Discovery of a Novel Yadav-Kunal Reflex in Context of Upper Motor Neuron Lesions: A Report of Three Cases.

Introduction: Numerous reflexive responses have been documented as alterations to the Babinski sign within upper motor neuron lesions. However, scant attention has been given to reflexes beyond these, which exhibit independence from the extensor plantar response. These reflexes predominantly form polysynaptic arcs, with nociceptive stimuli acting as afferents. Case Report: The reflex was serendipitously discovered in an 18-year-old female patient who presented with spastic paraplegia with bowel and bladder involvement, as a consequence of an aneurysmal bone cyst of the D3 (dorsal) vertebrae, and the same was named after the authors as "Yadav-Kunal reflex" which can be defined as: "In individuals with spastic paraparesis, forcibly plantarflexing the toes will result in sudden jerky flexion of the knee and hip on the same side." This novel reflex was further investigated and validated in two additional patients with spastic paraplegia: one, a 45-year-old female with D9-D10 Pott's spine and bowel and bladder involvement, and the other, a 65-year-old male with D10-D11 compressive myelopathy and bowel and bladder involvement. This reflex was meticulously tracked until the abatement of spasticity following surgical intervention. Notably, its manifestation was evident in individuals experiencing spastic paraparesis, dissipating concomitantly with the resolution of spasticity - a direct clinical correlation. Conversely, the reflex was conspicuously absent in cases of flaccid paraplegia. Conclusion: Spasticity, characterized by an increase in muscle tone on swift stretching movements, is a manifestation of a stretch reflex disorder. This condition is primarily induced by lesions affecting upper motor neurons. The activation of muscle spindles in toe dorsiflexors (primarily governed by the L5 nerve) occurs during forceful elongation caused by plantarflexion.

Mechanical thromboprophylaxis for hip fractures in elderly patients: a prospective randomized controlled study.

BACKGROUND: Hip fractures, most common in the geriatric age group, can develop proximal deep vein thrombosis (DVT). There is no consensus regarding the ideal method or duration of prophylaxis, particularly in a trauma patient. This study bridges this lacuna in data by making a random comparison between mechanical prophylaxis alone vis-a-vis combined with mechanical and Enoxaparin-based chemoprophylaxis. MATERIALS AND METHODS: 75 Elderly hip trauma patients from January 2019 to October 2020 at a single tertiary care center were randomly allocated into two groups using the sequentially numbered opaque sealed envelope method (SNOSE): one (n=44) receiving Enoxaparin and Mechanical prophylaxis and another (n=31) receiving Mechanical prophylaxis alone. All patients underwent CT (computed tomography) venography to screen for proximal DVT between days 5 to 10 of injury. The primary outcomes were the incidence of proximal DVT and pulmonary embolism (PE), and safety outcomes (wound complications and adverse systemic events) were recorded during the treatment. RESULTS: No symptomatic or asymptomatic proximal DVT and death incidence was reported in either group. One case of pulmonary embolism was seen in the combined prophylaxis group. There was no significant difference between the groups regarding the above-mentioned parameters mentioned. CONCLUSIONS: There is no significant difference in the incidence of proximal DVT between mechanical alone and combined chemical-mechanical prophylaxis in elderly patients sustaining hip trauma. The incidence of proximal DVT can be reduced by mechanical prophylaxis alone. It was efficacious and safer than combined mechanical and enoxaparin prophylaxis in preventing venous thromboembolism in elderly hip trauma patients.

Sacrococcygeal chordoma-illustrative cases and our experience.

