Functional outcome of gastrocnemius advancement flap augmented with short flexor hallucis longus tendon transfer in chronic Achilles tear.

BACKGROUND: There are various techniques of Achilles tendon (TA) repair and reconstruction in chronic Achilles tear. However, there is no clear consensus on the relevance of one method over the other. The short flexor hallucis longus tendon (FHL) transfer has recently gained popularity because of its same phasic action, ease of harvesting and tensile strength. METHODOLOGY: Fifteen chronic Achilles tear (>6 weeks) were treated with tendon repair using gastrocnemius advancement flap augmented with FHL transfer. The patients were followed-up at 1.5, 3, 6, 12 and 24 months. The clinical outcome at latest follow-up was evaluated using the American Orthopedic Foot and Ankle Score (AOFAS) and the Achilles Tendon Rupture Score (ATRS). RESULTS: The mean age was 43.5 ± 12.4 years and the median time from injury to surgery was 17.13 ± 9.64 weeks. The mean gap between the retracted ends of the ruptured tendon was 5.67 ± 1.63 cm (range 4-10 cm). The mean follow-up was 19.07 ± 3.15 months (range, 13-24 months). The mean AOFAS and ATRS improved from 72.07 ± 8.29 (62-83) to 98.4 ± 2.03 (94-100) and 61.73 ± 8.16 (52-70) to 98 ± 1.85 (94-100) respectively (paired t-test, p-value 0.0001). All patients resumed their pre-injury daily activities, and there was no donor site morbidity. Two patients had sterile serous discharge, and one patient had a staphylococcus infection. These patients responded to debridement with prolonged antibiotic therapy. There were no nerve injuries or re-rupture. CONCLUSION: The functional outcome of chronic Achilles tear treated with gastrocnemius advancement flap augmented with short FHL transfer is rewarding.

Trochanteric osteotomy for safe surgical approach to bilateral hip dislocations with femoral head fractures.

A 23-year old male with bilateral hip dislocations and associated femur head fractures (Pipkin type-II) presented with pain and flexion deformity of both hips after 9 days. After imaging, closed reduction was attempted but failed. Open reduction through Kocher-Langenbeck approach was performed and the femoral head fracture was accessed through Ganz's safe surgical dislocation. The fracture was reduced anatomically and fixed with headless Herbert screws. After two years, the patient was walking without pain or limp and there was no evidence of osteonecrosis. Simultaneous sequential Ganz's safe surgical dislocation can be performed in bilateral Pipkin's fracture dislocation with excellent short term outcome.

Clinico-radiological Outcomes of Using Modified Stoppa Approach for Treating Acetabular Fractures: An Institutional Review.

