Pubic Symphysis Tuberculosis Recurrence - A Rare Case Report and Literature Review.

Introduction: Tuberculosis (TB) of pubic symphysis is an extremely uncommon condition accounting <1% of all musculoskeletal TB. Further recurrence of TB of symphysis pubis is a rare clinical scenario requiring a high level of suspicion for diagnosing the condition. Recurrence of tuberculosis can occur either be due to relapse of the original infection or reinfection due to exogenous Mycobacterium tuberculosis strain. There have only been nine case reports on TB of the pubic symphysis in the last three decades and only 40 patients were identified in English language medical literature so to the best of our knowledge this is the first case report on the recurrence of TB of pubic symphysis. Case Report: A 26-year-old female patient presented with pain over symphyseal area for 2 months. Laboratory and radiological investigations were suggestive of TB of symphysis pubis. She was started on oral, category I anti-tubercular therapy (ATT) from DOTS center. Patient on improvement in symptoms discontinued taking ATT after 6 months. About 7 months after stopping ATT, she again presented with pain over symphyseal area and difficulty in walking. Laboratory, radiological investigation, and biopsy were obtained to rule out multidrug-resistant (MDR) TB. The patient improved on 12 months' oral daily ATT regime (HRZES2+HRZE4+HRE6). She was followed up for another 1 year with clinical examination and laboratory investigation after stopping ATT. At present, she is asymptomatic with no signs of recurrence after 1 year of completion of treatment. Conclusion: ATT intake should be continued for 12 months for musculoskeletal TB for preventing recurrence. The biopsy needs to be taken from the affected region in recurrence TB to rule out MDR.

Deltoid Intramuscular Injections: A Systematic Review of Underlying Neurovascular Structures to the Muscle and Proposing a Relatively Safer Site.

The deltoid is the preferred site for intramuscular injection (IMI) because of its easy accessibility for drug and vaccine administration. Government immunization advisories, standard anatomy textbooks, and researchers have proposed various injection techniques and sites, but specific guidelines are lacking for the administration of IMIs in the increasingly used deltoid site. This study analyzes the procedures of administering IMIs in the deltoid related to the neurovascular network underlying the muscle and proposes a preferred site with the least chance of injury. The review protocol was submitted with PROSPERO (ID: 319251). PubMed, Google Scholar, and Websites of National Public Health Agencies were searched from 1950 up to 2022 for articles, advisories, and National Immunization Guidelines using Medical Subject Headings (MeSH) terms, including IMIs, deltoid muscle, safe injection sites, to identify recommendations for safer sites and techniques of administering deltoid IMIs. All the authors strictly adhered to a well-developed registered review protocol throughout the study and followed the risk of bias in systematic reviews (ROBIS) guidance tool. The proposed sites and landmark data were tabulated, and each site was analyzed based on the underlying neurovascular structures. Data were depicted by self-generated images. The initial search identified 174 articles. After applying the inclusion and exclusion criteria, 57 articles were shortlisted. Out of the 39 selected articles, 18 focused on the administration of deltoid IMIs, whereas seven focused on the variations in the underlying neurovascular structures in proximity to the deltoid muscle. The remaining 14 articles were the immunization guides issued by the National Public Health Agencies of the Government of India and abroad, whose data was used for comparison. Twelve deltoid IMI sites and techniques were identified. A site 1-3 fingerbreadths/5 cm below the mid-acromion point (7 studies); mid-deltoid site/densest part of the deltoid (1 study); a site at the middle third of the deltoid muscle (1 study); triangular injection site (1 study). Limitations included the unavailability of free access to complete text in many articles resulting in exclusion. The area around the shoulder joint and up to the lower level of the intertubercular sulcus is highly vascularized by the presence of many anomalous arterial patterns. To avoid injury, a safer site is proposed of 5 fingerbreadths/10 cm below the midpoint of the lateral border of the acromion. The authors received no specific funding for this study except for the journal publication charges.

Neglected Isolated Sleeve Fracture of the Superior Pole of the Patella in a Healthy Adult - A Case Report and Review of Literature.

