Surgeons Deal Research Articles

The Effect of Adverse Events on Orthopaedic Surgeons: A Review.

The purpose of this review was to evaluate the effect of adverse events (AEs) on orthopaedic surgeons, illustrate common ways orthopaedic surgeons deal with AEs, and describe solutions to reduce the negative effect of AEs and prevent them from recurring. AEs are common in orthopaedic surgery and increase the risk of depression, anxiety, and suicide. Orthopaedic surgeons may experience negative effects after AEs even when they are not at fault. AEs are linked to moral injury, second victim syndrome, burnout, and disruptive physician behaviors. Many surgeons deal with AEs in isolation out of fear of a negative effect on their professional reputation, potentially leading to increased psychological distress and unhealthy coping mechanisms. Healthy ways to address AEs and improve the well-being of surgeons include destigmatizing psychological stress after AEs and creating a culture of receptivity and peer support.

Microbiological Profiles of the Anatomical Sites of Perforation Peritonitis: A Cross-Sectional Study.

Introduction One of the most frequent emergencies that a general surgeon deals with is perforation peritonitis. The anatomical site of the perforation, which in turn affects the source of infection, has a major impact on the mortality rate due to perforation peritonitis. Early and suitable antibiotic therapy can be started in the postoperative period with the aid of knowledge about the microbiological profile and sensitivity of peritoneal fluid culture with respect to the anatomical sites of perforation peritonitis. Methods A cross-sectional study was conducted from June 2021 to November 2021 where peritoneal fluid samples were collected intraoperatively from patients with perforation peritonitis. This was subjected to culture and sensitivity, and results were analyzed with respect to anatomical sites of perforation. Results Forty cases were investigated. The ileum (30%) was the most common site of perforation, followed by the stomach (22.5%), appendix (20%), duodenum (12.5%), caecum (5%), jejunum (5%), transverse colon (2.5%), and rectum (2.5%). Escherichia coli (E. coli) and Klebsiella spp. were the most frequently found organisms in all sites of perforation peritonitis. The most sensitive antibiotics covering all isolated organisms were amikacin and meropenem. Sensitivity to amikacin was found in 85.18% of cases of E. coli and 84.6% of cases of Klebsiella. Sensitivity to meropenem was found in 76.9% of cases of E. coli and 80% of cases of Klebsiella. Conclusion In patients with perforation peritonitis, the peritoneal fluid cultures did not reflect the major differential normal flora according to the region of the gastrointestinal tract. The most prevalent organism isolated among all the sites of perforation peritonitis was E. coli. Antimicrobial activity against organisms isolated from perforation peritonitis patients was significantly demonstrated by aminoglycosides, piperacillin and tazobactam, and meropenem and colistin, with considerable resistance to third-generation cephalosporins.

“In My Experience..The Challenges of Educating and Training Modern Residents and Fellows in Orthopaedic Surgery”

The author discusses his experience on how the busy, overworked, academic orthopedic surgeon deals with the challenges of educating modern residents and fellows.

Facial Asymmetry-Demystifying the Entity.

Perfect facial symmetry has always been considered a hallmark of beauty, but, is almost elusive in nature. However, clinically evident skeletal facial asymmetry on the other hand is quite common, which can result from congenital deformities, developmental abnormalities, secondary to maxillofacial trauma and it is an entity maxillofacial surgeons deal with on a regular basis. Surgical correction of facial asymmetry is challenging, as it not only involves the correction of the skeletal asymmetry for an aesthetic outcome, but, also the improvement of the soft tissue drape and dental occlusal harmony. This results in rehabilitation of functional components of orofacial complex like speech, deglutition and phonation. With this paper, we intend to throw a light on this challenging aspect of maxillofacial surgery, along with giving the next generation of maxillofacial surgeons a direction to explore the topic further. Meticulous evaluation and diagnosis of the patient's problems with latest diagnostic methods like 3-dimensional imaging and surgical treatment with orthognathic surgery, gap arthroplasty or distraction osteogenesis, utilizing cutting edge 3-D virtual planning will result in better outcomes.This review will collate the information available in the literature, along with the authors' recommendations for better planning and execution of this challenging puzzle of facial asymmetry.

