Periprosthetic Distal Femoral Fractures Around a Total Knee Arthroplasty: a Meta-analysis Comparing Locking compression Plating and Retrograde Intramedullary Nailing

Purpose

The number of total knee replacements (TKRs) performed per year has been increasing annually and it is estimated that by 2030 demand would reach 3.48 million procedures per year in the United States Of America. The prevalence of periprosthetic fractures (PPFs) around TKRs has followed this trend with incidences ranging from 0.3% to 3.5%. Distal femoral PPFs are associated with significant morbidity and mortality. When there is sufficient bone stock in the distal femur and a fracture pattern conducive to fixation, locking compression plating (LCP) and retrograde intramedullary nailing (RIMN) are commonly used fixation strategies. Conversely, in situations with loosening and deficient bone stock, a salvage procedure such as a distal femoral replacement is recognized as an alternative. This meta-analysis investigates the rates of non-union, re-operation, infection, and mortality for LCPs and RIMNs when performed for distal femoral PPFs fractures around TKRs.

Method

A search was conducted to identify articles relevant to the management of distal femoral PPFs around TKRs in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. Articles meeting the inclusion criteria were then assessed for methodological quality using the methodological items for non-randomised studies (MINORS) criteria. Articles were reviewed, and data were compiled into tables for analysis.

Results

10 articles met the inclusion criteria, reporting on 528 PPFs. The overall incidence of complications was: non-union 9.4%, re-operation 12.9%, infection 2.4%, and mortality 5.5%. This meta-analysis found no significant differences between RIMN and LCP in rates of non-union (9.2% vs 9.6%) re-operation (15.1% vs 11.3%), infection (2.1% vs 2.6%), and mortality (6.0% vs 5.2%), respectively.

Conclusion

This meta-analysis demonstrated no significant difference in rates of non-union, re-operation, infection, and mortality between RIMN and LCP and both remain valid surgical treatment options.

Anatomic Total Shoulder Arthroplasty Versus Reverse Total Shoulder Arthroplasty in Patients Aged Over 70 Without a Full-Thickness Rotator Cuff Tear: A Systematic Review and Meta-Analysis

Introduction

This systematic review and meta-analysis compared the revision rates, complications, and outcomes in anatomic total shoulder arthroplasty (aTSA) and reverse TSA (rTSA) performed for primary glenohumeral osteoarthritis in patients aged over 70 years without a full-thickness rotator cuff tear.

Materials and Methods

We performed a systematic literature search identifying comparative studies meeting the above patient criteria and published from January 2010 to May 2022 from 3 databases: MEDLINE, EMBASE, and Cochrane Library. We performed the systematic review in accordance with PRISMA guidelines and the study was prospectively registered on PROSPERO.

Results

From the 1798 studies identified from the initial literature search, 4 met our inclusion criteria. Two thousand seven hundred thirty-one shoulder arthroplasties (1472 aTSA and 1259 rTSA) were evaluated with a minimum follow up of 2 years. A statistically significant lower revision rate was observed in rTSA compared to aTSA (odds ratio [OR] 0.50, 95% confidence interval [CI]: 0.30, 0.84, p < .05). No significant difference was noted between aTSA and rTSA in overall complication rate (OR 0.98, 95% CI 0.34, 2.86, p = .97) while aTSA displayed a statistically significant improved postoperative Constant-Murley score [aTSA: 80(75; 82), rTSA: 68(66; 76.5), p < .001].

Conclusion

Higher revision rates were identified following aTSA in our study population, although admittedly this is within retrospective studies. aTSA displayed equal functional results and postoperative complications compared to rTSA in patients over 70 without a full-thickness rotator cuff tear. Given these similar results a shoulder surgeon must carefully consider each patient individually prior to deciding the optimal form of arthroplasty to offer.

EP.FRI.175 Outcomes from the introduction of routine Geriatrician review for General Surgical patients over 65 years old undergoing Emergency Laparotomy at a large District General Hospital

Aims

The National Emergency Laparotomy Audit (NELA) results show that only 28.8% of all patients over 65years having emergency laparotomy had Geriatrician input. Advancing age predisposes to more complex medical needs due to a higher prevalence of co-morbidities, polypharmacy, cognitive impairment, and physiological frailty. Introduction of perioperative geriatrician input has been demonstrated to significantly reduce post-operatively mortality (national average 9.5%, rising to 20-40% in older age). We introduced a Geriatrician led liaison team with the initial aim to reduce 30-day mortality in older patients undergoing emergency laparotomy.

Methods

Prospective database was maintained of all eligible patients reviewed by the new service. Data on Rockwood Clinical Frailty Score (CFS), NELA risk prediction score, length of stay, mortality and complications were analysed. In this service development pilot we specifically assessed age and frailty demographics, expected mortality, and actual mortality in the cohort.

Results

All NELA patients 65 and over were reviewed by the service between September and December 2020, 35 in total. Median age 77 years; Median CFS 3 (range 2-6); Median NELA mortality risk 12% (range 0.9%-55.8%). Inpatient mortality was 2.9% and 30-day mortality 2.9% during this study period, compared to 18% in the previous year. 

