Pravin Nepal

Comparison of Ponseti and Kite's method of treatment for idiopathic clubfoot.

Background: The manipulation and corrective cast application for club foot was known to be done by Kites method. The Kites method of manipulation (center of rotation of malaligned foot and fulcrum on cuboid) was modified by Ponseti (fulcrum on head of talus). Recently, Ponsetis method has gained popularity and vastly improved results are reported. We report randomized controlled trial where manipulation of club foot was done by Ponsetis and Kites method and correction evaluated by Pirani score to compare the outcome of treatment. Materials and Methods: Sixty feet in 38 patients, 22 with bilateral and 16 with unilateral clubfeet in children less than two years of age and without any prior manipulation or surgical treatment were randomly allocated to the Ponseti (30 feet) and Kite (30 feet) methods of manipulation. This process resulted in the right and left feet of the same patient in 12 bilateral cases being compared with one another (Paired analysis). In the remaining 10 bilateral cases, four patients had both feet treated by Ponseti and six had both feet treated by Kite (unpaired analysis). Finally, in 16 unilateral cases, 10 feet were allocated to the Ponseti and six to Kite methods of manipulation (unpaired analysis). Feet were followed up weekly for 10 weeks for change of cast and recording of hindfoot, midfoot and total Pirani scores. Correction was measured as a difference between hindfoot, mid foot and total Pirani scores weekly from weeks 1 to 10 and corresponding baseline scores. Absolute correction and rate of correction in (i) bilateral clubfeet treated by Ponsetis method on one side and Kites method on the other side in the same patient were compared using paired Students t test and (ii) patients with unilateral clubfoot (where either of the methods was used) or those with bilateral clubfoot (where both feet treated by either of the two methods on both the sides) were compared using difference between means (mean correction by Ponseti minus mean correction by Kite) for magnitude of difference and unpaired Students t test (if data was normally distributed) or Mann Whitney U statistics (otherwise) for significance of difference. Results: In 12 bilateral clubfeet, where one foot received Kites method and the other Ponsetis manipulation, feet treated by Ponsetis technique showed faster rates of decrease in Pirani score (improvement) as compared to feet treated by Kites method with the mean of difference between baseline and follow up scores showing significantly greater (P<0.05) difference from zero from fourth week onwards to up to 10 weeks. In unpaired analysis, both for unilateral or bilateral clubfeet, regardless of side, mean Pirani scores in Ponseti feet improved much faster than Kite feet but the difference achieved statistical significance only at the 10th week from the start of treatment. Conclusions: Hind foot, midfoot and total Pirani scores reduce much faster with Ponseti than the Kites method of manipulation of clubfoot. In paired analysis the difference becomes statistically significant at fourth week and in unpaired analysis at 10th week from the start of treatment.

Instrument fails, but surgeon should not. Surgical techniques for retrieval of broken intramedullary reamer from tibia

Intramedullary interlocking nail has become standard mode of treatment for fracture of long bones of leg. Where instrumentations, like flexible reamers, are restraint, it can be sufficed with serial reaming with straight reamer. However, straight reamer makes the surgery difficult at times, because it has a tendency to break. We encountered a similar situation and would like to share how we retrieved the broken piece of straight reamer from the medullary canal.

Multiple Pelvic digits: a rare congenital anomaly

Eleventh finger or pelvic digit is an uncommon congenital anomaly. Many cases are detected incidentally while evaluating back pain or other pelvic pathology. Though resembles Myositis Ossificans, clear cortico medullary differentiation and history of trauma ease up to diagnose this rare entity.

Use of ring fixator in the management of degloving injuries of lower limb

High-velocity trauma causes degloving injuries of extremities. Management depends upon the viability of the degloved flap. The degloved area must be covered either with flaps or with split skin grafts. Various methods have been described to provide skin coverage. However, graft uptake depends upon the surgical expertise, graft quality, graft bed circulation and of course immobilization of the grafted area, especially across joints. We describe here a simple technique, which eventually helps graft bed preparation, eases application of graft tissue, facilitates graft care and allows passive mobilization of joints as well.

Tumor de células gigantes da extremidade distal do fêmur: um desafio de tratamento

Apresentamos aqui um caso de tumor de celulas gigantes na extremidade distal do femur direito tratado com resseccao da massa tumoral em bloco com remocao aguda da extremidade proximal e distal e fixado com hastes longas em K atravessando o joelho, do femur a tibia. Apos a consolidacao / uniao completa das extremidades, foi feita a remocao da haste em K, seguida pela corticotomia juntamente com a osteogenese da distracao com o auxilio do anel fixador de Ilizarov. O comprimento foi alcancado com este processo. O resultado final foi muito bom neste caso. Revisamos as opcoes de tratamento para tumor maligno de celulas gigantes na extremidade distal do femur e as dificuldades de trata-lo.

Giant Malignant Nerve Sheath Tumor of Lumbosacral Plexus with Intraspinal Extension in a Child with Neurofibromatosis Type 1

Malignant peripheral nerve sheath tumors (MPNSTs) are the leading cause of death in young adults and are one of the most frequent non-rhabdomyosarcomatous soft tissue tumors in pediatric age. These tumors usually occur in young adults from a previously recognized neurofibroma, neurofibromatosis type 1 (NF1), with a noted change in size and pain. This child reached the age of 10 without the presence of the more commonly seen manifestations of NF1. Pseudoarthrosis in children has a high rate of association with NF1, and in this case diagnosis of NF1 was supported by development of MPNST in a pre-existing plexiform neurofibroma.

It is a glomus tumor! Not at all a paronychia.

We report an interesting case of chronic obscure pain over the toe tip. This earlier was misdiagnosed as chronic paronychia and operated twice. Obvious clinical appearance and high index of suspicion rendered it a glomus tumor on histopathology. We cite here a simple technique of advancement of flap for covering scarred defects created due to nail bed excision.

Luggage tag tie technique for delayed primary closure of fasciotomy wounds

Split skin graft for managing fasciotomy wound is one of the commonest routine operating room procedures. However, it requires multiple surgical interventions ensuing into undesirable scaring both at donor and fasciotmy sites. Amongst the various delayed primary closures, we key out a controlled and segmental dermatotraction technique with easily available materials which reduces the cost of treatment, hospital stay and the surgical intervention as well. Our dynamic wound closure method facilitates resolution of edema, provides controlled traction at each point, takes care of tissue and prevents re-compartment syndrome. A simple modification, respecting the biochemical and physiological properties of skin, yields good results with luggage tag tie technique of delayed primary closure of fasciotomy wound.

Solitary diaphyseal exostosis of femur, how common is it?

Osteochondroma, the most common benign tumor, is very often diagnosed as an incidental finding on radiographs obtained for other purposes. The World Health Organization (WHO) defines osteochondroma as a cartilage-capped bony projection on the external surface of a bone. Whether sessile or pedunculated, the medullary canal of the stalk and the bone are in continuity by definition. Most are asymptomatic, but they can cause mechanical symptoms depending on their location and size. Symptomatic lesions should be excised completely. Usual site of origin is metaphysis, we report a solitary diaphyseal exostosis of femur in this case report.

Why we still punish school kids

Musculoskeletal injuries in children who were punished in school are unusual injuries. Literature is tacit about such injuries. Manners of punishment differ across the globe but none results in physical harm, culminating in musculoskeletal injuries. We report one such injury where school child was punished keeping an ink pen in between index and middle finger and pressing them thereafter, which resulted in a type II epiphyseal injury of proximal phalynx of index finger.