Late presentation of extrauterine adenomyomas after laparoscopic morcellation at hysterectomy: a case report.

BACKGROUND: An adenomyoma is a well circumscribed form of adenomyosis and can be located within the myometrium, in the endometrium as a polyp, or extrauterine with the last being the rarest presentation amongst the three. With the ongoing advancement in gynecological surgery, the use of electromechanical morcellators have made the removal of large and dense specimens possible with minimally invasive techniques. However, it has also caused an increase in complications which were previously rare. Whilst the tissue is being grinded within the abdominal cavity, residual tissue can spread and remain inside, allowing for implantation to occur and thereby giving rise to recurrence of uterine tissue as a new late postoperative complication. Case presentation A 45-year-old woman presented with worsening constipation and right iliac fossa pain. Her past surgical history consists of laparoscopic supra-cervical hysterectomy that was indicated due to uterine fibroids. Computerized tomography and magnetic resonance imaging were done, which showed an irregular lobulated heterogeneous mass seen in the presacral space to the right, located on the right lateral aspect of the recto-sigmoid, measuring 4.5 × 4.3 × 4.3 cm in size. A transvaginal ultrasound revealed a cyst in the left ovary. The patient had a treatment course over several months that included Dienogest (progestin) and Goserelin (GnRH analogue) with add-back therapy. In line with the declining response to medications, the patient was advised for a laparoscopic ovarian cystectomy. During the surgery, an additional lesion was found as a suspected fibroid and the left ovarian cyst was identified as pockets of peritoneal fluid which was sent for cytology. The surgical pathology report confirmed adenomyosis in both specimens, namely the right mass and the initially suspected fibroid. CONCLUSION: In this case report, we showcase a rare occurrence of an extrauterine adenomyoma presenting two years post laparoscopic morcellation at hysterectomy. This poses questions regarding the benefits versus risks of power morcellation in laparoscopic hysterectomy.

Comparison of the Recurrence Rate of Entropion via Subciliary Route and Transconjunctival Route in Combined Lateral Tarsal Strip with Retractor Advancement Procedure for Involutional Entropion Correction.

OBJECTIVE: To compare the recurrence rate of entropion via subciliary route and transconjunctival route in combined lateral tarsal strip with retractor advancement procedure for involutional entropion correction. STUDY DESIGN: Quasi-experimental study. PLACE AND DURATION OF STUDY: Department of Eye, Combined Military Hospital, Jhelum Cantt, Pakistan from March 2018 to November 2020. METHODOLOGY: Seventy-eight eyes of 78 patients with entropion were randomly divided into two groups of 39 each. One group underwent a lateral tarsal strip procedure combined with retractor advancement through the subciliary approach; and the second group underwent the same procedure through the transconjunctival approach. A strip of preseptal orbicularis was excised in every case. Recurrence rate of entropion was recorded in both groups at six-month postoperation. Duration of surgery was recorded in each case. Fisher's Exact test was selected to compare the recurrence rate of entropion and independent samples 't' test was elected for comparing duration of surgery among the two groups. RESULTS: The recurrence rate of entropion with transconjunctival route repair was statistically not significant compared with the subciliary route repair (p>0.999). The transconjunctival route repair achieved statistically significant shorter duration of surgical time as compared to the subciliary route (p<0.001). CONCLUSION: The transconjunctival approach for involutional entropion correction is as effective as the subciliary approach with lateral tarsal strip and retractor advancement procedure. Surgery duration through the transconjunctival route is significantly shorter as compared to the subciliary approach. Key Words: Entropion, Involutional, Lateral tarsal strip, Lower eyelid, Retractor advancement, Recurrence, Subciliary, Transconjunctival.

Ivabradine in Post-operative Junctional Ectopic Tachycardia (JET): Breaking New Ground.

Junctional ectopic tachycardia (JET) is the commonest tachyarrhythmia in the early post-operative period in children undergoing open-heart surgery. It frequently leads to hemodynamic instability and needs to be managed aggressively. Amiodarone is the first-line agent along with non-pharmacological interventions. We report our initial experience with the use of Ivabradine in post-operative JET. A retrospective case records review of children with post-operative JET during the period from June 2018 to May 2019 was performed. Eight patients with post-operative JET were treated with Ivabradine during this period. The first patient was initially treated with Amiodarone. All eight patients responded to Ivabradine. The initial response was rate control permitting overdrive pacing. One patient had recurrence of JET 10 h after Ivabradine and after return to sinus rhythm. Amiodarone was administered along with the second dose of Ivabradine resulting in remission to sinus rhythm. Ivabradine appears to be an effective alternative to Amiodarone in children with post-operative JET based on our initial clinical experience.

