Comparative study of functional outcomes of arthroscopic anterior cruciate ligament reconstruction using anteromedial portal and translateral all-inside technique.

Background: Anterior Cruciate Ligament (ACL) injuries are common in the active population of the Armed Forces. Symptomatic instability prompts individuals to seek a cure or a sheltered appointment. Despite the increasing numbers of ACL reconstructions performed, the outcomes have not been so spectacular with only a meager percentage of our patients returning to preinjury levels of activity. With the premise that an all-inside ACL reconstruction is likely to result in better functional outcomes, the aim of this study was to compare the short-term functional outcomes of a large consecutive series of patients undergoing ACL reconstruction using the translateral all-inside ACL reconstruction technique (AI) and standard anteromedial portal technique (AM) with a minimum follow-up of one year. Methods: A total of 240 patients with isolated ACL tear underwent ACL reconstruction via the AI or AM technique. Their preoperative and postoperative scores were compared to look for any significant differences in functional outcomes. Results: The two groups were matched for age, BMI, mechanism of injury, and interval from injury to surgery. There was no difference in their preoperative scores. Postoperatively, although there were significant improvements across both groups, there was no significant difference between the groups at any point of time. Conclusion: The AI technique has garnered interest in recent literature in addressing ACL injuries. This study found no discernible benefit of the AI technique when compared to the AM technique in terms of functionality following an ACL reconstruction at any point of time up to 1 year following surgery.

Pulmonary function parameters and its determinants among cement factory workers in Chhattisgarh: A cross-sectional study.

BACKGROUND: Cement in one hand is the most used substance for construction all over the world but on the other hand prolonged exposure from cement dust particles along with smoking, long working duration in dusty environments and increasing age impairs pulmonary functions. OBJECTIVES: The study aimed to determine the effect of cement dust on the pulmonary functions of cement factory workers. METHODS: It was a cross-sectional observational study conducted from October 2019 to February 2020 among 360 workers of cement factories of Chhattisgarh state selected by systematic random sampling who were interviewed. Spirometry was done and their forced vital capacity, forced expiratory volume in one second, Forced expiratory flow, peak expiratory flow rate, and lung age were determined with a flow-sensing spirometer. Data were collected, entered in MS Excel spreadsheet, and analyzed using SPSS software (version 20.0) for Chi-square test, linear regression, and general linear model. RESULTS: One-third of the study subjects had pulmonary dysfunction, out of which 10% and 30% were having severe and moderate dysfunction, respectively. Significant higher Odds for developing impaired pulmonary functions were seen among >40 years of age (adjusted odds ratio [AOR] =1.88 [1.13, 3.12]), more than 10 years of service (AOR = 4.69 [2.32, 9.53]) and smokers (AOR = 4.45 [2.53, 7.83]). CONCLUSION: Working in dusty environment along with other factors in cement factories significantly decrease lung parameters. Exposure with dust is strong predictor for chronic respiratory symptoms.

Investigating ataxia in childhood.

Ataxia is a common presentation to an acute paediatric unit and it can often be difficult to determine the cause. It is important to distinguish between serious causes, for example, brain tumours and encephalitis, and more benign causes in order to guide investigations and treatment. In this review, we describe the different types of ataxia, the causes associated with them, the examination findings and what investigations to perform in order to make a diagnosis.

Fifteen-minute consultation: When medicines don't work-the child with poorly controlled seizures.

Drug-resistant epilepsy (DRE) occurs in 20%-30% of children with epilepsy with significant impact on their quality of life. Management of this group of children has greatly improved in the recent years with streamlining of epilepsy surgery services and associated quaternary multimodal evaluation. This article provides a review of DRE in children and management based on recent evidence and published opinion. We have also presented an algorithmic approach to the child with possible DRE.

Fifteen-minute consultation: Approach to the child with an acute confusional state.

Acute confusional state (ACS) refers to sudden impairment of cognitive function and represents a major medical emergency. The impairment may be global or confined specifically to a particular faculty of higher mental function, such as memory. This review highlights the importance of relevant medical history and clinical signs and symptoms in reaching the correct diagnosis. In this review, we have presented a diagnostic approach to a child presenting with ACS and described commonly encountered causes, their treatments and outcomes. We have also presented an algorithm for the diagnostic approach to the child with ACS.

