Establishing a bone bank within a hospital setting in India: early insights from a tertiary care center in Northern India-a review article.

When addressing bone defects resulting from trauma, infection, or tumors, the use of allogenic bone is often necessary. While autografts are considered the standard, they have limitations and can lead to donor site morbidity. Consequently, there has been exploration into the feasibility of utilizing allogenic bone and bone graft replacements. Allogenic bone transplants are acquired from donors following rigorous procurement, sterile processing, and donor screening procedures. To ensure the safe storage and effective utilization of allograft material, a bone banking system is employed. Establishing and managing an orthopedic bone bank, entails navigating complex legal and medical organizational aspects. This paper examines the establishment and operation of bone banks in India, drawing upon our first-hand experience in managing one at a tertiary care center in Northern India.Level of evidence: Level IV.

Computed tomography-based morphometric analysis of normal distal tibiofibular syndesmosis in the Indian population.

BACKGROUND: In suspected Ankle Instability, the parameters that can be defined in the X-ray have their limitation owing to their variability in positioning and rotation of the tibiofibular joint. This inaccuracy further increases due to variability in morphometric parameters of distal tibiofibular syndesmosis among different populations based on race and sex. This research aims to study morphometry of normal distal tibiofibular syndesmosis based on computed tomography imaging in the Indian population. METHODS: An Prospective observational study was performed from December 2020 to October 2022 on normal ankle CT scans of 100 Indian population using axial, sagittal, and coronal CT images. Anterior and posterior tibiofibular distance, Morphology of the incisura fibularis based on depth, Tibiofibular clear space (TFCS) and tibiofibular overlap (TFO), Transverse and longitudinal length of the fibula, and Relationship between the center of the talus and the center of a line joining the outer aspect of malleoli in the coronal plane were measured and analyzed by two different observers. RESULTS: Out of the 100 participants, 77 (77 %) were male, and 23 (23 %) were female. The overall mean age of participants was 34.69 ± 9.7 years. The incisura fibularis was concave in 54 %, and shallow in 46 %. Anterior tibiofibular distance, Posterior tibiofibular distance, and Tibiofibular overlap were significantly different in comparison to the male with female populations (p-value < 0.05). CONCLUSION: This study gives the indices that describe normal variations in the anatomical relationship between the fibula and fibular incisure in the Indian population, which will be helpful for improving the diagnostic accuracy of distal tibiofibular syndesmoses and providing optimal treatment in order to improve functional outcomes and reduce the risk of complications. LEVEL OF EVIDENCE: III.

Outcome of early versus delayed presentation of proximal femur fractures in children: A prospective cohort study.

OBJECTIVE: We hypothesized that the exact time of fixation of paediatric proximal femur fractures will have an effect on the ultimate clinical and radiological outcome. This article aimed to compare the clinical-radiological outcomes in paediatric proximal femur fractures having early and delayed presentation. METHODOLOGY: A prospective cohort study was conducted from January 2019 to November 2022 in patients of age of 5 to 16 years presented with proximal femur fracture and divided into two groups: group A: early presentation, presented <48hours of injury; group B: delayed presentation, presented >48hours of injury. Patients underwent internal fixation treatment modality and followed up to assess clinical outcomes and radiological outcomes, and final outcome was assessed as per Ratliff's criteria. RESULTS: In the study of 44 patients, 72.72% were male, and 27.27% were female, with male-to-female ratio to be 2.6:1. The commonest mode of injury was fall from height accounting for 52.27% followed by road traffic accidents (RTA) in 38.63%. The most common fracture type observed was Delbet type II, which was observed in 43.18%. There was significant shorter duration of surgery in group A (p-value=0.013), VAS score (p=0.045), and limb length discrepancy (p=0.022). Also, there was a statistical difference in AVN (p-value=0.0295) and growth disturbance (p-value=0.0394) between two groups. Also, there was statistically significant difference between Ratliff's criteria two groups (p-value=0.030). CONCLUSION: Early presentation has shorter duration of surgery, less VAS score at final follow-up, and less limb length discrepancy, less development of complications like avascular necrosis of the femoral head, and growth disturbance. LEVEL OF EVIDENCE: III.

Articulated lengthening fixation apparatus (ALFA) for the management of gap non-union of distal femur: Initial experience on a new technique.