Introduction Acetabular fractures are complex intra-articular fractures. The extra-pelvic ilioinguinal (IL) has been the workhorse for the anterior approach and remains the gold standard. The major difference between the IL and the Stoppa approaches is that Stoppa allows for the avoidance of the middle window of the IL approach. Hence, the modified Stoppa approach (MSA) can be adopted by a comparatively less experienced surgeon with minimal complications. The purpose of this study is to evaluate the radiological and functional outcomes of patients operated on using the MSA. Materials and methods Patients operated on by the MSA for acetabular fractures with a minimum of one year of clinical and radiographic follow-ups were reviewed. CT scans and radiographs were evaluated for the fracture pattern, time to surgery, operative time, blood loss, quality of reduction (Matta criterion), FO [Harris hip score (HHS) and Nach Merle d'Aubigné and Postel score (NMAPS)] and complications (perioperative and follow-up). Twenty-three of 26 patients with 45 acetabular fractures operated between January 2016 and November 2018 were included. Descriptive statistics were used for demographic data, and Pearson's chi-squared statistic was calculated for the association between radiological and functional outcomes. Results  Among the 23 patients, the mean age was 38.5 years (range: 15-65) with a male-to-female ratio of 18:5. The average time to surgery was 11.5 days (range: 2-32), operating time was 155 minutes (range: 90-243), and average blood loss was 650 ml (range: 500-1,250). A supplemental lateral window was used in 20 patients (87%), and three underwent the combined anterior and posterior [Kocher Langenbacks (KL)] approach. All cases were unilateral. The transverse fracture was the most common pattern (eight patients) followed by the associated both-column fracture in six and T-type, isolated anterior column fracture, and anterior column and posterior hemi-transverse fractures seen in three patients each. Iliac blade (high anterior column) fracture was seen in 14 cases and one patient had associated sacral type II fracture. Road traffic accidents accounted for 61% of the injuries and injury severity score (ISS) of >15 (polytrauma) was seen in more than 50% of the cases (associated with other organ injuries). The radiological outcome was anatomical in 52% of the cases, imperfect in 39%, and poor in 9%. The functional outcomes were good to excellent in 74% (HHS) and 79% (NMAPS) of the cases. The association and correlation between them were nonsignificant (p-value: >0.5). Two patients developed a superficial infection and three had iatrogenic obturator nerve palsy. One patient had a direct inguinal hernia, one had grade 3 bedsores, and two patients developed grade 2 arthritic changes during the follow-up. No case of vessel injury was encountered. Conclusion Adoption of the MSA for the treatment of acetabular fractures leads to a good-to-excellent anatomical reduction in most cases while providing direct visualization of the quadrilateral plate and posterior column. The learning curve is smaller for less-experienced surgeons in terms of complications and results. We recommend this technique as a viable alternative to the IL approach for anterior acetabular fixation.

Complete Agenesis of Dorsal Wall of Sacral Canal: A Case Report.

The sacral canal is the continuation of the vertebral canal in the sacrum. The sacral canal contains spinal meninges, lumbar and sacral part of spinal nerves and filum terminale. So sacral canal has been used for the caudal epidural block. During routine osteology demonstration classes for undergraduate students, we observed a dry human sacrum with complete agenesis of the dorsal wall of the sacral canal. Knowledge of these variations is important to diagnose lower back pain, sciatica, caudal regression syndrome and to avoid complications related to caudal epidural block and other spinal surgeries like in placement of screw for spinal fusion.

Arthroscopic ankle fusion to manage sequel of loss of lateral malleoli in compound crushed ankle injury.

Defect in the lateral malleolus along with lateral ligamentous injury of ankle is rare. It occurs mainly due to resection of distal fibula tumors and severe trauma leading to loss of lateral malleolus. Lateral malleoli has the major contribution in weight transmission to foot and ankle stability. To avoid persistent pain and gait abnormality due to ankle instability, reconstruction of bony defect is inevitable. Methods to address these defects are iliac crest bone grafting, vascular and nonvascular proximal fibula transfer, patella tendon bone graft and allograft. Donor site morbidity, allograft related problems are not rare. Arthrodesis of ankle gives painless stable joint. Arthrodesis can be performed by open and arthroscopic methods. Open method has more soft tissue dissection and too difficult in scenario with previous skin grafting with adherent skin to bone. We managed a case of compound ankle injury with loss of lateral malleolus with loss of lateral ligament in stages, first management of compound crushed ankle followed by arthroscopic ankle arthrodesis. Even after 6 year of follow patient has stable pain less ankle with satisfactory gait.

Postoperative Lumbar Pyogenic Spondylodiscitis: An Institutional Review.