Propensity Score-Matched Analysis of Minimal Invasive Surgery versus Open Surgery for Colorectal Cancer in Older Patients.

Introduction: Currently, surgeons deal with an older patient cohort, confronting new challenges brought by the raised life expectancy. This population is unrepresented in surgical trials; therefore, the optimal therapy is still a matter of debate. The efficacy of open versus minimal invasive management of colorectal cancer (CRC) in an elderly cohort is not clearly established. The current study assesses the minimal invasive approach in elderly patients undergoing colorectal surgery. Material and Methods: The General Surgery Department database was inquired between 2012 and 2015 using the following filters: age â?¥ 65 and rectal or colon adenocarcinoma. After applying the exclusion criteria, 975 cases were obtained: 842 underwent open surgery (OS) and 133 underwent minimal invasive surgery (MIS). A propensity score matching was performed to reduce patient selection bias. Results: After the propensity score matching, the MIS group had a shorter postoperative hospital stay than the OS group (p = 0.025). From the preoperative variables, the presence of chronic lung disease was significantly higher in the OS group (p = 0.039). The presence of chronic lung disease positively associates with the Clavien-Dindo classification (p 0.001) and with the number of days from surgery to discharge (p = 0.028). Conclusion: The chronological age alone should not be a limit to MIS granting that it showed no inferiority to the OS in terms of postoperative morbidity, correlating with lower postoperative stay in the elderly. Further prospective studies are needed to assess the outcome of MIS in elderly population.

How Do We Physicians and Surgeons Deal With our Own Disease?

It is a "known secret" that physicians and surgeons do not make good patients and neglect their own health by ignoring early warning signs of physical and psychological problems. Moreover, often, they seek help late. What are the reasons for this self-neglect? Is it because we think we are "super humans," or we think that we will not get sick, cannot get sick, should not get sick, have no "right" to get sick, as we must care for others? Do we ignore ourselves because we must go to one more meeting, do one more thing, write or present one more paper, give one more lecture, or take the call even with a fever, cough, and chills? Why can't we call in sick? Is this the "macho" effect? Is this culture of denial pervasive everywhere, even though we should know better? Yes, it is! Don't we need to remember the advice given by airlines to put on an oxygen mask on yourself first before helping others? Unfortunately, many of us do not do it. In this article, we will present a personal reflection as an example and review how we physicians and surgeons neglect our own health, ignoring the early warning signs of physical and psychological problems, and how we often seek help late. We also discuss potential reasons for this becoming a "norm" for many of us. Lastly, we review measures taken by some healthcare systems to remedy this situation.

A study on the preoperative risk factors for primary healing failure in the reconstruction of deep sternal wound infection with platelet-rich plasma and negative pressure trauma therapy.

Deep sternal wound infection (DSWI) is a relatively complex wound in wound reconstruction surgery. Because plastic surgeons deal with DSWI patients late. The primary healing (healing by first intention) after reconstruction of DSWI is restricted by many preoperative risk factors. The purpose of this study is to explore and analyse the risk factors of primary healing failure in patients with DSWI treated with platelet-rich plasma (PRP) and negative pressure trauma therapy (NPWT). 115 DSWI patients treated with the PRP and NPWT (PRP + NPWT) modality were retrospectively (2013-2021) analysed. They were divided into two groups according to primary healing results after the first PRP + NPWT treatment. Univariate and multivariate analyses were used to compare the data of the two groups to find out the risk factors and their optimal cut-off values were identified by ROC analysis. The primary healing results, debridement history, wound size, sinus, osteomyelitis, renal function, bacterial culture, albumin (ALB), platelet (PLT) between the two groups were significantly different (P < 0.05). Binary logistic regression showed that osteomyelitis, sinus, ALB and PLT were the risk factors affecting primary healing outcomes (P < 0.05). ROC analysis showed that AUC for ALB in the non-primary healing group was 0.743 (95% CI: 0.650-0.836, P < 0.05) and its optimal cutoff value of 31 g/L was associated with primary healing failure with a sensitivity of 96.9% and specificity of 45.1%. AUC for PLT in the non-primary healing group was 0.670 (95% CI: 0.571 ~ 0.770, P < 0.05) its optimal cutoff value of 293 × 109 /L was associated with primary healing failure with a sensitivity of 72.5% and specificity of 56.3%. In the cases included in this study, the success rate of primary healing of DSWI treated with PRP + NPWT was not affected by the most common preoperative risk factors for wound non-union. It is indirectly confirmed that PRP + NPWT is an ideal treatment. However, it should be noted that it will still be adversely affected by sinus osteomyelitis, ALB and PLT. The patients need to be carefully evaluated and corrected before reconstruction.

