Masood Umer

Autoclaved tumor bone for reconstruction: an alternative in developing countries.

The options for reconstruction after excision of skeletal tumors include reimplanting the autoclaved tumor-bearing bone. We asked whether such bone will survive and unite with normal bone and whether the local tumor recurrence rate increases after its use. We ascertained the functional outcome (Musculoskeletal Tumor Society score) and complications in 19 patients. After wide excision, the bony segment was autoclaved at 120° for 10 minutes and reimplanted at the original defect with intramedullary nails and compression plates. Twelve of our 19 patients were available for followup. The autoclaved segment united with the normal bone in 11 of the 12 patients. No patients had fracture or resorption of the autoclaved segment. Two patients had local tumor recurrence in nearby soft tissues, apparently unrelated to the autoclaved bone. The mean functional score was 70%. Complications included fatigue failure of the nail in one patient, superficial infection in three patients, and deep infection in two patients. Reconstruction with autoclaved tumor-bearing bone is a simple and effective tool in limb salvage. This technique is a cost-effective alternative for developing countries circumventing complications of prosthetic and allograft reconstruction.Level of Evidence: Therapeutic study, Level IV (case series). See the Guidelines for Authors for a complete description of levels of evidence.

Use of Tranexamic acid is a cost effective method in preventing blood loss during and after total knee replacement

Background & PurposeAllogenic blood transfusion in elective orthopaedic surgery is best avoided owing to its associated risks. Total knee replacement often requires blood transfusion, more so when bilateral surgery is performed. Many strategies are currently being employed to reduce the amount of peri-operative allogenic transfusions. Anti-fibrinolytic compounds such as aminocaproic acid and tranexamic acid have been used systemically in perioperative settings with promising results. This study aimed to evaluate the effectiveness of tranexamic acid in reducing allogenic blood transfusion in total knee replacement surgery.MethodologyThis was a retrospective cohort study conducted on patients undergoing total knee replacement during the time period November 2005 to November 2008. Study population was 99 patients, of which 70 underwent unilateral and 29 bilateral knee replacement. Forty-seven patients with 62 (49.5%) knees (group-I) had received tranexamic acid (by surgeon preference) while the remaining fifty-two patients with 66 (51.5%) knees (group-II) had did not received any tranexamic acid either pre- or post-operatively.ResultsThe mean drop in the post-operative haemoglobin concentration in Group-II for unilateral and bilateral cases was 1.79 gm/dl and 2.21 gm/dl, with a mean post-operative drainage of 1828 ml (unilateral) and 2695 ml (bilateral). In comparison, the mean drop in the post-op haemoglobin in Group-I was 1.49 gm/dl (unilateral) and 1.94 gm/dl (bilateral), with a mean drainage of 826 ml (unilateral) and 1288 ml (bilateral) (p-value < 0.001).InterpretationTranexamic acid is effective in reducing post-operative drainage and requirement of blood transfusion after knee replacement.

Predictors of length of hospital stay after total hip replacement

Purpose. To identify variables affecting length of hospital stay after total hip replacement (THR) while controlling for potential confounders. Methods. Records of 199 consecutive elective unilateral THRs were reviewed. Clinical and demographic data including age, gender, body mass index, comorbidities, surgical factors (surgical approach, type of prosthesis, use of cement, operating time), anaesthetic factors (type of anaesthesia, ASA physical status), and length of hospital stay were recorded. Results. 64% of patients left hospital within 12 days, 28% within 3 weeks, and 8% after 3 weeks. The median length of hospital stay was longer in women than men (11.5 vs. 9 days, p=0.009), in patients aged >65 years than those younger (13 vs. 9 days, p<0.0001), and in those with American Society of Anesthesiologists (ASA) grades 3 and 4 than grades 1 or 2 (14 vs. 9 days, p<0.0001). A greater proportion of women than men (45% vs. 27%, p=0.007), patients aged >65 years than those younger (61% vs. 37% or 24%, p<0.0001), and those with ASA grades 3 and 4 than grades 1 and 2 (68% vs. 25%, p<0.0001) stayed 12 days or longer. In the multiple regression analysis, the predictors for prolonged hospital stay (≥12 days) were patient age >65 years (p<0.003), female gender (p<0.05), and ASA grades 3 and 4 (p<0.0001). Of the 72 patients with prolonged stay, 7% had no, 26% had one, 42% had 2, and 25% had all 3 predictors. Conclusion. Prolonged hospital stay after THR is largely predetermined by case mix. Our study helps to identify individuals who need longer rehabilitation and more care.

Subacromial impingement syndrome

Subacromial impingement syndrome (SAIS) represents a spectrum of pathology ranging from subacromial bursitis to rotator cuff tendinopathy and full-thickness rotator cuff tears. The relationship between subacromial impingement and rotator cuff disease in the etiology of rotator cuff injury is a matter of debate. However, the etiology is multi-factorial, and it has been attributed to both extrinsic and intrinsic mechanisms. Management includes physical therapy, injections, and, for some patients, surgery. No high-quality randomized controlled trials are available so far to provide possible evidence for differences in outcome of different treatment strategies. There remains a need for high-quality clinical research on the diagnosis and treatment of SAIS.

Functional outcome, mortality and in-hospital complications of operative treatment in elderly patients with hip fractures in the developing world.

Hip fracture has been increasing in frequency for several decades, and 70–90% of patients who sustain a hip fracture survive for at least one year. Many of these survivors fail to regain their prefracture functional status. No work in this regard has been done in the developing world. Elderly patients with acute intertrochanteric fracture and fracture of the femoral neck were followed up prospectively for 12xa0months after surgery to record the mortality, morbidity, functional status and complications. Three hundred and forty-five patients (61% female) were assessed at six and 12xa0months after surgery, which included 62.9% intertrochanteric fractures and 37% femoral neck fractures. The mechanism of injury was from a fall in 67% of the cases. Nineteen patients died within six months after surgery while another eight died during the next six months. Obesity, male gender, multiple comorbidities and below normal ambulation status before fracture were identified as major determinants of bad functional outcome.

