Prediction of Hamstring Autograft sizes for Anterior Cruciate Ligament Reconstruction using Preoperative Magnetic Resonance Imaging

BACKGROUND

The purpose of this study is to determine whether preoperative magnetic resonance image measurements can predict the hamstring tendon autograft diameter during anterior cruciate ligament reconstruction.

METHODS

We prospectively evaluated Forty-two patients with anterior cruciate ligament injury who underwent reconstruction using hamstring tendon autograft. Preoperative diameters and cross-sectional areas of the hamstring tendons were estimated using magnetic resonance imaging of the knee. Intraoperative diameters of the hamstring tendon graft were measured using a cylindrical graft sizer. We used Pearson's correlation test to compare the Preoperative and intraoperative graft size measurements. A possible cutoff value for the hamstring graft size was determined using Receiver operating characteristic analysis.

RESULTS

The mean age of the patient in the study was 27.5 ± 8.5 years. There were statistically significant correlations between preoperative and intraoperative hamstring tendon graft measurements (P < 0.001). Our study found 13.3 mm² cross-sectional area as the cutoff for predicting 7mm of quadrupled hamstring graft size with both sensitivity and specificity of 85.7 %, respectively.

CONCLUSIONS

We can conclude that preoperative magnetic resonance imaging measurements can predict the intraoperative graft size. This study can help in preoperatively planning for the graft choice.

Anterior Cruciate Ligament Injury among Patients with Knee Injury Visiting the Out-patient Department of Orthopaedics of a Tertiary Care Centre: A Descriptive Cross-sectional Study

Introduction

Anterior cruciate ligament injury diagnoses are often missed at initial presentation. Though better diagnosed by physical examinations when done by orthopaedics surgeons, proper history is also important in diagnosing it. This study aimed to find the prevalence of anterior cruciate ligament injury among patients with knee injury visiting the out-patient Department of Orthopaedics of a tertiary care centre.

Methods

This descriptive cross-sectional study was conducted on patients visiting the out-patient Department of Orthopaedics of a tertiary care centre within the study period from 31 January 2019 to 1 February 2020, after obtaining clearance from the Institutional Review Committee [Reference number: 321(6-11-E)2/075/076]. The anterior cruciate ligament injury diagnosis was made using a Magnetic Resonance Imaging scan. They were inquired about the specific history features at the time of injury: leg giving way, inability to continue the activity, massive swelling of knee joint within 6 hours, and 'pop' heard or felt. Point estimate and 95% Confidence Interval were calculated.

Results

Among 127 cases of knee injury, anterior cruciate ligament injury was found in 109 (85.83%) (79.76-91.89, 95% Confidence Interval). History of the leg giving way, inability to continue the activity, massive swelling of the knee and 'pop' heard or felt were present in 90 (82.60%), 92 (84.40%), 91 (83.50%), and 86 (78.90%) cases of anterior cruciate ligament injury respectively. At least two history features were present in 104 (95.41%) cases.

Conclusions

The prevalence of anterior cruciate ligament injury was found to be similar to the published studies.

Keywords

anterior cruciate ligament; diagnosis; history; orthopaedics.

Hospital Resilience After the 2015 Earthquake in Nepal: Results From Semi-structured Interviews With Hospital Staff

Background: Resilient hospitals are increasingly recognized as a cornerstone of disaster reduction in global policies such as the Sendai Framework for Action. However, current hospital resilience frameworks emerged from pre-disaster conceptualizations, and have not been verified in real-life disaster contexts nor in the frontlines. Our aim was to study a tertiary hospital's resilience after the 2015 earthquake in Nepal, as experienced by its staff. Methods: We undertook a qualitative study in the Tribhuvan University Teaching Hospital (TUTH), where we conducted 18 semi-structured interviews with hospital staff. We inductively created themes to describe the earthquake burden to the hospital, and to analyze individual resilience of hospital staff. In addition, we deductively documented the resilience of the hospital as a system, according to the system resilience dimensions: means of resilience (redundancy and resourcefulness), and ends of resilience (robustness and rapidity). Results: In terms of robustness, TUTH increased its capacity for earthquake victims as elective activities were temporarily interrupted and quality of care was not a priority. Three stages of rapidity were identified: critical rapidity to address immediate needs, stabilizing rapidity until the hospital re-started routine activities, and recovery rapidity. In addition to the disaster plan, emerging adaptations played a major role in redundancy and resourcefulness. We found that individual resilience depended on three determinants: safety, meaningfulness, and sense of belonging. Conclusions: Hospital resilience results from a complexity of emerging and planned adaptations, as well as from interdependencies with individual resilience. Frameworks and plans to improve hospital resilience must reflect flexibility of response, and a concern for well-being of hospital staff is central for sustainable disaster response and improved resilience.

