Arthroscopies; review in clinically suspected knee injuries but normal MRI [42 CASES]

Knee pain due to injury is a common presentation in orthopedic outpatient department. X-rays, MRI and arthroscopy are the basic investigation tools when meniscoligametous injury is suspected. If MRI is normal usually arthroscopy is withheld. In this study we analyzed the arthroscopic findings of such cases in which X rays and MRI were normal or near normal. 1- To find out knee injuries in patients with painful knees. 2- To find out any other pathology of knee joint. It's a retrospective study in which 42 such cases were analyzed who underwent arthroscopy with a normal or near normal MRI. This study includes cases done at CMH Rawalpindi, Muzaffarabad, Kharian and Malir. Period includes May 2005 to August 2014. A total number of 209 arthroscopies were done by the same orthopedic surgeon. Out of 42 cases 31 were males while 11 were females. Mean age was 31.4 years [range 18-54 years].In all cases arthroscopy was done by the same orthopedic surgeon within 6 weeks of MRI. MRI films were reported by a qualified radiologist. In all cases there was a strong clinical suspicion of menisco-ligamentous injury while X-rays and MRI were near normal or normal. Out of 42 cases in 36 [85.7%] cases, one or more findings were detected on arthroscopy which were not picked by MRI. It is concluded that if a menisco-ligamentous injury is strongly suspected in a knee on clinical examination, arthroscopic evaluation should not be denied to a patient even if X-rays and MRI are normal

Comparison of efficacy of phenol and sodium hydroxide matricectomies for management of ingrown toenails

To compare the efficacy of Phenol and Sodium Hydroxide Matricectomies in terms of frequency of pain and wound healing in the management of Ingrown Toenails. Randomized Clinical Trial Out Patient Department of Surgery Combined Military Hospital Kharian from Aug 2010 to Feb 2011. A total of 140 cases with Ingrown Toenails were selected and randomly divided into two groups of 70 each. Cases of Group A and B were subjected to Phenol Matricectomy [PMC] and Sodium Hydroxide Matricectomy [SHMC] respectively. Postoperative pain was comparatively and Southampton Wound Grade for wound healing were analyzed at 2[nd] and 10[th] postop day. Mean age of Group A was 28.86 +/- 6.423 whereas that of Group B was 28.80 +/- 5.997. Group A had 58 [83%] males and 12 [17%] females. Group B had 48 [69%] males and 22 [31%] females. Postoperative pain was comparatively less in group A with statistical difference between two groups on 2[nd] day [p = 0.014], whereas it was less intense in group B with no statistical significant difference on 10[th] day [p=0.662]. Wound healing was better in group B with statistical difference between two groups on 2[nd] [p = 0.022] and 10[th] day [p = 0.024]. Group B [91.4%] had more statistically significant efficacy than Group A [71.4%] [p = 0.004]. SHMC is superior to PMC in reducing pain and improving wound healing for managing Ingrown Toenails

POP boot traction; its efficacy in pre-op management of acute fractures of upper end of femur

Introduction: Fractures of upper end of femur are generally applied some traction pre- peratively. Traditionally either skin or skeletal traction is applied. In this study we applied traction via POP Boot with a T behind ankle in 354 cases of fracture upper end of femur during pre-operative management and the results were compared with those of skin and skeletal traction

Objectives: to see whether effective pre-op traction can be applied via POP Boot in upper femur fractures and what are the complications and cost effectiveness as compared to skin and skeletal traction

Study: in 354 patients POP Boot was applied and 3 kg tration applied to the injured limb with fracture femur while in 50 cases skin traction and in another 50 cases skeletal traction was applied

Design: it's a randomized prospective double blind study

Settings: study was carried out in tertiary care hospitals including combined military hospitals of Rawalpindi, Muzaffarabad and Kharian

Period: study was conducted between the periods of 10 Sep 2003 to 20 Sep 2012 [9 years and 10 days]

Methods: all patients have either simple or communited fracture of upper end of femur. All patients were adults and received same amount of analgaesia. 3 kg traction was applied as standard in all cases. All patients were operated for their fracture femur within 2 to 10 days of applying traction

Results: results were compared in terms of pain control, reduction achieved, rotational control, and discomfort during application of tration, complications, and cost effectiveness and compared with standard skin and skeletal tractions

Conclusion: POP Boot traction is an easily applied, effective and cost effective way of traction which has very low rate of complications and should be used for pre-op traction in all adult cases with upper femur fracture

Polypropylene suture versus skin staples for securing mesh in lichtenstein inguinal hernioplasty

