Does malnutrition in clubfoot patients affect Ponseti technique and its outcome?

OBJECTIVES: Malnutrition is a crucial health problem predominantly in the developing countries. Malnutrition in children is one of the main risk factors for diseases and mortality. Club foot or congenital talipes equinovarus (CTEV) is the most common form of congenital orthopaedic abnormality. Over the past 20 years, the Ponseti method is considered the gold standard for the treatment of clubfoot. Our objective is to determine the prevalence of malnutrition in clubfoot patients, and its effects on the outcome of Ponseti technique in patients presenting to the Orthopaedic Clinic of tertiary care Hospital in Karachi, Pakistan. METHOD: The cross-sectional study was conducted from January to December 2018. Total 153 clubfoot patients were treated and the World Health Organization (WHO) classification of weight-for-age index was used to assess the nutritional status of patients, and its impact on outcome of Ponseti technique was recorded and analysed with a P value ≤ .05 as significant. RESULTS: Of the 153 patients, 112 (79.7%) were found in good nutritional status and 42 (20.6%) were malnourished. The average number of casts per patient and patients requiring 6+ casts in the undernutrition group was higher compared with good nutrition group (45.5% vs 21.42%, respectively). The number of Achilles tenotomy performed in the undernutrition group was also higher (76.4% vs 51.8%). CONCLUSION: A significant correlation between patients' nutritional status and outcome of the Ponseti technique is found as it influences the number of casts, possible relapse and failure of treatment.

Functional outcome following olecranon osteotomy approach for fixation of T/Y fractures of distal humerus.

OBJECTIVE: To evaluate the functional outcome of fixation of T/Y fracture distal humerus through olecranon osteotomy. STUDY DESIGN: Quasi experimental study. PLACE AND DURATION OF STUDY: Department of Orthopedics, Jinnah Postgraduate Medical Centre, Karachi from June 2011 to December 2011. METHODOLOGY: Patients of either sex presenting with T/Y(configuration) fracture Humerus of Risenborough-Radin type II-IV and less than three weeks duration were included. Diagnosis was made by X-rays and underwent fixation by posterior approach through olecranon osteotomy. Functional outcome was measured by using Risenborough-Radin criteria of range of motion as good, fair and poor. The data was analyzed using SPSS version 13. RESULTS: 71 patients aged between 20-50 years were enrolled. Mean duration of trauma was 12.2±4.4 days. Majority 55 (77.5%) had type III fracture. Patients less than 40 years had good outcome in 52.8% cases and fair outcome in 41.7% cases better than patients more than 40 years age. In females, outcome was 68.8% which was better than males. Trauma of less than 12 days of duration had good outcome in 60.5% of cases. Type II fracture had better outcome than other types. Overall, 39 patients (54.9%) had good outcome, fair outcome in (33.80%) 24 patients and poor outcome in (11.27%) 8 patients. CONCLUSIONS: Posterior approach using Transolecranon osteotomy is a satisfactory procedure for fixation of T/Y fracture of distal humerus, because it achieves good functional outcome post operatively in terms of range of motion of elbow compared to other procedures.

Difficulties in maintenance of clubfoot abduction brace and solutions - maintenance of clubfoot abduction brace, locks and keys.

OBJECTIVE: To determine the frequency of early relapse after achieving good initial correction in children who were on clubfoot abduction brace. METHODS: The cross-sectional study was conducted at the Jinnah Postgraduate Medical Centre, Karachi, and included parents of children of either gender in the age range of 6 months to 3years with idiopathic clubfoot deformities who had undergone Ponseti treatment between September 2012 and June 2013, and who were on maintenance brace when the data was collected from December 2013 to March 2014. Parents of patients with follow-up duration in brace less than six months and those with syndromic clubfoot deformity were excluded. The interviews were taken through a purposive designed questionnaire. SPSS 16 was used for data analysis. RESULTS: The study included parents of 120 patients. Of them, 95(79.2%) behaved with good compliance on Denis Browne Splint, 10(8.3%) were fair and 15(12.5%)showed poor compliance. Major reason for poor and non-compliance was unaffordability of time and cost for regular follow-up. Besides, 20(16.67%) had inconsistent use due to delay inre-procurement of Foot Abduction Braceonce the child had outgrown the shoe. Only 4(3.33%) talked of cultural barriers and conflict of interest between the parents. Early relapse was observed in 23(19.16%) patients and 6(5%) of them responded to additional treatment and were put back on brace treatment; 13(10.83%) had minor relapse with forefoot varus, without functional disability, and the remaining 4(3.33%) had major relapse requiring extensive surgery. Overall success was recorded in 116(96.67%) cases. CONCLUSIONS: The positioning of shoes on abduction brace bar, comfort in shoes, affordability, initial and subsequent delay in procurement of new shoes once the child's feet overgrew the shoe, were the four containable factors on the part of Ponseti practitioner.

