Morbid obesity is not a contraindication to lower limb arthroplasty

There are concerns that increased BMI is associated with a greater length of stay (LOS) and perioperative complications following total knee (TKR) and total hip replacements (THR). We analysed data from a six-month period to see if there was a correlation between BMI and LOS. We performed a subgroup analysis for patients with morbid obesity (BMI >40) looking at perioperative complications. 285 TKRs and 195 THRs were analysed. For TKRs, the average length of stay was 2.7 days. The average BMI was 32.4. There was no significant correlation between BMI and LOS (r=-0.0447, p=0.2267). The morbidly obese category (n=33) had the shortest LOS (2.5 days) compared to other BMI categories. 30- day readmission rate was 6%. 90-day re-admission rate was 12%. Six patients had minor wound issues requiring no intervention or antibiotics only. The was one prosthetic joint infection, one stitch abscess, one DVT and one patellar tendon injury. For THRs, the average LOS was 2.9 days. The average BMI was 29.9. There was no significant correlation between BMI and LOS (r=0.007, p=0.4613). The morbid obese category (n=9) had the shortest LOS (1.9 days) compared to other BMI categories. No patients were readmitted within 90 days or had documented complications. We have shown that for TKRs and THRs, increased BMI is not associated with increased LOS. The morbidly obese were found to have the shortest LOS. Re-admission rates and complications were commendable for patients with morbid obesity. BMI >40 is not a contraindication to TKR or THR.

Mesh abdominoplasty for rectus diastasis in women and men

Purpose Meshes clearly have improved outcomes for tissue approximation over suture repairs for incisional hernias. A knowledge gap exists as to the surgical complication rate and post-operative outcomes of a mesh rectus diastasis repair with a narrow well-fixed mesh that simultaneously narrows the rectus muscles and closes the widened linea alba. Methods Inclusion criteria for mesh abdominoplasty were patients who (1) underwent a retrorectus planar mesh for repair of rectus diastasis (2) did not have a concurrent incisional hernia and (3) underwent skin tailoring as part of a cosmetic aspect of their care. The primary endpoint was surgical site occurrence (SSO) at any time after surgery as determined with review of their office and hospital medical records. Secondary endpoints included the length and complexity of the return to the operating room for any reason, non-surgical complications, readmission, post-operative recovery, surgical site infection, recurrence/persistence of abdominal wall laxity, and soft tissue revision rates. Results SSO rate was 0% for the 56 patients who underwent this procedure. There were 40 women and 16 men. Superficial infections requiring oral antibiotics were required in three patients. One was a drain site erythema, one was for a superficial stitch abscess, and the third was for a mesh strip knot infection 6 months after the procedure. One patient underwent further tightening of the abdominal wall. Rates of soft tissue revision in the office for improved cosmesis were 23% in women and 6% in men. Conclusion Repair of rectus diastasis with a narrow well-fixed mesh and concurrent skin abdominoplasty is a well-tolerated and reliable procedure with low recurrence and low SSO in the manner described. It is a procedure that works for both female and male pattern rectus diastasis, and has become our procedure of choice for moderate and severe rectus diastasis.

A randomised study to evaluate wound outcome following delayed primary vs primary closure of skin in duodenal perforation peritonitis

Background: This study aimed to evaluate wound outcome following delayed primary versus primary closure of skin in duodenal perforation peritonitis.Methods: The present study was a randomised interventional study that included 90 patients on accrual of duodenal perforation peritonitis which were divided into primary closure (PC) and delayed primary closure (DPC) groups comprising 45 patients each. The outcome measures were complications, surgical site infections, hospital stay and final wound status during the follow up of 30 days. Data collected was compared taking P-value <0.05 as significant.Results: The patients were in the age group of 12–60 years, with men in majority in both groups. Mean SSI score in PC and DPC was comparable (2.67 SD 1.58 vs. 2 SD1.61, P=0.058). SSI was more in PC group than DPC group (11.11% vs. 2.22%, P<0.05). Wound/pus culture was positive in 62.22% in PC and 46.67% in DPC. Major complications like wound dehiscence was noticed mainly in PC group while minor Complications like Stitch abscess, granuloma, sinus was more in DPC group. Mean of duration of stay (days) was comparable between PC and DPC group (14.07 SD 7.64 vs. 13.96 SD 6.94, P=0.805). Final wound outcome after 30 days was healthy scar in majority of patients in PC and DPC group (57.78% vs. 66.67%) with no significant difference between them (p=0.434).Conclusions: In conclusion, DPC showed comparable results with PC with similar SSI and wound healing without significant complications.