The Prognostic Value of the Fracture Level in the Treatment of Displaced Supracondylar Humeral Fractures in Children

Background Supracondylar fractures are subclassified as high and low type depending on whether they are above or below the isthmus of the distal humerus and it play an important role in determining outcome. Objective To compare the clinical and radiological outcomes of patients with fractures above and below the distal humeral isthmus treated with closed reduction and percutaneous pinning. Method This is a prospective non-randomized analytical study of 40 patients with displaced extension type supracondylar fracture of distal humerus treated by closed reduction and percutaneous pinning. Radiological and functional outcomes was followed up to 6 months postoperatively. The significance of differences between means (baumann angle, carrying angle and time to recovery) were calculated using the independent t-test. Result Twenty-four (60%) patients were high type and 16 (40%) patients were low type. According to Flynn grading, there was no statistical significance between the high type and low type (p = 0.601). The time to recovery for the high type was 15.58 ± 2.95 weeks and for low type was 18.75 ± 2.18 weeks. Hence, the time to recovery for the low type was longer than high type and it was statistically significant (p = 0.001). Conclusion Low type supracondylar fractures require a longer period for the gain of elbow range of motion. However, in long term the prognosis of low type is comparable with that of high type fracture. Hence, the prognostic value of fracture level in the treatment of displaced supracondylar fractures is not statistically significant.

Non-neoplastic indications and outcomes of the proximal and distal femur megaprosthesis: a critical review

Purpose

Megaprosthesis or endoprosthetic replacement of the proximal and distal femur is a well-established modality for treatment of tumors. The indications for megaprosthesis have been expanded to the treatment of some non-neoplastic conditions of the knee and hip, with the severe bone loss associated with failed arthroplasty, communited fractures in the elderly with poor bone quality, and resistant non-union. Th aim of this study is to find out whether megaprosthesis of the knee and hip is successful in the treatment of non-neoplastic condtions. The study comprises a review of the indications, complications, and outcomes of megaprosthesis of the proximal and distal femur in non-neoplastic conditions of the knee and hip joints.

Methods

We extensively reviewed the literature on non-neoplastic indications for megaprosthesis of the proximal and distal femur after performing a detailed search of the Pubmed database using the medical subject heading (MeSH) terms ‘proximal femur replacement’ or ‘distal femur replacement’ and ‘hip or knee megaprosthesis.’ The data obtained after the structured search were entered into a Microsoft Excel spreadsheet. The frequency distribution of the demographic data, indications, complications, and outcome was calculated.

Result

We included ten studies (seven proximal femur replacement and three distal femur replacement) of 245 proximal femur and 54 distal femur mega prostheses for treatment of non-neoplastic conditions. Bone loss in failed arthroplasty, either due to periprosthetic fracture or deep infection, was the most common indication for megaprosthesis. Dislocation was the most common complication after proximal femur megaprosthesis, and infection was the leading cause of complications after distal femur megaprosthesis.

Conclusion

Megaprosthesis for treatment of non-neoplastic conditions around the distal and proximal femur is a viable option for limb salvage, with an acceptable long-term outcome. Although the complications and survival rates of megaprosthesis in non-neoplastic conditions are inferior to a primary arthroplasty of the hip and knee but are comparable or better than the mega prosthetic replacement in the neoplastic conditions. Proximal femoral megaprosthesis has higher dislocation rates and requirement for revision compared to distal femoral megaprosthesis. However, the proximal femoral megaprosthesis has lower rates of infection, periprosthetic fractures, and soft tissue complications, as compared to distal femoral megaprosthetic replacement. Both associated with aseptic loosening but not statistically significant.

Clinical and demographic profile of admitted victims in a tertiary hospital after the 2015 earthquake in Nepal

Background

In 2015, an earthquake killing 9,000 and injuring 22,000 people hit Nepal. The Tribhuvan University Teaching Hospital (TUTH), a reference tertiary hospital, was operational immediately after the earthquake. We studied the profile of earthquake victims admitted in TUTH and assessed what factors could influence hospital length of stay.

Methods

An earthquake victim dataset was created based on patient records, with information on sex, age, date of admission and discharge, diagnosis, and surgical intervention. We performed an initial descriptive overview of the earthquake victims followed by a time-to-event analysis to compare length of hospital stay in different groups, using log rank test and cox regression to calculate Hazard Ratios.