Chordoma is an uncommon malignant bone tumour of low metastatic potential, the commonest site of which being sacrum. We intend to report two cases of giant sacrococcygeal chordoma managed surgically. The first patient presented with natal cleft swelling since past 3 years which on examination had a size of 12*10*14 and was mildly tender, non reducible, non pulsatile and non fluctuant. The swelling had a variegated surface and extended from sacral region till 2 cm above anal verge. The second patient presented with low backache with radiation to the left lower limbs along with numbness in posterior aspect of left thigh. Physical examination in the second patient was near similar to that in first case except the decreased perianal sensation with otherwise normal neurology in the second patient. The imaging and histopathology was consistent with sacroccocygeal chordoma in both cases. Both patients underwent wide margin resection with preservation of both S2 and right S3 roots. Effective management of sacrococcygeal chordoma requires early diagnosis, accurate preoperative staging, definitive and adequate surgical resection with proved tumour-free cut margins while in those declining surgery, radiotherapy can be considered as an alternative.

Ten-Segment Classification has Lowest Inter/Intra-Observer Reliability as Compared to Schatzker, Three-Column and AO Systems for Tibial Plateau Fractures: A Comparison Based on Surgeons' Experience.

Objectives: The primary aim of this study was to assess the reliability of the ten-segment classification system proposed (TSC) by Krause et al. and see how it compares with the traditionally used Schatzker classification, AO classification system, and Luo's "Three columns" classification (ThCC) system. The second aim of this study was to assess the inter-observer reliability of the above classifications based on professional experience by comparing the entry level of residents (1 year into postgraduation), senior residents (1 year after postgraduation completion), and faculty (>10 years after postgraduation completion). Methods: 50 TPFs were classified by a 10-segment classification system, and its intra-observer (at 1-month interval) and inter-observer reproducibility was checked using k values by three different groups with varying levels of experience (Group I, II, and III comprised of 2 juniors residents, senior residents and consultants each), and the same was compared for three other common classification systems (Schatzker, AO and 3 -column). Results: 10-segment classification showed least k for both inter-observer (0.08) and intra-observer (0.03) reliability. Highest individual inter-observer (k= 0.52) and intra-observer reliability (k= 0.31) was for Schatzker classification in Group I. Lowest individual inter-observer and intra-observer reliability was seen for 10-segment classification (k= 0.07) and AO classification system (k= -0.03) respectively. Conclusion: 10-segment classification showed the lowest k for both inter-observer and intra-observer reliability. The inter-observer reliability for the Schatzker, AO, and 3- column classifications reduced with increasing experience of the observer (JR>SR>Consultant). A possible reason could be a more critical evaluation of the fractures with increasing seniority.

Modified Posterior 2-Portal Technique of Arthroscopic Subtalar Joint Arthrodesis: Improved Pain and Functional Outcome at Mean 15 Months Follow-up-A Case Series.

Introduction: Posterior arthroscopic subtalar joint arthrodesis (PASTA) via a posterior 2-portal technique has been described. We modified the surgical technique of creating the portals in the plane of the posterior facet (under fluoroscopy guidance) to enhance the ease of access to the joint, easier and complete removal of articular cartilage along with maintaining the heel height. Methods: Patients of post-traumatic subtalar joint arthritis, treated by PASTA during 2016 till 2019 were included in the study. Exclusion criteria: significant height collapse of calcaneum, lateral blow out or heel widening. The confirmation of subtalar joint as the source of pain was done by injection of local anaesthetic inside the joint under the image intensifier, bringing immediate pain relief. The primary outcome variables assessed were the pain and functional scores, assessed using visual analogue scale and AOFAS (American Orthopaedic Foot and Ankle Society) score, respectively. Results: The total of 16 patients (7 males, 9 females) was included. The average age was 40.68 years (23-58 years). The underlying pathology in all patients was post-traumatic subtalar arthritis secondary to calcaneus fracture malunion in 8 patients (50%), talus fracture malunion in 4 (25%) and ligament injury in 2 patients (12.5%). No bone grafting was done. The mean duration of follow-up was 15.6 months (9-24 months). There was a statistically significant improvement (p < 0.001) in mean VAS score at follow up (2; range 0-4) as compared to the mean preoperative score (7; range 6-9). The AOFAS score also improved significantly (p < 0.001) at the follow up (mean 79; range 68-89) as compared to the preoperative score (mean 18; range 10-25). Conclusion: The posterior arthroscopic fusion of subtalar joint gives good results in terms of pain relief and functional scores when done for carefully selected patients of subtalar joint arthritis. Our slight modification of the original technique improves the ease of removing cartilage from subtalar joint with minimal height loss; thus, precluding any need for bone graft. It also makes the instrument movement easier inside the joint.