Fifteen-minute consultation: when is a seizure not a seizure? Part 1, the younger child.

Paroxysmal non-epileptic events (PNEs) are common, and occur in all age groups ranging from neonates to young adults. The key to diagnosis in the majority is a detailed history and careful observation. However, a few can pose diagnostic challenges for the paediatrician to differentiate them from epileptic seizures. PNEs are usually recurrent, stereotyped and some of them tend to repeatedly occur within the same context. Although the vast majority have a benign nature, they can be a source of parental anxiety, unnecessary investigations and even potentially harmful treatments. In this review, we have described the common PNEs occurring in infants and preschool children. This will be followed by a second review for older children and adolescents. We have provided a practical diagnostic approach by dividing these events into three broad categories: PNEs associated with altered consciousness, PNEs not associated with apparently altered consciousness and sleep-related PNEs.

Treatable childhood neuronopathy caused by mutations in riboflavin transporter RFVT2.

Childhood onset motor neuron diseases or neuronopathies are a clinically heterogeneous group of disorders. A particularly severe subgroup first described in 1894, and subsequently called Brown-Vialetto-Van Laere syndrome, is characterized by progressive pontobulbar palsy, sensorineural hearing loss and respiratory insufficiency. There has been no treatment for this progressive neurodegenerative disorder, which leads to respiratory failure and usually death during childhood. We recently reported the identification of SLC52A2, encoding riboflavin transporter RFVT2, as a new causative gene for Brown-Vialetto-Van Laere syndrome. We used both exome and Sanger sequencing to identify SLC52A2 mutations in patients presenting with cranial neuropathies and sensorimotor neuropathy with or without respiratory insufficiency. We undertook clinical, neurophysiological and biochemical characterization of patients with mutations in SLC52A2, functionally analysed the most prevalent mutations and initiated a regimen of high-dose oral riboflavin. We identified 18 patients from 13 families with compound heterozygous or homozygous mutations in SLC52A2. Affected individuals share a core phenotype of rapidly progressive axonal sensorimotor neuropathy (manifesting with sensory ataxia, severe weakness of the upper limbs and axial muscles with distinctly preserved strength of the lower limbs), hearing loss, optic atrophy and respiratory insufficiency. We demonstrate that SLC52A2 mutations cause reduced riboflavin uptake and reduced riboflavin transporter protein expression, and we report the response to high-dose oral riboflavin therapy in patients with SLC52A2 mutations, including significant and sustained clinical and biochemical improvements in two patients and preliminary clinical response data in 13 patients with associated biochemical improvements in 10 patients. The clinical and biochemical responses of this SLC52A2-specific cohort suggest that riboflavin supplementation can ameliorate the progression of this neurodegenerative condition, particularly when initiated soon after the onset of symptoms.

Fifteen-minute consultation: when is a seizure not a seizure? Part 2, the older child.

Paroxysmal non-epileptic events (PNEs) refer to episodic changes in behaviour, sensation or consciousness that lead to unusual movements, which may resemble epileptic seizures, but are not, due to excessive neuronal firing in the cerebral cortex. A significant proportion of patients seen in epilepsy clinics do not actually have epilepsy. Therefore, it is paramount for clinicians to be able to recognise these transient non-epileptic events in order to avoid unnecessary antiepileptic treatments and to provide appropriate management as required. These PNEs can be observed within the context of a neurological disorder such as migraine or with no direct neurological basis such as simple tics. In this review, we have described common PNEs presenting in school-age children and adolescents alongside the clinical approach to differentiate them from epileptic seizures. PNEs occurring in infancy and younger children have been covered in our first review of this series.

Fifteen minute consultation: tremor in children.

Tremor is defined as a rhythmic, involuntary, oscillatory movement of body parts. Although constituting nearly 20% of presentations with paediatric movement disorders, tremor in childhood, beginning in the neonatal period, has rarely been described in the literature. Tremor may be an isolated finding or a part of associated neurological or systemic disorders. In this review we aim to discuss the classification, aetiology, clinical features and management of various tremor syndromes in childhood.

Fifteen-minute consultation: the child with idiopathic intracranial hypertension.