Management of humeral fracture nonunion in severe osteoporosis by a combination of locking plating and intramedullary fibular grafting.

Nonunion of the humerus in a severely osteoporotic bone is a likely event especially if the fracture is transverse. The management of such a combination is a challenge. Most of the conventional fixation methods are unlikely to succeed as the bone failure precedes implant failure in osteoporosis. The challenge is further compounded in severe osteoporosis when the cortical thickness is affected more severely. We used a combination of an intramedullary fibula with a locking plate in 5 cases. The results show that it may be a good combination in such situations as the bone strength is augmented and the plate pullout is less likely.

Pontibacillus salipaludis sp. nov., a slightly halophilic bacterium isolated from a salt pan.

Two novel Gram-stain-positive, facultatively anerobic, rod-shaped, motile, endospore-forming bacterial strains, 9DMT and 6DM, were isolated from Tuticorn, India. The high 16S rRNA gene sequence similarity (99.9 %) and DNA-DNA relatedness (88±2 %) indicated that strains 9DMT and 6DM were members of a single species. Based on 16S rRNA gene sequence analysis these strains were identified as belonging to the genus Pontibacillus and were related most closely to the type strains of Pontibacillus chungwhensis (99.7 % sequence similarity) and Pontibacillus marinus (97.9 %). The DNA G+C content of strains 9DMT and 6DM was 41.6 and 41.4 mol%, respectively. However, the level of DNA-DNA relatedness of these strains with P. chungwhensis KCTC 3890T and P. marinus KCTC 3917T was only 40.9 + 0.8 and 39.8 + 0.9 %, respectively. Strains 9DMT and 6DM were facultative anaerobes with optimal growth at 37 °C, at pH 7.0-8.0 and with 2-3 % (w/v) NaCl. The cell-wall peptidoglycan of strain 9DMT contained meso-diaminopimelic acid. Polar lipids included diphosphatidylglycerol, phosphatidylglycerol, phosphatidylethanolamine, a phospholipid and three unknown lipids. The isoprenoid quinone was MK-7. Major fatty acids of strain 9DMT were anteiso-C15 : 0, iso-C15 : 0, iso-C16 : 0 and anteiso-C17 : 0. The results of phylogenetic, chemotaxonomic and biochemical tests allowed the clear differentiation of strains 9DMT and 6DM, which are considered to represent a novel member of the genus Pontibacillus, for which the name Pontibacillus salipaludis sp. nov. is proposed. The type strain is 9DMT (= KCTC 33742T=LMG 29102T= CGMCC 1.15353T).

The Musculoskeletal Manifestations of Type 2 Diabetes Mellitus in a Kashmiri Population.

OBJECTIVES: Diabetes mellitus (DM), is affecting an ever increasing number of people worldwide. Diabetes is associated with several musculoskeletal manifestations. These may involve, the upper as well as the lower limb. We conducted this study to find out the prevalence of musculoskeletal problems in type 2 diabetics in the Kashmiri population. METHODOLOGY: The study was conducted on 403 patients with diabetes and 300 controls. All patients underwent screening for any musculoskeletal abnormalities. The patients with musculoskeletal abnormalities were further assessed to find the exact diagnosis according to predefined criteria. RESULTS: The hand was involved in 80 patients [19.8%] in the diabetic group and 15 (5%) patients of the control group. The elbow was affected in 56 patients [14%] in the diabetic group and 24 patients [5.9%] in the non-diabetic group. The shoulder involvement was diagnosed in 61 patients [15%] on the diabetic cohort and 15 patients in the non-diabetic cohort. All the upper limb figures showed a statistically significant difference i.e. P value <0.05. CONCLUSION: The prevalence of musculoskeletal complications in type 2 diabetics in Kashmir is quite high.

Management of humeral fracture nonunion in severe osteoporosis by a combination of locking plating and intramedullary fibular grafting / 中华创伤杂志(英文版)

Nonunion of the humerus in a severely osteoporotic bone is a likely event especially if the fracture is transverse. The management of such a combination is a challenge. Most of the conventional fixation methods are unlikely to succeed as the bone failure precedes implant failure in osteoporosis. The challenge is further compounded in severe osteoporosis when the cortical thickness is affected more severely. We used a combination of an intramedullary fibula with a locking plate in 5 cases. The results show that it may be a good combination in such situations as the bone strength is augmented and the plate pullout is less likely.

