Functional outcome of routine versus on-demand removal of the syndesmotic screw: a multicentre randomized controlled trial

Aims The aim of this study was to investigate whether on-demand removal (ODR) is noninferior to routine removal (RR) of syndesmotic screws regarding functional outcome. Methods Adult patients (aged above 17 years) with traumatic syndesmotic injury, surgically treated within 14 days of trauma using one or two syndesmotic screws, were eligible (n = 490) for inclusion in this randomized controlled noninferiority trial. A total of 197 patients were randomized for either ODR (retaining the syndesmotic screw unless there were complaints warranting removal) or RR (screw removed at eight to 12 weeks after syndesmotic fixation), of whom 152 completed the study. The primary outcome was functional outcome at 12 months after screw placement, measured by the Olerud-Molander Ankle Score (OMAS). Results There were 152 patients included in final analysis (RR = 73; ODR = 79). Of these, 59.2% were male (n = 90), and the mean age was 46.9 years (SD 14.6). Median OMAS at 12 months after syndesmotic fixation was 85 (interquartile range (IQR) 60 to 95) for RR and 80 (IQR 65 to 100) for ODR. The noninferiority test indicated that the observed effect size was significantly within the equivalent bounds of -10 and 10 scale points (p < 0.001) for both the intention-to-treat and per-protocol, meaning that ODR was not inferior to RR. There were significantly more complications in the RR group (12/73) than in the ODR group (1/79) (p = 0.007). Conclusion ODR of the syndesmotic screw is not inferior to routine removal when it comes to functional outcome. Combined with the high complication rate of screw removal, this offers a strong argument to adopt on demand removal as standard practice of care after syndesmotic screw fixation. Cite this article: Bone Joint J 2021;103-B(11):1709–1716.

Hardware Removal in Maxillofacial Trauma: A Retrospective Study

Background. Miniplates are commonly used for the fixation of maxillofacial fracture segments. Removal of the hardware is controversial. A retrospective study of medical records was performed to observe the reasons for plate removal. Materials and Methods. A 10-year retrospective study of medical records was performed. Demographics, type of fracture, location, type of miniplate used, the time gap between the insertion and removal, and causes of hardware removal were assessed. Results. About 1472 patients had undergone internal fixation for the facial fractures. Stainless steel miniplate was used in 489 patients, and titanium was used in 983 patients. Out of the 42 cases, 22 cases involved the removal of titanium hardware and 20 patients involved the removal of stainless steel hardware. Infection/osteomyelitis was the main cause of hardware removal. The maximum amount of hardware failure was in the mandible. 78.6% of hardware removal was performed in males. Conclusion. Based on our study, routine removal of titanium miniplates can be performed in children to avoid growth disturbances, not indicated in adult patients unless symptomatic.

Is the Routine Removal of Titanium Plates and Screws Following Miniplate Osteosynthesis of Maxillofacial Bone Fractures Justified? A Fifteen-Year Experience in a Maxillofacial Centre, Saudi Arabia

Background Routine removal of titanium miniplates in the maxillofacial region is still controversial. This current study hopes to share our experience with the different reasons for maxillofacial plates and screws removal following miniplate osteosynthesis. Methods This was a retrospective study of plates and screws removal following Open Reduction and Internal Fixation (ORIF) of maxillofacial fractures at King Khalid Hospital, Kingdom of Saudi Arabia, from 2005-2019. Information collected includes demographics, etiology and pattern of maxillofacial fractures, treatment modalities as well as reasons for plates and screws removal. Data was stored and analyzed using IBM SPSS Statistics for windows Version 25 (Armonk, NY: IBM Corp). Results A total of 985 patients with maxillofacial bone fractures had ORIF during the study period out of which 149 had miniplates and screws removed, giving a prevalence rate of 15.1%. There were 141 (94.6%) males and 8 (5.4%) females, with a M:F of 17.6:1. Their ages ranged from 4-65 years with mean (SD) at 24.6 (12.2) years. The age group from 16-30 years had the most cases of plates removal with statistical significance ( P = .000). Young age (43 (28.8%)) constituted the majority of reasons responsible for plate removal. The angle of the mandible is the site with the largest number of plate removal with 34 (22.8%) cases followed by the parasymphyseal site with 21 (14.1%) cases. Conclusion With removal rate of 15.1%, this study concluded that there is no evidence to support routine removal of asymptomatic plates and screws in maxillofacial region.