Outcome of one stage combined open reduction, pelvic and derotation femoral osteotomy in congenital dislocated hips of children younger than three years age.

OBJECTIVE: To determine the outcome of one-stage combined operative management of congenital dislocation of hips in children aged 18-36 months. METHODS: The descriptive case series study was conducted at the Department of Orthopaedic Surgery, Jinnah Postgraduate Medical Centre, Karachi, from January 2005 to December 2011. Children aged 18-36 months suffering from congenital dislocation of hips were included. Those with Tonnis stage III and IV were managed with one-stage operative procedure without preliminary traction. The operative procedure included adductor tenotomy, open reduction, capsulorraphy, Salter's osteotomy and a femoral derotation osteotomy. Catteral's 'Test of Stability' was used after open reduction as an indicator for need of pelvic and femoral osteotomies. Follow-up ranged between 1 and 7 years. The patients were evaluated clinically on McKay's criteria and radiologically on Severin's criteria. Klisic's overall rating was used to know mean of the assessments. RESULTS: There were 38 patients with 50 congenital dislocations of hip. There were 26 (68.42%) females and 12 (31.57%) males with a female-to-male ratio of 2:1. Mean age at the time of operation was 24.26 ± 7.6 months. Of the total, 12 (31.57%) patients had bilateral involvement, 11 (28.94%) had right-sided and 15 (39.47%) had left-sided involvement. Right side to Left ratio was 1:1.2. At the time of last follow-up, 25 (50%) hips behaved excellent on McKay's criteria. According to radiographic classification on Severin's criteria, 24 (48%) hips were in excellent class. Avascular necrosis of femoral head was noted in 3 (6%) hips, re-subluxation/re-dislocations were observed in 3 (6%) hips and 1 (2.6%) patient had 1 cm femoral lengthening. CONCLUSION: One-stage open reduction, capsulorrapyhy, Salter's osteotomy and femoral derotation osteotomy without preliminary traction to re-locate congenital dislocation of hips in late presenting children is a safe and highly effective method. It produces a low rate of complication and need for repeat surgery. It reduces the cost of treatment, minimises socio-economic burden and psychological trauma incurred by lengthy hospitalisation of treatment with traction followed by closed reduction.

Improvised explosive device bombing police bus: Pattern of injuries, patho-physiology and early management.

OBJECTIVE: To understand the different types of blast injuries, their mechanisms, patho-physiology of wounds and clinical consequences caused by improvised explosive device detonation, and their early management. METHODS: The retrospective study related to 70 Special Security Unit personnel of police travelling on duty in a bus that was struck with an Improvised Explosive Device on February 13, 2014, at 7:48am.The data of triage, primary survey and resuscitation and secondary survey on arrival at the Accident and Emergency section of Jinnah Postgraduate Medical Centre, Karachi, were noted and later analysed. RESULTS: Police commandos aged 20-32 years were brought to hospital within 35-55 minutes of blast by ambulances. Triage at Emergency labelled 11(15.7%) Black, 15(21.4%) Red, 19(27.2%) Yellow and 25(35.7%) Green. Primary blast waves led to 11 closed blast lung presenting as pneumothorax in 9(12.8%) patients; 11(15.7%) chest tube thoracotomies were performed. Primary blast waves also produced ear drum and eyeball perforation. Seven (10%) patients received calcaneal fractures; 2(2.8%) with bilateral calcaneal fractures. Tertiary blast waves also caused amputations, and lower leg open fractures. Patients who died had received multi-system involvement injuries due to combined primary and secondary blast waves. CONCLUSIONS: Improvised explosive devices produce a variety of serious and uncommon injuries requiring special care and early multi-disciplinary response. Repeated primary and secondary survey in Accident and Emergency are very important.