Purpose: Distal femur non-union is difficult to deal with because of limited or no bone stock left for holding pins. Also, knee range of motion is a major concern in case of distal femur non-union to deal with. ALFA is a new modality of definitive external fixator with limited literatures. This paper aims to present the series of cases of gap non-union of the distal femur managed with an ALFA fixator and their outcome as an initial experience on a new device. Methods: Eight patients of gap non-union distal femurs where the ALFA fixator application was done between January 2022 to June 2022 were evaluated. Patients with intra-operative bone gap <5 cm were acutely docked and >5 cm were left as it is as a bon gap and gradual distraction was done to achieve bone gap length and limb length discrepancy. Patients were assessed for functional, radiological, and clinical outcomes, at the time of surgery, completion of distraction, and completion of consolidation. The scores from our study were compared with the Ilizarov and mono-lateral fixator with the available data. Results: Eight patients managed with ALFA fixator had mean age of 32.12 ± 6.82 years. The mean limb length discrepancy at the time of operation was 5.25 ± 3.11 cm, with Intra-operative bone gap of 4.68 ± 3.47 cm where 5 patients managed with acute docking and 3 patient managed with leaving the bone-gap. The mean regenerate gained after distraction was 9 ± 4.63 cm at the mean distraction duration of 113.37 ± 67.34 days. The mean time of removal of the fixator (n = 5), was 203 ± 111 days, and the mean external fixator index, days/cm (n = 5) was 34 days/cm. The number of complications per patient was 0.25 per patient. The Mean residual LLD was, 0.43 ± 0.58, with significant improvement of Limb Length compared to pre-operative LLD with a p-value of 0.0014. Conclusion: ALFA fixator for gap non-union as an alternative to Ilizarov, and LRS provides adequate distraction osteogenesis, less neurovascular complication due to pins, better patient tolerability, and user-friendly distraction of the distal femur with preserved knee range of motion. Level of evidence: III.

Hydatid Disease of Tibia Reconstructed with Allograft: A Rare Case Report and Literature Review.

Background: Hydatid disease of bone shows a well-defined, multiloculated lytic lesion with the appearance of a bunch of grapes. The presenting symptoms are pain and swelling with or without pathological fracture. The treatment options include surgery followed by a long duration of albendazole. Removal of the involved bone is required to decrease the chances of recurrences. Case Report: In our study, we have included a case of 28-year-old woman presented with complaints of pain and difficulty in weight bearing over her right lower limb for 2.5 months. Radiograph suggested an eccentric lytic lesion in midshaft of tibia and biopsy revealed granulosus cyst wall, nucleate germinal layer, the brood capsule, and protoscolices with visible hooklets. Patient was subjected to surgery with the excision of cyst along with extended curettage of bone creating a bone defect around the lesion and with anterolateral platting with coverage of bone defect by allogenic bone grafting. Patient was kept on above knee slab with non-weight-bearing mobilization for 6 weeks. Postoperative chemotherapy with Albendazole was given for 3 months. Patient was followed up every 6 weeks for 3 months and every month thereafter on outpatient basis. Return to work and patient satisfaction were excellent. Conclusion: Definitive Surgical management with Preoperative and postoperative chemotherapy seems to be effective to avoid recurrence. The bone defect caused by the disease or surgery can be managed with a bone graft either of autograft or allograft.

A rare case of cutaneous leishmaniasis in Kathmandu presenting with features of bacterial skin infection: A case report.

Leishmaniasis is an infectious disease caused by different species of genus Leishmania and transmitted by sandflies. Lesions of CL are most commonly present in the exposed areas, and the most familiar morphological type is papulo-nodular. The diagnosis of CL should be considered while dealing with common skin lesions, as well as encountering uncommon pathologies. We present a case of a 26-year-old man living in Kathmandu originally from Humla whose clinical course was complicated by unsuccessful treatment with suspicion of bacterial skin infection. The patient first presented with an erythematous papule with some scale and crust with central ulceration over the left side of his upper lip and mild fever. With the suspicion of bacterial infection, he was initially treated with antibiotics, which showed no improvement prompting the referral to a tertiary center with further diagnostic workup. Punch biopsy confirmed the presence of amastigote form of leishmaniasis Donovan bodies. Also, the rk39 antibody test was positive. Clinicians need to pay more effort to the diagnosis of CL and include it in the differential diagnoses of patients presenting with typical lesions even if the region is not known to be endemic for CL or in the patient with no known history of insect bite.

