Causes of late-presenting developmental dislocation of the hip beyond 12 months of age: A pilot study.

Background & objectives: Developmental dysplasia of the hip (DDH), when detected early, can usually be managed effectively by simple methods. A delayed diagnosis often makes it a complex condition to treat. Late presentation of DDH is fairly common in developing countries, and there is scarcity of literature regarding the epidemiology and reason for late presentation. Through this study, we attempted to identify the reasons for late presentation of DDH in children more than 12 months of age. Methods: Fifty four children with typical DDH and frank dislocation of hip in whom treatment was delayed for 12 months or more were included. Parents were interviewed with a pre-structured questionnaire and data were collected for analysis with Microsoft Excel 2016 and SPSS version 26. Results: Diagnostic delay was the most common reason for late presentation and was observed in 52 children (96.2%). The mean age at diagnosis was 24.7 months. The mean age at treatment was 37.3 months with a mean delay of 12.5 months from diagnosis and 22.1 months from initial suspicion. Physician-related factors contributed 55.3 per cent, while family and social issues accounted for 44.7 per cent of overall reasons for diagnostic and treatment delays. Interpretation & conclusions: Late presentation of DDH in walking age is common. Physician- and family-related factors accounted for most of these cases. Failure or inadequate hip screening at birth by the attending physician is a common reason for late diagnosis. The family members were unaware about the disorder and developed suspicion once child started walking with an abnormal gait.

Infralingular Versus Supralingular Medial Osteotomy in Sagittal Split Osteotomy of the Mandible: A Randomized Control Study.

PURPOSE: A recently proposed modification of the sagittal split osteotomy (SSO) of the mandible places the horizontal medial cut 'low and short' of the lingula. The purpose of the study was to answer the following clinical question: Among patients undergoing mandibular setback procedures (≤ 8 mm) via SSO, does the placement of the medial horizontal osteotomy below the lingula (infralingular), when compared to placement above the lingula (supralingular), results in different neurosensory, bite force, and range of motion outcomes? MATERIALS AND METHODS: This was a single-center, double-blind, parallel-group study among patients undergoing mandibular setback by SSO (≤ 8 mm), between January 2021 and September 2022. Patients were randomly allocated in a ratio of 1:1 to the supralingular (control) and the infralingular (study) group. Primary outcome variables included neurosensory disturbance of the inferior alveolar nerve based on clinical neurosensory testing and severity graded using Zuniga and Essick's protocol, bite force, and maximum mouth opening evaluated postoperatively during the first week (T1), first month (T2), and third month (T3) of follow-up. Secondary outcome measures included the incidence of a bad split and distal segment interferences intraoperatively. Association between the variables was assessed using Pearson chi-squared test or Fisher's exact test based on the expected observations. A P value of ≤.05 was considered statistically significant. RESULTS: A total of 29 patients (58 osteotomies) were included in the study. Group 1 consisted of 15 patients (9 females and 6 males) with a mean age of 26.4 years. Group 2 consisted of 14 patients (8 females and 6 males) with a mean age of 25.9 years. Patients with severe neurosensory disturbance of the inferior alveolar nerve were more common in group 2 (n = 15, 53.6%) than group 1 (n = 4, 13.3%) at T1 (P value = .0001) and insignificant between the two groups at T2 (P value = .63) and T3 (P value = .99). Comparison of maximum mouth opening between the two groups at T1 (P value = .535), T2 (P value = .934), and T3 (P value = .703) and bite force at T1 (P = .324), T2 (P = .113), and T3 (P = .811) was not significant. CONCLUSION: Both SSO techniques have similar clinical outcomes among patients having mandibular setbacks (≤ 8 mm) for the variables studied.

Clinico-Radiological and Functional Outcome of Difficult Talipes Equinovarus Deformity Corrected With an Ilizarov Fixator.