"The role and ability of orthopaedic postgraduate resident's clubfoot treatment with ponseti's methodology." A comparative study of resident's versus consultant's directed treatment.

OBJECTIVE: To evaluate the outcome of Ponseti treatment carried out by the Postgraduate Orthopaedic Trainees compared with the treatment given by their Mentors. METHODS: The prospective comparative case series study was conducted at Jinnah Postgraduate Medical Centre, Karachi, and comprised idiopathic Congenital Clubfoot Deformity patients treated from September 2012 to December 2013. Also included were a few cases treated between September 2006 and September 2012, who had complete record, serial photograph and updated follow-up. The patients were divided into two groups. Those treated by residents formed Group A and those by consultants were in Group B. The follow-up duration ranged from 06 months to 05 years. Outcome measures included the number of casts required to achieve correction with Pirani score 0.5, the rate of Per-Cutaneous Achilles Tenotomy (PCAT), the rate of early relapse and treatment and failure to maintain correction. SPSS 13 was used for statistical analysis. RESULTS: Of the 172 patients in the study, 111(64.5%) patients with 185 feet were treated by the residents, while 61(35.5%) patients with 96 feet were treated by consultant. The overall mean age was 25.8±32.88 weeks (range: 1-156 weeks). The difference in age between the two groups was significant (p=0.01). A total of 166(96.51%) patients were on maintenance phase in Foot Abduction Bracing and 6(3.48%) completed the treatment successfully without residual deformity. The median number of cast per patient given by Group A was 6 and 5 in Group B. The number of 8+ casts given in Group A were 46 (24.86%) and 17 (17.7%) in Group B. Tenotomies performed in Group A were 106 (57.27%) and 70 (73%) in Group B, and overall PCAT performed were 183 (65.12%). The overall success rate was nearly similar between the two groups, with the difference of<1%. CONCLUSIONS: The best practice to achieve excellent to good results from the beginners in Ponseti technique is to provide mentorship training for the skill of Ponseti manipulation, application of cast and continued treatment.

Total hip arthroplasty in a 6-month-old acetabulum fracture-dislocation of the hip: an 8-year follow-up.

Old unreduced acetabulum fracture-dislocation is common in developing countries due to various factors. Different options including arthrodesis, Girdlestone arthroplasty and total hip replacement (THR) are used for its treatment. THR with reconstruction of the acetabulum is recommended, but not much work has been reported so far in our country. Till date, arthrodesis in youngsters and resection arthroplasty in the elders has been the treatment of choice.THR, however, is being done by a few, but the experience has not been published. We are reporting a case of a middle-aged woman, who had a 6-month-old acetabulum dislocation of the hip with fracture of the posterior wall of the acetabulum. It was treated by THR and acetabulum reconstruction and had good functional result 8 years after the surgery.

A Comparative Study of Salter Versus Pemberton Osteotomy in Open Reduction of Developmental Dysplastic Hips and Clinical Evaluation on Bhatti's Functional Score System.

Objective The study was aimed to compare the outcome of Salter's and Pemberton's osteotomy to achieve adequate acetabular coverage in the open reduction of developmental dysplastic hips (DDH). The functional outcome was evaluated as measured on Bhatti's Functional Score System (BFSS). Patients and methods The study includes 60 children with 82 hips of developmental dysplasia in walking-age children. They were operated on for open reduction and Salter's or Pemberton's pelvic osteotomy to achieve concentric anatomical reduction with good anterolateral coverage of the femoral head. Patients for Salter's and Pemberton's osteotomies were randomly selected. Preference was given to Pemberton's osteotomy in cases with double/irregular acetabulum and in bilateral DDH. All patients were operated on by a single surgeon from January 2014 to December 2016 and were followed up till June 2020. The overall radiological outcome was assessed on Severin's classification, comparing the pre and postoperative acetabular index (AI) and the clinical outcome on Bhatti's Functional Score System. Results The overall functional behavior on Bhatti's Functional Scoring revealed satisfactory outcome (excellent and good) in 73.17% (60/82) hips. On the radiological evaluation, 85.36% (70/82) hips achieved satisfactory development of hips (Severin Class IAB and IIAB) while 12.19% (10) hips developed a moderate deformity of the hip (Severin Class III; p>0.05). Comparing outcomes in both the Pemberton and Salter groups, the acetabular index significantly reduced after both procedures (p<0.05), however, the Pemberton group was more effective than the Salter group. Avascular necrosis (AVN) of Caput Femoris was noticed in 9.57% (8) hips, subluxations in 2.43% (2) hips, and impingement and stiffness in 12.19% (10) hips. Salter's group had more numbers of AVN and subluxations as compared to the Pemberton group, whereas impingement and stiffness were more in Pemberton's but none in the Salter group. Conclusion The hips with Pemberton's acetabuloplasty exhibited better acetabular coverage and progressive development of hips as compared to Salter's osteotomy group. Both groups, however, behaved equally on functional assessment with Bhatti's Functional Score System. The risk of subluxation and AVN was found higher in Salter's group, and femoroacetabular impingement in Pemberton's group. Pemberton's osteotomy was the best option for a single-stage open reduction in bilateral DDH in terms of less risk of bleeding, good stability, better postoperative pain control, and a second surgery to remove transfixation K-wires.

