One of the most dreaded complications of fracture management is a nonunion. Nonunions are usually difficult to manage and can be a source of significant mental, physical, and financial distress to the patient. The incidence of nonunion is dependent on multiple factors including degree of comminution, open versus closed, concomitant infection, and vascular status, and therefore the management of such nonunions continues to be an often debated topic. Currently, there is no clear consensus on the role of reamed exchange nailing for tibial shaft nonunions. While reamed exchange nailing for aseptic tibial shaft nonunions has shown promising results, with very high union rates, many surgeons prefer newer novel techniques such as plating along with osteoperiosteal decortication or the use of more conventional compressive plating with bone grafts. The aim of this article is to critically review and understand the available evidence base on reamed exchange nailing in nonunion of tibial shaft fractures and to explore the other options available and their indications.

Background Postoperative ileus is one of the most prevalent and troublesome problems after any elective or emergency laparotomy. Gum chewing has emerged as a new and simple modality for decreasing postoperative ileus. The aim of this study was to determine the effectiveness of chewing gum in reducing postoperative ileus in terms of passage of flatus and total length of hospital stay. Patients and methods This single‐blinded, randomized clinical trial was conducted in department of surgery, Services Hospital Lahore, between November 2013 and November 2015. The patients were divided into two groups: chewing gum (Group A) and no chewing gum (Group B). Starting 6 h after the operation, Group A patients were asked to chew gum for 30 min every 8 h; bowel sounds, passage of flatus and total length of hospital stay were noted. Outcome measures such as passage of flatus and total length of hospital stay in patients undergoing reversal of ileostomy were compared using t‐test. Results Mean age of the patients in Group A was 26.12 (± 7.1) years and in Group B was 28.80 (± 10.5) years. There were 25 males (50%) and 25 females (50%) in Group A. In Group B, there were 29 males (58%) and 21 females (42%). Mean BMI in Group A was 23.5 (± 5.3), and in Group B was 21.4 (± 4.6). The mean time to pass flatus was noted to be significantly shorter, 18.36 (± 8.43) hours, in the chewing group (Group A), whereas in the no chewing gum group (Group B), it was 41.16 (± 6.14) hours (p value < 0.001). The mean length of hospital stay was significantly shorter 84 (± 8.3) hours in the chewing gum group (Group A) as compared to 107.04 (± 6.4) hours in the no chewing gum group (Group B) (p value 0.000). Conclusion It is concluded that postoperative chewing of gum after the reversal of ileostomy is accompanied with a significantly shorter time to passage of flatus and shorter length of hospital stay.

Situs inversus is a rare condition. It is characterised by reverse handed positioning of the internal viscera. Laparoscopic cholecystectomy is the standard procedure for cholelithiasis, but it may lead to technical difficulties in case of situs inversus, especially to right-handed surgeons. A 40-year female presented to the department with epigastric pain and bloating usually after fatty meals. Diagnosis of symptomatic gall bladder stone was made. She was a known case of situs inversus. Laparoscopic cholecystectomy was performed by right-handed surgeon with uneventful recovery.

IntroductionThe aim of this study was to investigate the incidence of shoulder morbidity in our cohort of patients with latissimus dorsi flap reconstruction after mastectomy.MethodsThis is a retrospective study of prospectively collected data of 72 patients using validate Oxford shoulder score for function and quickDASH score for disability. Scores were collected preoperatively and at time of final review or study. We also reviewed patient records for patients who had a formal diagnosis of shoulder pathology. Results were analysed with student t-test.ResultsAnalysis of scores showed a statistically significant worsening of both oxford shoulder score (p < 0.005) and quickDASH score (p < 0.005), when pre and post-operative scores were compared. Seven patients had a formal diagnosis of shoulder pathology, and all of them recovered well. There was no significant difference in oxford shoulder score or quickDASH scores between patients with or without shoulder pathology. About 40% patients had some functional loss or disability at 4 years after the surgery.ConclusionOur study shows a high incidence of significant shoulder functional morbidity following latissimus dorsi flap reconstruction but number of patients requiring specific treatment is low.Level of evidenceLevel IV, therapeutic study.