Relapsed, resistant, and untreated congenital talipes equinovarus poses significant challenges in view of functional outcome following conventional serial casting and soft tissue release procedures. The Ilizarov ring fixator here offers significant possibilities as an extended conservative treatment modality. The aim of the present study was to critically evaluate effectiveness of the Ilizarov ring fixator with regard to radiological, clinical, and functional outcomes, in the difficult clubfeet. The study was carried out on patients presenting with relapsed, resistant, or untreated congenital talipes equinovarus deformity, who underwent deformity correction using the Ilizarov ring fixator application. All patients were reviewed at 6 monthly intervals for over 3 years following fixator removal with an objective clinical, radiological, and functional assessment. Twenty-three patients with 30 clubfeet were enrolled in our study. The mean age was 8.3 ± 3.6 (range 4-17) years. The postoperative clinical, radiological, and functional scores showed statistically significant improvement among all patients when compared with the preoperative data. All 30 feet developed varying complications during treatment with pin track infections being the most common. However, they were managed while continuing the distraction correction process. The Ilizarov ring fixator is an effective and reliable solution for difficult and challenging clubfeet. However, one must be aware of a strict adherence to a bracing protocol to avoid recurrence of deformities. A regular periodical functional and clinical follow up must be ensured among these children for a favorable outcome.

Efficacy of Ponseti Technique in Virgin and Relapsed Clubfeet: A Comparative Study.

Doubts still loom over the effectiveness of Ponseti casting in treating children with recurrent clubfeet. We have undertaken this study to confirm whether excellent results obtained in treating virgin clubfeet by Ponseti casting can be reproduced with equal success in relapsed clubfeet. The patients were divided into 2 groups; Group I was untreated children with congenital clubfeet younger than 1 year of age (21 feet) and Group II was children with relapsed congenital clubfeet younger than 2 years of age (21 feet). The Ponseti method was applied with equal success in both groups. Groups I (virgin) and II (recurrent) were similar in terms of number of casts, period of immobilization, and successful initial correction. We did not find statistically significant differences (p value = .75) when comparing the number of casts required for correcting deformity in virgin (mean 6.3) and relapsed group (mean 5.5). The Pirani score improved significantly after treatment from 4.3 to a post-treatment value of 0.4 (p < .001) in recurrent clubfeet and from 5.4 to 0.31 (p < .001) in virgin clubfeet. The results of our study suggest that excellent initial correction of deformity can be achieved without the need for an extensive soft tissue release in more than 95% of children with recurrent clubfeet.

Influence of ethnic background on left atrial markers of inflammation, endothelial function and tissue remodelling.

BACKGROUND: It has been suggested that ethnicity can make a significant difference to the likelihood of thromboembolic stroke related to atrial fibrillation. Ethnic differences have been shown to alter inflammatory and haemostatic factors; however, this may all be confounded by differences in cardiovascular risk factors between different ethnicity. The impact of different ethnicities on the thrombogenic profile is not known. The aim of this study was to investigate differences in markers of inflammation, endothelial function and tissue remodelling between Caucasian and Indian populations with supraventricular tachycardia (SVT). METHODS: Patients with structurally normal hearts undergoing catheter ablation for SVT were studied. This study included 23 Australian (Caucasian) patients from the Royal Adelaide Hospital, Adelaide, Australia and 24 Indian (Indian) patients from the Christian Medical College, Vellore, India. Blood samples were collected from the femoral vein, and right and left atria. Blood samples were analysed for the markers of endothelial function (ADMA, ET-1), inflammation (CD40L, VCAM-1, ICAM-1), and tissue remodelling (MMP-9, TIMP-1) using ELISA. RESULTS: The study populations were well matched for cardiovascular risk factors and the absence of structural heart disease. No difference in the echocardiographic measurements between the two ethnicities was found. In this context, there was no difference in markers of inflammation, endothelial function or tissue remodelling between the two SVT populations. CONCLUSION: Caucasian and Indian populations demonstrate similar inflammatory, endothelial function or tissue remodelling profiles. This study suggests a lack of an impact of different ethnicity in these populations in terms of thrombogenic risk.