90-Day Complications Following the Distal Tibia Allograft Procedure

Objectives: To describe complications occurring within 90-days following the distal tibia allograft (DTA) procedure. Methods: Consecutive patients undergoing DTA for anterior glenohumeral instability by fellowship-trained surgeons were included for analysis. Indications for DTA included primary or recurrent anterior instability with clinically significant anterior glenoid bone loss, failed prior arthroscopic stabilization, and/or failed prior Latarjet. All complications that occurred within 90-days of surgery were analyzed and correlated with demographic factors. Results: A total of 63 consecutive patients (average age 26.4±8.2 years, 90% male) were included. Fifty patients (79%) had undergone prior ipsilateral shoulder surgery, including 8 undergoing prior Latarjet (13%). The average glenoid bone loss prior to DTA was 29±7%. There were 5 total complications within 90 days of surgery, for an overall short-term complication rate of 7.9%. The 58 patients without complications had an average age of 26.2±7.9 years (95% male), with 45 (78%) having had prior shoulder surgery. Three of these 5 required subsequent surgery, including 1 revision DTA for hardware failure, 1 subscapularis repair, and 1 debridement for retained foreign body. The remaining 2 complications were transient and resolved with non-operative treatment, including 1 patient with postoperative pain requiring a subacromial injection, and 1 patient with a stitch abscess treated with oral antibiotics. The 5 patients experiencing complications had an average age of 29.0±11.5 years (40% male), with all 5 (100%) having had prior shoulder surgery. There were no episodes of recurrent instability. Conclusion: The overall 90-day complication rate following DTA is 7.9%, substantially lower than the previously described rate of 25% in patients undergoing Latarjet, despite the majority of patients having had at least 1 prior ipsilateral shoulder surgery. This information can be used to counsel patients on the risks of early complications following DTA.

WOUND INFECTION;

Objective: The aim of the study was to evaluate the frequency of infection in clean surgical cases (General & Orthopaedic).Study D e s i g n : A descriptive study. Place & Duration of Study: This descriptive study was conducted at department of surgery & orthopaedicDHQ Teaching Hospital Sargodha from July 2007 to Dec, 2008. Patients & M e t h o d s : In this study 1500 clean surgical cases were included.Wounds were examined on third post operative day and then regularly after removal of stitches. Surgical wounds were examined finally onfifteenth post operative days. Description of wound condition and detailed data of patients were collected on preformed performas. Patientswith wound infection developed pain at operation site and fever on third post operative day. Wounds were examined for swelling, redness,discharge; stitch abscess. Routine investigations were done as per protocol ie complete blood examination, complete urine examination, bloodsugar, C-reactive proteins etc. Wounds swab was taken for microscopy and culture sensitivity. Results: This study was carried out on fifteenhundred clean surgical cases (General & Orthopaedic). There were 1064 males and 436 females. Male to Female ratio was 2.4:1. Infectionwas detected in 110 patients (7.3%) while no infection was found in 1390. Infection was maximum in patients more than 60 yrs of age (10.9%).Wound infection was minimum in young patients (3.5%).commonest micro organism isolated from the infected wound was staphylococcusareus. Other organism isolated was streptococcus pyogenes, proteus and pseudomonas. No MRSA was detected. C o n c l u s i o n : In our casestudy clean cases were found generally free of infection especially young patients. Whereas increased incidence of infection was noted in oldpatients. Wound infection is associated with significant morbidity in the form of delayed wound heeling, prolonged hospital stay and increasedeconomical pressure on the patient.

OPEN PROSTATECTOMY

Objectives: To study the morbidity of open prostatectomy. To assessthe frequency of complications after open prostatectomy. Study design: Descriptive cross sectional. Setting: SurgicalUnit-IV, DHQ Hospital, Faisalabad. Duration: 01-01-2003 to 31-12-2003 (One Year). Subjects: Patients of bladderoutlet obstruction due to benign prostatic hyperplasia (PBH) were operated by open surgery (Transvesical or retropubicprostatectomy). Results: Open prostatectomy was performed in 54 cases. In 38 cases, suprapubic transvesicalprostatectomy was performed, while in 6 cases, retropubic prostatectomy was done. Our youngest patient was 42 yearsold and oldest 90 years. Mean age was 62 years. In our study, the most common complications were wound associatedseen in 7(12.96%) cases. They included cellulites in 3(5.56%) cases, stitch abscess in 1(1.85%) cases, seroma in1(1.85%) cases, and abscess in 2(3.70%) cases. Other complications were bleeding in the form of reactionaryhaemorrhage/clot retention in 2(3.70%) cases and secondary haemorrhage in 3(5.56%) cases. Urinary fistula was seenin 5(9.26%) cases while retrograde ejaculation in 6(11.11%) cases, stricture urethra in 3(5.56%) cases, urinaryincontinence in 4(7.41%) cases and urinary tract infection in 5(9.26%) cases. Epididimo-orchitis, deep vein thrombosisand osteitis pubis were not seen in our study. The average duration of hospital stay was 6 days. Most cases weredischarged within five days of operation, while stitches were removed on the eighth postoperative day. Conclusions:The morbidity of open prostatectomy is higher than transurethral resection (TURP), as TURP is better procedure dueto lower complication rate, short hospital stay, cost effectiveness and better tolerated by old and unfit patients,presenting with small fibrotic prostate. Open prostatectomy is still a good option for BPH where TURP facilities are notavailable.