it is crucial to acknowledge the occurrence of unusual manifestations of paediatric trigger thumbs, since paediatric trigger thumbs are considered a separate disease entity compared to the commonly seen stenosing tenosynovitis in adults.

CASE PRESENTATION

We report a case of a 18-year-old young lady presenting with atraumatic locked trigger thumb, which was successfully treated surgically with intra-operative finding confirming abnormally thickened flexor pollicis longus tendon signifying a paediatric trigger thumb pathology.

CLINICAL DISCUSSION

Adult and paediatric trigger thumbs have different aetiology, with thickened A1 pulley and tendon sheath being the culprit in adults, whereas in paediatric thumbs thickened tendon nodules (Notta's node) are usually the causes of triggering.

CONCLUSION

This uncommon presentation in this case report is atypical in the age group presentation of paediatric trigger thumb, and should be distinguished from the usual trigger thumb pathology in adults. Although a transient period of extension lag in the early post-operative period may be evident, it can still be successfully treated with surgical release.

Effects of enhanced recovery after surgery practices on postoperative recovery and length of stay after unilateral primary total hip or knee arthroplasty in a private hospital

INTRODUCTION

Enhanced recovery after surgery (ERAS) practices improve postoperative recovery and reduce postoperative length of stay (LOS) in patients undergoing primary total hip arthroplasty (THA) or total knee arthroplasty (TKA). Our study investigated whether these promising results could be reproduced in a private hospital setting.

METHODS

In total, 228 patients were included in the study cohort: the conventional group comprised 117 patients from 2012 to 2014, while the ERAS group comprised 111 patients from 2017 to 2018. All patients had undergone unilateral primary THA or TKA at a private hospital in Hong Kong. The outcome was postoperative LOS; factors affecting LOS were also investigated.

RESULTS

No significant differences were found in any baseline parameters between the two groups of patients. The mean LOS was significantly shorter in the ERAS group than in the conventional group (3.28 ± 1.04 vs 5.16 ± 2.06 days, P<0.001). Moreover, a significantly greater proportion of patients could be discharged on or before postoperative day 3 in the ERAS group, compared with the conventional group (77.5% vs 13.7%, P<0.001). A significant difference in LOS was observed between general ward and private ward patients (3.06 ± 0.59 vs 3.66 ± 1.46 days, P=0.003). Sex, age, and nature of surgery (TKA vs THA) did not have significant effects on LOS.

CONCLUSIONS

The ERAS practices yielded a significant improvement in postoperative LOS, compared to conventional practices, among patients who underwent unilateral primary THA or TKA in a private hospital.

Psoas hematoma formation after violation of the intertransverse plane during posterior spinal surgery for adolescent idiopathic scoliosis

Psoas hematoma is a rare yet potentially serious complication following posterior spinal surgery as it is a possible nidus for infection. We present a case of psoas hematoma formation following scoliosis surgery due to intraoperative violation of the intertransverse plane. A 13-year-old female patient with adolescent idiopathic scoliosis underwent a posterior deformity correction and instrumented fusion which was complicated with intraoperative inadvertent violation of the intertransverse plane during dissection of the posterolateral gutter leading to a unilateral psoas hematoma. She experienced abdominal pain and a CT scan confirmed the presence of a psoas hematoma. Antibiotic coverage was provided in view of positive blood culture of Bacillus species to avoid infective seeding of the hematoma. Resolution of the hematoma was observed on the reassessment CT one month postoperatively. It is not uncommon for patients to develop atrophic transverse processes due to spinal deformity. This may cause difficulties in identification of the anatomy intraoperatively and thus, extra caution should be exercised during dissection to prevent violation of the intertransverse plane and subsequent psoas hematoma complication.