Shahryar Noordin

Hip fracture surgery: does type of anesthesia matter?

Background. Hip fracture surgery is a common procedure, and the geriatric population with its multiple comorbid conditions is at most at risk of developing anesthesia-related complications. Data on the impact of type anesthesia on postoperative morbidity and mortality is limited. The effects of regional and general anesthesia on postoperative outcomes need to be clearly elucidated. Methods. In this study, all patients who underwent dynamic hip screw (DHS) fixation for intertrochanteric fractures, between January 2005 and December 2010, at the Aga Khan University Hospital, were included. Patients were divided into two groups; group A included those patients who received general anesthesia, and group B consisted of patients who had received regional anesthesia. The two groups were compared for differences in morbidity, mortality, and intraoperative complications based on the type of anesthesia administered. Results. During this period, 194 patients underwent DHS fixation. One hundred and seven patients received general anesthesia whereas eighty-seven patients received regional anesthesia. The mean operative time was significantly lower in the group receiving regional anesthesia (1.25 ± 0.39u2009hrs) as compared to those who received general anesthesia (1.54 ± 0.6u2009hrs) (P < 0.05). There were no statistically significant differences in the rates of wound infections, length of hospital stay, postoperative ambulation status, intraoperative blood loss, postoperative complications, and mortality between the regional and general anesthesia groups. Conclusion. Even though administration of regional anesthesia was positively correlated with shorter operative duration, the type of anesthesia was not found to affect surgical outcomes in the two study groups. Based on these results, we recommend that anesthesia should be tailored to individual patient requirements.

Evolution of trauma management at a tertiary care hospital: A cohort study

OBJECTIVEnTo analyze the characteristics of polytrauma patients and to assess the outcome of trauma care as this specialty has evolved over the years at a university hospital.nnnMETHODSnThe study included all polytrauma patients treated between January 1998 and September 2005 at a tertiary care hospital in a megacity. Data of 1009 patients was collected prospectively and analyzed retrospectively. Patients were divided into two groups A and B, based on their presentation before and after the introduction of a formal trauma training course in 2002. The analysis included demographic data, injury severity score, vital signs including hemodynamics and GCS on admission, intubation rates, mortality and complications.nnnRESULTSn435 patients were included in group A (1998-2001) whereas group B (2002-2005) comprised of 574 patients. The proportion of patients with accidental versus intentional injuries was similar in both groups. The mean injury severity score of group A was 11.9 whereas that of group B was 11.7. Almost 50% of patients were transferred from other hospitals. Transferred patients had significantly lower GCS (pxa0<xa00.001), higher ISS (pxa0<xa00.001) and longer ICU stays (pxa0<xa00.001) in both (A and B) patient groups, while in group A mortality was also higher (pxa0=xa00.018). A significantly higher number of patients in group B went into shock. The overall mortality rate was 9.7% for group A which significantly decreased to 5.7% for group B (pxa0<xa00.05).nnnCONCLUSIONSnThis study supports the view that as trauma care evolved at our hospital with the establishment of a formal training program, the mortality rates have significantly decreased.

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

INTRODUCTIONnA 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).nnnMETHODSnAll 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.nnnRESULTSnDuring 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.nnnDISCUSSIONnOutcomes 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

BACKGROUNDnResident 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.nnnMETHODSnPatients 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.nnnRESULTSnThe 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.nnnCONCLUSIONnResident 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.

Terrorist attacks in the largest metropolitan city of Pakistan: profile of soft tissue and skeletal injuries from a single trauma center

BACKGROUNDnPakistan has been hugely struck with massive bomb explosions (car and suicide bombs) resulting in multiple casualties in the past few years. The aim of this study is to present the patterns of skeletal and soft tissue injuries and to review the outcome of the victims who presented to our hospital.nnnMETHODSnThis is a retrospective chart review from January 2008 to December 2012. The medical record numbers of patients were obtained from the hospital Health Information and Management Sciences (HIMS) as per the ICD-9 coding.nnnRESULTSnDuring the study period, more than 100 suicide and implanted bomb blast attacks took place in the public proceedings, government offices, residential areas and other places of the city. Altogether 262 patients were enrolled in the study. The mean age of the patients was 31±14 years. The shrapnel inflicted wounds were present on to the upper limb in 24 patients and the lower limb in 50.nnnCONCLUSIONnLong bone fractures were the most common skeletal injuries. The fractures were complicated by penetrating fragments and nails which result in post operative infections and prolonged hospital stay.

