Surgical Update: International Journal of Surgery and Orthopedics

Non-invasive preoperative assessment of ureteral stone impaction using peri-calculus ureteral thickness on Non-Contrast CT (NCCT) scan: A prospective Study

2020-05-19T11:22:40+00:00

Background: Ureteral stone can be measured on the NCCT scan as peri-calculus ureteral thickness. If this depicts significant calculus impaction, the patient could be counseled regarding intra-operative risk and incomplete stone clearance. The present study was planned to evaluate the use of NCCT in patients with ureterolithiasis for the prediction of a favorable clinical outcome.

Materials and methods: Patients who underwent ureterorenoscopy for ureteric calculus with pre-operative NCCT scan were included and intraoperative data were recorded. Operating surgeons were blinded for proximal ureteric wall thickness (p-UWT), peri-calculus ureteric wall thickness (p-CUT), and distal ureteric wall thickness (d-UWT) values. The guidewire was negotiated before each URS. Stone was considered impacted if guidewire could not be negotiated in 2 attempts. Intra-operative stone impaction score (SIS) assigned on a scale of 0 (dislodged spontaneously), 1 (dislodged with saline pressure), 2 (dislodged after lithotripsy), 3 (fragments impacted in edema) and 4 (open). Intra-operative findings were correlated to preoperative NCCT measurements of ureteral thickness. Other variables like duration of symptoms, hydronephrosis, stone size in the longest dimension, and stone location were also recorded.

Results: Of total patients 108 patients, 70 patients had non-impacted calculus and 38 patients had impacted calculus. Patients with an impacted calculus had significantly higher p-UWT (9.76 ±3.11mm), p-CUT (6.82±2.57mm), and d-UWT (6.26±2.28mm) as compared to non-impacted. There was a positive correlation in SIS with p-UWT, p-CUT, and p-DWT in both impacted and non-impacted groups.

Conclusion: Pre-operative ureteric wall thickness in proximal, peri, and distal to calculus can predict intraoperative risk and impaction of calculus.

A study of functional outcome of bimalleolar fracture treated with fully threaded 4 mm cancellous cannulated screw in medial malleolus fracture

2020-05-19T11:27:53+00:00

Aim: To analyse the functional outcome of Medial malleoli after Internal Fixation of medial malleolar fracture with fully threaded 4 mm cancellous cannulated screws.

Introduction: Ankle fractures are one of the commonest fractures encountered by an orthopaedic surgeon with the majority being treated with open reduction and tension band wiring but it has a midterm and long term complications like hardware prominence, low-grade infection and hardware removal. Purpose of this study on medial malleolus fracture is to evaluate functional outcome after open reduction and fully threaded 4 mm cancellous cannulated screw fixation which has a very low complication rate.

Materials and Method: This is a prospective study done in c u shah medical college and hospital Surendranagar. In the present study 30 cases of bimalleolar ankle fracture.Common Mechanism of Injury was Road traffic accidents and fall from height. the diagnosis was confirmed by Anteroposterior, lateral and Mortise radiograph. Classifications used are Lauge-Hanse Classification and DenisWeber Classification. Fully threaded 4 mm Cannulated cancellous screw was used for medial malleolus fixation.The anatomical plate used for fibula fixation.

Post-op protocol: Postoperatively limb were immobilized in a plaster splint for 6 weeks and limb were elevated.

Results: According to Baird and Jackson scoring system out of 30 cases, 56.67% were excellent and 26.67% were good, 13.34% were fair and 3.32% were poor.

Conclusion: Open reduction and tension band wiring fixation of medial malleolus has biomechanically proved stable fixation but it has a midterm and long term complications like hardware prominence, low-grade infection and hardware removal. The current study has studied that open reduction and fully threaded 4 mm cancellous cannulated screw in medial malleolus fracture have a comparable functional outcome with a low complication rate.

Evaluation of factors determining the functional outcome of DHS in trochanteric fractures

2020-05-18T08:56:40+00:00

Background: In spite of improvement and modification for intertrochanteric fracture in the conservative line of treatment the ideal anatomical and functional result could not be achieved.Until now mentioned factors posteromedial support communition has been considered to bea major prognostic factor in the determination of the functional outcome. Current literature almost neglects other important potential prognostic factor i.e. lateral trochanteric wall fracture.The current study has aimed at studying Assessment of functional outcomes of Dynamic Hip screw fixation in intertrochanteric fracture Evans 3 and 4 types.

