Hayat Ahmad Khan

Cotard's syndrome and delayed diagnosis in Kashmir, India

Cotards syndrome is a rare syndrome, characterized by the presence of nihilistic delusions. The syndrome is typically related to depression and is mostly found in middle-aged or older people. A few cases have been reported in young people with 90% of these being females. We present a case of a young pregnant woman suffering from Cotards syndrome. This is the first report of this syndrome in a pregnant woman. The case was diagnosed late, due to lack of awareness of psychiatric problems in primary care physicians resulting in undue suffering, loss of precious time and resources for the patient. Besides highlighting the rare combination of pregnancy and Cotards syndrome this report delineates the difficulties faced by patients with such symptoms in a low resource setting.

Correlation Between Magnetic Resonance Imaging and Arthroscopic Findings in the Knee Joint

Background: The knee joint is the largest and the most complex joint of the human body. It is not covered by any thick muscular covering anteriorly. Objectives: The purpose of this study was to explore the diagnostic capabilities of clinical examination, magnetic resonance imaging (MRI), and arthroscopy in traumatic disorders of the knee joint, to seek correlation between clinical findings, MRI findings and arthroscopic. Patients and Methods: A total of 26 patients with a presentation suggestive of traumatic knee pathology were studied prospectively. A detailed history was taken and relevant clinical examination was done, which was followed by MRI of the knee. The patients were scheduled for arthroscopy under general/spinal anesthesia, whenever indicated. Results: Keeping arthroscopic examination as standard, the correlation between clinical and arthroscopy showed a sensitivity of 80%, specificity of 86%, accuracy of 63.16%, negative predictive value of 93.48%; whereas MRI vs. arthroscopy showed a sensitivity of 74.42%, specificity of 93.10%, accuracy of 84.21%, and negative predictive value of 88.04%. Conclusions: The clinical examination is an important and accurate diagnostic modality for evaluation of traumatic derangement of the knee joint. It is noninvasive, easy, available, and valuable diagnostic modality. The MRI is an accurate diagnostic modality. It can be used whenever there is an uncertain indication for arthroscopy. However, costs have to be kept in mind, especially in patients with low socio-economic status.

Functional Outcome of Distal Radius Fractures Managed by Barzullah Working Classification

Background: Management of distal radius fractures (DRFs) is still controversial and may be influenced by the initial fracture classification. Even though numerous classification systems have been proposed in this regard, the evaluation and management of this fracture has remained problematic. Objectives: The purpose of this study was to evaluate the functional outcome of DRF managed on the basis of a new classification. This classification named as Barzullah Working Classification represents a modification of Melone classification, which is based on fracture stability. Patients and Methods: A total of 310 DRFs of patients skeletally matured referred to a tertiary care hospital at a period of 18 months were classified as per the new classification system into four types; metaphyseal stable, metaphyseal unstable, radiocarpal stable, and radiocarpal unstable fractures. They were managed and followed over a mean period of 15.10 ± 5.4 months, and the results were recorded at the final follow-up. Results: The mean age of the patients was 51.22 ± 20.58 years. Most of the patients were females (n=189, 64.19%). The minimal follow up was 6 months with a mean of 15.10 ± 5.4 months. Mean mayo wrist scores were 95 ± 4, 80 ± 7.4, 75 ± 7.4, and 70 ± 6.9, for stable metaphyseal fractures, unstable metaphyseal radial, stable radiocarpal fractures and unstable radiocarpal fractures, respectively. The overall mean mayo wrist functional score was 80.58 ± 12.3 (good results) at final follow up. Conclusions: Various modalities of treatment used differentially in different types of DRFs based on the Barzullah Working Classification give good results in spite of conflicting literature.

Interobserver Agreement and Intraobserver Reproducibility of Barzullah Working Classification of Distal End Radius Fractures among Orthopaedic Residents

BACKGROUND The purpose of this study is to test the hypothesis of the new classification system of distal end radius fractures (Barzullah working classification) proposed by one of the author in a prospective cohort study, among the orthopaedic residents. METHODS The initial post-injury radiographs of 300 patients with distal radius fractures in a tertiary centre were classified by two junior residents (JR1 and JR2) and two senior residents (SR1 and SR2) in the emergency department over a period of two years. The collected data was analysed statistically by using Cohans kappa for measuring Intraobserver reproducibility and Fleiss kappa for measuring Interobserver agreement. RESULTS The mean kappa value for Interobserver agreement was 0.53 (moderate agreement) at the end of one year and the mean kappa value at the end of study period was 0.64 (substantial agreement). The mean kappa value for Intraobserver reproducibility of JR1 was 0.45 (moderate agreement), JR2 was 0.39 (fair agreement), SR1 was 0.62 (substantial agreement) and SR2 was 0.67 (substantial agreement). CONCLUSIONS Barzullah working classification of distal radius fractures presented in this study has good characteristics compared to those of already studied classification systems among orthopaedic residents.