INTRODUCTION: Sleeve fracture (SF) represents an unusual type of patellar fracture and has been reported mainly in children or adolescents. Superior pole fracture in adults is a very rare occurrence because the enthesis of the adult patella is more resilient to avulsion injury as compared to an immature pediatric skeleton. Due to the rarity of these fractures in adults and vague radiographic findings, the chances of missing the fracture are very high. CASE REPORT: An 18-year-old boy presented to our outpatient department with a history of fall while trying to jump across a wall 6 months ago. At the time of presentation, the patient mainly complained of loss of active extension of the knee in the sitting position and a palpable gap over the upper part of the patella. After radiographic evaluation, a diagnosis of SF was made. The patient was managed surgically, and thereafter, early rehabilitation was done. After 10 weeks post-surgery, the patient was free from any pain, had a full range of motion, and was able to walk without support. CONCLUSION: Adults presenting with acute injury to knee with limitation of extension and palpable gap over the superior pole of the patella, a differential diagnosis of SF must be suspected and should be ruled out by clinical examination and relevant investigations.

Kuntscher Nail: A Forgotten Entity Yet a Reliable Modality in Treatment of Winquist Type I and II Closed Femoral Shaft Fractures.

Background Interlocking intramedullary nail is used for almost all types of femoral shaft fractures worldwide because of its better mechanical stability. In countries like India with limited healthcare infrastructure, the use of Kuntscher nail (K-nail) in Winquist type I and type II isthmic fractures is still debated. Therefore, we conducted this study to compare the functional outcome, radiation exposure, and cost of the implant between closed reduction and internal fixation of Winquist type I and II fractures in the middle one-third shaft region by K-nail and intramedullary locked nails (IMILN), respectively. Methods This was a hospital-based non-blinded randomized trial which included 56 patients with closed Winquist type I and II femoral shaft fractures of the middle one-third femoral shaft (isthmic and paraisthmic zone). All the patients were either treated by K-nail or IMILN. The patients were followed up every three weeks for the initial six months and quarterly thereafter. Per operative duration of surgery and radiation exposure by C-arm was documented and assuming scattered radiation 20%, radiation exposure to the surgeon was calculated and patients were assessed clinically and radiologically for union. Results The patients were divided into two groups: group I (K-nail, n = 25) and group II (IMILN, n = 31). In groups I and II, the patients achieving radiological union were 88% (n = 22/25) and 84% (n = 27/31) at six months' duration, respectively. The mean duration for the radiological union was 3.65 ± 0.55 months in group I (K-nail) and 3.76 ± 0.59 months in group II (IMILN), respectively. There was no statistically significant difference in the duration of the union (p = 0.4963). The average number of C- arm exposures was 16.36 ± 3.18 in group I as compared to 27.29 ± 4.01 in group II, and the mean scattered radiation was 5.0 ± 1.63 in group I and 6.61 ± 4.06 in group II. This difference was statistically significant. Conclusion Kuntscher intramedullary nailing can provide comparable rates of union as is achieved with interlocking intramedullary nailing with an advantage of less radiation exposure and duration of surgery, provided the patient selection is proper (isthmic and paraisthmic zone).

Giant Extra-Articular Synovial Chondromatosis of the Ankle Joint - A Rare Case Report.

INTRODUCTION: Synovial chondromatosis (SC) commonly involves large joints such as the knee and hip with smaller joints being less frequently involved. Extra-articular involvement is very rare, and here, we are presenting the first case of giant extra-articular SC originating from the ankle joint. CASE REPORT: A 42-year-old male presented to the outpatient department with painless swelling over the lateral malleolus for 2 years. Diagnostic imaging suggested the involvement of the synovial lining with the swelling. The mass was excised and histopathology proved the diagnosis of SC. CONCLUSION: Extra-articular involvement in SC has been mainly reported in the synovial sheath or bursae of the hand and foot, but they can involve ankle joint also. In recent times, there have been concerns about potential malignant transformation of these lesion to chondrosarcoma, diagnosing these lesions have become important.

Isolated Pure Lateral Dislocation of Elbow in a 9-year-old Child: A Rare Case Report.