The effect of tranexamic acid in unilateral and bilateral total knee arthroplasty in the South Asian population: A retrospective cohort study

INTRODUCTIONnTogether with evidence of higher bleeding tendencies, the vulnerability of the South-Asian population to anemia secondary to a higher prevalence of hemoglobinopathies and micronutrient deficiencies merits further exploration of the effects of tranexamic acid on this population. Additionally, limited access to self-care facilities and certain sociocultural beliefs and practices may not be conducive to a speedy recovery from surgical complications. The aim of this study is to investigate the effects of intraoperative administration of tranexamic acid during total knee arthroplasty when considering the South-Asian population.nnnMETHODOLOGYnMedical record files of 355 patients who underwent total knee arthroplasty (2007-2015) were reviewed to collect data regarding patient characteristics, surgical variables and post-operative complications. Unilateral and Bilateral total knee arthroplasty were studied separately. Analysis was done using t-test, Mann-Whitney U test, chi-square and Fishers exact square where appropriate. The threshold for significance was pu202f<u202f0.05.nnnRESULTSnThe study showed that for unilateral surgery, tranexamic acid caused a significant reduction in estimated blood loss (p-value=0.011), total operative time, calculated blood loss, and hemoglobin change (p-value<0.001) whereas in bilateral surgery, tranexamic acid only caused a significant reduction in calculated blood loss (p-value < 0.001) and hemoglobin change (p-value=0.001). Interestingly, in those who received tranexamic acid vs. those who did not, there was a significant increase in length of hospital stay (p<0.001) and special care unit admissions (p-value=0.033) in unilateral and bilateral surgery respectively.nnnCONCLUSIONSnAlthough tranexamic acid effectively reduces intraoperative blood loss, it does not have an effect on the need for post-operative blood transfusions. The increased length of stay and special care unit admissions associated with tranexamic acid use should be explored further to reveal the complete safety profile of tranexamic acid administration in the South-Asian population during total knee arthroplasty.

Hip arthroscopy: Indications, outcomes and complications

Hip arthroscopy has recently occupied an important place in the armamentarium of General Orthopedic and especially hip surgeons. It is an effective and innovative procedure with rapidly expanding indications. Advancements in surgical tools and refinement in techniques has revolutionalized modern Hip arthroscopy. Surgeons are now able to address pathology in and around the hip joint that was either misdiagnosed or poorly understood. The procedure allows detailed visualization of acetabular labrum, femoral and acetabular chondral surfaces, fovea, ligamentum teres, synovium and the extra-articular peri-trochanteric space. Minimally invasive surgery is now performed for diagnoses as well as treatment of a variety of Hip disorders. The acceptance and rates of hip arthroscopy are increasing across the board and the associated literature is expanding every day. Increasing surgical experience and improving technology is contributing for more advanced procedures to become popularized, however long-term outcome data about hip arthroscopy is still relatively sparse. We aim to review hip arthroscopy in the light of recent literature and will discuss the current indications, outcomes and complications of the procedure.

Total knee Arthroplasty: risk factors for allogeneic blood transfusions in the South Asian population

BackgroundTotal knee arthroplasty (TKA) is the recommended treatment for end-stage knee osteoarthritis. Considering the various risks associated with intra and postoperative blood transfusions, better understanding is required with respect to the risk factors contributing to a greater possibility of blood transfusion during or after surgery. Although literature highlights several such factors, our study is among the first to identify these risk factors in the South Asian population which differs from other populations in several ways.MethodsThe study consists of a review of 658 patients undergoing TKA from 2005 to 2015. Data was obtained from patient medical records and was analysed using logistic regression analysis. The relationship between each predictor and the outcome variable was calculated as an Odds ratio (OR), the threshold of significance for which was pxa0=xa00.25 and pxa0=xa00.05 for univariate and multivariable analysis respectively.ResultsThe mean age of the patient population was 63xa0years (78% female), 25% of whom received one or more blood transfusions. Multivariable analysis revealed 5 significant independent predictors for increased risk of blood transfusions including bilateral knee surgery (OR:5.51), preoperative anemia (OR:4.15), higher ASA (American Society of Anaesthesiologists) status (3–4) (OR:1.92), female sex (OR:3.44) and BMI (Body mass index) ≤30 (OR:1.79) while increasing co-morbidities and age (>60) were found to be insignificant.ConclusionsThe factors identified for the South Asian population are largely similar to those for other populations. Identification of high risk patients will permit the application of an international multipronged approach which not only targets the modifiable risk factors but also the decision making process and blood management protocols in order to minimize the transfusion associated risks for a patient undergoing a TKA.

Does surgeon volume affect the outcome of total knee arthroplasties in a developing country? - A retrospective cohort study

Introduction Recent studies have shown that in addition to patient factors, surgeon volume has influenced total knee arthroplasty (TKA) outcomes greatly. With recent propositions of regionalization of arthroplasties to higher volume centers, the need for further evidence is warranted. Materials and methods Retrospective Cohort Study done at Aga Khan University Hospital, Pakistan from January 2007 to December 2015. High Volume (HV) group was set as at least 50 TKAs/year and Low Volume (LV) was set as at most 25 TKAs/year. A total of 615 patients undergoing a unilateral or bilateral TKA were included in our study. Results LV group was associated with a higher length of stay (LOS) as compared to HV group in patients undergoing a bilateral TKA after adjusted logistic regression [OR 2.395 (1.47,3.91)]. We found no association between surgeon volume and postoperative complications. Conclusion Patients getting a bilateral TKA by LV surgeons were twice more likely to have a longer LOS as compared to HV group. Further research is warranted comparing all aspects and possible confounders to different variables before a conclusion can be made.

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

INTRODUCTIONnSeptic 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.nnnCASE PRESENTATIONnA 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.nnnDISCUSSIONnBone 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.nnnCONCLUSIONnDespite 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.