Mucoid degeneration of the anterior cruciate ligament: can platelet-rich plasma combined with reductionplasty provide better results?

Introduction: Mucoid degeneration of the anterior cruciate ligament (ACL) is commonly treated with arthroscopic debridement of the ACL. But many studies have reported the weakening and laxity of ACL postoperatively and on follow-up. Platelet-rich plasma (PRP) is known to influence musculoskeletal healing through multiple growth factors. Methodology: Five patients who were diagnosed as a case of mucoid degeneration of the ACL based on MRI, over a period of 1 year (December 2018-2019), were included in the study. Autologous PRP, prepared by double spin protocol, was injected into the remaining ACL after partial debridement was done. Results: Visual analogue scale and Lysholm scores improved compared with preoperative scores, along with strength (anterior drawer test and Lachman test). Conclusion: PRP can be used to improve the healing and strength of a weakened ACL after partial debridement, but further research is needed to demonstrate its efficacy.

Mucoid degeneration of the anterior cruciate ligament (ACL) of the knee can cause knee pain and other symptoms. For treatment of this, partial removing of bulky ACL is generally done, which causes weakness of the ACL. Nowadays, orthobiologics such as platelet-rich plasma (PRP) are increasingly used in ligament surgeries to improve healing. This study used PRP to augment the weakened ACL and followed patients for 1 year to assess outcomes. The results found improved functional scores and pain scores compared with preoperative levels. As this improvement might not be entirely due to PRP, high-end comparative studies are needed to confirm its efficacy.

Clinical outcome and correction following V osteotomy for genu valgum in adolescents and young adults: A systematic review.

BACKGROUND: Genu Valgum usually originates from distal femur and many open and closed wedge osteotomies of distal femur have been reported but none has proved to be the best. Distal femur V osteotomy is a wedgeless osteotomy and is a rarely reported osteotomy with only a few case series and 167 cases of isolated distal femur V osteotomy for genus valgum in young patients (<25 years) in literature but with a tendency to have an excellent outcomes. PURPOSE: To determine correction and clinical outcome following V osteotomy for genu valgum in adolescents and young adults (10-25 years). PATIENT AND METHODS: A systematic research was conducted of PubMed, MEDLINE and Google Scholar to identify studies reporting the correction and clinical outcome following V osteotomy in adolescents and young adults (10-25 years) for genu valgum by 2 different authors according to PRISMA guidelines. RESULTS: 5 studies with 167 patients and 263 knees were identified meeting the inclusion criteria for review. The follow-up period ranged from 3 months to 36 months. Overall complication rate was 12.3%, the most common being plaster sore, 4.2% (11/263) followed by superficial infection, 2.7% (7/263). The mean correction was 19.1° and a mean post-operative valgus was 5.7°. In those compared with Bostman score (157/167), 94.3% had excellent (148/157) and remaining 5.7% (9/157) had good scores (20-27/30) with none showing poor score (<20/30). CONCLUSION: V osteotomy is a reliable method of distal femoral osteotomy to attain a good correction with an excellent clinical outcome even with variations of fixation however longer follow-up period are required for better evaluation of recurrence.

Apixaban or enoxaparin: Which is better for thromboprophylaxis after total hip and total knee arthroplasty in Indian patients?