Ponseti Method After Walking Age - A Multi-Centric Study of 429 Feet: Results, Possible Treatment Modifications and Outcomes According to Age Groups.

Objective: Ponseti method is suitable to treat neglected clubfoot after the walking age. However, limited evidence exists on its effectiveness, outcomes and rate of relapse. Methods: 429 clubfeet in 303 patients with no previous treatment and older than one-year were treated with the Ponseti method in 15 centers from seven countries. The median age at treatment onset was three years, and the median follow-up of 1.3 years. Standard Ponseti Method was applied. Bilateral abduction brace was recommended after casting. Patients were classified according to group ages (<2 years, 2-4 years, >4-8years, >8 years). Feet were evaluated by Pirani score and a clinical outcome classification. Relapses were described in a subset of 103 clubfeet with minimal follow-up of two years. Results: Ponseti method was able to correct the deformity in 87% (373 of 429) of neglected clubfeet, after a mean of 6.8 casts. Residual equinus was treated with percutaneous sectioning of the Achilles tendon in 356 (83%) of 429 clubfeet. A bilateral foot abduction brace was prescribed and used in 70% of children. Relapses occurred in 31% (32 of 103) of clubfeet and were associated with age less than 4 years at treatment onset, and bracing noncompliance. Conclusion: The Ponseti method is effective to correct neglected clubfeet. Relapses occurred in one-third of clubfeet, mainly in children younger than four years and in noncompliance with the brace. Our study reinforces the recommendation for the Ponseti method with no major modification to treat neglected clubfoot in patients after walking age.Level of Evidence: IV.

Influence of age on the outcome of single stage reconstructive surgery for congenital dislocation of the hip joint.

OBJECTIVE: This study was conducted to assess the effect of age on the ultimate outcome measures following single stage surgical procedure of soft tissue release, relocation, capsulorrhaphy, femoral shortening with varus/derotation osteotomy and pelvic osteotomy. STUDY DESIGN: A case series. PLACE AND DURATION OF STUDY: The study with two groups of pretest-posttest design was conducted at Department of Orthopaedic Surgery, Jinnah Postgraduate Medical Centre (JPMC), Karachi, from 1993 to January 2008. METHODOLOGY: Patients included were having neglected, congenital dislocation of the hip joint, aged over 3 years. Patients with failed previous surgery, paralytic, teratological, traumatic or septic dislocations and patients with less than 5 years follow-up were excluded from the study. The patients were divided into two groups, 3-7 years (37 hip joints) and over 7 years (13 hip joints). The single stage surgical procedure of open relocation, femoral shortening/derotation/ varus osteotomy and pelvic osteotomy was the dependent variable; whereas, the final clinico-radiological results based upon Tonnis grading, Severin's clinical/radiological grading, Klisic's overall rating and acetabular index were the independent variables of the study. Pre- and postoperative data was assessed for overall improvement and the difference in outcome measures between the two age groups. RESULTS: Significant overall improvement on all parameters was achieved after surgery. When results were compared between two age groups, there was no significant difference in the final outcome as per Tonnis grading and Severin's clinical typing as modified by Gibson (97.3% versus 84.4% normal hip joints or Tonnis grade 1 and 78.37% versus 53.85% Severin's type 1) but the results based upon Severin's radiological grading (62.16% versus 15.38%) and Klisic's overall rating (62.16% versus 15.38%) were significantly better in 3-7 years as compared to those over 7 years. There was no significant difference between the two age groups when compared for improvement in acetabular index. On further analysis, a progressive deterioration of results with increasing age was observed, yet the results in those aged over 7 years were reasonably justified surgical correction of congenital dislocation of the hip joint. Majority of the complications were seen in children operated at the age of 4-5 years. There were 7 cases (14%) of redislocation/subluxation and 6 were in 3-7 years age group. There were 4 cases (8%) of the avascular necrosis of the femoral head. Three patients had residual coxa vara and 2 had significant limb shortening. Limb lengthening was done in these 2 cases. CONCLUSION: The final results displayed progressive deterioration of clinical, radiological and functional outcome measures with aging after single stage reconstructive surgery for the congenital dislocation of hip joint. However, despite this, the results in children over 7 years were also good/excellent in most of the cases justifying surgery.