Conclusion

Our pilot study demonstrates that development of an embedded Geriatrician liaison service for patients undergoing emergency laparotomy is achievable in a district general hospital. Consistent with other larger scale studies we demonstrated significant mortality reduction in older adults undergoing emergency laparotomy with the new service offering enhanced inter-disciplinary Surgical, Critical Care and Geriatrician team-working.

Ischemic Stroke as a Manifestation of Cholesterol Embolization Syndrome Following Percutaneous Coronary Intervention

Cholesterol embolization syndrome (CES) is one of the major, yet underdiagnosed cause of morbidity and mortality following invasive coronary interventions. The major risk factors are elderly, male, atherosclerotic disease, anticoagulation and femoral access route. This multisystem disease affects skin, kidney, brain, eye and gastrointestinal tract. Only few cases of cholesterol embolization syndrome manifesting as an ischemic stroke are reported. We present a case of an elderly man, admitted to our ICU after percutaneous coronary intervention (PCI) who developed neurological deficits along with skin changes and renal failure. cholesterol embolization syndrome was suspected based upon the presence of cardiovascular risk factors, invasive cardiovascular intervention and clinical signs. The diagnosis of ischemic stroke made through plain MRI brain, revealed multiple areas of lacunar infarcts. He was treated with intermittent hemodialysis, statins and anti-platelet agents. On follow up, skin lesions and renal functions were improved; but slurring of speech and paresis persisted.

Knowledge, Attitude and Practice of Contraception among Postpartum Women Attending Kathmandu Medical College Teaching Hospital

Background Failure to plan a pregnancy can adversely affect the health of the family as a whole. High parity is related to increased maternal, perinatal and infant deaths and is associated with nutritional problems of both mother and child. Hence, good knowledge, attitude and practice of family planning among women are important. This study is aimed to determine the knowledge, attitude and practice of contraception among the postpartum women attending Kathmandu Medical College Teaching Hospital. Objective To determine the knowledge, attitude and the practice of various contraceptive methods among the postpartum women. Method A cross-sectional observational study was conducted in the department of Obstetrics and Gynecology on 400 postpartum women (within 42 days of delivery) who delivered and came for follow-up in this institution. All the postnatal women were interviewed with pre-designed questionnaire and information on sociodemographic variable, awareness and knowledge of various contraceptive methods, previous and current use of family planning methods, source of information, utilization and reasons for use/non-use of family planning methods were obtained. Data collected were entered and analyzed using SPSS 20. The results were presented as percentages, means, tables and charts. Result Majority of the participants 363 (90.8%) were aware of contraceptive usage. Amongst 60.5% of women who had previously used contraception, OCPs were the commonest one. Maximum number of participants (60.35%) had used modern contraceptives in the past. The most common source of information on contraception was media (55.7%). The reason of using contraception was spacing between the subsequent pregnancies, while the most common reason of discontinuation or not willing to use family planning methods was husband being abroad, fear of side effects and not knowing which contraceptives to use. Conclusion The contraceptive awareness and knowledge among the postpartum women was high but their usage was low. Hence, efforts should be made to educate the public about safety and convenience of modern methods of contraceptives. Health care personnels should also counsel the clients for adopting the contraceptives according to their need.

Prevalence and Risk Profile Of Unread Messages To Patients In A Patient Web Portal

BACKGROUND

Excitement around the adoption of electronic communication between physicians and patients is tempered by the possibility of increased clinical and legal risk. If patients do not read messages in a timely fashion, duplicative communication efforts may be required and patient safety may be jeopardized.

OBJECTIVE

We sought to assess the prevalence and risk profile of unread messages in a mature patient portal.

METHODS

We analyzed six years of messages (2005-2010) from physicians to patients to determine the prevalence and associated characteristics of unread messages in a patient portal. We focused on clinical messages, and excluded announcements. Because some physicians sent clinical messages to groups of patients, we labeled messages sent to more than 5 patients as "outreach" messages and excluded them from general analyses. We performed a chart review of 75 clinical messages to assess for harm.

RESULTS

We found that 3% of clinical messages were unread after 21 days. Messages arriving outside of business hours were slightly more likely to go unread (RR 1.15 95% CI 1.11-1.19). Patients who were male (OR 1.14 CI 1.04-1.26) African American (OR 1.69 CI 1.29-2.22) or Hispanic (OR 1.74 CI 1.17-2.59), or in the lowest income group (OR 1.72 CI 1.19-2.49) were more likely to have unread messages. Chart review showed no evidence of harm, but 13% of sampled unread messages were associated with potential delays in care. Incidentally, we found 50% of the physician-initiated outreach messages were unread.

CONCLUSIONS

Overall, secure messaging appears a safe form of communication, but systems to notify senders when messages are unread may have value. While most clinical messages were read, many outreach messages were not, providing caution for relying on such systems for information dissemination. Similar to other studies, differences by race and income were observed and require further study.

Spectrum of surgical trauma and associated head injuries at a university hospital in eastern Nepal

Background:

Trauma is one of the common surgical emergencies presenting at B. P. Koirala Institute of Health Sciences (BPKIHS), Nepal, a tertiary referral center catering to the needs of the population of Eastern Nepal and nearby districts of India.