Method: 126 cases were registered in the study out of which 64 cases of Trochanteric fractures which were admitted in the Orthopaedic wards and treated by internal fixation using standard Dynamic Hip Screw (DHS) were included in the study. Preoperative assessment of fracture geometry was done using Evan’s classification.

Result: Age of patients ranged from 22 years to 88 years, with the average being 55 yrs. the anatomical reduction was achieved in 82.5% of group A with intact lateral trochanteric wall whereas it was achieved in only 33% of the other group. Average impaction in group A was found to be 5.5mm and average impaction in group B was 14mm. 85% of group A had functional outcome excellent to good whereas in 66% of group B it was fair to poor.

Conclusion: Intact lateral trochanteric wall helps in achieving anatomical reduction, imparts inherent stability and prevents excessive collapse, limb shortening and sliding of the screw. Thus it helps in achieving good functional outcome making lateral trochanteric wall fracture good predictor of functional outcome.

Study of surgical management of trochanteric fracture of the femur with dynamic hip screw

2020-05-18T08:55:29+00:00

Background: The use of a dynamic hip screw (DHS) for stable trochanteric hip fracture fixation has been successfully applied in fracture healing for more than 20 years. DHS fixation on unstable trochanteric fractures still has a more failure rate, particularly in osteoporosis patients. Thus, this study is aimed to investigate the biomechanical property of the DHS system to provide the lesser trochanter fragment stable fixation.

Material and methods: This cross-sectional, observational, and follow-up study was conducted in the Department of Orthopedics, GSL Medical College and General Hospital, Rajamahendravaram with a total of 40 cases of trochanteric fractures. All surgeries were performed under spinal anesthesia. Surgery done was an internal fixation with DHS and 135-degree angled blade plate.

Results: Among 40 cases, 32.5% were Type I, and 67.5% were Type II Trochanteric fractures. 40% cases had grade 3 osteoporosis and 30% had grade4-osteoporosis rest of the patients were having grade 2 (20%), grade 5 (7.5%), grade 6 (2.5%) and grade1 (0%), according to Singh’s index. The clinical and functional outcomes of the procedure were excellent in 10 hips (25%), Good in 20 hips (50%), Fair in 6 hips (15%), and 4 (10%) of the patients had poor results.

Conclusions: Trochanteric fractures are essentially fractured of the elderly, with osteoporotic bones. The dynamic hip screw is the operative treatment of choice for stable trochanteric fractures.

A study to evaluate the functional outcome of displaced supracondylar humerus fracture in pediatrics treated with closed reduction and k-wire fixation

2020-05-19T11:43:41+00:00

Introduction: Supracondylar fracture of the humerus is the most common elbow injury in children and makes up approximately 60% of all elbow injuries. The purpose of the present study is to evaluate the functional outcome of the displaced supracondylar humerus fracture treated with closed reduction and k-wire fixation by lateral and cross pinning technique.

Material and Method: 50 children with fractures of the supracondylar humerus out of which 30 were boys and 20 were girls taken for prospective study at C.U. Shah Medical College from May 2017 to August 2019 was analyzed clinically and radiologically using Flynn’s criteria. Out of 50 cases 28 patients treated with lateral pinning and 22 patients treated with cross pinning technique based on the surgeon’s preference.

Result: among patients treated with lateral pinning technique 19(68%) had an excellent result, 9(32%) had a good result. Similarly in patients treated with cross pinning technique, 9(41%), 7(32%), 2(9%), 4(18%) had excellent, good, fair, and poor outcomes respectively. 9 patients developed iatrogenic ulnar nerve palsy in cross pinning technique whereas 2 patients developed cubitus varus following cross pinning technique.

Conclusion: Thus it can be concluded that closed reduction and K-wire fixation is an excellent method for the treatment of supracondylar fracture of the humerus with the significant difference in functional outcome between lateral pinning and cross pinning technique. The chances of ulnar nerve palsy increase following cross pinning technique which is not so in the case of lateral pinning. Thus suggesting the use of lateral pinning technique for the treatment of displaced supracondylar fracture of the humerus.

A clinical study to evaluate the outcome of diaphyseal humerus fracture in adult age group treated with anterior biological plating

2020-05-18T08:53:22+00:00

Background: Anterior biological plating is one of the many options to treat diaphyseal humerus fractures in the adult age group. A clinical study was performed to evaluate outcomes over 6 months follow up period in 25 patients.