Characterization of thrombogenic, endothelial and inflammatory markers in supraventricular tachycardia: a study in patients with structurally normal hearts.

Patients with atrial fibrillation (AF) are at an increased risk of thromboembolism and stroke primarily from the development of thrombi within the left atrium. Pathological changes in blood constituents and atrial endothelial damage promote left atrial thrombus formation. It is not known whether factors predisposing to left atrial thrombus formation in AF are disease specific or also evident within the normal heart. The present study examined whether there are differences in platelet reactivity, endothelial function and inflammation in blood samples obtained from intracardiac and peripheral sites in subjects within structurally normal hearts. Sixteen patients with diagnosed left-sided supraventricular tachycardia (SVT) undergoing a routine elective electrophysiological study and ablation were investigated. Blood samples were taken simultaneously from the femoral vein, right atrium and left atrium, immediately following trans-septal puncture and prior to heparin bolus administration. Between peripheral and atrial sample sites, patients with SVT showed no change in platelet reactivity or aggregation (P-selectin (CD62P) P = 0.91; platelet-derived soluble CD40 ligand P = 0.9), thrombus formation (thrombin-antithrombin complex; P = 0.55), endothelial function (von Willebrand factor P = 0.75; asymmetric dimethylarginine (ADMA) P = 0.97; nitric oxide P = 0.61), or inflammation (vascular cell adhesion molecule-1 P = 0.59; intercellular adhesion molecule-1 (ICAM-1) P = 0.69). However, SVT patients had lower ADMA and ICAM-1 levels than AF patients. The present study demonstrates, for the first time, that SVT subjects with structurally normal hearts have consistent haemostatic function between atrial and peripheral sites. These results suggest that the atria of SVT patients do not contain predisposing thrombogenic, endothelial or inflammatory factors that promote and/or initiate thrombus formation.

Optimal Depth of Penetration to Access the Superior Joint Space in Temporomandibular Joint Arthroscopy: A Single Institutional Retrospective Study.

Aim: To identify the optimal depth of penetration required to access the superior joint space (SJS) for arthroscopic procedures of the temporomandibular joint (TMJ) among the study population. Materials and Methods: The study included all patients with internal derangement (ID) of the TMJ, managed by TMJ arthroscopy in our institution. The study was conducted with data retrieved from the hospital records over five years (January 2018-April 2022). Demographic factors and depth of penetration (mms) were the variables included in our study. For all the statistical interpretations, p < 0.05 was considered statistically significant. Results: The study included 66 patients (males, n = 25; females, n = 41) who underwent arthroscopic procedures of the TMJ (right = 29, left = 37). The mean duration between the development of symptoms and the point of intervention (TMJ arthroscopy) in our study was 3.94 months. The mean depth of penetration of the arthroscope as measured from the skin to the point of entry into the SJS was 20.60 ± 1.85 mms in males and 19.56 ± 1.38 mms in females (p value < 0.05). Variables such as age, duration of symptoms, side involved and stage of ID did not have any influence on the optimal depth of penetration required to access the joint space among our study population. Conclusion: The optimal depth of penetration (mean) required to access the SJS was less than 25 mms in our study population.

An early loaded implant-supported mandibular complete arch fixed prosthesis in a young completely edentulous patient: a case report.

The restoration of the mandibular arch up to the first molars with 5 one-piece implants presents a viable and cost-effective treatment plan in patients with adequate bone volume and favorable ridge relationships. The early loading of the implants with a provisional restoration reduces the period of edentulousness and restores the patient's ability to eat, talk, and smile effectively. Implants in younger patients prevent resorption of the residual alveolar ridge. This article presents a case report of the restoration of an edentulous mandibular arch with an early loaded implant-supported fixed restoration in a young patient.

Role of iodoform in jaw lesions: a systematic review.