Objective:

The objective of this study is to analyze the magnitude, epidemiological, clinical profile and outcome of trauma at B P Koirala Institute of Health Sciences.

Materials and Methods:

This descriptive case series study includes all patients with history of trauma coming to BPKIHS emergency and referred to the surgery department. We noted the detailed clinical history and examination, demographics, mechanism of injury, nature of injury, time of reporting in emergency, treatment offered (operative or non operative management) and analyzed details of operative procedure (i.e. laparotomy, thoracotomy, craniotomy etc.), average length of hospital stay, morbidity and outcome (according to Glasgow outcome scale). Collected data were analyzed using EpiInfo 2000 statistical software.

Results:

There were 1848 patients eligible to be included in the study. The mean age of the patients was 28.9 ± 19.3 years. Majority of the patients (38%) belonged to the age group of 21 - 40 years and the male to female ratio was 2.7:1. Most of the trauma victims were students (30%) followed by laborers (27%) and farmers (22%) respectively. The commonest causes of injury were fall from height (39%), road traffic accident (38%) and physical assault (18%); 78% of the patients were managed conservatively and 22% underwent operative management. Postoperative complications were seen in 18%. Wound infection 7.5%, neurological deficit including cerebrospinal fluid (CSF) otrorrhea was seen in 2.2% patients. Good recovery was seen in 84%, moderate disability in 5.2% patients and severe disability in 1.4% patients. The mortally was 6.3% and most of the deaths were related to traumatic brain injuries.

Conclusions:

In Nepal, trauma-related injury contributes significantly to morbidity and mortality and is the third leading cause of death. There are very few studies on trauma from this country and hence this study will help in understanding the etiology and outcome particularly in the Eastern region of Nepal.

Unusual cause for ventriculoperitoneal shunt failure: carcinoma breast compressing distal catheter

Insertion of a ventriculoperitoneal (VP) shunt is one of the most common surgical procedures in any neurosurgery unit worldwide. Distal catheter obstruction outside the peritoneum is a rare cause of shunt failure. We report the first case of distal obstruction in a 70-year old female by carcinoma breast engulfing the catheter and causing kinking. Intraoperatively, the catheter was intratumoral with no flow of cerebrospinal fluid distally. She underwent relocation of a new catheter to the opposite side of the abdomen and modified mastectomy with resolution of the hydrocephalus. The postoperative course has been uneventful.

Parietal Epidural Dermoid Mimicking a Scalp Abscess in an Infant: Case Report

Scalp masses that involve the scalp or the cranium especially over the parietal bone are uncommon presentation in infants. We report a case of an 8-week old female child who presented with a left parietal scalp mass which had been progressively increasing since birth. CT scan revealed the mass extending into the cranium with underlying bone defect over the parietal area, with medial extension till the sagittal suture. Intraoperatively there was presence of thick white infected flaky material with small tufts of hair which was removed completely till the bone edges and from the epidural space. There was no recurrence postoperatively and the baby was discharged after a week of antibiotics. This case provides an example that simple looking scalp masses in infants and children should be managed with caution to prevent further morbidity. Key words: Dermoid, Scalp abscess   doi: 10.3126/jnps.v29i2.2048 J. Nepal Paediatr. Soc. Vol 29, No. 2, pp.98-100

Perforated duodenal ulcer in a young child: an uncommon condition

Duodenal ulcer is an uncommonly diagnosed entity in children. H. pylori infection, blood group 'O' or secondary to medications like non steroidal anti-inflammatory drugs (NSAID) and corticosteroids or physiological stress in burns, head injury and mucosal ischemia are implicated as risk factors for their causation. The diagnosis is usually overlooked because of vague and variable symptoms and remote index of suspicion accounted for their low incidence in children. Undiagnosed or mistreated perforations may carry high morbidity and mortality. We report a successfully treated 41/2 year old male child who presented with features of perforation peritonitis and was incidentally found to have a perforated duodenal ulcer.

Perforated Duodenal Ulcer in a Young Child: An Uncommon Condition

Duodenal ulcer is an uncommonly diagnosed entity in children. H. pyloriinfection, blood group ‘O’ or secondary to medications like non steroidal anti-infl ammatory drugs (NSAID) and corticosteroids or physiological stress in burns, head injury and mucosal ischemia are implicated as risk factors for their causation. The diagnosis is usually overlooked because of vague and variable symptoms and remote index of suspicion accounted for their low incidence in children. Undiagnosed or mistreated perforations may carry high morbidity and mortality. We report a successfully treated 41/2 year old male child who presented with features of perforation peritonitis and was incidentally found to have a perforated duodenal ulcer. Key Words: duodenal ulcer, laparotomy, perforation

Hepatic abscess following hepatic arterial infusion chemotherapy with an implantable pump

A patient with an intrahepatic abscess associated with an implantable pump for hepatic arterial infusion for metastatic colonic tumor is described. In view of the increased use of this device, clinicians should be aware of this complication.