How dentists and oral and maxillofacial surgeons deal with tooth extraction without a valid clinical indication.

This study pertains to a secondary data analysis aimed at determining differences between oral and maxillofacial surgeons (OMFSs) and dentists handling dental extractions without an evident clinical indication. A survey of 18 questions was conducted among 256 OMFSs in the Netherlands and a random sample of 800 dentists Respondents could answer the questions in writing or online. The data was collected in the period from November 2019 to January 2020, during which two reminders were sent. Analysis of the data took place via descriptive statistics and Chi Square test. The response rate was 28.1% (n = 72) for OMFSs and 30.3% (n = 242) for dentists. In the past three years, 81.9% (n = 59) of the OMFSs and 68.0% (n = 164) of the dentists received a request for extraction without a clinical indication. The most common reasons were financial and severe dental fear (OMFSs: 64.9 and 50.9% vs dentists: 77.4 and 36.5%). Dentists were significantly more likely (75.6%, n = 114) than OMFS (60.7%, n = 34) to comply with their last extraction request without a clinical indication. Almost none of them regretted the extraction afterwards. As for the request itself, it was found that 17.5% (n = 10) of the OMFSs and 12.5% (n = 20) of the dentists did not check for patients' mental competency (p = 0.352). Given that most of the interviewed dental professionals complied with non-dental extraction requests when such extractions are ethically and legally precarious, recommendations for handling such requests are greatly needed.

Complications Patients Faces while Fixation, in Terms of Pain Relief, Walking, Sitting

Background: The fracture of the trochanteric area of the femur is one of the most frequent and challenging complications orthopedic surgeons deal daily. In virtually all instances, fractures develop through the highly vascular cancellous bone and heal within 8 to 12 weeks, independent of therapy. Malunion and varus angulations are prevalent. Due to the demands placed on the patient, nursing staff, and length of hospitalization, conservative therapy is no longer acceptable. Seventy percent of intertrochanteric fractures are considered unstable. During regular exercises, the proximal femoral loading has been calculated to reach up to three times the body weight. Muscle attachments apply force vectors in several directions, hence contributing to a trend for fracture displacement. This fracture is typically accompanied by severe comminution and osteopenia. Objective: The main objective of this study is to find thecomplications patients faces while fixation, in terms of pain relief, walking, witting. Materials and Methods: Descriptive study conducted at Department of Orthopedic Surgery, Chittagong Medical College Hospital, Chittagong, with the sample size of 36 patients aged above 50 years admitted to the Chittagong Medical College Hospital with closed trochanteric fracture. The aim of the study is to find out the Effectiveness of dynamic hip screw in fixation of trochanteric fractures of femur in elderly patients. Results: The patients' ages ranged from 52 to 95 years. The majority of patients were 70-79 years old (36.1 percent), followed by 80-89 years (25 percent), 60-69 years (22.2 percent), 50-59 years (11.1 percent), and 90-99 years (5.6 percent). The mean (±SD) age of the total study patients (n=36) was 72.± 1.20 years, male (n=21) was 75.05±12.62 years and female (n=15) were 68.07±7.46 years. There are considerable disparities between the age groups of 70-79 and 90-99.Males made up the majority of patients (58.3 percent), while females made up 41.7 percent. ....