Iodoform formulations are used as packing material following the surgical removal of jaw lesions. The purpose of this review was to explore the evidence and efficacy of iodoform-based dressings. We have systematically reviewed published articles according to the PRISMA statement. The search was conducted in PubMed, Google Scholar, Semantic Scholar, and the Cochrane Library database for articles mentioning the use of iodoform as dressing material for jaw lesions from January 2000 to March 2022. Finally, 92 studies were included. A total of 386 patients whose ages ranged from five months to 86 years (male n = 180, female n = 117). Different formulations of iodoform used were BIPP (n = 67), Whitehead's varnish (n = 17), iodoform (n = 7) and, iodine (n = 1) for its antiseptic properties. An iodoform impregnated gauze pack was changed once a week, most commonly, for a stipulated duration, until complete healing of the cavity. In the present review, iodoform was used, most commonly, in pathological cavities following surgical treatment of ameloblastoma and odontogenic keratocyst. Toxicity was reported in two studies. Based on the current review, iodoform is relatively safe and can be used in the management of extensive jaw lesions in which secondary healing is expected. Prospective and randomised control trials are recommended to assess the efficacy of various formulations and to delineate the timeframe for patient compliance.

Predictors of atrial fibrillation post coronary artery bypass graft surgery: new scoring system.

BACKGROUND: Atrial fibrillation (AF) following coronary artery bypass graft surgery (CABG) is common and results in significant increases in hospital stay and financial encumbrance. OBJECTIVE: Determine and use the predictors of postoperative AF (POAF) following CABG to develop a new predictive screening tool. METHOD: A retrospective case-control study evaluated 388 patients (98 developed POAF and 290 remained in sinus rhythm) who undertook CABG surgery at Townsville University Hospital between 2016 and 2017. The demographic profile, risk factors for AF including hypertension, age≥75 years, transient ischaemic attack or stroke, chronic obstructive pulmonary disease (HATCH) score, electrocardiography features and perioperative factors were determined. RESULTS: Patients who developed POAF were significantly older. On univariate analysis HATCH score, aortic regurgitation, increased p-wave duration and amplitude in lead II and terminal p-wave amplitude in lead V1 were associated with POAF; as were increased cardiopulmonary bypass time (103.5±33.9 vs 90.6±26.4 min, p=0.001) and increased cross clamp time. On multivariate analysis age (p=0.038), p-wave duration ≥100 ms (p=0.005), HATCH score (p=0.049) and CBP Time ≥100 min (p=0.001) were associated with POAF. Receiver operating characteristic curve demonstrated that with a cut-off of ≥2 for HATCH score, POAF could be predicted with a sensitivity of 72.8% and a specificity of 34.7%. Adding p-wave duration in lead II >100 ms and cardiopulmonary bypass time >100 min to the HATCH score increased the sensitivity to 83.7% with a specificity of 33.1%. This was termed the HATCH-PC score. CONCLUSION: Patients with HATCH scores ≥2, and those with p-wave duration >100 ms, or cardiopulmonary bypass time >100 min were at greater risk of developing POAF following CABG.

Extracranial schwannoma of the maxillary nerve misdiagnosed as trigeminal neuralgia in an elderly patient with schizophrenia - A diagnostic dilemma.

The present paper discusses the diagnostic challenges we faced in a 60-year-old woman with a history of schizophrenia, presenting with left unilateral facial pain for the past three months. Based on the elaborate clinical examination and diagnostic nerve blocks, the patient was diagnosed with trigeminal neuralgia (TN) and non-surgical therapy commenced. Further investigations with magnetic resonance imaging (MRI) and ultrasound-guided fine needle aspiration cytology (FNAC) revealed the presence of an extracranial schwannoma involving a branch of the maxillary nerve. The patient was symptomatically relieved after surgical excision of the benign tumor under general anesthesia. Hence, we emphasize the need for special care and attention in psychiatric patients presenting with orofacial pain.