Functional and Radiological Outcome of Unstable Intertrochanteric Fracture Post Dynamic Hip Screw Fixation.

Introduction Intertrochanteric fractures are the most frequently operated fracture type and have the highest postoperative fatality rate. The most commonly used devices are the dynamic hip screw (DHS) with side plate assemblies and proximal femoral nail (PFN). The aim of this study was to determine the functional and radiological outcome of unstable intertrochanteric fracture post DHS fixation at a tertiary care hospital in Karachi, Pakistan. Methods A study was carried out in the department of orthopedics at the Jinnah Postgraduate Medical Center (JPMC), from 12th June 2016 to 8th September 2017. A total of 106 patients between 18 and 75 years of age with unstable intertrochanteric fracture were included. Those patients who had multiple injuries and open fractures, subtrochanteric fractures, intracapsular fractures neck of femur, pathological fractures and patients who were non-ambulatory prior to their injury were excluded. Functional outcomes were measured both during pain using the visual analog scale and range of motion on goniometer between 80 and 100 degrees. Satisfactory outcomes were measured after three months. Results A total of 106 patients with the radiological diagnosis of the unstable intertrochanteric fracture having post DHS fixation were included in this study. Out of which, 69.8% (74) were males and the mean age was 66.61 ± 7.79 years over the range of 50 to 80 years. Patients with type II diabetes were 22.6% (24) with a mean duration of 4.3 ± 8.37 years. At the end of three months, no pain was reported in 82.1% (87) patients and 85.8% (91) patients had normal function. The satisfactory radiological outcome was observed in 86.8% (92) patients. Overall, acceptable outcomes were observed in 81.1% (86) patients at the end of three months. Conclusion The treatment of unstable intertrochanteric fracture with dynamic hip screw (DHS) fixation results in better outcomes. In our study, we observed acceptable outcomes in a vast majority, 81.1%, of patients after three months of DHS fixation of the unstable intertrochanteric fracture.

Hydatid Cyst of Skeletal Muscle Presenting as Soft Tissue Tumour.

Hydatid disease is helminthic infection caused by tape worm echinococcus granulosis. It commonly involves liver (65-75%) and the lungs (25 to 30%). Involvement of bones and skeletal muscle is very rare, i.e. 3 to 5%. This is the report of a 21-year girl, city resident, presented with mass involving left proximal thigh. The mass was painless and had gradually increased in size over three years. MRI revealed solid cum cystic lesion in vastus medialis muscle. Tru-Cut needle biopsy of the lesion revealed necrotic material. Intraoperative findings were of different sized cystic lesions, typical of hydatid cyst. The cysts were removed intact. No recurrence was seen in 11-month follow-up. Hydatid cyst involving skeletal muscle is very rare entity, but should be considered while making differential diagnosis of soft tissue mass.

Intra pelvic total migration of sliding screw in intertrochanteric fracture.

A type of fixation failure of Dynamic Hip Screw system (DHS) is presented following a collapse of intertrochanteric fracture fixation. The patient presented three months after DHS fixation with severe lower abdominal pain, painful stiff hip and an uncontrolled diabetes mellitus. The radiographic examination of pelvis revealed intrapelvic presence of DHS sliding screw. The intrapelvic total migration of sliding screw has never been reported so far.