Idiopathic intracranial hypertension (IIH) is a rare condition where intracranial hypertension is found in the context of normal brain parenchyma and no mass lesion, ventriculomegaly, underlying infection, or malignancy. Our understanding of this condition has greatly improved in the recent years with neuroimaging features and normal values for lumbar puncture opening pressure now well defined. This article provides a review of IIH in children and revised diagnostic criteria based on recent evidence and published opinion. We have also presented an algorithmic approach to the child with possible IIH.

Comparison of extramedullary and intramedullary devices for treatment of subtrochanteric femoral fractures at tertiary level center.

OBJECTIVE: The treatment of subtrochanteric fractures is challenging and treatment modalities and implants are constantly evolving. This study attempts to revisit and compare extramedullary vs. intramedullary devices in relatively young population. METHODS: Thirty patients with subtrochanteric fractures were enrolled and treated with extramedullary or intramedullary devices and follow-up continued one year for clinico-radiological assessment. RESULTS: The mean age of patients was 37.53 years. Most were males between 21-40 years. The dominant mode of injury was traffic accidents (66%). Fractures were classified according to Russell-Taylor classification. Forty percent were Russell-Taylor type IA, 37% type IB and 23% type IIA. Average time to surgery was 3.6 days from the time of admission to hospital. Mean duration of surgery was 45 minutes for intramedullary device (group A) and 105 minutes for extramedullary device (group B). Average blood loss was 100 ml in group A and 200 ml in group B. Mean duration of radiation exposure was 130 seconds and 140 seconds for groups A and B, while average duration of hospital stay was 12 days and 16 days respectively. Excellent results were seen in 47% of cases in group A and 33% of cases in group B. CONCLUSION: Intramedullary device is a reliable implant for subtrochanteric fractures. It has high rates of union with minimal soft-tissue damage. Intramedullary fixation has biological and biomechanical advantages, but surgery is technically demanding. Gradual learning and patience is needed to make this method truly rewarding.

Tillaux fracture of the ankle in an adult: a rare injury.

The Tillaux fracture of the ankle is an external rotation ankle injury resulting in an avulsion fracture of the anterolateral tibial plafond. This injury is known to occur in adolescents, although it has rarely been reported in adults. We report a case of a Tillaux fracture in an adult. A brief description of the history, mechanism of injury, required imaging, and treatment and other management options are provided in the present report. Anatomic reduction, rigid fixation, and early mobilization are emphasized to obtain a satisfactory functional outcome, shown by the long-term follow-up findings.

What is the easier and more reliable dose calculation for iv phenytoin in children at risk of developing convulsive status epilepticus, 18 mg/kg or 20 mg/kg?

BACKGROUND: With the Convulsive Status Guidelines due for renewal, we wondered if a phenytoin dose of '20 mg/kg' would be easier to calculate correctly and therefore safer than the current '18 mg/kg'. An educational exercise in dose calculation was therefore undertaken to assess ease of calculation. METHOD: A standard question paper was prepared, comprising five clinical scenarios with children of varying ages and estimated body weights. Medical students, trainee doctors at registrar and senior house officer level, and consultant paediatricians were asked to complete the exercise, in private, by one of two medical students (SD, PS). Calculations were done with and without a calculator, for 18 mg/kg and for 20 mg/kg in randomised order. Speed and errors (greater than 10%) were determined. The data analysis was performed using SPSS version 18. RESULTS: All answered all 20 scenarios, giving a total of 300 answers per doctor/student group, and 300 answers per type of calculation. When comparing the 2 doses, the numbers of errors more than 10% were significantly less in 20 mg/kg dose (0.33%) as compared to the 18 mg/kg dose (9.3%) (p<0.0001). Speed off calculation was significantly decreased in 20 mg/kg dose when compared with 18 mg/kg dose, with (p<0.001) or without (p<0.0001) the calculator. Speed was more than halved and errors were much less frequent by using a calculator, for the 18 mg/kg dose but no difference with or without the calculator for 20 mg/kg dose. CONCLUSION: We recommend that the future guidelines should suggest iv Phenytoin at 20 mg/kg rather than 18 mg/kg. This will make the calculation easier and reduce the risk of significant errors.

Fifteen-minute consultation: The child with acute ataxia.

