Rizwan Haroon Rashid

Hip fracture surgery: Does time of the day matter? A case-controlled study

INTRODUCTION A prevailing perception regarding night time surgery is that the probability of complications may be higher due to decreased availability of support staff, surgeon fatigue and other logistical factors. However there is little data supporting this notion in hip fracture surgery and we studied this in the context of Inter-trochanteric fractures fixed with dynamic hip screws (DHS). METHODS All patients who underwent DHS fixation for inter-trochanteric fracture from January 2005 to December 2010 were included. Patients were divided into two groups. An after-hours group was defined as an operation done between 5:00 P.M. to 7:00 A.M. and a daytime group was defined as surgery done between 7:00 A.M. to 5:00 P.M. Data was analyzed using SPSS version 19. RESULTS During this period 194 patients underwent DHS fixation. One hundred and fourteen patients were included in the daytime group and 80 patients in the after-hours group. There was no difference in the rates of wound infection, length of hospital stay, postoperative ambulation status, intra op blood loss, type of anesthesia, and mortality between the two groups. Tip apex index was found to be similar between the two groups. Two patients in the daytime surgery required revision surgery compared to 5 patients in the after-hours group, however this difference was not statistically significant. DISCUSSION Outcomes in terms of adequacy of fixation, post-operative complications and post-operative 30-day mortality are comparable to routine day time surgery while offering the benefits of early fixation and mobilization to the patient. This also has a positive impact on the financial burden on this population as early fixation translates into decreased length of stay and reduced cost of treatment.

Resident work hour reforms: Implications regarding hip fracture surgery

BACKGROUND Resident work hour reforms were developed by Aga Khan University Postgraduate Medical education committee in the year 2005. These reforms were implemented by the section of Orthopedics in winter 2006. We designed this study to determine if there is a difference in morbidity and mortality following Dynamic Hip Screw (DHS) fixation for intertrochanteric fracture patients before and after implementation of work hour reforms. METHODS Patients who underwent DHS fixation for inter-trochanteric fracture from January 2005 to December 2008 were included. These patients were divided into two groups. Group A included those patients who underwent DHS fixation prior to the implementation of work hour reforms and Group B patients had their hip fracture surgery after the implementation of these reforms. RESULTS The mean operative time was 1.6±0.6 h and 1.3±0 h for group A and B patients respectively (p<0.001). There was no change in the rates of wound infection, length of hospital stay, post operative ambulation status, inadequate fixation, repeat surgeries and mortality in the two groups. CONCLUSION Resident work hour reform was associated with a significant decrease in the mean operative time for patients undergoing DHS fixation. However morbidity and mortality following DHS fixation for Intertrochanteric fractures has not decreased after implementation of these reforms. Further research evaluating patient outcomes in orthopedic surgery following work-hour restrictions are needed. Moreover, the impact of these reforms on the educational and research activities of the residents also needs to be determined.

Proximal Femur Locking Plate for Sub-Trochanteric Femur Fractures: Factors Associated with Failure

Introduction: Proximal femur locking compression plates (PF-LCP) have gained popularity since their inception due to superior biomechanical stability and durability but clinical experience has shown conflicting results including implant failure. Objective: To study the incidence of implant failure in patients with sub-trochanteric fractures managed with proximal femoral locking compression plate and identify potential risk factors associated with the failure. Materials & Methods: Fifty patients with sub-trochanteric fractures, operated upon with titanium PF-LCP were included in the study from January 2012 to December 2014. These plates were of two designs including one five 5.0 mm proximal locking screws (implant A) and other with three 6.5 mm proximal locking screws (implant B). Fractures were classified according to AO/OTA and Seinsheimer classification. Patients had regular follow-up visits for at least a year, allowing for clinical and radiological assessment of union and implant-related complications. Results: A total of 13 out of 50 (26%) plates failed of which 7 were implant fractures, 3 screw breakage and 3 screw cut outs. 70% of the failures occurred in elderly females. Overall implant failure was significantly more common in patients >50 years (p 0.04). Comparing the two different designs of implants used, implant A was more likely to fail at a plate screw density of 0.8 or more (p 0.02), whereas implant B was associated with significant failure when less than 4 proximal screws were used (p 0.03). Conclusion: This study revealed a high failure rate (26%) of this implant. Attention to the neck shaft angle difference, number of proximal screws and plate screw density may help reduce failure rates, particularly in elderly osteoporotic females.