Background Postoperative discitis (POD) remains a dreaded complication in the present era of asepsis. The treatment has been traditionally conservative, but the safety of spinal implants in infective settings has prompted the surgeons to provide rigid immobilization for promoting healing. A major concern in a country like ours is huge patient inflow and long waiting list added to the woe of patient's refusal for a second operative intervention after a first undesirable outcome. Objectives The aim of the study was to evaluate the functional and radiological outcome of conservative management of POD and determine the methods of prevention. Settings and Design A retrospective case study series in a tertiary-level hospital. Materials and Methods Between January 2015 and 2017, 12 cases of POD (10 own and 2 referred) were managed and followed up clinically, radiologically, and with laboratory investigation. Two cases were managed surgically-one with kyphotic deformity and the other with discharging pus. Rest were managed conservatively with analgesics and intravenously followed by oral antibiotics. At 1-year follow-up, patient satisfaction was evaluated using the MacNab outcome assessment. Statistical Analysis The descriptive data were analyzed mainly by descriptive statistics using mean, median, standard deviation, and interquartile range. Results Mean follow-up in our series was 15.2 months. Except for two operated cases, we did not go for the invasive procedure for isolation of organism in any of our cases. The total duration of antibiotic in our series was for the mean of 7.3 weeks. Visual analog scale score returned from8 initially to baseline and at final follow-up-4 excellent, 6 good, and 2 had fair outcome. There was no adverse outcome. Conclusions The majority of POD can be managed conservatively. Surgery is reserved only for special cases. Magnetic resonance imaging is the investigation of choice for diagnosing discitis. Intraoperative use of gentamicin-mixed normal saline wash reduces the incidence of discitis.

Estimation of Femoral Neck Anteversion in Adults: A Comparison Between Clinical Method, Radiography, and Computed Tomography at a Tertiary-care Center in Eastern India.

Introduction Femoral anteversion is the anterior inclination of the femoral neck and head in relation to the shaft of the femur. Femoral anteversion provides torsional stability of the hip - an important clinical factor for conditions such as trauma, arthroplasty, developmental dysplasia of the hip, and Legg-Calve Perthes disease. Precise measurement is important to avoid instability in pathological conditions of the hip. Computed tomography (CT) measures the angle more accurately as compared to plain radiography and is considered the gold standard procedure for measurement. Patients are exposed to significantly more ionizing radiation in CT, especially the pediatric population, which is more susceptible. Material and methods A prospective study of 25 individuals was undertaken wherein the femoral anteversion angle was comparatively measured by clinical, radiographic, and CT methods. Results The radiological evaluation depicted mean values that were far from those of the CT evaluation as compared to the clinical evaluation. Conclusion The clinical method (trochanter prominence angle test) can be used to measure femoral anteversion to avoid exposure to ionizing radiation and cases where CT is unavailable.

Compartment syndrome as a late presentation of brachial artery pseudoaneurysm following shaft of humerus fracture.

Peripheral artery pseudoaneurysm is rare in upper extremities compared with lower extremities. Early diagnosis and prompt management are two cornerstones of successful outcomes in these cases. Delay can lead to limb and life-threatening complications. We present a case of compartment syndrome of upper limb as a sequel to pseudoaneurysm of brachial artery for which we had to do shoulder disarticulation. The patient recovered uneventfully.

Non-compressive postoperative cauda equina syndrome following decompression and transforaminal interbody fusion surgery.

Postoperative cauda equina syndrome (CES) is a known rare complication following lumbar disc surgery. Seldom are they seen following decompression for spinal stenosis and may be actually more frequent and under-reported? Emergent surgical exploration remains the mainstay of management as the factors responsible for postop CES remains a variety of compressive forces. Yet many a time postoperative imaging or surgical exploration fails to identify a pathology and this leads to an ischaemic theory responsible for CES. Our article highlights conservative management in these selective group. We share our experience in two cases of incomplete CES during our routine transforaminal interbody fusion which we followed closely without re-exploration eventually ending in a favourable outcome. Key messages: The factors responsible for postop CES remains mostly a variety of compressive forces though in some instances postoperative imaging or surgical exploration fails to identify such in some cases. This leads to an ischaemic theory responsible for CES. The role of conservative management of postoperative CES in certain selective cases has a favourable outcome as illustrated in our cases.

A Rare Case of Extra-abdominal Desmoid-type Fibromatosis Arising from the Popliteal Fossa.