Materials and Methods: The present study included 25 patients of the adult age group having diaphyseal humerus fracture treated with anterior biological plating between February 2018 to June 2019.Pathological, Malunited, and Gustilo Anderson open to grade 3 fractures were excluded from the study. Locking Compression Plating was done in all cases using the MIPO technique after closed indirect reduction. Functional outcome was assessedusing the DASH score at 6 months follow up.

Results: The study consisted of 16 males and 9 females. The mean age was 42.36 years (range: 19-73 years).7 fractures out of 25 were 12A1, 2 were 12A2, 10 were 12A3,2 were 12B1 and 4 were 12B2 based on AO classification. Mean DASH score in the present study was 7.9 with 21 patients achieving excellent DASH Score and 4 patients achieving good DASH score with none of the patients having fair or poor DASH scores.

Conclusion: ABP for mid-shaft humerus fractures is a safe and effective treatment modality yielding high rates of the union, excellent functional recovery, minimal biological disruption, better cosmesis, and superior patient satisfaction.

Bipolar hemiarthroplasty versus total hip replacement in displaced femoral neck fracture in elderly

2020-05-20T07:32:22+00:00

Introduction: Fractures of the neck of the femur are commonly seen in the geriatric population resulting in significant morbidity and mortality. Primary arthroplasty helps in rapid mobilization while decreasing the chances of implant failure and complications such as deep vein thrombosis, pulmonary complications, infection, and bedsores. The purpose of this can be fulfilled either by Bipolar Hemiarthroplasty as well as by Total Hip arthroplasty. The aim of this study is to determine whether total hip replacement is clinically and functionally better than bipolar hemiarthroplasty in the neck of femur fracture in older patients.

Method: It is a prospective study done at Sri Ramachandra Medical College, Chennai, and Velammal Medical College, Madurai on 70 patients diagnosed with the unstable neck of femur fractures who were treated with bipolar hemiarthroplasty and total hip replacement from April 2018 to September 2019. The inclusion criteria were age more than 60 years and Unstable neck of femur fractures as per the Garden classification. The exclusion criteria were pathological fractures, associated fracture of lower limbs, and non-ambulatory patients prior to the injury. A functional assessment was carried out using the Harris Hip Score.

Results: In the group that underwent a total hip replacement, the mean Harris Hip Score was 70.6, 74.4, 77.68 and 80.95 at the follow-up visits at week 6, 3 months, 6 months and 1 year respectively. In the group that underwent bipolar hemiarthroplasty, the mean Harris Hip Scores were 63.50, 66.25, 68.72, and 71.26 at the follow-up visits at week 6, 3 months, 6 months and 1 year respectively.

Conclusion: Total hip arthroplasty is recommended over hemiarthroplasty for the displaced neck of femur fractures in elderly patients owing to the higher Harris Hip Scores and lower re-operation rates.

Functional outcome of minimally invasive plate osteosynthesis (MIPO) in proximal tibial fractures

2020-05-20T07:31:23+00:00

Introduction: This study is undertaken to evaluate the outcome of the MIPO technique in Proximal Tibial Condyle Fractures which is expected to provide a stable fixation with minimum exposure, early mobilization, fewer complications, and a better quality of life.

Material and methods: Study design: Prospective cohort study carried out at C.U Shah Medical College. 30 cases of proximal tibia fractures (Schatzker type 1- VI) operated with the MIPO technique. Follow-up of these patients was done at 6 months and 9 months after surgery by using Sanders's 40-point functional scale.

Results: There were 16 cases of Schatzker type I fractures, 5 cases of Type II, 4 cases of type III, 2 cases of type IV, 1 case of type V and 2 cases of type VI fractures. The healing process was determined by radiographically and functionally. Meantime to union was 17.6 weeks, with 50 % of fractures uniting in 14-16 weeks. Infection was observed in two cases (10%), two cases of collapse of fracture, and two cases of malunion. Sanders's score was applied to analyze the functional outcome among the cases. 63% of patients had excellent performance, 20% had good results, 13% had fair results and one patient performed poorly.

Conclusion: MIPO is a good technique to stabilize the proximal tibia condyle fractures especially when used with meticulous intraoperative handling of soft tissues.