Ilizarov hip reconstruction osteotomy – A review

Hip joint instability can be secondary to congenital hip pathologies like developmental dysplasia (DDH) or acquired such as sequel of infective or neoplastic process. An unstable hip is usually associated with loss of bone from the proximal femur, shortening, abnormal gait, and pain. Many authors have suggested proximal femoral valgus osteotomy for the treatment of unstable hip joints. Ilizarov modified this technique and performed a double-level osteotomy. In addition to proximal femoral valgus extension osteotomy, he introduced a distal femoral varus osteotomy which would lead to limb lengthening and correction of mechanical axis of the leg. This effectively reduces the limp, improves the abductor lurch and leg length, and provides stability to the destroyed joint.

Outcome of Judet's quadricepsplasty for knee contractures and the effect of local infiltration of epinephrine on reducing blood loss

Objective To evaluate the effectiveness of Judets quadricepsplasty for treatment of knee contractures and to identify the effect of local infiltration of epinephrine on blood loss associated with this procedure. Methods A retrospective cohort study was conducted in which all cases of knee contractures managed with Judets quadricepsplasty from 1st January 2009 to 31st December 2013 were included and were divided into two groups. The epinephrine group included patients who were infiltrated with diluted epinephrine (1:400,000) along with xylocaine, around the operative field 15 min prior to the incision time, while the control group did not receive any infiltration. Judets outcome, blood loss, drop in hemoglobin and required blood transfusion were noted for all patients and compared between both groups. Results Most common preceding pathology identified for the development of knee contractures was periarticular fracture while ilizarov application was the most common etiology. Both groups were found similar in all preoperative characteristics except preoperative flexion contracture (p = 0.02). All functional outcome measures including Judets outcome were similar in both groups. In contrast, duration of surgery (p = 0.01), blood loss (p = 0.02), drop in hemoglobin (p = 0.01) and number of transfusions (p = 0.03) were significantly reduced in epinephrine group. Conclusion Judets quadricepsplasty is a useful procedure to increase the range of motion of rigid knees and local infiltration of epinephrine is effective in decreasing the amount of subsequent blood loss and transfusion requirements.

Glenohumeral tuberculous arthritis complicated with beta haemolytic streptococcus: An extraordinary rare association: A case report.

INTRODUCTION Septic arthritis of the glenohumeral joint is a rare entity and its diagnosis is difficult with a superadded infection in the presence of underlying tuberculosis. We report the first case of group B beta haemolytic streptococcal glenohumeral arthritis with underlying tuberculosis. CASE PRESENTATION A 40 year old lady previously diagnosed to have poliomyelitis, rheumatoid arthritis, hepatitis C, and diabetes mellitus for the last 10 years, presented to the emergency room with diabetic ketoacidosis. Two weeks prior to presentation she developed fever along with pain and swelling in left shoulder with uncontrolled blood sugars. Local examination of the shoulder revealed global swelling with significant restricted range of motion. MRI showed a large multiloculated collection around the left shoulder joint extending into the axilla, and proximal arm. Urgent arthrotomy performed and about 120ml thick pus was drained. The patient was started on clindamicin and antituberculous chemotherapy and her symptoms dramatically improved. DISCUSSION Bone and joint involvement accounts for approximately 2% of all reported cases of tuberculosis (TB), and it accounts for approximately 10% of the extra pulmonary cases of TB. Tuberculosis of the shoulder joint constitutes 1-10.5% of skeletal tuberculosis. Classical symptoms of fever, night sweats, and weight loss may be absent, and a concurrent pulmonary focus may not be evident in most cases. CONCLUSION Despite acute presentation of septic arthritis, in areas endemic for tuberculosis and particularly in an immunocompromised patient, workup for tuberculosis should be part of the routine evaluation.