To compare polypropylene suture and skin staples for securing mesh in Lichtenstein inguinal hernioplasty in terms of mean operating time and postoperative pain. Randomized clinical trial. Surgical Ward, Combined Military Hospital, Kharian, from August 2011 to February 2012. All individuals fulfilling inclusion criteria underwent elective Lichtenstein inguinal hernioplasty as admitted patients, under spinal anaesthesia and with aseptic measures. In group 1, during the operation, mesh fixation was done with 2/0 polypropylene suture and skin was closed with subcuticular 2/0 polypropylene suture whereas in group 2, the anchorage of mesh was done with skin staples and skin was closed with staples from the same stapler. Mean operative time and postoperative pain, assessed on a visual analog score, were compared between the groups. The overall postoperative pain was lower [p = 0.026] when staples were used to anchor mesh. Moreover, operative time was also lower [37.42 +/- 2.69 minutes] in staple group versus [42.44 +/- 2.55 minutes in polypropylene group]. Mean operating time and postoperative pain is less in securing mesh with skin staples as compared to polypropylene suture in Lichtenstein inguinal hernioplasty

Missed vascular injuries: presentation and outcome

Objective: To describe the different presentation, diagnostic evaluation, management and outcome of complications of missed vascular injuries. Study Design: A case series. Place and Duration of Study: Combined Military Hospital, Rawalpindi and Combined Military Hospital, Kharian Cantt, from June 2009 to June 2012

Methodology: All the patients with vascular injuries missed at the time of causative trauma who reported during this study period were included. Patients presented with acute vascular injuries and iatrogenic aneurysm at the vascular anastomosis site were excluded. All cases were evaluated with either CT or conventional angiography and managed with various open vascular surgical techniques and their results were assessed

Results: Twenty eight patients with missed vascular injury underwent various vascular repairs. Age of patients ranged from 16 to 78 years [mean = 33.7 +/- 15.4 years]. Male to female ratio was 6:1. Twelve [42.8%] patients presented with pseudoaneurysm alone, 10 [35.7%] with traumatic arteriovenous fistulae, 4 [14.3%] with post-traumatic thrombosis and occlusion and 2 [7.1%] with pseudoaneurysm and hemorrhage. Penetrating injuries were the commonest cause in 19 [67.8%]. The time interval between injury and presentation in hospital ranged from 2 to 1300 weeks [mean 228 weeks]. Lower limb vessels were affected in 20 [71.4%], the upper limb in 5 [17.8%] and neck vessels in 3 [10.7%]. Superficial femoral artery was the most frequently involved artery in 9 [32.1%] cases. Interposition reverse autogenous saphenous vein graft was most common type of repair in all types of missed vascular injuries. One [3.5%] patient had amputation after secondary hemorrhage

Conclusion: Low velocity penetrating trauma was the common cause of missed vascular injury. Pseudoaneurysm was the most common presentation

Intramedullary interlocking nailing without image intensifier and ortho table

Interlocking nails are the gold standard treatment of fractures of shaft of long bones of lower limbs. It is also frequently performed for most of the humerus fractures. The procedure is commonly performed using an image intensifier and orthotable. These are expensive and are not readily available in peripheral/field hospitals especially in resource - poor countries. Retrospective study. Field Hospital Muzaffarabad and Combined Hospital Kharian. Sep 2007 to July 2011. 138 consecutive cases of fractures of femur, tibia and humerus shafts fixed with I/M I/L Nails in a field hospital. Reduction was achieved by open method in 87 [96.66%] cases of femur, 24 [60%] case of tibia and 5[62.5%] of humerus. There were 34 females and 100 males' ratio 1:2.94. All the cases were adults with mean age 38.2 years and range was 16-78 years. Bones fixed were femur [90] 65.21%, tibia [40] 28.21%, and humerus [8] 5.70%. Fracture line was transverse in 104 [75.3%] and communited 10 [7.2%]. Fractures were closed 112 [81.2%] and 26 [18.8%] of case. Recent fractures were 122 [88.4%] and old non united 16 [11.6%]. Mean follow up period was 06 months - range 3 months to 1 _ years. Complications were failure to achieve distal interlocking 6 cases, infection 3 cases. Union time averaged 3.5 months. It is therefore concluded that I/M I/L nailing can be done without image and traction table

Total thyroidectomy for multi - nodular goitre

To assess the efficacy and safety of total thyroidectomy for benign multi-nodular goitre. Descriptive study. The study was conducted in the Department of General Surgery, Combined Military Hospital Kharian from January 2004 to December 2008. A total of 66 patients with bilateral benign multi nodular goitre [61 females and 5 males] underwent total thyroidectomy. Sixty two cases were euthyroid while 4 had hyperthyroidism Surgical dissection techniques involved identifying both recurrent laryngeal nerves through out their course, securing of parathyroid glands with their intact blood supply and ligation of inferior thyroid artery branches close to the thyroid capsule. All the patients were evaluated post operatively for signs of recurrent laryngeal nerve injury and hypoparathyroidism and other complications. All patients were put on thyroxin replacement therapy post-operatively and were followed for 9 to 12 months. There was no injury to the recurrent laryngeal nerves. One case of injury to external laryngeal nerve was found. Transient hypocalcaemia occurred in 4 patients without permanent hypoparathyroidism. All cases of transient hypocalcaemia recovered fully within 3 months. Four patients had occult malignancy diagnosed post-operatively on histo-pathology. In experienced hands total thyroidectomy is an effective and relatively safe operation for benign multi-nodular goitre and its complication rate is same as that of a sub-total thyroidectomy