Effectiveness of a standard protocol for tranexamic acid administration in total hip and knee arthroplasty – does it make a difference?

2020-05-22T09:27:49+00:00

Background: Intraoperative blood loss plays a key role in the outcome of any surgery and is most important during the immediate post-operative period in the management, for both the operating surgeon and the anesthetist. The present study compares postoperative hemoglobin decrease and blood transfusion requirements in total knee and hip arthroplasty with and without standardized perioperative tranexamic acid infusion.

Methods: This is a prospective randomized controlled study done on 41 patients undergoing a major joint replacement (total knee and hip arthroplasty) in the south Indian population in a single center. The primary aim of the study was to prove the efficiency of standardized tranexamic acid administration in reducing blood loss and need for blood transfusion in total knee and hip arthroplasty by comparing postoperative hemoglobin levels, peri-operative hemoglobin drop and frequency of blood transfusion in 2 groups one receiving and the other not receiving tranexamic acid during the peri-operative period.

Results: The mean pre-operative hemoglobin in the tranexamic acid group was 13.45 and in the control group was 13.0 with a p-value of 0.267, The mean hemoglobin level as on a postoperative day 1 in the tranexamic acid group was 12.32 and in the control group was 10.78 with p-value <0.001. The mean post-op hemoglobin levels on POD 3 in the tranexamic acid group were 11.75 and in Control group was 9.31 with p-value <0.001. The hemoglobin drop in the tranexamic acid group from pre-op to POD 3 was 1.7 mg/dl whereas in the control group the hemoglobin drop from pre-op to Pod 3 was 3.69 mg/dl which was more than double when compared to the tranexamic acid group. Out of 20 patients in the control group 3 patients, one patient who underwent total knee arthroplasty and two patients who underwent Total hip arthroplasty needed 1 unit of blood transfusion postoperatively.

Conclusion: The use of standardized Tranexamic acid infusion during the perioperative period of Total Hip and Knee Arthroplasty reduced the perioperative blood loss which was evident by high mean postoperative hemoglobin levels and low mean postoperative hemoglobin drop and decreased need for blood transfusion in Tranexamic acid group when compared to the control group.

Evaluation of the significance of Alvarado score in the diagnosis of acute appendicitis in tribal area

2020-05-22T09:26:22+00:00

Background: Acute Appendicitis is a common surgical emergency which even with modern diagnostic facilities remains a challenging task for the surgeon. The variation in the presentation can confuse even experienced surgeons. On looking at the literature, it was found that a negative Appendicectomy rate has been consistently mentioned Aim- The following study was therefore conducted for Evaluation Of Significance Of Alvarado Score In Diagnosis Of Acute Appendicitis In Tribal Area. This is an old standard scoring system, very economical, noninvasive, and revalidation was done in the tribal area to reach the diagnosis.

Material and Methods: A Study of 180 patients of acute appendicitis was conducted in tribal areas and Alvarado score carries high significant value in diagnosis and management of acute appendicitis. The period to study was from August 2018 to January 2020.

Result: 180 patients were subjected to Appendicectomy. Out of the 33 were operated by laparoscopy (18.33%). All the Appendicectomy specimens were studies macroscopically and microscopically. All the specimens were cut open and inspected for pathology.

Conclusion: The present study concludes that the Alvarado score, an economical, noninvasive clinical scoring system, carries high significant value in the diagnosis and management of acute appendicitis in the tribal area.

A rare complication of ERCP: colocutaneous fistula

2020-05-24T07:51:07+00:00

Endoscopic Retrograde Cholangiopancreatography (ERCP) is the most widely used diagnostic and therapeutic modality for hepatobiliary and pancreatic diseasesbut is not free from complications. Though rare, the common complications are migration of biliary stent, perforation, pancreatitis, hemorrhage, cholangitis, intra-abdominal sepsis, obstruction, etc. Here, we report a rare complication of ERCP presented as colocutaneous fistula. Colocutaneous fistulas are abnormal communications between the colon and the abdominal skin. They can occur spontaneously in patients with inflammatory bowel disease (most common) as well as after an injury or a surgical procedure. About one-third of fistulas close spontaneously with medical treatment and surgery being reserved for failures after optimal medical treatment. This case of colocutaneous fistula following ERCP presented to us was successfully treated as a single staged procedure without any complication. To the best of our knowledge, this is the first case reported of colocutaneous fistula following ERCP.