Trends in Endodontic Protocols Amongst Dentists in Lahore

OBJECTIVES: To determine the trends in endodontic protocols amongst practicing dentists in teaching institutions and private clinics in Lahore. METHODOLOGY: A cross sectional survey was conducted amongst dentists working in the teaching institutions and in the private clinics of Lahore. A pre-piloted questionnaire survey adopted from Kohli et al with slight modifications was used. In this descriptive study 270 practicing dentists were selected using consecutive sampling with a 5% level of significance and margin of error. RESULTS: The 270 respondents had a mean age of 28.16 ± 6.18 participated in this study among which 111 (41.1%) were males and 159(58.9%) were females with the mean age of 30.28 ± 7.416 and 26.68 ± 4.62 respectively (12.2%) were consultants, 175(64.8%) were general dentists whereas 62(23%) were postgraduate residents. In our study population, 76(28.1%) dentists were using magnification among which 67(88.2%) were using loupes and 9(11.8%) were using microscope. The prevalence of the rubber dam usage for isolation among our respondents was 110(40.7%) only, 201(74.4%) dentists reported for routine removal of smear layer. Manual canal preparation technique was the most commonly used method practiced by 149(55.2%) dentists. 136(50.4%) dentists were using beveled needles for irrigation, whereas only 71(26.3%) were using side venting irrigation needles. Majority of the dentists (45.2%) were not using any method to increase the efficacy of the irrigants. CONCLUSION: There are deficiencies in the endodontic protocols followed by majority of the dentists in Lahore and these short comings should be addressed by governing bodies. KEYWORDS: Root canal therapy, Endodontic, Practice Patterns, Dentists HOW TO CITE: Lodhi Sk, Ehsan S, Rafique A, Saleem MN. Trends in endodontic protocols amongst dentists in Lahore. J Pak Dent Assoc 2020;29(4):239-245. DOI: https://doi.org/10.25301/JPDA.294.239 Received: 30 July 2020, Accepted: 08 September 2020

Infections after routine syndesmotic screw removal – a retrospective quality study

ABSTRACTBackgroundInfections after routine removal of syndesmotic screws are an unwanted complication.MethodsWe included all patients treated with syndesmotic screw with routine removal in a five-year period and extracted information regarding fracture characteristics and patient characteristics. Infections were classified as superficial or deep incisional.Results1246 patients with ankle fractures were treated surgically in the study period. 343 had routine removals of the syndesmotic screw. We identified 6 cases with infection (1.7%) developing after routine syndesmotic screw removal.ConclusionsWe found a low infection rate but when infections did occur, they frequently required surgical revision(s) and long-time antibiotic treatment.

Is Mini-Plate Removal Necessary for Oral and Maxillofacial Surgery Patients? A Five-Year Case-Control Study

Objectives: The purpose of this study was to determine the mini-plate and screw removal rate and reasons in maxillofacial surgery patients under previous semi-rigid fixation treatment in the past five years at the main trauma center of Mashhad. Materials and Methods: This was a census-based retrospective study. All the candidates who admitted to our department for maxillofacial plate removal due to symptomatic or infected mini-plates were included in this study. The patients’ age and gender, plate removal etiologies, and the time between plate insertion and removal were analyzed. Results: Mini-plates were inserted for 1026 patients. However, only 94 patients with a mean age of 29.4±11.1 years were candidates for plate removal. The plate removal rate was 9.16%. Infection and exposure were the most common causes of plate removal. The most prevalent removal site was the mandible (angle and body). The interval between mini-plate insertion and removal was an average of 12.9±5.6 months. It is noteworthy that the shortest lasting duration was when plate removal was secondary to pain (6.67 months) and infection (11.45 months). Conclusion: This research showed that the routine removal of plates does not appear to be generally indicated in healthy subjects unless there is an obvious and definitive clinical indication.