Concomitant Mitral Valve Re-Repair for Mixed Congenital and Degenerative Mitral Disease, Tricuspid Repair, and Cox-Maze Procedure in a College Athlete.

A significant proportion of patients undergoing repair of congenital mitral valve disease will require a subsequent reoperation. During somatic growth, mitral valve repair is preferable to replacement as it allows for annular growth, preservation of ventricular function, and avoidance of lifelong anticoagulation. Techniques to facilitate successful re-repairs for congenital and non-rheumatic mixed degenerative mitral valve disease are not well-described in the literature. Description of the encountered pathology and surgical maneuvers utilized in this case provides real-world tools to help surgeons deal with limited orifice availability, fibrosis, and multilevel lesions. We describe a mitral valve re-repair in a young athlete for a rare cleft posterior mitral leaflet, with a simultaneous tricuspid valve repair and Cox-Maze procedure. We focus on technical pearls that address specific anatomic challenges within our surgical approach.

Oral maxillofacial surgical residency and its impact on the academic and research productivity at different levels in Pakistan.

Oral and maxillofacial (OMF) surgery is a unique speciality. In many countries, OMFS is a dental speciality but the scope of its practice significantly overlaps with other specialities, including otolaryngology, head and neck surgery, plastic surgery, and orthopaedics. Thus, OMF surgery represents a true amalgamation of medical and dental specialities. There are different requirements of OMF residency training, which include a dental undergraduate training, medical training, or both. The training pathways for this speciality have evolved much in the last three decades and there is still no consensus over a single uniform path of becoming an OMF surgeon. An OMF surgeon deals with trauma, cysts, tumours and other pathologies of the maxilla, mandible, and zygomatic complex that need surgical correction. In addition to being a diverse speciality, the academic and research domains of residency have also changed. In Pakistan, residency training in OMF surgery started in 1994 and since then a lot of growth has taken place. This paper summarises the evolution and scope of OMF surgery and the contribution of this speciality in the overall academia and research in Pakistan's national dental scenario.

Neglected Monteggia fracture: a review.

Monteggia fracture is characterized by radial head dislocation combined with proximal ulnar fracture.If not diagnosed at an early stage, these lesions can gradually lead to forearm deformities and dysfunction, finally resulting in neglected Monteggia fracture. When the radial head is not reduced, several deformities develop at the humeroradial joint, including cubitus valgus and osteoarthritis.Adequate radiographs are crucial when the surgeons deal with forearm injuries.At present, proximal ulnar osteotomy and open reduction of chronic radial head dislocation provides satisfactory functional outcomes because of anatomic alignment reconstruction.Supplementary procedures, including transcapitellar pinning and repair or reconstruction of the annular ligament, which are performed in order to enhance stability of the humeroradial joint, should be thoroughly assessed based on joint rotational stability after reduction and on potential complications.

Epidemiology, Classification and Management of Zygomatic Fractures Among Children

The zygomatic bone, which includes the lateral and inferior orbital rims as well as the malar eminence, comprises the lateral part of the midface, giving it width and projection. Zygomatic arch fractures account for 10% to 15% of all facial fractures and are commonly caused by a direct blow to the face. Zygomatic fractures are most caused by blunt trauma. Paediatric zygomatic fractures are a rare complication in the continuum of craniofacial injuries that cosmetic and reconstructive surgeons deal with. The combination between etiology, force of damage, and stage of craniofacial development determines the location and distribution of facial fractures in children. The purpose of this research is to review the available information about the epidemiology, classification and management of zygomatic fractures in children. Although facial fractures especially zygomatic fractures in children are quite uncommon and rare, appropriate screening and diagnosis, as well as prompt treatment, are necessary to avoid consequences. Surgeons face tremendous hurdles when dealing with facial trauma associated with serious injuries, as there is a functional and aesthetic impact on the growing children, as well as a financial and emotional burden on the patient and family. The early management of zygomatic fractures in children, like any trauma, detects situations that require rapid treatment to avoid life-threatening consequences. Paediatric zygomatic fractures are quite uncommon due to the specific anatomic, physiologic, social, and environmental aspects that accompany craniofacial growth however the literature data is lacking and quite scarce, more epidemiological studies targeting age group of children are needed.

