Anil Mehtani

Evaluation of Ponseti method in neglected clubfoot

Background: Gentle passive manipulation and casting by the Ponseti method have become the preferred method of treatment of clubfoot presenting at an early age. However, very few studies are available in literature on the use of Ponseti method in older children. We conducted this study to find the efficacy of Ponseti method in treating neglected clubfoot, which is a major disabler of children in developing countries. Materials and Methods: 41 clubfeet in 30 patients, presenting after the walking age were evaluated to determine whether the Ponseti method is effective in treating neglected clubfoot. This is a prospective study. Pirani and Dimeglio scoring were done for all the feet before each casting to monitor the correction of deformity. Quantitative variables were expressed as mean ± standard deviation and compared between preoperative and postoperative followup using the paired t-test. Also, the relation between the Pirani and Dimeglio score, and age at presentation with the number of casts required was evaluated using Pearsons correlation coefficient. No improvement in Dimeglio or Ponseti score after 3 successive cast was regarded as failure of conservative management in our study. Results: The mean age at presentation was 3.02 years (range 1.1 - 10.3 years). The mean followup was 2.6 years (range 2–3.9 years). The mean number of casts applied to achieve final correction were 12.8 casts (range 8 - 18 casts). The mean time of immobilization in cast was 3.6 months. The mean Dimeglio score before treatment was 15.9 and after treatment were 2.07. The mean Pirani score was 5.41 before treatment and 0.12 after treatment. All feet (100%) achieved painless plantigrade feet without any extensive soft tissue surgery. 7 feet (17%) recurred in our average followup of 2.6 years. Conclusions: Painless, supple, plantigrade, and cosmetically acceptable feet were achieved in neglected clubfeet without any extensive surgery. A fair trial of conservative Ponseti method should be tried before resorting to extensive soft tissue procedure.

Pediatric cervical disc calcification simulating tubercular spondylitis - A case report.

Calcification of intervertebral disc in children is rare. It mostly affect lower cervical region and present with acute neck pain, torticolis, restriction of range of motion. Neurological deficit or dyspahagia are rare features. The presence of fever, leukocytosis and elevated erythrocyte sedimentation rate, gives impression of tuberculosis or other infections. This differentiation is important as the management of pediatric disc calcification is mostly conservative and prognosis is good.

Letter to the Editor: Intra-articular tranexamic acid wash during bilateral total knee arthroplasty.

To the Editor: We read with interest the article by Zhu et al.1 The authors concluded that topical tranexamic acid (TXA) wash decreased the blood transfusion rate and length of hospital stay. Perioperative and total blood loss were mentioned, but the difference between the 2 was not elaborated. Perioperative includes the pre-, intraand post-operative periods. Only the haemoglobin balance method was described for calculation of blood loss. Generally the drop in haemoglobin level following bilateral total knee arthroplasty is 3 to 5 g/dl.2 However, the total drop in haemoglobin level in the TXA group ranged from 1.55 to 2.75 g/dl. As the minimum trigger for blood transfusion was a haemoglobin level of 9 g/dl, how did any patient receive a transfusion? What are the reasons for such a low haemoglobin drop in their series? When was the postoperative haemoglobin level measured? The haemoglobin level usually continues to drop for 2 to 4 days after surgery and then plateaues.3 The lowest value should be considered when calculating total blood loss. Please clarify the protocol for measurement of postoperative haemoglobin level. Drains were not used. Drains are thought to decrease haematoma collection, and in the TXA group, clamping of the drain for some time may have increased the contact time with TXA and may have increased its efficacy. Can the authors comment on this? In patients without a drain, was there any postoperative swelling, ecchymosis, or haematoma collection? Intra-articular TXA may be absorbed systemically. The authors used a combined dose of 3 g of TXA (1.5 g for each knee). The risk of systemic toxicity with such a high dose in the absence of a drain cannot be overlooked. Did the authors check the serum TXA level? Was there any advantage of topical use over intravenous use in bilateral cases? In our opinion, the intravenous route is preferred, particularly for bilateral cases, as a single low dose of 10 to 15 mg/kg may be effective for both knees. It avoids 10 minutes of waiting period/contact time, and decrease in surgical time itself may reduce blood loss. The authors mentioned only the functional criteria for discharge from hospital. Discharge of a patient depends on wound condition, oozing from wound, and fever. These may not have been controlled. The decision to discharge largely depends on the treating surgeon, and thus observer bias cannot be ruled out. The use of TXA is not the only cause of earlier discharge. Its effect on the length of hospital stay remains to be evaluated with further studies.