Bullet-induced synovitis as a cause of secondary osteoarthritis of the hip joint: A case report and review of literature

BackgroundWith increasing prevalence of gunshot injuries we are seeing more patients with retained bullet fragments lodged in their bodies. Embedded lead bullets are usually considered inert after their kinetic energy has dissipated hence these are not removed routinely. However, exposure of any foreign body to synovial fluid may lead to rapid degradation and hence result in systemic absorption, causing local and systemic symptoms. We present the case of a thirty year old man who came to our out patient department with a history of progressive, severe hip pain ten years after a gun shot injury to his right hip.ConclusionThe common belief that intraarticular bullets should not be removed has no benefit and may result in unwanted long term complications.

Suicide bombings: process of care of mass casualties in the developing world

In recent times Pakistans biggest city, Karachi, has witnessed numerous terrorist attacks. The city does not have an emergency response system and only one of the three public sector hospitals has a trauma centre. We describe the pattern of injuries and management of two terror-related mass casualty incidents involving suicide bombers in a developing nation with limited resources. The first incident occurred in May 2002 with 36 casualties, of whom 13 (36%) died immediately and 11 (30.5%) died at the primary receiving hospitals. The second incident was targeted against the local population in May 2004. The blast resulted in 104 casualties, of which 14 (13.46%) died at the site. All patients had their initial assessment and treatment based on Advanced Trauma and Life Support principles and documented on a trauma form.

Morphology of the proximal femur in a Pakistani population

Purpose. To measure the morphology of the proximal femur in a Pakistani population. Methods. Standardised anteroposterior pelvic radiographs of 116 male and 20 female healthy volunteers aged 20 to 50 (mean, 33) years were taken. Morphologic dimensions of the proximal femur were measured, including canal flare index (CFI), morphological cortical index (MCI), femoral head offset, femoral head diameter, and femoral head position. Results. Based on the CFI, 67% of the subjects had normal canal shapes (CFI, 3.0–4.7), whereas 1% and 33% of the subjects had stovepipe shapes (CFI, <3) and champagne-flute shapes (CFI, 4.7–6.5), respectively. Based on the MCI, 29% of the subjects had cylindrical shapes (MCI, <2.7) and 71% had trumpet shapes (MCI, >2.7). Conclusion. Morphology of the proximal femur in our study population differed significantly from those in western populations, indicating regional variation. It could also be due to the younger age of our population.

Salvage of infected non-union of the tibia with an Ilizarov ring fixator

Purpose. To review outcomes of 24 patients who underwent Ilizarov ring fixation for infected non-union of the tibia. Methods. Medical records of 21 men and 3 women aged 13 to 74 (mean, 38) years who underwent Ilizarov ring fixation for infected non-union of the tibia were reviewed. The mean bone defect was 3.3 (range, 2–5) cm. The mean time from injury to presentation was 11.9 (range, 1–36) months. The mean number of previous surgeries was 2 (range, 0–14). A local flap was used in 2 patients and a free flap was used in one patient. Nine of the patients underwent Ilizarov ring fixation without soft tissue and bony resection, as inadequate stability was the reason for non-union. Patients were assessed using the Association for the Study and Application of the Method of Ilizarov criteria. Results. Patients were followed up for a mean of 11 (range, 8–46) months. Functional outcome was excellent in 8 patients, good in 12, fair in 2, and failure in one, whereas bone union outcome was excellent in 6 patients, good in 14, fair in one, and poor in 2. The mean time to union was 8 (range, 3–31) months. The mean external fixation index was 4.2 (range, 1.5–15.7) cm/month. Complications encountered were pin tract infection (n=5), re-fracture (n=2), soft tissue impingement by Ilizarov rings (n=2), recurrence of wound infection (n=1), mal-union (n=1), and mortality (n=1). Conclusion. Ilizarov ring fixation is a viable option for infected non-union of the tibia. Adequate assessment of bone union is crucial before removal of fixator to prevent re-fracture.

Four year experience of sarcoma of soft tissues and bones in a tertiary care hospital and review of literature

BackgroundSarcoma encompasses an uncommon group of cancer and the data is insufficient from Pakistan. We report our four years experience of Sarcoma of soft tissues and bones.MethodsThis cross sectional study was carried out at Aga Khan University Hospital from 2004 to 2008. The patients were divided into two groups from the outset i.e. initially diagnosed and relapsed group and separate sub group analysis was conducted.ResultsOut of 93 newly diagnosed patients, 58 belonged to bone sarcoma and 35 to soft tissue sarcoma group. While for relapsed patients, 5 had soft tissue sarcoma and 9 had bone sarcoma. Mean age was 32.5 years. At presentation, approximately two third patients had localised disease while remaining one third had metastatic disease. The Kaplan Meier estimate of median recurrence free survival was 25 months, 35 months, and 44 months for Osteogenic sarcoma, Ewings sarcoma and Chondrosarcoma respectively. For Leiomyosarcoma and Synovial sarcoma, it was 20 and 19 months respectively. The grade of the tumour (p = 0.02) and surgical margin status (p = 0.001) were statistically significant for determination of relapse of disease.ConclusionThe median recurrence free survival of patients in our study was comparable to the reported literature but with significant lost to follow rate. Further large-scale, multi centre studies are needed to have a more comprehensive understanding of this heterogeneous disease in our population.