Comparison of Intralesional Placentrex Versus Hyaluronidase and Dexamethasone Injection in the Symptomatic Management of Stage II Oral Submucous Fibrosis - a Prospective Study.

AIM: The present study aimed to compare the effectiveness of intralesional placentrex versus hyaluronidase + dexamethasone injection in the symptomatic management of stage II OSMF. MATERIALS AND METHODS: This was a non-randomized prospective study conducted over a period of 14 months at a tertiary referral center. Patients with clinical stage II OSMF were randomly grouped into A(n = 18) and B(n = 17). These patients were treated with weekly intralesional injection of placentrex and hyaluronidase + dexamethasone respectively, over a period of six weeks. Variables such as mouth opening, burning sensation and colour of mucosa were evaluated at baseline(T0), second week(T1), fourth week(T3), sixth week(T4) of follow up. A p-value < 0.05 was considered statistically significant. RESULTS: A total of 15 patients completed the study in each group with regular follow up. The mean improvement in mouth opening was 4.3 ± 0.57 mms in group A(p-value < 0.001) and 7.2 ± 0.76 mms in group B(p-value < 0.001) which were significant at the end of six weeks. Mean change in burning sensation at the end of six weeks in group A was 1.2 ± 0.73(p-value < 0.001), and 3.6 ± 0.63(p-value < 0.001) in group B. Mean change in colour of mucosa at the end of six weeks was 1.4 in group A(p-value > 0.05) and 2 in group B(p-value > 0.05). On comparison between both groups, patients in group B exhibited better mouth opening and reduction of burning sensation than patients in group A(p-value < 0.001). CONCLUSION: Both intralesional placentrex and hyaluronidase + dexamethasone injection are effective in alleviating the symptoms of stage II OSMF. However, hyaluronidase + dexamethasone injection showed slightly better improvement in mouth opening and burning sensation after six weeks.

Direction-dependent conduction abnormalities in the chronically stretched atria.

AIMS: There is increasing evidence of the role direction-dependent conduction plays in the arrhythmogenic interaction between ectopic triggers and abnormal atrial substrates. We thus sought to characterize direction-dependent conduction in chronically stretched atria. METHODS AND RESULTS: Twenty-four patients with chronic atrial stretch due to mitral stenosis and 24 reference patients with left-sided accessory pathways were studied. Multipolar catheters placed at the lateral right atrium, crista terminalis, and coronary sinus (CS) characterized direction-dependent conduction along linear catheters and across the crista terminalis. Bi-atrial electroanatomic maps were created in both sinus rhythm and an alternative wavefront direction by pacing from the distal CS. This allowed an assessment of conduction velocities, electrogram, and voltage characteristics during wavefronts propagating in different directions.  While differing wavefront directions caused changes in both chronic atrial stretch and reference patients (P< 0.001 for all), these direction-dependent changes were greater in chronic atrial stretch compared with reference patients, who exhibited greater slowing in conduction velocities (P= 0.09), prolongation of bi-atrial activation time (P= 0.04), increase in number (P< 0.001) and length (P< 0.001) of lines of conduction block, increase in fractionated electrograms (P< 0.001), and decrease in voltage (P= 0.08) during left-to-right compared with right-to-left atrial activation. These direction-dependent changes were associated with a greater propensity for chronically stretched atria to develop atrial fibrillation (P= 0.02). CONCLUSIONS: Atrial remodelling in chronic atrial stretch exacerbates physiological direction-dependent conduction characteristics. Our data suggest that the greater direction-dependent conduction seen in patients with chronic atrial stretch may promote arrhythmogenesis due to ectopic triggers from the left atrium.

Comparison of the effectiveness of soft and hard splints in the symptomatic management of temporomandibular joint disorders: A randomized control study.

