Ashok Kumar Banskota

Open reduction for neglected traumatic hip dislocation in children and adolescents.

Neglected traumatic dislocation of the hip is extremely rare in children, and the preferred treatment remains unclear. This retrospective case series includes 8 children treated by open reduction. The mean age was 7.5 years (range, 2-16 years), and the mean follow-up was 7 years and 7 months (range, 4 month-16 years). Presenting complaints included pain (5/8) and gait disturbance (8/8). Traction failed to achieve a reduction in all cases. At follow-up, 6 hips remained reduced, and 2 achieved a nonconcentric reduction. All patients had evidence of avascular necrosis. Two patients, in whom a nonconcentric reduction was achieved, developed progressive flattening and joint space narrowing. Two patients had mild pain at follow-up, and 6 patients were able to squat. Range of motion was restricted both before and after open reduction, most notably in abduction and rotation. Postoperative improvement was seen in abduction (4 cases). Leg lengths were within 2 cm in 7 of 8 cases, and only 1 patient had a discrepancy greater than 2 cm. The results according to Garrett et al were good in 3, fair in 3, and poor in 2. The mean Harris hip score was 89. Patients with a concentric reduction had an adequate functional outcome despite evidence of avascular necrosis. The prognosis remains guarded, and we expect that a subset of patients will develop premature degenerative joint disease. However, we continue to offer patients an operative reduction, which we feel is preferable to other methods. A failed open reduction does not preclude options for salvage.

Tuberculosis of the Musculoskeletal System

Summary: Tuberculosis remains a major source of morbidity and mortality worldwide, and orthopaedic surgeons working in developing nations, especially in South East Asia, are likely to encounter patients with osteoarticular manifestations of the disease. Chemotherapy is effective, and surgery serves as an adjunct for specific indications. Tuberculous osteomyelitis is the least common presentation, and the radiographic features may be confused with a variety of other diagnoses. A biopsy is required, and curettage may be performed in addition to chemotherapy. Bone Grafting is generally not required. The natural history of articular disease evolves over several years from a synovitis to joint destruction, and the prognosis is related to the stage of disease at presentation. In addition to chemotherapy, a synovectomy may be indicated in patients who have synovitis without significant joint destruction. For later stage disease, salvage options include osteotomy, arthrodesis, or prosthetic reconstruction. Approximately 50% of patients will have spinal involvement, and chemotherapy is effective in the majority of cases. The indications for surgery remain somewhat controversial, but may include uncertainty with the diagnosis, lack of response to chemotherapy, profound or progressive neurologic deficit, mechanical instability, or progression of deformity.

Traumatic laceration of the radial nerve following supracondylar fracture of the elbow. A case report.

Traumatic laceration of the median, ulnar, or radial nerve is an extremely rare complication of supracondylar fracture of the humerus in children. A recent review of the literature disclosed only two reported cases of a laceration involving the radial nerve; a third such injury in an 8-year-old boy is reported in the present paper. Traumatic neuropraxia of one or more of the three adjacent peripheral nerves is a more common complication of supracondylar fracture, with the great majority of these lesions responding to conservative treatment. Vascular compromise secondary to traumatic laceration of the brachial artery is a more frequently observed injury, with an incidence in some series as high as 10%. Clinical findings that suggest vascular injury, therefore, warrant a more aggressive approach, either by arteriography or surgical exploration.