Desmoids are rare soft-tissue tumors of the abdominal wall that may sporadically occur extra-abdominally. It manifests as clonal fibroblastic proliferation with an infiltrative tendency and capacity to recur without metastasizing. An adolescent male presented with a gradually increasing globular, non-tender, firm, non-pulsatile swelling (8 × 5 × 3 cm3) in the left popliteal fossa that had been present for five months. Following thorough investigation with imaging and Tru-cut biopsy, finally, an excisional biopsy was done. Histopathological examination confirmed a desmoid tumor, and the patient received adjuvant radiotherapy. At the one-year postoperative follow-up, there was no recurrence; the patient had been explained the prognosis. This case highlights a rare site of an extra-abdominal desmoid but with classical clinical presentation, imaging, intraoperative, and histopathological findings. Awareness and knowledge of this entity are of paramount importance for clinical practitioners.

Transgenic tobacco plants expressing siRNA targeted against the Mungbean yellow mosaic virus transcriptional activator protein gene efficiently block the viral DNA accumulation.

Mungbean yellow mosaic virus (MYMV) is a bipartite begomovirus that infects many pulse crops such as blackgram, mungbean, mothbean, Frenchbean, and soybean. We tested the efficacy of the transgenically expressed intron-spliced hairpin RNA gene of the transcriptional activator protein (hpTrAP) in reducing MYMV DNA accumulation. Tobacco plants transformed with the MYMV hpTrAP gene accumulated 21-22 nt siRNA. Leaf discs of the transgenic plants, agroinoculated with the partial dimers of MYMV, displayed pronounced reduction in MYMV DNA accumulation. Thus, silencing of the TrAP gene, a suppressor of gene silencing, emerged as an effective strategy to control MYMV.

Artificial miRNA-mediated down-regulation of two monolignoid biosynthetic genes (C3H and F5H) cause reduction in lignin content in jute.

Artificial microRNAs (amiRNA) provide a new feature in the gene silencing era. Concomitantly, reducing the amount of lignin in fiber-yielding plants such as jute holds significant commercial and environmental potential, since this amount is inversely proportional to the quality of the fiber. The present study aimed at reducing the lignin content in jute, by introducing amiRNA based vectors for down-regulation of two monolignoid biosynthetic genes of jute, coumarate 3-hydroxylase (C3H) and ferulate 5-hydroxylase (F5H). The transgenic lines of F5H-amiRNA and C3H-amiRNA showed a reduced level of gene expression, which resulted in about 25% reduction in acid insoluble lignin content for whole stem and 12-15% reduction in fiber lignin as compared to the non-transgenic plants. The results indicate successful F5H-amiRNA and C3H-amiRNA transgenesis for lignin reduction in jute. This is likely to have far-reaching commercial implications and economic acceleration for jute producing countries.

Catecholase activity, DNA cleavage and cytotoxicity of six Zn(II) complexes synthesized from designed Mannich ligands: higher reactivity of mononuclear over dinuclear.

Six zinc(II) complexes have been synthesized from two designed Mannich-base ligands which consist of three dinuclear complex [Zn2(L(1))2X2] (1-3) and three mononuclear complex [ZnH(L(2))X2] (4-6), respectively, where X = Cl(-) (1,4), Br(-) (2,5), I(-) (3,6), as reported earlier by us (Sanyal et al., Inorg Chem 53:85-96, 2014). The catecholase activity of the complexes has been investigated under completely aerobic conditions in DMF-water medium (9:1) at pH 8.5 against the model substrate 3,5-di-tert-butylcatechol (3,5-DTBC). Saturation kinetic studies show that the order of conversion of substrate to product (quinone) follows the trend 5 > 4 > 2 > 1 while 3 and 6 are inactive. The generation of phenoxyl radicals, confirmed by UV-vis and EPR spectral studies, is supposed to be responsible for the oxidation of 3,5-DTBC. The in vitro evaluation of 1-6 comprises the study of their DNA-cleaving ability using plasmid DNA and the assessment of their cytotoxic activity against Jurkat (T cell lymphoma) cell line by MTT assay. The mechanisms of toxicity appeared to be predominantly by reactive oxygen species (ROS). The comparative analysis helps to arrive at the following facts under experimental conditions: (1) mononuclear species prevail over the dinuclear ones, unlike the behavior in phosphatase activity as reported in Inorganic Chemistry; (2) the halide substituents at the active site control the overall activity in the order: (a) In catecholase activity, Cl(-) < Br(-) (dinuclear) and Cl(-) > Br(-) (mononuclear) and (b) in biological activity, Cl(-) > Br(-) > I(-) regardless of nuclearity.