The potential of artificial intelligence as an equalizer of gender disparity in surgical training and education

The aim of this work is to offer a panoramic view on how artificial intelligence (AI) can help to break down gender disparity in enrollment and training of women in surgery. Nowadays, many visible and concealed obstacles still exist for women who pursue a surgical career. Impediments due to gender disparity prevent women from choosing surgical specialties. Furthermore, female surgical trainees have to face many difficulties during their training, such as inequity during the residency selection process, sexual harassment, discrimination in pregnancy experience and parental leave, and work-life balance problems. AI has been successfully employed for several applications in surgery to improve patient management, implement the decision-making process, and support training. AI could represent an effective way to overcome barriers related to gender disparity and overcome the obstacles women face during surgical education and training. Virtual and augmented reality, remote mentoring, and simulators could help female surgeons deal with disparities during their training and could positively impact the choice of women when pursuing a surgical career.

The Epidemiology of Osteomyelitis in Children.

Pediatric osteomyelitis remains challenging to treat. Detailed epidemiological data are required to estimate future developments. Therefore, we aimed to analyze how the incidence has changed over the last decade depending on age, gender, osteomyelitis subtype, and anatomical localization. Cases were quantified for patients aged 20 years or younger, using yearly reported ICD-10 diagnosis codes from German medical institutions for the time period 2009 to 2019. Incidence rates of osteomyelitis increased by 11.7% from 8.2 cases per 100,000 children in 2009 to 9.2 cases per 100,000 children in 2019. The age-specific incidence rate revealed the highest occurrence of osteomyelitis in patients aged 10–15 years (15.3/100,000 children), which increased by 23% over the observation period, followed by the age group 5–10 years (9.7/100,000 children). In 2019, out of all diagnoses, 39.2% were classified as acute, 38.4% as chronic, and 22.4% were unspecified, whereby chronic cases increased by 38.7%. The lower extremity was mainly affected, with 58.9% of osteomyelitis diagnoses in 2019. In conclusion, pediatric osteomyelitis is a serious issue, even in a developed and industrialized country such as Germany. Considering the recent incidence increase, the permanent need for appropriate treatment should let pediatricians and orthopedic surgeons deal with diagnosis and treatment protocols.

Machine learning in gastrointestinal surgery.

Machine learning (ML) is a collection of algorithms allowing computers to learn directly from data without predetermined equations. It is used widely to analyze "big data". In gastrointestinal surgery, surgeons deal with various data such as clinical parameters, surgical videos, and pathological images, to stratify surgical risk, perform safe surgery and predict patient prognosis. In the current "big data" era, the accelerating accumulation of a large amount of data drives studies using ML algorithms. Three subfields of ML are supervised learning, unsupervised learning, and reinforcement learning. In this review, we summarize applications of ML to surgical practice in the preoperative, intraoperative, and postoperative phases of care. Prediction and stratification using ML is promising; however, the current overarching concern is the availability of ML models. Information systems that can manage "big data" and integrate ML models into electronic health records are essential to incorporate ML into daily practice. ML is fundamental technology to meaningfully process data that exceeds the capacity of the human mind to comprehend. The accelerating accumulation of a large amount of data is changing the nature of surgical practice fundamentally. Artificial intelligence (AI), represented by ML, is being incorporated into daily surgical practice.