Hip arthrodesis in children: A review of 28 patients

Background: The best method of treating intractable hip pain in an unsalvageable hip joint in a child is still a subject open to debate. We believe that hip arthrodesis in such patients provides a painless and stable hip for most activities of daily living in our challenging rural terrain. Therefore, we conducted this study to assess the functional ability of children with painful hip arthrosis treated by arthrodesis of the hip. Materials and Methods: A retrospective evaluation of 28 children (out of 35) who had an arthrodesis of the hip performed between 1994 and 2008 was carried out. The average age was 14 years, with 12 males and 16 females. There was involvement of the right hip in 13 and left in 15 cases. The average duration of follow-up was 4.87 years. The preferred position of the hip for arthrodesis was 20–30° of flexion, neutral abduction-adduction, and neutral rotation, irrespective of the method of fixation. Results: The average duration of clinical and radiological arthrodesis was found to be 4 months (2–6 months). At the last follow-up, all patients were painfree and had good ambulatory capacity. The average Modified Harris Hip Score increased from 53 to 84 and the average post-surgical limb length discrepancy was 1.3 cm, which was well tolerated in all cases. Patients, however, had difficulty in squatting and had to modify their posture for foot care, putting on shoes, etc. Also, some patients complained of ipsilateral knee, contralateral hip, or low back pain with prolonged activity, but this was not severe enough to restrict activity except in one case that was known to have juvenile rheumatoid arthritis and needed ambulatory aid. Conclusion: In an environment where pathology generally presents very late and often in a dramatic manner, where the patients socioeconomic status, understanding, compliance, and the logistics of follow-up are consistently a challenge in management, hip arthrodesis has been an important procedure for our patient group, with good short-term results and promising midterm, and, hopefully, long-term prospects. In our series of patients, we have been successful in restoring painfree mobility.

Musculoskeletal Training for Orthopaedists and Nonorthopaedists: Experiences in Nepal

Orthopaedic surgical training in Nepal began in 1998, and four major centers now produce between 15 and 20 graduates annually. The duration of the training is four years in one center and three years in the remaining centers. Trainees have adequate trauma exposure. The major challenges include: tailoring training to suit local needs, avoiding the dangers of market driven orthopaedic surgery, adequately emphasizing and implementing time honored methods of closed fracture treatment, and ensuring uniformity of exposure to the various musculoskeletal problems. Training in research methods needs to be implemented more effectively. The evaluation process needs to be more uniform and all training programs need to complement one another and avoid unhealthy competition. Training for nonorthopaedists providing musculoskeletal care is virtually nonexistent in Nepal. Medical graduates have scant exposure to trauma and musculoskeletal diseases during their training. General surgeons provide the majority of trauma care and in the rural areas, health assistants, auxiliary health workers and physiotherapy assistants provide much needed basic services, but all lack formal training. Traditional “bone setters” in Nepal often cater to certain faithful clientele with sprains, minor fractures etc. A large vacuum exists in Nepal for trained nonorthopaedists leading to deficiencies in prehospital care, safe transport and basic, primary emergency care. The great challenges are yet to be addressed.

Clubfoot Etiology, Pathoanatomy, Basic Ponseti Technique, and Ponseti in Older Patients

Clubfoot is a common congenital condition that leads to disability when untreated. This chapter discusses the etiology and pathoanatomy of this condition and then describes the Ponseti method.

Neuroarthropathy of the hip following spinal cord injury.

We present the case of a 33-year-old male who sustained a burst fracture D12 vertebrae with spinal cord injury (ASIA impairment scale A) and a right mid-diaphysial femoral shaft fracture around 1.5 years back. The patient reported 1.5 years later with a swelling over the right buttock. Arthrotomy revealed serous fluid and fragmented bone debris. The biopsy showed a normal bony architecture with no evidence of infection and malignant cells. Hence, a diagnosis of Charcot’s hip was made. Charcot’s neuroarthropathy of the feet is a well-recognized entity in the setting of insensate feet resulting from causes such as diabetes or spina bifida. Although Charcot’s disease of the hips has been described, it is uncommon in association with spinal cord injury, syphilis and even with the use of epidural injection. The present case highlights the fact that neuroarthropathy of the hip can occur in isolation in the setting of a spinal cord injury, and this can lead to considerable morbidity.

Neglected Septic Arthritis in Children

The sequelae of septic arthritis can lead to considerable disability in children especially in weight-bearing joints. Various strategies are available for salvage, but the best results are with early diagnosis and treatment.