Approximately 20-30% of patients with metastatic germ cell cancers (GCCs) can develop relapsed or refractory (RR) disease, about 40-50% of patients who relapse after salvage chemotherapy may reach long-term remission. The goal of this review was to identify patients who appear to benefit from high-dose chemotherapy (HDCT) and autologous stem cell transplant (ASCT). To access this, we performed a systematic medical literature review to evaluate the effectiveness of HDCT in the frontline setting, as well as in patients with RR testicular cancer. We searched databases for interventional clinical studies and identified 5883 studies. We selected 49 studies for inclusion, which included a total of 5985 patients. Seventeen studies reported results of newly diagnosed poor-risk GCC patients and 32 studies reported results of RR patients. For newly diagnosed patients with poor prognostic predictors, a risk adjusted strategy using unfavorable tumor marker decline with initial standard chemotherapy regimen and upfront HDCT demonstrated improved outcomes. Our data suggest a minimum of two HDCT cycles with ASCT should be standard of care for patients with RR GCC. Failure of HDCT results in a poor prognosis with only 10% of patients achieving lasting remission with salvage therapy.

Bioabsorbable interference screws have been effective for graft fixation in anterior cruciate ligament (ACL) reconstruction. The overall complication rate associated with the use of these screws is low but some unique problems have been reported in the literature. We present a case of unusual tissue reaction to a bioabsorbable interference screw following ACL reconstruction.A young male underwent ACL reconstruction, during which a bioabsorbable interference screw was used for graft fixation at the tibial end. The patient presented with a pretibial swelling at 30 months after the operation. Exploration revealed chalky white remnants of the bioabsorbable screw with no evidence of infection. Histological studies confirmed a foreign body reaction against screw remnants with the presence of multinucleated giant cells.The patient had a full recovery with no compromise to graft stability. Bioabsorbable interference screws are usually inert but can initiate a tissue reaction. The presentation can be as late as 2-3 years postoperatively and may mimic an infection. Satisfactory results can be achieved by proper exploration and debridement.

Gossypiboma or textiloma is a rare but very unfortunate complication of surgery. It refers to a retained foreign body usually forgotten within the abdominal cavity at the end of an operation. It may be a surgical sponge, gauze pad or other form of textile.We present the case of a middle aged lady who following cholecystectomy had a forgotten gauze which underwent transmural migration and was later expelled via the rectum demonstrated by radiological studies.

Objective: To observe the effect of modified ultrafiltration on hemodynamics of pediatric patients. Study Design: A descriptive cross-sectional study. Place and Duration of Study: Pediatric Cardiac Surgery department, AFIC/NIHD Rawalpindi, from Jun 2019 to Dec 2019. Methodology: A total of 60 pediatric patients were included undergoing open-heart surgery with cardiopulmonary bypass, having age ≤6 years and weights ≤15kg. To assess hemodynamics parameters observed were pre modified ultrafiltration and post modified ultrafiltration measurements of haemoglobin level, systolic pressure, diastolic pressure, central venous pressure and the number of transfusions given after off-bypass. The data was entered and analyzed in SPSS-23. Results: The pre-operative mean Hb level of the 60 sampled patients was 12.08 ± 2.89 g/dl. The findings taken pre modified ultrafiltration and post modified ultrafiltration of haemoglobin level was (9.91 ± 0.91 g/dl and 13.09 ± 1.38 g/dl, p<0.05) after an average filtration of 370.83 ± 66.56 ml of the filtrate. The mean of systolic pressure was (61.3 ± 2.01 mmHg and 70.68 ± 1.76 mmHg, p<0.05), diastolic pressure was (49.95 ± 1.35 and 59.7 ± 6.85, p<0.005), Central Venous Pressure was (10.07 ± 1.18 and 9.9 ± 1.09, p>0.005) compared pre modified ultrafiltration and post modified ultrafiltration respectively. Conclusion: The study concluded that modified ultrafiltration has a significant impact on haemoglobin levels after bypass, decreases the allogenic transfusions and also improve the hemodynamics of the patient.