Both apixaban and enoxaparin are Food and Drug Administration-approved standard therapy for prophylaxis of deep-vein thrombosis; however, the superiority of one over the other is still controversial. With an objective to observe efficacy and safety outcomes of apixaban and enoxaparin in patients undergoing total hip (THA) and knee (TKA) arthroplasty, 96 patients undergoing THA/TKA (October 2018 to August 2019) were randomly allocated into 2 groups; (n = 48) apixaban; and (n = 48) enoxaparin. Efficacy outcomes and safety outcomes were recorded at 2 and 5 weeks post-TKA/THA. Follow-up functional scoring was done at 6 months postoperatively. Apixaban and enoxaparin were found to be equally efficacious in preventing venous thromboembolism; however, apixaban had a better safety profile. The apixaban group had nonsignificant higher tendency for wound discharge, atrial fibrillation and transient ischaemic attack. Enoxaparin had nonsignificant greater tendency for bleeding, wound dehiscence and pulmonary complications. Apixaban is a safe alternative to conventionally used enoxaparin for chemoprophylaxis in patients undergoing THA or TKA.

Improvement in Pain Following Ganglion Impar Blocks and Radiofrequency Ablation in Coccygodynia Patients: A Systematic Review.

Nearly 90% of cases of coccydynia can be managed with conservative medical treatment; the remaining 10% need other invasive modalities for pain relief, such as ganglion impar block (GIB) or radiofrequency ablation (RFA) of the ganglion impar. A systematic research was conducted of PubMed, MEDLINE, and Google Scholar to identify studies reporting pain relief in terms of visual analogue scale (VAS), or its counterparts, following GIB or RFA in coccydynia patients with the purpose to determine the efficacy of GIB and RFA of the ganglion impar in controlling pain in coccydynia patients. Seven studies were delineated, with a total of 189 patients (104 in GIB group and 85 in RFA group). In the GIB group, the mean VAS improved from 7.83 at baseline to 3.11 in the short-term follow-up, 3.55 in the intermediate-term follow-up, and 4.71 in the long-term follow-up. In the RFA group, the mean VAS improved from 6.92 at baseline to 4.25 in the short-term follow-up, and 4.04 in the long-term follow-up. In the GIB group, a 13.92% failure rate (11/79) and a 2.88% complication rate (3/104) were reported, while in the RFA group, a 14.08% failure rate (10/71) and no complications (0%) were reported. Total success rate was > 85% with either modality. Ganglion impar block and RFA of the ganglion impar are reliable and probably excellent methods of pain control in coccydynia patients not responding to conservative medical treatment. However, a demarcation between responders, non-responders, and late non-responders should be considered, and larger studies with a longer follow-up (> 1 year) are needed.

Modifiable Risk Factors of Plantar Fasciitis in Non-Athletic Patients and Proposal of a New Objective Assessment System - RKISP.

Objective To determine the modifiable risk factors associated with severity of plantar fasciitis and to formulate an objective scoring system for indexing plantar fasciitis in the non-athletic population. Methods This was a prospective observational study. The main outcome measure was the association of a modifiable risk factor, which was measured with the Pearson coefficient (R-value) and the level of significance, which was kept as p < 0.05. Result In a sample size of 50 patients, the body mass index (BMI) and ill-cushioned shoes were found to be significantly associated with pain in plantar fasciitis. All the other risk factors were either non-modifiable or had no significant association. Conclusion Based on available data and further interpretation, an index was be formulated, named as Ranjeet-Kunal Index for Scoring Plantar fasciitis (RKISP), which can be successfully used for not only grading plantar fasciitis but also prognosticating the conservative management of the same, thus deciding the modality of treatment.

Modifiable Risk Factors of Plantar Fasciitis in Non-Athletic Patients and Proposal of a New Objective Assessment System - RKISP / Fatores de risco modificáveis para fasciíte plantar em pacientes não atletas e proposta de um novo sistema de avaliação objetiva - RKISP

Abstract Objective To determine the modifiable risk factors associated with severity of plantar fasciitis and to formulate an objective scoring system for indexing plantar fasciitis in the non-athletic population. Methods This was a prospective observational study. The main outcome measure was the association of a modifiable risk factor, which was measured with the Pearson coefficient (R-value) and the level of significance, which was kept as p < 0.05. Result In a sample size of 50 patients, the body mass index (BMI) and ill-cushioned shoes were found to be significantly associated with pain in plantar fasciitis. All the other risk factors were either non-modifiable or had no significant association. Conclusion Based on available data and further interpretation, an index was be formulated, named as Ranjeet-Kunal Index for Scoring Plantar fasciitis (RKISP), which can be successfully used for not only grading plantar fasciitis but also prognosticating the conservative management of the same, thus deciding the modality of treatment.