Anterior Tarsal Tunnel Syndrome With Thrombosed Dorsalis Pedis Artery: A Case Report

Introduction: The aanterior tarsal tunnel syndrome denotes the entrapment of the deep peroneal nerve under the inferior extensor retinaculum. Although various etiological factors have been reported to cause anterior tarsal syndrome, its occurrence with thrombosed dorsalis pedis artery has not been reported in the English literature. Case Presentation: A 40 -year-old male patient was presented with the history of persistent pain along the dorsal surface of right foot, which was aggravated with the activities. Conservative management was tried without much relief. Diagnosis of anterior tarsal tunnel syndrome was made and the patient was planned for surgery. Thrombosed dorsalis pedis artery was found along with two adjacent collateral vessels. Retinaculum was released and nerve was mobilized. Tight compartment got released. Postoperative period was uneventful. No recurrence was seen on follow-up. Conclusion: The anterior tarsal tunnel syndrome is a known disease. A high index of clinical suspicion is required while dealing with the chronic cases. A detailed history to rule out any traumatic event is necessary too. Timely investigations and surgical release give dramatic relief.

Considerations regarding autologus blood injection for tennis elbow tendinopathy.

Dear Editor, We read with interest the article by Karimi Mobarakeh et al. (1) titled as “Autologous Blood Injection for Treatment of Tennis Elbow”. We would like to congratulate the authors for taking up such a study. However, we have several considerations regarding this manuscript: What was the number of patients who received the local steroid injections before being in the study and also, what was the duration from the last steroid injection before patients were given the autologous blood injection. After injection, the authors state that “Immobilization via a long arm cast was done for 3 weeks”. Unfortunately, the authors have omitted to mention the reasons leading to cast immobilization. Also, there is no information concerning the occurrence of post injection stiffness of elbow when a 3 weeks long arm cast immobilization was maintained. In the Results column, the manuscript states that “The mean duration of symptoms was 7.9 ± 1.3 months. Table 1 shows results of NPS and VAS before and 1, 3 and 6 months after ABI”. However, there is no table available to support the results. Furthermore, in the results column, the authors say that “The level of patient satisfaction on Verhaar scale is shown in Figure 1; 84% of patients showed a high level of satisfaction at the end of the study. None required a second injection, although some of them were obliged to change their activities”. However, no Figure is shown to justify such data. The authors have mentioned that their results were comparable to other studies. However, the studies mentioned in the reference column had used ultrasound guided autologous blood injection for tennis elbow (2). Only one study from the references has used autologous blood injection similar to the present study (3). We would rather suggest the authors to compare their results with comparable studies to justify their implication for the healthcare policy making. We hope our suggestions will be taken with a positive note and the revised manuscript with all missing Figures and Tables will be made available.

Long Term Results in Refractory Tennis Elbow Using Autologous Blood

Tennis elbow (TE) is one of the commonest myotendinosis. Different treatment options are available and autologous blood injection has emerged as the one of the acceptable modalities of treatment. Long term studies over a larger group of patients are however lacking. The purpose of this study was to evaluate these patients on longer durations. One-hundred and twenty patients of TE, who failed to respond to conventional treatment including local steroid injections were taken up for this prospective study over the period from year 2005 to 2011 and were followed up for the minimum of 3 years (range 3-9 years). Two mL of autologous blood was taken from the ipsilateral limb and injected into the lateral epicondyle. The effectiveness of the procedure was assessed by Pain Rating Sscale and Nirschl Staging, which was monitored before the procedure, at first week, monthly for first three months, at 6 months and then 3 monthly for first year, six monthly for next 2 years and then yearly. Statistical analysis was done and a P value of <0.05 was taken as significant. The patients (76 females and 44 males) were evaluated after procedure. The mean age group was 40.67±8.21. The mean follow up was 5.7±1.72 (range 3 to 9 years). The mean pain score and Nirschl stage before the procedure was 3.3±0.9 and 6.2±0.82 respectively. At final follow up the pain score and Nirschl were 1.1±0.9 and 1.5±0.91 respectively. Autologous blood injection was found to be one of the modalities for treatment of TE. Being cheap, available and easy method of treatment, it should be considered as a treatment modality before opting for the surgery. Universal guidelines for the management of tennis elbow should be made as there is lot of controversy regarding the treatment.