Results

There were in total 501 admitted victims, with the peak of admissions occurring on the fifth day after the earthquake. About 89% had injury as main diagnosis, mostly in lower limbs, and 66% of all injuries were fractures. Nearly 69% of all patients underwent surgery. The median length of hospital stay was 10 days. Lower limb and trunk injuries had longer hospital stays than injuries in the head and neck (HR = 0.68, p = 0.009, and HR = 0.62 p = 0.005, respectively). Plastic surgeries had longer hospital stays than orthopaedic surgeries (HR = 0.57 p = 0.006). Having a crush injury and undergoing an amputation also increased time to discharge (HR = 0.57, p = 0.013, and HR = 0.65 p = 0.045 respectively).

Conclusions

Hospital stay was particularly long in this sample in comparison to other studies on earthquake victims, indirectly indicating the high burden TUTH had to bear to treat these patients. To strengthen resilience, tertiary hospitals should have preparedness plans to cope with a large influx of injured patients after a large-scale disaster, in particular for the initial days when there is limited external aid.

Tuberculous pseudotumor of fibular head

Tuberculous osteomyelitis of long tubular bone is uncommon, the reported incidence is about 2-3 %. Tuberculous osteomyelitis of fibular head is very rare and it mimics neoplasm. Here we report a case of a 28 year old male presenting with unremitting right knee pain with swelling around fibular head with knee radiography showing lytic lesion of proximal fibula,excisional biopsy was done and histopathological report confirmed it as tuberculous osteomyelitis. Journal of Society of Surgeons of Nepal, 2015; 18 (2), page: 33-35

Correlation between Clinical Features and Magnetic Resonance Imaging Findings in Lumbar Disc Prolapse

BACKGROUND

Magnetic resonance imaging is routinely done for diagnosis of lumbar disc prolapse. Many abnormalities of disc are observed even in asymptomatic patient.This study was conducted tocorrelate these abnormalities observed on Magnetic resonance imaging and clinical features of lumbar disc prolapse.

METHODS

A This prospective analytical study includes 57 cases of lumbar disc prolapse presenting to Department of Orthopedics, Tribhuvan University Teaching Hospital from March 2011 to August 2012. All patientshad Magnetic resonance imaging of lumbar spine and the findings regarding type, level and position of lumbar disc prolapse, any neural canal or foraminal compromise was recorded. These imaging findings were then correlated with clinical signs and symptoms. Chi-square test was used to find out p-value for correlation between clinical features and Magnetic resonance imaging findings using SPSS 17.0.

RESULTS

This study included 57 patients, with mean age 36.8 years. Of them 41(71.9%) patients had radicular leg pain along specific dermatome. Magnetic resonance imaging showed 104 lumbar disc prolapselevel. Disc prolapse at L4-L5 and L5-S1 level constituted 85.5%.Magnetic resonance imaging findings of neural foramina compromise and nerve root compression were fairly correlated withclinical findings of radicular pain and neurological deficit.

CONCLUSIONS

Clinical features and Magnetic resonance imaging findings of lumbar discprolasehad faircorrelation, but all imaging abnormalities do not have a clinical significance.

Effect of phacoemulsification surgery on various parameters in patients with glaucoma

BACKGROUND

Cataract and glaucoma are both common conditions and are often present in the same patient. The incidence of these diseases increases with age. Besides vision impairment, these diseases are associated with decrement in quality of life (QOL).

OBJECTIVE

To study the effect of phacoemulsification surgery on various parameters in patients with glaucoma.

MATERIALS AND METHODS

We enrolled 50 eyes of 36 patients with glaucoma and concomitant cataract scheduled for phacoemulsification cataract surgery . A record was made which included number of anti-glaucoma medications, visual acuity (VA), intra-ocular pressure (IOP), anterior chamber depth (ACD), cataract category/grade, visual field (VF) analysis (mean deviation (MD) and pattern standard deviation (PSD) and responses to Indian visual function questionnaires (IND-VFQ). The patients were re-evaluated at one month after cataract extraction and the above parameters were again obtained to compare them with the firs values.

RESULTS

The mean age of the patients was 66.34 yrs ± 7.96; 10 eyes (20 %) had angle closure and 40 (80 %) had open angle glaucoma. Following cataract extraction, VA improved, IOP decreased, number of glaucoma medications decreased and AC depth increased. The VF analysis showed that the improvement in MD was significant while changes in PSD were not. The improvements seen in the visual function questionnaires (VFQ) were significant. When these parameters were analyzed based on the types of glaucoma, in the angle closure glaucoma (ACG) group, the decrease of IOP from 15.30 ± 6.18 to 12.70 ± 2.71 was not significant ( p = 0.24). In the open angle glaucoma (OAG) group, the changes in the number of anti-glaucoma medication were not significant. When the parameters were analyzed in subgroups, based on cataract category, nuclear sclerosis and posterior sub-capsular, the VA improved significantly in both and the MD improved in the posterior sub-capsular surgery. Improvement in VFQ's was observed in denser nuclear sclerotic and posterior subcapsular cataracts.