English

BACKGROUND The SARS-CoV-2 is known to be highly contagious from respiratory tract droplets and aerosol exposure. ENT surgeons deal with the upper airway and are exposed to aerosol generating procedures on a daily basis. Aerosol generating procedure such as tracheostomy is necessary in patients with head and neck cancers having airway obstruction. METHODS We share our experience of 38 cases where we had to perform tracheostomy during these Covid times under various circumstances in a tertiary care centre with a dedicated Covid Isolation centre for 5 districts with 210 beds reserved for Covid patients. RESULTS All 38 tracheostomies were performed successfully following the guidelines formulated by our team, with proper precautions not a single team member got infected with Covid-19. No test is 100 % sensitive, so all precautions must be taken while dealing with every patient and PPEs should be used in all tracheostomies. CONCLUSIONS No test is 100 % sensitive, so all precautions must be taken while dealing with every patient and PPEs should be used in all tracheostomies. Our policy of anticipating tracheostomy in patients with impending stridor helped us reduce the risk of having to perform emergency tracheostomies with Covid status unknown. KEY WORDS Aerosol, COVID-19, PPE - Kit, SARS-CoV-2, Stridor, Tracheostomy

A comparative mechanical study of two types of femur bone implant using the finite element method.

The femoral bone fracture is one of the most common fractures that orthopedic surgeons deal with. These fractures are associated with a significant percentage of death due to non-orthopedic complications. For this reason, it is necessary that the surgeon be well-aware of the condition of the patient and also of the biomechanical conditions of the bone and implant before surgery, in order to use the best surgical technique. Nowadays, the use of implants is a popular technique among the available methods for the treatment of femoral fractures. In the present study, two patients with different ages, three types of femoral bone fractures, that is, oblique, reverse oblique, and neck fracture, and two types of implants, namely, the dynamic hip screw (DHS) and the Gamma nail have been investigated. The behavior of the implants has been investigated at the two stages of treatment, that is, before and after bone union. The analysis of implants was based on the amount of stress and displacement induced in different parts of the bone and the implant. From the viewpoint of the stresses induced in the bone, all models are quite similar and in terms of the implant stresses, the Gamma nail is more reliable than the DHS. Additionally, the relative displacement of the fractured bone segments at the fracture planes was calculated. According to the obtained results, it can be concluded that the relative displacement of the fracture planes with the use of Gamma nail is somewhat less than the DHS, but this difference is not significant.

A rare presentation of midgut malrotation as an acute intestinal obstruction and perforation in an adult

Midgut malrotation is a congenital anomaly seen usually in childhood. Its presentation as an acute intestinal obstruction is extremely rare in adults usually identified intra operatively. A high index of suspicion is always required when dealing with any case of acute intestinal obstruction. We report a case of young adult who presented with symptoms of acute intestinal obstruction and was diagnosed intra-operatively as cecal volvulus with impending perforation caused by midgut malrotation. Malrotation of the intestinal tract is seen due to aberrant embryology. The presentation of intestinal malrotation in adults is very rare. Contrast enhanced Computed tomography (CT) can show the abnormal anatomy clearly. Anomalies like midgut malrotation can present as an operative dilemma and awareness regarding these conditions can help surgeons deal with these conditions.

Modified Interlaminar Endoscopic Lumbar Discectomy for Highly Upmigrated Disc Herniation: A Proctorship Description of the Technique via Translaminar Route.

Lumbar disc herniation (LDH) comprises one of the most common causes of low back pain. 35%–72% of LDH is associated with disc fragment migration. The migration of the disc fragments can be high-grade up, low-grade up, high-grade down, and low-grade down. Spine surgeons deal with unique challenges during surgical management of migrated discs. Operational challenges with open surgery include extensive lamina excision, pars excision, and potential for iatrogenic instability without fixation. In contrast, rigid instruments and poor visualization are the challenges with transforaminal endoscopic spine surgery (ESS). Hence interlaminar approach with ESS is an excellent choice with these migrated LDH. The creation of a translaminar crater in the cranial lamina without dealing with the interlaminar window or ligamentum flavum could be an excellent option to deal with these herniations face front. The lamina is the only anatomical barrier between the endoscope and the migrated disc fragment. Hence with a translaminar approach, unnecessary flavectomy can be avoided. In this technical report and video, we demonstrate the surgical technique of performing the translaminar ESS for highly upmigrated LDH with the preservation of optimal natural anatomy.