INTRODUCTION: Dislocations of elbow constitute about 3-6% of all injuries occurring around elbow in children. Posterior dislocations are the most common type, whereas other types of dislocations, especially lateral dislocation in a child are extremely rare. CASE REPORT: A 9-year-old boy with a history of trauma presented with complaints of pain, swelling, and difficulty to move his left elbow. Radiographs revealed lateral dislocation of elbow associated with avulsion of medial condyle. Closed reduction was done successfully under short general anesthesia. CONCLUSION: Pure lateral dislocation of the elbow is rare in pediatric age group. Lateral elbow dislocation is mostly managed surgically, but a chance of conservative management should be given before surgery.

Clinical Outcome of Treatment of Diaphyseal Fractures of Humerus Treated by Titanium Elastic Nails in Adult Age Group.

INTRODUCTION: Humerus shaft fracture is one of the most common injuries to the musculoskeletal system, which are managed both conservatively and surgically. There are pitfalls, advantages and disadvantages in each method. The individual fracture analysis determines the therapeutic options. AIM: To assess the clinical outcome of treatment of diaphyseal fractures of humerus treated by Titanium elastic nail in adult age group by DASH scoring. MATERIALS AND METHODS: It was a prospective study of 20 cases of diaphyseal fracture of humerus admitted to Era's Lucknow Medical College and Hospital between October 2014 and September 2015 treated with close reduction and internal fixation with titanium elastic nail. Functional outcome was evaluated using DASH scoring system and radiological outcome was evaluated by serial radiographs. The data was processed with SPSS software version 16.0 (Chicago, inc. USA) and it was summarized in proportion and percentage. RESULTS: In our series of 20 patients, 17 were males and three were females. Most of the patients were between 30-50 years of age (mean 38 years). Most common mode of injury, side of involvement, level of fracture and fracture type were road traffic accidents (60%), right side (53.3%) and mid one third (75%), transverse (60%) respectively. So, in 65% of the patients, there was no disability of arm shoulder and hand as DASH score was within normal range and in 15% of the patients the disability was mild to moderate as scoring was slightly higher than normal and in 20% the disability was severe as the DASH score could not be calculated because of non union. CONCLUSION: Elastic nail fixation require very minimal soft tissue dissection and being a close reduction, the biology of the fracture is also not disturbed and the chances of nerve injury are much less and as the non union was seen in oblique and spiral fracture type hence it should be used with caution or else other alternative methods of fixation should be used.

A Comparative Study of the Results of the Anatomic Medial Portal and All-inside Arthroscopic ACL Reconstruction.

INTRODUCTION: Many techniques of graft placement in Arthroscopic Anterior Cruciate Ligament (ACL) reconstruction is available now-a-days, like trans-tibial, anatomical accessory medial portal and anatomical all-inside technique. AIM: To compare the improvement in clinical status of patients treated by anatomic accessory medial portal and all-inside arthroscopic ACL reconstruction technique pre-operatively post-operatively using International Knee Documentation Comittee (IKDC) Subjective Knee Scores, Lysholm Knee Score, Knee Society Score, Lachman test, Visual Analog Score (VAS) in both the groups. MATERIALS AND METHODS: After informed consent from patients and clearance from Ethical Committee, we included patients aged 18 to 50 years with ACL injury and clinical laxity admitted in Department of Orthopaedics, King George Medical University, Lucknow. We included 100 patients in the study, which were divided into two groups, Group1 comprised of patients treated by Anatomic accessory medial portal technique and group 2 comprised of patients treated by All-Inside technique. Then the patients were followed up post-operatively at 6 weeks, 12 weeks and 6 months, clinically for functional status using Lysholm Knee Score, IKDC Subjective Knee Score, Knee Society Score and VAS score. Grading of laxity was evaluated by Lachman test at pre-operative stage and 6 months follow-up. After collection of the data, analysis was carried out on SPSS software version 16.0 (Chicago, inc. USA) and the statistical test that was used was 2-Way Analysis of Variance (ANOVA). RESULTS: IKDC Subjective Knee Score, Lysholm Knee Score, Knee Society Score, Lachman Test and VAS Score was better in group 2 treated by All-inside technique as compared to group1 and the difference was significant (p<0.005). CONCLUSION: All- Inside arthroscopic ACL reconstruction technique (group2) is a better technique than arthroscopic Anatomic accessory medial portal technique (group1).