AIM: Splint therapy is a well-established modality in the management of temporomandibular joint disorders (TMDs). We aimed to evaluate and compare the effectiveness of hard and soft splints in the symptomatic management of TMDs using the modified Helkimo index. METHODS: This study included 91 patients diagnosed with TMDs. Participants were randomly allocated into two treatment groups. All these patients were treated by hard or soft stabilization splint therapy. Group 1: hard splint group, n = 42 (mean age - 31.62 ± 8.5 years), 10 males and 32 females; group 2: soft splint group, n = 49 (mean age - 32.86 ± 9.06 years), 13 males and 36 females. The anamnestic and clinical dysfunction component of the modified Helkimo index was used to evaluate the outcomes at baseline (T0 ), first month (T1 ), and third month (T2 ). RESULTS: Symptoms such as clicking of the joints, temporomandibular joint (TMJ) pain and muscle pain showed improvement in both groups (P < .05). Restriction and deviation of mouth opening did not show significant improvement in either group. The patients who underwent hard splint therapy showed an early improvement of symptoms at T1 (P < .05). However, there was no statistical difference in the improvement of symptoms between hard and soft splints at T2 . CONCLUSION: Both hard and soft stabilization splints were effective in the symptomatic management of TMDs. However, hard splints provide an earlier reduction of symptoms.

Palatal Flap: An Optimistic Salvagable Option to Negate the Maxillectomy Defects in COVID Related Rhino-Orbito-Cerebral Mucormycosis.

We present three cases diagnosed with COVID-19 associated Rhino-orbito-cerebral mucormycosis, managed by aggressive debridement and resection of the involved maxilla, followed by primary closure with preserved palatal flap, thus trying to establish its versatility for the closure of the maxillectomy defects.

Ludwig's angina in a COVID positive patient-An atypical case report.

The management of odontogenic infections is established and several guidelines have been proposed for its effective treatment. Outbreak of COVID-19 has posed serious challenge in the management of odontogenic infections, further complicated by immunocompromised status of the patient, where adequate evaluation and prompt attention is mandatory to avoid untoward consequences. Ludwig's angina being a life threatening infection by itself, association or simultaneous presentation with COVID-19 infection can add further complexity in the management for a maxillofacial surgeon. Here we present a case report of Ludwig's angina in a patient who tested positive for Coronavirus infection and how we treated her successfully.

Retrieval of Migrated Embedded Sewing Machine Needle from the Tongue.

Foreign body in the oral cavity can be encountered by Head and Neck Surgeons in their clinical practice. Here, we report a rare case of an embedded sewing machine needle in the posterior tongue that migrated by tongue movements, and was retrieved successfully by surgical intervention.

Complications of arthroscopic lysis and lavage in internal derangement of the temporomandibular joint - A single institutional experience with review of literature.

PURPOSE: To evaluate the complications of arthroscopic lysis and lavage with joint sweep (ALL) procedure in the management of disc derangement of the temporomandibular joint. METHODS: Patients with internal derangement of the TMJ who were treated by ALL in a tertiary institution from July 2018 to December 2021 were studied retrospectively. RESULTS: The study included 39 patients (males, n = 14; females, n = 25) and 50 joints. The complications observed in the study were classified into intra and post operative complications. Post operative complications such as pain (16%), swelling (6%), reduced mouth opening (22%) and neurological complications were the most commonly observed ones. Rare complications such as ipsilateral palatal swelling (6%), parapharyngeal swelling (4%), and post operative malocclusion (2%) were also observed. CONCLUSION: Although the complications of ALL are entirely unavoidable, their incidence can be reduced by strict adherence to standard techniques. Three-dimensional awareness and orientation of the dangerous angles and depth around the TMJ region is mandatory to reduce the complications.

Post-traumatic Actinomycotic Oro-antral Fistula Closure with Three-dimensional Stereolithographic Modeling and Patient-Specific Titanium Implant.

We report an interesting case of a post-traumatic actinomycotic oro-antral fistula of the left posterior maxilla, that was not salvageable via local flaps due to the size of the defect and was managed with the patient-specific titanium implant, fabricated by three-dimensional stereolithographic model planning followed by primary closure.