Transfer of extensor carpi radialis brevis as an extensor to extensor motor transfer (EEMT) in ulnar nerve palsy.

OBJECTIVE: To evaluate functional outcome and correction of deformity with extensor carpiradialis brevis motor transfer to replace the intrinsic muscles as an extensor to extensor motor transfer (EEMT). METHOD: This was a prospective observational study with one group pretest posttest design conducted from 1996 to 2004. Convenience sampling technique was used and the sample size was twenty one. The independent variable was transfer of extensor carpiradialis brevis to replace the intrinsic muscles. The dependent variable was functional outcome and the correction of deformity. The extraneous variables were age, sex interval between injury and transfer as well as local factors related to wound and grafts used. The average follow up was 22.5 months. RESULTS: The mean preoperative unassisted extensor lag was 56.79 +/- 10.39 which improved to 9.6% +/- 5.4 (correction of 83%) at six months after surgery. With open hand assessment 76.19% reported good to excellent results, while 79.89% achieved good to excellent results with closed hand assessment. The mechanism of closing was good to excellent in 89.42% cases, however only 71.42% patients considered their hands good to excellent. Significant problems were seen with use of tendoachilles as a graft. CONCLUSION: Extensor carpiradialis brevis transfer to replace the intrinsic muscles as an extensor to extensor motor transfer can achieve good functional outcome as well as correction of deformity despite shortcomings in physical rehabilitation.

Bilateral treponema periostitis.

Symmetrical exuberant periostitis is a rare disease caused by variety of infectious and non-infectious causes. Treponematosis is one of the rare causes of this condition. We report a patient who presented with left arm swelling, secondary to onion peel periostitis of the humerus, which was caused by Treponema species.

Frequency, presentation and postintervention prognosis of chondroblastoma.

OBJECTIVE: To evaluate the frequency of clinico-radiological presentation and the prognosis after treatment of chondroblastoma. DESIGN: A descriptive, observational study. PLACE AND DURATION OF STUDY: The study was carried out at the Department of Orthopaedic Surgery, JPMC, Karachi over the period of 16 years, January 1986 to June 2002. METHODOLOGY: Patients in teenage, presenting with signs and symptoms of a primary bone tumours, were included by retrospectively reviewing the tumour registry record. Detailed scrutiny of clinical record was carried out to analyze the clinico-radiological presentation and posttreatment prognosis criteria of healing was symptom-free centripetal and homogeneous ossification. RESULTS: Seven (1.24%) out of 563 primary bone tumour cases were chondroblastoma. The clinico-radiological presentation in the 2 out of 7 (28.57%) cases was classical, 2 simulated osteomyelitis and other 3 as chondromyxoid fibroma, aneurysmal bone cyst and giant cell tumour. Lesions were treated with curettage and bone grafting. One patient (14.28%) developed recurrence within 2 years after curettage and healed after re-curettage and bone grafting. Five out of 7 (71.42%) tumours showed good response and 2 out of 7 (28.57%) showed satisfactory response. CONCLUSION: Chondroblastoma is very rare benign primary bone tumour with high local recurrence rate. The lesions confined to epiphysis of weight-bearing bone present early with symptoms of mild arthritis. Lesions in non-weight-bearing bones often present late and simulates epiphysio-metaphyseal tumours. Lesions heals with centripetal healing and need more than 2 years follow-up to achieve recurrence-free healing.

Malignant fibrous histiocytoma: vascular invasion and metastasis to heart.

Two cases of biopsy-proven malignant fibrous histiocytoma are presented which showed local as well as vascular spread resulting in cardiac metastasis and peri-and postoperative complications leaving palliative surgery as the prime management.

Giant cell tumour of proximal radius in a 48 years old lady.

Giant cell tumour is a locally aggressive tumour of long-bones of epiphyseal region commonly occurring in adults aged 20-40 years. Most common location is distal femur, proximal tibia and distal radius. Different treatment options being used are curettage with bone graft or bone cement, resection with arthrodesis, reconstruction, radiation and chemotherapy. We are reporting a case of giant cell tumour of proximal radius in a 48 years old lady. It is very rare and only 4 cases have been reported in literature. It was treated by wide margin resection without reconstruction.