Acute ataxia is a relatively common presentation to the paediatric acute services or child neurologist. Although the cause of ataxia is most often benign, it is important during initial assessment to recognise or exclude serious causes including brain tumour and central nervous system infections. It is equally important to recognise the non-neurological causes of unsteady gait and to avoid unnecessary investigations. In this review, we have presented a diagnostic approach to a child presenting with acute ataxia and described various causes, their treatments and outcomes.

Spontaneous urinary voiding of metallic screws in a patient with symphyseal plating for type II pelvic ring disruption.

With rapid advancement in surgical techniques and improvement in implant materials, rate of internal fixation for pubic symphyseal disruption in rotationally and vertically unstable pelvic ring injuries has increased. Among various modes of implant failure, screw/plate breakage and loosening are common complications following unstable fixation. Migration of loose screws into the urinary bladder has been reported as an extremely uncommon complication of pubic symphyseal plating. Here we present a case report of a 52-year-old female who presented with asymptomatic passage of screws in her urine following migration into the bladder, 2 years after symphyseal plating for pubic diastasis in an anteroposterior compression pelvic ring injury.

Retrieval of broken intra-medullary guide wire in femoral shaft fracture: A case report and surgical technique.

Intramedullary Nailing is a standard procedure for fixation of various fractures in orthopedic practice. With the procedure also important is being aware of the complications and methods of managing them. A broken or stuck hardware can result in these procedures. We present a case with broken guide wire in a case of femoral shaft fracture in a young individual and the technique we used to retrieve it retrogradely from the fracture site. This technique shall be a useful technique to all the orthopedic surgeons if such a situation arises.

Pediatric Traumatic Hip Dislocation: How Common is it in the Asian Population? A Case Report and Review of Literature.

Introduction: Pediatric hip dislocation is a rare event in the pediatric population. The management involves a timely diagnosis and emergent reduction for successful outcome. Case Report: We present a case of a 2-year-old male patient with a posterior dislocation of hip. The child underwent an emergent closed reduction using Allis maneuver. Subsequently, the child had an uneventful recovery and resumed his functional activity completely. Conclusion: Posterior hip dislocation in a child is an extremely rare entity. The key to management in such a case is to timely diagnose and reduce it.

Late Presentation of Giant Osteochondroma of Talar Neck in Elderly: A Case Report and Review of Literature.

Introduction: Osteochondroma is a benign bone tumor of the bone primarily seen in younger age groups. However, late presentation of the same is a rare incidence, as the symptoms develop rapidly due to compression of nearby structures. Case Report: We present a case of a 55-year-old male patient with a giant osteochondroma originating from the neck of the talus. The patient presented with a huge 100 × 70 × 50 mm swelling over the ankle. The patient underwent an excision of the swelling. Histopathological examination of the swelling confirmed the findings of an osteochondroma. The patient had an uneventful recovery after the excision and resumed his functional activity completely. Conclusion: Giant osteochondroma around the ankle is an extremely rare entity. Even rarer is a late presentation in the 6th decade onward. However, the management like others involves the excision of the lesion.

Atraumatic Reciprocal Scapula Fracture - A Case Report and Review of Literature.

Introduction: Scapula fractures are very rare and bilateral reciprocal involvement is rarest of all. Due to the protective nature of surrounding musculature, it is least prone to fracture with reported incidence of 1% of all skeletal fractures. However, synchronized firing of the periscapular muscles could overcome the bone strength resulting into the fracture as in the cases of electrocution and seizure attack. Case Report: We present a case of 54-year-old ex-military male patient with a history of acute onset seizure of multiple episodes. Magnetic resonance imaging showed cerebrovascular thrombosis. The patient was admitted in the intensive care and complained pain over bilateral shoulder with restricted movement in the post-ictal phase. X-ray showed bilateral comminuted extra-articular scapular fractures. The severity of the injury and displacement of the fracture pronounced operative intervention. Modified Judet approach was used to approach the fractures. After a successful surgery, rehabilitation protocol constituted of passive range of motion exercises with gradual active exercises of shoulder. One-year follow-up showed good consolidation of both fracture with full recovery of function. Conclusion: Periscapular musculature protects the scapula from traumatic events due to the significant bulk that it provides but these can on the other hand be source of deforming force in the patient who has history of simultaneous contraction as in the case of recurrent episodic seizure or electrocution. Scapular fracture should always be suspected in the patient with insidious development of shoulder pain following strong seizure attack. These fractures if indicated should be managed operatively.