A combined experimental and theoretical investigation on the role of halide ligands on the catecholase-like activity of mononuclear nickel(II) complexes with a phenol-based tridentate ligand.

Three new mononuclear nickel(II) complexes, namely, [NiL(1)(H2O)3]I2·H2O (1), [NiL(1)(H2O)3]Br2·H2O (2), and [NiL(1)(H2O)3]Cl2·2H2O (3) [HL(1) = 2-[(2-piperazin-1-ylethylimino)methyl]phenol], have been synthesized and structurally characterized. Structural characterization reveals that they possess similar structure: [NiL(1)(H2O)3](2+) complex cations, two halide counteranions, and lattice water molecules. One of the nitrogen atoms of the piperazine moiety is protonated to provide electrical neutrality to the system, a consequence observed in earlier studies (Inorg. Chem. 2010, 49, 3121; Polyhedron 2013, 52, 669). Catecholase-like activity has been investigated in methanol by a UV-vis spectrophotometric study using 3,5-di-tert-butylcatechol (3,5-DTBC) as the model substrate. Complexes 1 and 2 are highly active, but surprisingly 3 is totally inactive. The coordination chemistries of 1 and 2 remain unchanged in solution, whereas 3 behaves as a 1:1 electrolyte, as is evident from the conductivity study. Because of coordination of the chloride ligand to the metal in solution, it is proposed that 3,5-DTBC is not able to effectively approach an electrically neutral metal, and consequently complex 3 in solution does not show catecholase-like activity. Density functional theory (DFT) calculations corroborate well with the experimental observations and thus, in turn, support the proposed hypothesis of inactivity of 3. The cyclic voltametric study as well as DFT calculations suggests the possibility of a ligand-centered reduction at -1.1 V vs Ag/AgCl electrode. An electron paramagnetic resonance (EPR) experiment unambiguously hints at the generation of a radical from EPR-inactive 1 and 2 in the presence of 3,5-DTBC. Generation of H2O2 during catalysis has also been confirmed. DFT calculations support the ligand-centered radical generation, and thus a radical mechanism has been proposed for the catecholase-like activity exhibited by 1 and 2. Upon heating, 2 and 3 lose water molecules in two steps (first lattice waters, followed by coordinating water molecules), whereas 3 loses four water molecules in a single step, as revealed from thermogravimetric analysis. The totally dehydrated species are red, in all cases having square-planar geometry, and have amorphous nature, as is evident from a variable-temperature powder X-ray diffraction study.

The Limb-Abdominal Wall Complex Defects, a form of Amniotic Band Sydrome: A Rare Case Report.

The limb-body wall complex defects a form of amniotic band syndrome which consists of a polymal formation with a thoracic and /or an abdominal-schisis, eventration of the internal organ and anomalies of the extremities. We are presenting a case of a limb-body wall complex defect with the phenotype of a placenta-abdominal attachment, anomalies of the abdominal wall defect, absence of the right lower limb and genitourinary defects.

Giant congenital melanocytic nevi: a case report.

Congenital melanocytic naevi which are formed by the overgrowth of melanocytes, are present at birth, which are called as bathing trunk, coat-sleeve or stocking naevi, which are commonly found over the back and the thigh areas . The giant congenital naevi of sizes which are greater than 20 cm are pigmented and are often hairy. The risk of malignant melanoma for the giant naevi is approximately 6% and 50% of the melanomas that develop by the age of two years, and 80% of those that develop by the age of seven years. So, an early removal is recommended The objective of this paper is to present a unique case of giant naevi along with a review of the literature.