CONCLUSION

Cataract extraction results in significant improvement in vision, IOP reduction, decrease in the number of medications, deepening of AC and in the quality of life in patients with co-existing glaucoma when the cataract is of significant density.

Results of the Bhaktapur Glaucoma Study, Nepal

Introduction: The Bhaktapur Glaucoma Study is a population-based, cross-sectional and longitudinal study undertaken in one of the districts of Nepal. Objectives: To determine the prevalence of glaucoma in Bhaktapur district, Nepal. Materials and methods: Thirty clusters were randomly selected and a door-to-door census was conducted to identify citizens 40 years of age and older. Four thousand eight hundred individuals fulfilling the eligibility criteria were referred to the base hospital in Kathmandu for a detailed clinical examination. The diagnosis of glaucoma was based upon criteria described by the International Society for Geographic and Epidemiological Ophthalmology (ISGEO). Results: Complete data was available on 3991 subjects (response rate 83.15 %). The mean IOP was 13.3 mm Hg (97.5th and 99.5th percentiles, 18 and 20 mm Hg, respectively) and mean VCDR 0.26 (97.5th and 99.5th percentiles, 0.6 and 0.8 mm Hg, respectively). Seventy-five subjects had glaucoma, an age-sex-standardized prevalence of 1.80 (95 % confidence interval (CI), 1.68 - 1.92). The age-and sex-standardized prevalence of POAG was 1.24 % (CI, 1.14 - 1.34), PACG 0.39 % (CI, 0.34 - 0.45) and secondary glaucoma 0.15 % (CI, 0.07-0.36). The prevalence of glaucoma increased with increase in age and there was no significant difference in gender. Nine eyes were blind and two subjects bilaterally blind from glaucoma. Conclusion: The overall prevalence of glaucoma was 1.9 %. POAG was the most common form of glaucoma. Visual morbidity from PACG, however, was higher. A large majority of the subjects with POAG had not been previously diagnosed and had intraocular pressure within the normal range. Nepal J Ophthalmol 2013; 5(9):81-93 DOI: http://dx.doi.org/10.3126/nepjoph.v5i1.7832

Topiramate induced bilateral angle-closure glaucoma

Topiramate is a sulfamate-substituted monosaccharide and is used as an antiepileptic medication. It can also be used as a prophylactic agent for headache from migraine. The main purpose of this article is to create awareness among medical colleagues regarding severe ophthalmic side effect of topiramate. This is the first reported case of topiramate induced bilateral angle-closure glaucoma in Nepal. This case was managed successfully by discontinuing topiramate and by starting anti-glaucoma medication along with atropine eye drops which were tapered and eventually discontinued.

Glaucoma at a tertiary referral eye hospital in Nepal

Background: Glaucoma is an important cause of blindness. Objective: To report the distribution of various types of glaucoma among patients presenting to a tertiary eye hospital in Nepal. Materials and methods: All new patients visiting the hospital between March 2007 and February 2008 underwent a comprehensive eye examination. Whenever glaucoma was suspected, patients were referred to fellowship-trained glaucoma specialists. Patients received a comprehensive glaucoma workup including applanation tonometry, stereoscopic examination of the optic nerve head performed by the glaucoma specialists, and a Humphrey visual field analysis (SITA 24 - 2). Results: 447 patients were newly diagnosed with glaucoma. 171 (38.2 %) patients had primary open-angle glaucoma (POAG), while 143 (32 %) had primary angle-closure glaucoma (PACG). The average age of presentation of patients with POAG was 65.78 ± 9.1 years, while the average age for PACG patients was 54.6 ±12.8 years. 30 (21 %) patients with PACG had acute angle-closure on presentation, while 113 (79 %) had chronic angle closure glaucoma. 107 (75 %) of these patients with PACG had visual acuity of less than 3/60 (20/ 400) in the worse eye at presentation. The most common form of secondary glaucoma was lens-induced (5.3 %), followed by neovascular (3.2 %) and uveitic glaucoma (3.2 %). Conclusion: The most common glaucoma seen in a tertiary referral eye hospital of Nepal is primary open-angle glaucoma. Among the angle-closure glaucoma, chronic angle-closure is the most common. Lens-induced glaucoma is still the commonest cause of secondary glaucoma. Keywords: glaucoma, open-angle, angle-closure, lens-induced DOI: http://dx.doi.org/10.3126/nepjoph.v3i2.5263 Nepal J Ophthalmol 2011; 3(2): 123-127