Resumo Objetivo Determinar os fatores de risco modificáveis associados à gravidade da fasciíte plantar e formular um sistema objetivo de pontuação para indexação da doença na população não atlética. Métodos Estudo observacional prospectivo. A principal medida de desfecho foi a associação de um fator de risco modificável, mensurada pelo valor de R (coeficiente de Pearson) e pelo nível de significância de p < 0,05. Resultados Em uma amostra de 50 pacientes, o índice de massa corporal (IMC) e calçados com amortecimento inadequado foram associados de maneira significativa à dor na fasciíte plantar. Todos os demais fatores de risco eram não modificáveis ou não apresentaram associação significativa. Conclusão Com base nos dados à disposição e sua interpretação, um índice, denominado Índice de Ranjeet-Kunal de Pontuação da Fasciíte Plantar (RKISP, em inglês) , foi formulado e utilizado com sucesso não apenas na classificação da fasciíte plantar, mas também na determinação do prognóstico de seu tratamento conservativo, auxiliando a escolha da modalidade terapêutica.

Acute liver failure secondary to ABVD use.

Hodgkin's lymphoma (HL) is a type of cancer originating in the lymph nodes. The preferred therapy for advanced HL is a combination of chemotherapies including doxorubicin, bleomycin, vinblastine and dacarbazine (ABVD). ABVD has been standard therapy for advanced HL. It is generally considered as safe and rarely has been reported to cause acute liver failure. We present a case of 79-year-old woman with HL, who developed acute liver failure secondary to first cycle of ABVD chemotherapy.

Retroperitoneal fibrosis-clinical presentation and outcome analysis from urological perspective.

PURPOSE: To study clinical presentation, laboratory results, imaging findings and treatment options and outcomes of retroperitoneal fibrosis (RPF). To determine whether it follows the same natural course and response to treatment in the Asian population as in the Western world. MATERIALS AND METHODS: Medical records of patients diagnosed with RPF on imaging and histopathology between February 2010 and April 2016 were reviewed. RESULTS: Of the 21 patients analyzed, mean age at presentation was 50.81 years. The male to female ratio was 0.9:1. Pain was most common presenting complaint (95.23% cases), almost 85% cases were idiopathic and rests were postradiation induced. The median creatinine level was 1.8 mg/dL. The mean erythrocyte sedimentation rate (ESR) was 53.2 mm/h. Hydronephrosis was present in all patients and 47.6% had atrophic kidneys. Diffuse retroperitoneal mass was present in 61.1%. Ureterolysis with lateralization, omental wrapping or gonadal pedicle wrap was done in 17 cases. Two patients underwent uretero-ureterostomy. One patient underwent ileal replacement of ureter, and one ileal conduit. Eighteen patients received concurrent medical treatment, 11 were given tamoxifen, 2 steroids (Prednisolone), and five were given both. Of the 20 patients with follow-up, 70% had complete symptomatic relief; ESR improvement was seen in 77.8%. Follow-up ultrasound showed resolved and decreased hydronephrosis in 20% and 55% respectively. One patient had treatment failure and 17.65% had disease recurrence. CONCLUSIONS: RPF is a rare disease with varied presentation and outcomes. The male to female ratio may be equal in Asians and smoking could be lesser contributing factor. More Asian cohort studies are required to support same.

Prevalence of Depression among School-going Adolescents in an Urban Area of Bihar, India.