Nocardioides solisilvae sp. nov., isolated from a forest soil.

A Gram-stain positive, rod shaped aerobic bacterial strain designated Ka25(T) was isolated from a forest soil sample near Kasol, Himachal Pradesh, India. Based on 16S rRNA gene sequence analysis it was identified that strain Ka25(T) belongs to the class Actinobacteria and is most closely related to Nocardioides daejeonensis KCTC 19772(T) (97.2 %), Nocardioides dubius JCM 13008(T) (96.9 %), Nocardioides psychrotolerans CGMCC 1.11156(T) (96.8 %), Nocardioides pacificus DSM 27278(T)(96.7 %) and Nocardioides daphniae JCM 16608(T)(96.4 %) sequence similarity respectively. The chemotaxonomic properties of strain Ka25(T) are consistent with those of the members of the genus Nocardioides: MK-8(H4) is the predominant menaquinone, iso-C16 : 0, iso-C17 : 0 and C18 : 1ω9c were identified as the predominant cellular fatty acids and the cell-wall peptidoglycan is based on LL-2,6-diaminopimelic acid. The DNA G+C content of strain Ka25(T) was determined to be 71.6 mol %. The results of the polyphasic taxonomic analysis allowed a clear differentiation of strain Ka25(T) from all other members of the genus Nocardioides. Strain Ka25(T) is thus considered to represent a novel member of the genus Nocardioides, for which the name Nocardioides solisilvae sp. nov. is proposed. The type strain is Ka25(T) (=KCTC39528(T) =MCC2762(T)).

Salisediminibacterium haloalkalitolerans sp. nov., isolated from Lonar soda lake, India, and a proposal for reclassification of Bacillus locisalis as Salisediminibacterium locisalis comb. nov., and the emended description of the genus Salisediminibacterium and of the species Salisediminibacterium halotolerans.

A Gram stain-positive, rod-shaped, non-motile, orange-pigmented and non-endospore-forming novel bacterial strain 10nlg(T) was isolated from Lonar soda lake in India. Based on the 16S rRNA gene sequence analysis, it was belonged to the genus Salisediminibacterium and was most closely related to Salisediminibacterium halotolerans CGMCC 1.7654(T) (99.9 %), Bacillus locisalis CGMCC 1.6286(T) (99.1 %) and other members in the Bacillaceae (<93.6 %). Further, DNA-DNA hybridization results demonstrated that strain 10nlg(T) was distantly (<70 %) related to S. halotolerans halo-2(T) (59.6 %) and B. locisalis CGMCC 1.6286(T) (53.2 %). Strain 10nlg(T) was catalase positive and oxidase negative. The cell wall of the strain 10nlg(T) contains meso-diaminopimelic acid as the diagnostic amino acid. Polar lipids include diphosphatidylglycerol, phosphatidylglycerol, phosphatidylethanolamine, five phospholipids and two unknown lipids. The predominant isoprenoid quinone was MK-7. Anteiso-C15:0 (32.6 %) was the predominant fatty acid, and significant proportions of iso-C15:0 (9.3 %), anteiso-C17:0 (8.3 %), C16:0 (4.3 %) were also detected in the strain 10nlg(T). The DNA G+C content of the strain 10nlg(T) was 45.6 mol %. The results of phylogenetic, physiological and biochemical tests allowed a distinct differentiation of strain 10nlg(T) not only from S. halotolerans halo-2(T), the only member of the genus Salisediminibacterium, but also from the related Bacillaceae members. Strain 10nlg(T) represents a novel species of the genus Salisediminibacterium for which the name Salisediminibacterium haloalkalitolerans sp. nov. is proposed. The type strain is 10nlg(T) (=KCTC 33414(T) = CGMCC 1.12818(T)). B. locisalis CGMCC 1.6286(T) also represents a member of the genus Salisediminibacterium for which the name Salisediminibacterium locisalis CG1(T) is proposed. The type strain is CG1(T) = (CCM 7370(T) = CECT 7152(T) = CGMCC 1.6286(T) = DSM 18085(T)). In accordance with the new polar lipid data collected in this study, emended descriptions of the genus Salisediminibacterium and the species S. halotolerans halo-2(T) are also provided.