Atlas and axis injuries role of Halovest.

BACKGROUND The literature regarding the different patterns of atlas and axis injuries and their appropriate management and the progressive development in the management of these injuries is scarce from our world, so we presenting here our experience of management of these injuries by applying Halovest. MATERIALS AND METHODS Thirty patients (22 males, 8 females) with atlas and axis injuries were treated and then followed-up for an average of 24 months. The data was analysed with respect to type of injury and use of Halovest in the treatment of these injuries. The patients with neuro defecit were scored as per ASIA grading scale (from Grade A to Grade E). RESULTS The halo-vest immobilization was used for a mean period of 12 ± 3weeks (range 9 to 15 weeks) for atlas and axis injuries. Four patients had neurodeficit. Two patients recovered from ASIA Grade C to ASIA Grade D. One patient improved from ASIA grade D to ASIA grade E while as one patient with neurodeficit was lost to follow up. No death or worsening of the neurodeficit was observed during the follow up period. CONCLUSION The clinical as well as radiological outcome of these injuries is mostly satisfactory with the conservative management using Halovest. More studies should be conducted to form the guidelines regarding patient selection for conservative management using halovest.

Vertical Patellar Dislocation: Reduction by the Push Up and Rotate Method, A Case Report and Literature Review

Introduction Patellar dislocation is an emergency. Vertical patellar dislocation is rare, often seen in adolescents and mostly due to sports injuries or high-velocity trauma. Few cases have been reported in the literature. Closed or open reduction under general anesthesia is often needed. We report a case of vertical locked patellar dislocation in a 26-year-old male, which was reduced by a simple closed method under spinal anaesthesia. A literature review regarding the various methods of treatment is also discussed. Case Presentation A 26-year-old male experienced a trivial accident while descending stairs, sustaining patellar dislocation. The closed method of reduction was attempted, using a simple technique. Reduction was confirmed and postoperative rehabilitation was started. Follow-up was uneventful. Conclusions Vertical patellar dislocations are encountered rarely in the emergency department. Adolescents are not the only victims, and high-velocity trauma is not the essential cause. Unnecessary manipulation should be avoided. The closed reduction method is simple, but the surgeon should be prepared for open reduction.

Ensuring Carpal Tunnel Release: "Drop in", "Rail Road" or "the Open Door" Sign

Dear Editor, Carpal tunnel syndrome is one of the most common problems faced by people worldwide. It remains a concern for the developed world; although many treatment modalities are available, endoscopic release of the tight compartment is one such treatment modality (1, 2). As in all surgical fields, minimally invasive procedures are preferred over open surgical procedures wherever possible (3). Endoscopic procedures have a steep learning curve and they are much easier for those who have already mastered open procedures. However, the changing trend in orthopaedics has seen many young surgeons opting to focus on minimally invasive procedures (4). They thus need proper training, guidance, and confidence building regarding such procedures. The “rail road” sign and the “drop in” sign mentioned in one of the research articles are examples of the measures that surgeons around the world should be aware of (5). A good representative diagram makes mastering surgical techniques much easier. My personal experience with minimally invasive procedures is the same. When the flexor retinaculum is released, the two cut ends fall apart and the associated distance gives the wound a “rail road” appearance. The medial nerve can be freed from any adherent structure and mobilised to confirm the total release of the flexor retinaculum (6). The flexor retinaculum will only allow free passage when it is totally released, and it will fall back with the nerve (i.e., the “drop in” sign). This may result in an appearance akin to “the open door”, wherein two flaps can separate and then approximate to allow for decompression. The sign is reproducible in open, minimally invasive, and endoscopic procedures. It can be regarded as the key sign of minimally invasive procedures, and its presence can ensure that the surgeons have completely released the carpel tunnel. The sign can also be elicited in the release of tarsal tunnels; however, literature supporting this still has to evolve over time.