INTRODUCTION: Depression is one of the under-recognized health problems in adolescents. Emotional instability resulted from childhood to adulthood transition makes adolescents vulnerable to depression. AIMS: The aim of the study was to explore the prevalence of depression and its associated sociodemographic factors among school-going adolescents. MATERIALS AND METHODS: This cross-sectional study was undertaken from January 2016 to June 2016 in adolescents studying in 9-12th standard from forty schools located in an urban area of Patna, Bihar. The self-administered questionnaire of Beck's Depression Inventory II was utilized to assess the prevalence of depression. Statistical analysis was done with Pearson's Chi-square test using SPSS software version 21.0. RESULTS: Among the 1412 selected students, the prevalence of depression was found to be 49.2%, wherein the prevalence of severe depression was 7.7%. The overall prevalence of depression was significantly (P < 0.001) higher among girls (55.1%) than boys (45.8%). The prevalence of depression was found to be higher among students belonging to minorities (Buddhism, Jainism, etc.) (63.3%, P < 0.001). Elder students were found to be more depressed than younger students. Depression was found to be statistically significantly associated with gender and religion (P < 0.005). Guilty feeling (69.48%) was one of the most prominent clinical factors associated with depression followed by pessimism (58.14%), sadness (56.52%), and past failure (55.81%). CONCLUSIONS: Mental health is one of the most neglected aspects of our society. There is a need to increase awareness about depression among teachers and parents to identify and help depressed adolescents in the school.

Delayed Stevens-Johnson Syndrome Secondary to the Use of Lamotrigine in Bipolar Mood Disorder.

Lamotrigine is a mood-stabilizing drug used in maintenance treatment of bipolar I disease. There are adverse effects with lamotrigine such as a headache, blurred vision, diplopia, somnolence, ataxia, dizziness, rash, Stevens-Johnson syndrome (SJS), and toxic epidermal necrolysis. SJS is a life-threatening, blistering mucocutaneous disease. SJS is characterized by the presence of flat, diffuse erythematous maculopapular rashes with the involvement of <10% of the body surface area. Standard trigger is drugs including anticonvulsants, antibiotics, and Mycoplasma pneumoniae infection. We report a case where a patient developed SJS secondary to delayed-type hypersensitivity reaction after 6 months of the use of lamotrigine, while his initial response during the first 6 months did not show any sign of SJS.

PROP1 gene mutations in a 36-year-old female presenting with psychosis.

SUMMARY: Combined pituitary hormonal deficiency (CPHD) is a rare disease that results from mutations in genes coding for transcription factors that regulate the differentiation of pituitary cells. PROP1 gene mutations are one of the etiological diagnoses of congenital panhypopituitarism, however symptoms vary depending on phenotypic expression. We present a case of psychosis in a 36-year-old female with congenital panhypopituitarism who presented with paranoia, flat affect and ideas of reference without a delirious mental state, which resolved with hormone replacement and antipsychotics. Further evaluation revealed that she had a homozygous mutation of PROP1 gene. In summary, compliance with hormonal therapy for patients with hypopituitarism appears to be effective for the prevention and treatment of acute psychosis symptoms. LEARNING POINTS: Patients with PROP1 gene mutation may present with psychosis with no impairment in orientation and memory.There is currently inadequate literature on this topic, and further study on the possible mechanisms of psychosis as a result of endocrine disturbance is required.Compliance with hormonal therapy for patients with hypopituitarism appears to be effective for prevention and treatment of acute psychosis symptoms.

Sequential episodes of ethylene glycol poisoning in the same person.

Ethylene glycol is a common alcohol found in many household products such as household hard surface cleaner, paints, varnish, auto glass cleaner and antifreeze. While extremely toxic and often fatal on ingestion, few cases with early presentation by the patient have resulted in death; thus, rapid diagnosis is paramount to effectively treating ethylene glycol poisoning. In this study, we compare two sequential cases of ethylene glycol poisoning in a single individual, which resulted in strikingly different outcomes.