Implausible States: Prevalence of EQ-5D-5L States in the General Population and Its Effect on Health State Valuation

The EQ-5D is made up of health state dimensions and levels, in which some combinations seem less “plausible” than others. If “implausible” states are used in health state valuation exercises, then respondents may have difficulty imagining them, causing measurement error. There is currently no standard solution: some valuation studies exclude such states, whereas others leave them in. This study aims to address 2 gaps in the literature: 1) to propose an evidence-based set of the least prevalent two-way combinations of EQ-5D-5L dimension levels and 2) to quantify the impact of removing perceived implausible states from valuation designs. For the first aim, we use data from 2 waves of the English General Practitioner Patient Survey ( n = 1,639,453). For the second aim, we remodel a secondary data set of a Discrete Choice Experiment (DCE) with duration that valued EQ-5D-5L and compare across models that drop observations involving different health states: 1) implausible states as defined in the literature, 2) the least prevalent states identified in stage 1, and 3) randomly select states, alongside 4) a model that does not drop any observations. The results indicate that two-way combinations previously thought to be implausible actually exist among the general population; there are other combinations that are rarer, and removing implausible states from an experimental design of a DCE with duration leads to value sets with potentially different characteristics depending on the criterion of implausible states. We advise against the routine removal of implausible states from health state valuation studies.

An Unexpected Case of Late Fatal Central Venous Catheter Sepsis: A Case Report

Introduction Central venous catheters (CVC) are associated with risks and complications. Complications like vessel perforation, thrombosis, infection with significant morbidity and mortality, knotting, and ventricular perforation have been described. Another less-frequent complication is retained CVC fragments. We present a case of a very late but fatal complication after a CVC placement. This report is written in line with the consensus-based surgical case report guidelines (SCARE). Case A 46-year-old male presented to the emergency department in a critical (septic) shock. The patients' medical history featured a long–intensive care admission 28 years ago. The cause of this sepsis was not evident until a computed tomography scan was performed to exclude a pulmonary embolism, revealing a remnant of a central catheter in both pulmonary arteries. Despite extensive resuscitation, the patient died within 24 hours after admission. An autopsy was performed confirming that the catheter remnant was the only possible cause of the fatal sepsis. Discussion CVC's are associated with (fatal) complications; however, retainment of remnants are described unfrequently but do occur in almost 2% of the cases. Endovascular removal of these remnants has been performed successfully and should be the first treatment of choice if removal is considered. No evidence is available that suggests that routine removal has to be attempted but some longer term complications can be expected, so awareness of possible remnants after CVC removal should exist. Conclusion Retained fragments of CVC's are rare but are described after prolonged use. This case shows that these retained intravascular fragments can cause fatal complications on the long-term. Upon removal of CVC's, there should be awareness that retainment of fragments can occur.

Long-term outcomes of tracheal stents removal under fluoroscopy guidance: comparison of tracheal fistulas with tracheal stenosis

Background: No study compared the techniques and complications of stent removal under fluoroscopy guidance for tracheal fistula and tracheal stenosis.Methods: We conducted a retrospective analysis of 152 patients who underwent fluoroscopy-guided stent removal from January 2011 to June 2017. Eighty-five patients underwent stent removal for tracheal fistula (TF group), and 67 patients for tracheal stenosis (TS group). All patients underwent tracheal CT scans before stent removal and during follow up. The technical success rate, complications, survival rate were compared between the two groups.Results: The technical success rate of stent removal was 98.9% and 97.4% for tracheal fistula and tracheal stenosis, respectively. Except for the routine removal for half of patients, excessive granulation tissue was the common indications for stent removal, which was found 142.1±25.9 days later for tracheal fistula, and 89.9±15.0 day for tracheal stenosis. The total incidence of complications was 21.1% and 22.4% for tracheal fistula and tracheal stenosis, respectively. One perioperative death of asphyxia was found in TF group, and 2 deaths in TS group. Recurrence of fistula or stenosis requiring stenting was the most comment complication in both groups. The 0.5-, 3-, 6-year survival rates were 90.3%, 59.6%, and 36.1% for TF group, and 80.4%, 75.7%, 75.7% for TS group.Conclusions: Fluoroscopic removal of tracheal stent is safe and effective for both tracheal fistula and tracheal stenosis, with no significant difference. Recurrence of fistula or stenosis requiring stenting was the most comment complication.