Total Hip Replacement in Active and Inactive Tuberculosis Hip: A Systematic Review.

Introduction: Tuberculosis of the hip joint is a debilitating disease that can result in severe joint destruction, eventually leading to painful arthritis of the hip. Total hip arthroplasty (THA) in patients with advanced arthritis offers a painless and mobile joint with good functional outcome but some aspects of THA in TB hip have been controversial in the past due to the concerns of disease reactivation, especially when disease activity is factored in. Various factors like timing of surgery, Antitubercular therapy (ATT) initiation timing, reactivation, complications etc needs to be evaluated very carefully before planning for such cases. Methods: Electronic databases like MEDLINE, EMBASE, Cochrane library, Clinicaltrials gov and OpenGrey were searched. The key words used were "Tuberculosis", "Tuberculosis of hip", Hip tuberculosis, "TB", "THR", "total hip replacement", "total hip arthroplasty","THA", "ankylosed hip", "fused hip", "arthrodesis" along with boolean operators "AND" and "OR". Out of a total of 1634 articles, 38 were selected for full text review and 22 articles were finally included in the study. Results: For the timing of surgery most authors relied on the inflammatory markers to settle down with ATT before performing THA. 15 authors advocated use of pre-operative ATT with 6 studies recommending at least 2 weeks and 3 studies advocating atleast 3 months of ATT pre surgery.Single stage THA was performed in most studies(214 hips vs 18 hips) as opposed to 2 or 3 stage surgery. In the active disease 72.8% of the hips had uncemented prosthesis, 25.6% hips underwent cemented and 1.5% hips had hybrid THA fixation. Overall reactivation of the infection was seen in 2.47% cases. All authors reported excellent clinical improvement (mean HHS improvement 37.17 to 88.62).

Atypical hemolytic uremic syndrome (aHUS) responsive to mycophenolate mofetil: A case report from Nepal.

Introduction: An atypical hemolytic uremic syndrome is an extremely rare and life-threatening thrombotic microangiopathy. This disorder is caused by dysregulation of the alternative pathway of the complement system in association with genetic abnormalities or the development of autoantibodies. However, 30-50% of patients do not have genetic or acquired mutations in the complement system. Case report: Patient presented with fever and periorbital swelling. She had anemia, thrombocytopenia, and deranged liver function tests. Urinalysis revealed hematuria and proteinuria. Antibody tests and genetic analysis were negative. Renal biopsy revealed findings suggestive of thrombotic microangiopathy with predominantly glomerular involvement. Thus, the diagnosis of Atypical Hemolytic Uremic Syndrome, immunofluorescence negative, genetic negative, and anti-complement negative was made. Discussion: This article reports a case of atypical hemolytic uremic syndrome in a child with negative genetic analysis and anti-complement factor H antibody, which was treated successfully on steroid and mycophenolate mofetil. Early diagnosis along with prompt treatment and close monitoring will lead to recovery from atypical Hemolytic Uremic Syndrome. Conclusion: Although HUS is generally associated with genetic abnormalities or a positive antibody test, some patients with HUS may present atypically with negative genetic analysis and antibody tests.

Distal Nerve Transfer to Restore Wrist and Finger Extension - A Systematic Review.

Background: There are numerous options available for restoration of wrist and finger extension following radial nerve palsy. The aim of this study is to conduct a systematic review of the effectiveness of nerve transfer for radial nerve palsy. Methods: Electronic literature research of PubMed, Cochrane, Scopus and Lilacs database was conducted in June 2021 using the terms 'Distal nerve transfer' AND 'Radial nerve injury' 'Radial nerve palsy' OR 'Radial nerve paresis' OR 'Median nerve transfer' OR 'wrist extensor' OR 'finger extension' OR 'thumb extension' OR 'wrist motion'. The data extracted included the study details, demographic data, procedure performed and final functional outcome according to the muscle research council scale. Results: A total of 92.59% and 56.52% had satisfactory outcome following distal nerve transfer of median nerve to restore wrist and finger extension respectively. No significant correlation was found between time to injury duration and satisfactory outcomes. Conclusions: Outcomes of nerve transfers are comparable to tendon transfers. Multi-centric studies are needed to compare the results amongst various surgical procedures described. Level of Evidence: Level III (Therapeutic).