Tuberous sclerosis: Report of two cases diagnosed by computer assisted cranial tomography without cutaneous manifestations

We represent two patients suffering from tuberous sclerosis without cutaneous manifestations Both were diagnosed on cranial CT scan. Both had typical calcified ependymal lesions. Our first patient had bilateral renal angiomyolipomas as well. Second patient had typical calcified ependymal lesions near foraman of Monro and calcified left cerebella tubers

Repair of inguinal hernias with Lichtenstein techinique

Inguinal hernia is a very common surgical problem. It is more likely to occur in man than in woman because the spermatic cord passes through the abdominal wall in the inguinal region, leaving a site of natural weakness prone to hernia formation. Recurrences have been a significant problem following hernia repair, Prosthetic materials have been increasingly used in hernia repair to prevent recurrences. Their use has been associated with several advantages, such as less postoperative pain, rapid recovery, and low recurrence rates. In this case control study, 50 inguinal hernia repairs were performed between January, 2001 to December, 2001, using polypropylene mesh [lichtenstein technique]. The main outcome measure was early and late morbidity and especially recurrence. Inguinal hernia was indirect in 72% of cases [36 patients], direct in 28% [14 patients]. Mean patient age was 54.5 years [range, 27-82]. Follow up was completed in 50 patients [100%] by clinical examination. The median follow-up period was 1 year. Hematoma and seroma formation requiring drainage was observed in 2 and 3 patients, respectively, while transient testicular swelling occurred in one patient. We have not observed acute infection or abscess formation related to the presence of the foreign body [mesh]. In one patient, however, a delayed rejection of the mesh occurred after 4 months. There was no recurrence of the hernia. Postoperative neuralgia was observed in 3 patients [6%]

Mucormycosis: a devastating fungal infection in diabetics

Mucormycosis is a highly invasive, devastating and usually fatal fungal infection of the sinuses, brain, or lungs that occurs primarily in people with immune disorders. Despite advances in diagnosis and treatment, a high mortality still exists. We present a middle aged diabetic male with this serious fungal infection involving nose, paranasal area and adjacent periorbital regions with a high risk of progressing further towards the dura mater. He was promptly diagnosed and managed with serial surgical debridements with systemic antifungals and was later fitted with a nasal prosthesis

Non healing genital ulcer in a young woman. A case Report

A case of a young married female is reported here, who was treated with various topical and systemic medicines for non healing ulcer over labia majora. A faint scaly rash was noted over her face in addition to genital ulcer. On suspicion of secondary syphilitic rash, serological tests for syphilis were carried out which confirmed the diagnosis. She was then treated accordingly. The genital ulcer and the rash, both settled in about four weeks

Idiopathic calcinosis of the scrotum: a rare presentation a case report

Idiopathic scrotal ccdcinosis is a rare disorder of cutaneous deposits of calcium that occurs in the absence of known tissue injury or systemic metabolic defect. We present a case of this rare disease in a middle aged male in whom it was causing a great psychosocial concern and was removed completely with simple surgical excision

Lingual thyroid as a cause of snoring and sleep apnea

Lingual thyroid is a rare developmental abnormality. We describe a case of lingual thyroid in a 28 years old female who presented with symptoms of heroic snoring and obstructive sleep apnea. She was treated with surgery and was advised a life long thyroid hormone replacement therapy

Squamous cell carcinoma foot arising in deep mycosis [chromomycosis] A case report

An 87 years old male. presented with a large foul smelling, fungating and suppurative growth over dorsum of left foot. The lesion started about 25 years ago as a small soft nodule which slowly increased in size to involve most part of the dorsal surface of the foot and transformed into a verrucuous and crusted plaque in about two decades time. The lesion remained largely asymptomatic throughout until during last one year, when it increased in size rather rapidly to involve the ankle region and lower part of the leg and he also started complaining of pain in the lesion. During last two months it became more suppurative and foul smelling. There was no history of similar lesions else where over the body and the patient did not loose any significant weight during this period. Some times in the past the lesion was diagnosed as of deep fungal infection [chromoblastomycosis] for which he received systemic antifungal [itraconazole] irregularly and the response to treatment was not satisfactory. On examination a large fungating and verrucous growth with fairly well defined margins and having hard crusts and few ulcers over the surface was seen involving dorsal aspect of the left foot, ankle region and extending up to the lower part of the leg but sparing all the toes. [Fig.l]. Inguinal lymph nodes were not appreciably enlarged on either side. Laboratory investigations including blood