Management of congenital talipes equinovarus by the ponseti method - short-term and intermediate effectiveness of the technique and factors affecting outcome

Objective: To evaluate the effectiveness of the Ponseti method of clubfoot management in neonates and infants and to see which factors affect outcome

Study Design: Retrospective study

Place and Duration of Study: Department of Paediatric surgery, Military Hospital, Rawalpindi, from October 2012 to September 2014

Material and Methods: The Ponseti method for the management of congenital talipes equinovarus was applied in children of 7 days to 6 months age. While those with complex neurological problems, pathological clubfeet, syndromic clubfeet and older than 6 months at the time of presentation were excluded from the study

Assessment was done at presentation, at the removal of the last plaster cast and after one-year use of the foot abduction splint

Results: A total of 124 clubfeet of 89 children, including 63 males [70.78%] and 26 females [43.82%] were treated as outdoor cases. Eighteen feet [14.51%] were of rigid [typical] type whilst 106 [85.5%] were of flexible [typical] type. Bilateral involvement was seen in 35[37.31%] children. The mean pretreatment Pirani score was 5.4 and the mean number of plaster casts required was 5.8

The mean Pirani score at 1-year follow-up was 0.5 with successful outcome in 82.3 % of all cases [96.9 % of neonates]. Poor compliance with the use of the foot abduction splint adversely affected outcomes

Conclusion: The Ponseti method of treatment of congenital clubfeet is safe and easy to learn with effective and reproducible results. Early start of treatment and compliance with the use of the foot abduction splint during the maintenance phase are crucial to successful outcome

Intralesional bleomycin sclerotherapy: an effective treatment of cystic hygroma in children

To study the outcome of intralesional sclerotherapy with injection Bleomycin in cystic hygroma in children. A case series. The department of Pediatric Surgery at Military Hospital, Rawalpindi, Pakistan from Jan 2011 to Dec 2012. All patients with peripheral cystic hygroma [CH] presenting to us, were enrolled in the study. The cyst was aspirated in the operation theater under sedation. Injection bleomycin 0.5 mg /kg diluted in 10-15 cc of distilled water was injected in the cyst at multiple sites. Injection was repeated after every month depending upon the response. A total of 30 patients reported to the department with superficial cystic hygroma, 12 were males [40%] and 18 were females [60%], age ranged from 15 days to 8 years. Cervico-facial was the most common site. Results were assessed in terms of excellent [complete resolution], good [> 50% reduction in size] and poor [< 50% reduction in size]. In 2 patients, complete resolution was achieved after maximum seven shots of intra-lesional bleomycin injections [IBI], while 18/30 [60%] resolved after single dose. Twenty seven patients [90%] resolved completely, 2 [6.6%] had good response, 1 [3.3%] showed poor response. Minor complications were noted which were treated by symptomatic treatment. No major side effects or recurrence were noted in maximum 2 years follow up. Intralesional bleomycin sclerotherapy is safe and effective as primary treatment in cystic hygroma

Anterior saggital anorectoplasty; the treatment of anorectal malformations in female children

Anorectal malformation is the common congenital malformation. Ectopic anus and vestibular fistula are Intermediate types of anorectal malformations [ARM], which are the most common in female babies. Many surgical procedures have been described for the treatment of ARM. Anterior Saggital Anorectoplasty [ASARP] is not only convenient for the anesthetist for maintenance of anesthesia but also gives better exposure of surgical structures during surgery. To determine the technical suitability and outcome of ASARP in intermediate types of ARM in female children. This Descriptive study with prospective collection of data according to a set protocol. The study was carried out at the department of Pediatric Surgery, Military Hospital, Rawalpindi, Pakistan. November 2010 to March 2014, over the period of 3 years and 5 months. The data of all female patients presenting with intermediate types of ARM and undergoing ASARP, during the study period were analyzed, with respect to age, type, associated anomalies, complications and cosmetic outcome. A total of 36 patients of intermediate variety underwent ASARP. Age ranged from 6 months to 22 years. All patients had colostomy prior to this procedure. During surgery, posterior vaginal wall tear occurred in 2 patients [5.5%]. Postoperatively, 2 patients [5.5%] had retention of urine, 2 patients [5.5%] developed wound infection with superficial disruption, anal stenosis occurred in 2 patients [5.5%] and 1 patient [2.7%] had rectal mucosa prolapse. None of them required re_ do surgery. Cosmetic outcome was excellent in 31 patients [86.1%], while it was satisfactory in 5 [13.8%] patients. Anorectoplasty through anterior approach is not only technically easy but has good cosmetic results in intermediate type of imperforate anus in female children

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

Primary splenic lymphoma

A middle-aged lady presented with fever and splenomegaly and had been provisionally treated for malaria, typhoid and tuberculosis. Diagnostic splenectomy was performed which revealed diffuse large cell lymphoma, B type, localized to spleen. Patient had remission of disease after splenectomy

Wilms tumour a comparison of surgical aspects in patients with or without pre-operative chemotherapy

To compare the technical aspects of Wilms' tumour [WT] surgery in patients with and without pre-operative chemotherapy. Quasi-experimental. Military Hospital [MH] and Combined Military Hospital [CMH], Rawalpindi, from January 1999 to December 2004. Patients of WT, presenting between January 1999 and December 2001, were treated, using the NWTSG protocol, with primary surgery [group I]. Between January 2001 and December 2004, WT patients were treated according to SIOP protocol, with pre-operative chemotherapy followed by surgery [group II]. Volume reduction with chemotherapy, duration of surgery, rupture of tumour, extent of excision, adherence and damage to surrounding structures, blood loss, complications, stay in hospital and event-free survival [EFS] were compared in the two groups. Out of 22 patients in group I, 19 [86.4%] underwent primary surgery. Of the 23 patients in group II, 21 [91.3%] received pre-operative chemotherapy followed by surgery. Average volume reduction in this group was 54% with chemotherapy. Difference in duration of surgery and blood loss was significantly low in group II [p=0.003 and p<0.001, respectively]. In group I, rupture [6 vs 2], adherence [14 vs 10] and damage to surrounding structures [5 vs 2] were more. Complete macroscopic excision was possible in 90.5% of WT in group II as compared to 73.7% in group I. Immediate postoperative complications and length of hospital stay were similar in both groups. There was no difference in EFS. Pre-operative chemotherapy makes it technically easier and safer to operate, without jeopardizing the final outcome

Persistent hyperinsulinemic hypoglycemia of infancy-nesidioblastosis.

Persistent hyperinsulinemic hypoglycemia of infancy [PHHI] or nesidioblastosis is a rare condition presenting with severe hypoglycemia. Prompt diagnosis and early pancreatectomy can save many of them, in spite of the magnitude of surgery. We present two cases in which near total pancreatectomy was performed with favourable outcome. Both patients are normoglycemic, with one requiring pancreatic enzyme supplements