Intrauterine pregnancy with copper intrauterine contraceptive device in situ: A case report from Nepal.

Introduction: and importance: Intrauterine pregnancy on the background of intrauterine devices heralds its rare but possible failure. Despite having an excellent contraceptive pearl index, clients with copper-T may present with typical pregnancy symptoms. Case presentation: We present a case of a 22 year primigravida who after 42 months of successful use of copper-T, conceived an intrauterine pregnancy diagnosed at 7 weeks period of gestation.Clinical Findings and Investigations: A positive urine pregnancy test following cessation of menstruation for 2 months was reported by the patient on presentation. Urgent transabdominal ultrasound of the abdomen and pelvis revealed a gravid uterus containing a single gestational sac corresponding to 7 weeks of gestation. After a thorough explanation about possibility of viable pregnancy and also its pros and cons, she decided to terminate the pregnancy. Manual vacuum aspiration was done with removal of copper-T. Conclusion: Although ectopic pregnancy is a relatively common complication of intrauterine contraceptive device, it is necessary to consider the possibility of intrauterine pregnancy as a potential complication as well. Although, term pregnancies with excellent prognosis have been demonstrated in many studies after removal of intrauterine devices, close follow up is needed to identify misplaced copper-T and keep unwanted pregnancy at bay.

Neurobrucellosis presenting with the features of meningoencephalitis: A case report from Nepal.

Introduction and importance: Brucellosis or Malta fever is a zoonotic disease caused by the Brucella species. Patients with neurobrucellosis may present with features of meningoencephalitis. Thus, a high degree of suspicion is required for the diagnosis in the endemic region. Case presentation: A 13-year old female with a history of exposure to domestic animals presented with the features of meningoencephalitis (intermittent fever with chills and rigor and generalized tonic-clonic seizure). Clinical findings and investigations: Examination revealed drowsy and lethargic patient with bilateral edema up to mid-shin. Neck rigidity was present. Lab findings include leukocytosis with neutrophilic and erythrocyte sedimentation rate (25 mm/hr). CECT of the brain revealed vasogenic edema. Routine CSF examination was insignificant for common bacterial, viral, fungal or tubercular etiology. CSF ELISA confirmed the presence of Brucella antibody. Conclusion: When patients present with undulant fever, lethargy, seizure, or other features of meningitis/encephalitis, the diagnosis of neurobrucellosis must be considered after common pathological causes are ruled out.

Glomus Tumour of Hand--A Commonly Misdiagnosed Pathology: A Case Series.

Introduction: Glomus tumours are benign neoplasms arising from the glomus body, a network of specialized neuromyoarterial structures containing arteriovenous anastomosis and regulating temperature. It is often misdiagnosed as paronychia, arthritis, traumatic sequelae, and many other conditions including psychiatric misdiagnosis. A typical triad of paroxysmal pain, point tenderness, and cold intolerance characterize it. Surgical excision is the treatment of choice, either by transungual or lateral approaches. Materials and Methods: We carried out a retrospective study of cases operated in our department in the last 4 years. Patients are evaluated based on either clinical parameters (Love test, Hildreth test, and cold insensitivity) or radiological parameters (X-ray and magnetic resonance imaging). Parameters such as age, gender, tumour side, presenting complaints, duration of symptoms, diagnostic modality, follow-up duration, recurrence, and postoperative nail deformity were analysed. Visual analogue scale (VAS) score was the primary statistical parameter, and the change in VAS score following surgery was analysed with paired t test. Result: Mean preoperative VAS was 7.75 ± 0.5; in a total of four patients, and following surgery, VAS was reduced to a mean of 1 ± 1.5. Paired t test on the change of VAS score following surgery showed a significant difference in the VAS score (P = 0.002838). The average age was 39.25. The male-to-female ratio was 1:3, and the mean follow-up was 16 months (range 2-48 months). The mean duration of symptoms was 5.75 years (range 2-10 years). Two cases were in the right-hand side, and two cases were on the left-hand side; the thumb was most commonly involved with 50% (n = 2) incidence. Conclusion: Glomus tumours are often misdiagnosed and are intervened with different treatment options before being surgically intervened. With complete surgical excision, recurrence is nil but postoperative nail growth requires nearly 10 months. Level of Evidence: Level IV.