Epidural versus Intra-Articular Infusion Analgesia following Total Knee Replacement

To the Editor: We read with interest the article by Kasture and Saraf.1 What was the method of randomisation? Was there a pilot study or power analysis to calculate the sample size? Was ethical clearance or approval obtained? Was the patella resurfaced? Was there a significant difference in patellar resurfacing between the 2 groups? Was there any difference in postoperative range of motion? The intra-articular infusion group could have had better range of motion given that they were able to stand and walk early. Early range of motion is an advantage of local infiltrative analgesia over epidural analgesia, which has late motor recovery.2 Why was this criterion not used in the rehabilitation period? Complications of intra-articular infusion were not mentioned. Continuous intra-articular infusion is associated with knee swelling, wound-related complications, and blisters.3 The catheter tips may grow staphylococcus after 21 hours.4 Were cultures on the tips studied? Was there any early infection? Was there cardiotoxicity of bupivacaine? In addition, ketorolac, a non-steroidal anti-inflammatory drug, was used in the intra-articular infusion group. Owing to its inhibition of platelet aggregation, there may be a risk of increased bleeding.5 Was there any difference in drain output between the 2 groups? Multimodal analgesia is recommended, with medication started before the actual surgery.6 Was any regimen of multimodal analgesia used? Were any analgesics given prior to surgery? Why were only patients with moderate knee deformity included? Postoperative pain would be higher in those with severe osteoarthritis owing to more soft-tissue release. Was there any patient with valgus deformity? Patients with postoperative infection or deep vein thrombosis were excluded. Both these complications develop after 4 to 5 days. Why were they excluded? Patients were discharged at 5 days. How did the authors evaluate these complications after discharge and for how long? Continuous intra-articular infusion may be a source of infection. Excluding these patients may have caused bias. In addition, patients with previous lower limb surgeries were also excluded. How would a previous ankle or hip surgery affect the present study? There are concerns regarding toxicity of local anaesthesia used in local infiltration.7 Did the authors measure the serum bupivacaine level? A single application of local infiltration is effective to control postoperative pain.8 In our experience, continuous infusion has no added advantage over single administration, but has an increased risk of infection and drug toxicity. We agree that intraarticular infusion is an effective modality for pain control and has fewer complications, but 48 hours of continuous administration is too long and may affect early rehabilitation.

Delayed presentation of fracture of lateral condyle of humerus in pediatric age group treated by ORIF and ulnar peg grafting: A case series

Background: Fractures of lateral condyle of humerus in pediatric age group, the most common being distal humerus epiphyseal injury, are commonly associated with delayed presentation to terminal health care providers. Reasons accounted might be at every level, right from the patient to the physician. In the backdrop of existing disputed treatment strategy operative v/s non-operative treatment of fractures having more than 3-week duration of injury, same were treated by open reduction and k wire fixation using ulnar peg graft. Final functional result was evaluated with longest follow up of over 1 year. Materials and Methods: Twenty children having fracture of lateral condyle of humerus with duration of trauma more than 3 week were included in the prospective study. Age ranged from 5 years to 15 years. Average age was 8 years. Among the 20 patients, 8 were male and 12 were female. Average time of presentation was after 5 weeks of injury. Seven patients had milch type 1 injury and 13 patients had milch type II injury. All patients were treated by open reduction and internal fixation using k wires and ulnar peg graft. The follow-up period was over 1 year. Result: Results were evaluated using radiograph, and functional results were evaluated using the Liverpool elbow scoring system. In the present series, all fractures united with 92% excellent, 5% good, and 3% poor results. Poor results were associated with greater displacement of fracture, prior repeated attempts of close reduction, and history of massage. Conclusion: Being an epiphyseal injury and a common occurrence, fracture of lateral condyle of humerus in pediatric age group are commonly maltreated, with error contributed right from parents to even physician. Common reasons of delayed presentation are ignorance on parents′ side, malpractice by some bone-setters, poorly done radiograph, inaccurate radiographic interpretation by the physician, and poor selection of treatment methods.

Giant cell tumour--a very rare differential for a lytic lesion of the medial condyle of the humerous.

Tumours are rare around the elbow joint, and giant cell tumours are especially rare in this region. A single case report of a giant cell involving the distal humerous was found in the literature and none were found involving the isolated medial condyle. We present a rare case of a 22-year-old woman with progressively increasing painful swelling in her left elbow over a period of 6 months. A plain radiograph revealed an expansile epiphyseometaphyseal, radiolucent lesion in the medial end of the distal humerous, with the rim being thin but still intact. The MRI of the elbow revealed a solid lesion in the medial aspect of the elbow with no breach of cortex. Biopsy of the lesion revealed multinucleated giant cells along with mononuclear cells consistent with a diagnosis of giant cell tumour. Extended curettage with bone cement was performed through an anterior approach. There has been no recurrence of the tumour in 2 years of follow-up; the patient has a good range of elbow movements of 20–110°.

Isolated tuberculosis of scaphoid in the skeletally immature: a rare cause of chronic wrist pain

The hand and wrist are rare sites for tuberculosis and account for less than 1% of all skeletal tuberculosis. Though rare, tuberculosis of the wrist is a cause of major morbidity. A common feature in the available reports on hand and wrist tuberculosis was a delay in diagnosis causing residual stiffness and pain after treatment. Minimal initial symptoms, rarity of the lesion and ability of wrist tuberculosis to mimic more common pathologies account for the delay. No report of isolated scaphoid lesion in the paediatric age group has ever been reported. We present one such case, which was treated with multidrug chemotherapy. At the end of treatment the patient regained complete range of motion was completely pain free. No reactivation of disease was seen over 2-year follow-up.

Primary Tuberculosis of the Clavicle

Tuberculosis of the clavicle is a rare lesion, accounting for less than 1% of all osteoarticular tuberculosis. The lesion has been described in a few case reports. The lesion can have a varied presentation, ranging from dull, aching pain to bony swelling and a draining sinus. The rarity of the lesion, its nonspecific symptoms, and its striking resemblance to common cystic conditions such as bone tumors and metabolic conditions such as rickets make diagnosis difficult. The authors describe a series of 17 patients with primary tuberculosis of the clavicle. Radiographs and magnetic resonance images were obtained for all patients, and a preliminary diagnosis was made on the basis of clinical features and the results of erythrocyte sedimentation rate, C-reactive protein, and Mantoux tests. Erythrocyte sedimentation rate was uniformly elevated. Radiographs showed diffused thickening and honeycombing, eccentric expansile lytic lesions with surrounding osteopenia, or sequestration not unlike pyogenic infection. Magnetic resonance imaging is useful for determining the extent of the lesion and soft tissue involvement. The radiological and laboratory findings provided complementary information. The diagnosis was confirmed on biopsy material that was analyzed with histopathology, pus culture and sensitivities, gram stain, acid-fast stain, and cultures on Löwenstein-Jensen medium. Patients were treated with multidrug antitubercular chemotherapy for 18 months and were assessed on pre- and posttreatment radiology, erythrocyte sedimentation rate, and University of California, Los Angeles (UCLA) shoulder rating scale. The results of conservative management of tubercular osteomyelitis were uniformly good, and all patients recovered well.

A very rare cause of chronic foot pain in a child: metatarsal tubercular osteomyelitis

Pure tubercular osteomyelitis without joint involvement is rare and easily missed. Moreover the lesion is common in spine and large joints like hip and knee. The involvement of isolated metatarsal has been described rarely, only as few sporadic case reports. We present one such case of isolated first metatarsal involvement in an 8-year-old child who presented with chronic pain in left foot for over 6 months. The X-rays suggested a lytic lesion and lesion was confirmed on histopathology and acid-fast bacteria staining. The patient was treated with multidrug antitubercular chemotherapy. The results were excellent with complete healing of the lesion.

Postinfective skin contracture: a rare cause of fifth metatarsophalangeal joint subluxation

Dislocation or subluxation of the metatarsophalangeal joint (MTP) is common and usually follows a traumatic event. Non-traumatic causes usually include inflammatory arthritis (rheumatoid arthritis), connective tissue disorders, crowded shoewear or flexor digitorum longus tendon contracture. We present a very unusual case of subluxation of the fifth MTP joint following a postboil skin contracture. The case was treated with the release of contracture by Z-plasty. It resulted in concentric reduction of the joint and normal skin healing.