Streptomyces alkalithermotolerans sp. nov., a novel alkaliphilic and thermotolerant actinomycete isolated from a soda lake.

An alkaliphilic actinomycete, strain AC3(T), was isolated from Lonar soda lake, in India. Based on 16S rRNA gene sequence analysis it was identified that the strain belongs to the class Actinobacteria and was most closely related to Streptomyces sodiiphilus JCM 13581(T) (96.4 % sequence similarity), Streptomyces leeuwenhoekii DSM 42122(T) (96.1 %), Streptomyces albus NRRL B-2365(T) (96.1 %), Streptomyces panacagri Gsoil 519(T) (96.0 %), Streptomyces fimbriatus NBRC 15411(T) (95.9 %) and other members of the genus Streptomyces (<95.9 %).The strain formed a well separated clade in the genus Streptomyces based on the 16S rRNA gene analysis of all of the validly named Streptomyces species. Strain AC3(T) was observed to produce light-cream substrate and white aerial mycelia on most tested media. The optimum pH for growth was determined to be 9.5-10.0 with no growth at pH 7.0. The DNA G+C content of strain AC3(T) was determined to be 71.2 mol %. The results of the polyphasic analysis allowed a clear differentiation of strain AC3(T) from all other members of the genus Streptomyces. Strain AC3(T) is thus considered to represent a novel member of the genus Streptomyces, for which the name Streptomyces alkalithermotolerans sp. nov. is proposed. The type strain is AC3(T) (=KCTC 29497(T) = JCM 30167(T)).

Transmalleolar approach to a tubercular lytic lesion of the talar body: a case report.

Tuberculosis of the talus is a rare condition, and the diagnosis can be difficult to make because of inconclusive laboratory and ancillary testing. In such cases, accurate diagnosis and appropriate treatment may require the use of a transmalleolar osteotomy to gain access to the involved portion of the talar body. In the case described in this article, a transmalleolar approach was used to gain access to a lytic lesion of the talar body so as to obtain microbiological and histopathological specimens for diagnostic purposes, and to thoroughly debride the lesion. After 6 years of postsurgical follow-up, the patient was leading a normal life with a full range of ankle and subtalar motion. The rarity of the diagnosis, and the use of the transmalleolar approach to a lytic and likely infected lesion in the body of the talus, makes this case worthy of public discussion.

Stable relocation of the radial head without annular ligament reconstruction using the Ilizarov technique to treat neglected Monteggia fracture: two case reports.

INTRODUCTION: A Monteggia facture dislocation is not an uncommon injury, and the diagnosis can often be missed. Long-term follow-up of untreated Monteggia fracture dislocations reveals development of premature arthritis, pain, instability, and loss of pronation and supination. Methods involving annular ligament reconstruction require post-operative immobilization and use of transcapitellar pinning for maintenance of reduction, and thus a delay in rehabilitation. The literature reports satisfactory results with methods that involve ulnar osteotomy and open reduction of the radial head without annular ligament reconstruction. We used the Ilizarov method in two cases with neglected Monteggia fracture dislocations to stably reduce the radial head without open reduction and annular ligament reconstruction. CASE PRESENTATION: We report two cases of neglected Monteggia fracture dislocation, in two Kashmiri boys aged four and six years. Using ulnar osteotomy with distraction osteogenesis, we were able to relocate the radial head gradually and maintain the reduction without a requirement for open reduction and annular ligament reconstruction. CONCLUSION: Distraction lengthening and hyperangulation in different planes by use of the Ilizarov technique effectively reduces the radial head without open reduction and annular ligament reconstruction.

Delayed fixation of the transcervical fracture of the neck of the femur in the pediatric population: results and complications.

PURPOSE: To determine the impact of a substantial delay in providing surgical treatment on the final outcome in transcervical femoral neck fractures in children. METHODS: Data on all pediatric patients with transcervical fractures of the femoral neck that were fixed by reduction and internal fixation after a delay of ≥7 days in our department between 2000 and 2008 were collected both retrospectively and prospectively. RESULTS: The medical records of 14 patients (15 fractures) were analyzed. The results after an average of 43 months of follow-up showed that the complication and avascular necrosis rates were higher in cases in which treatment had been delayed compared to those in comparable fractures that had been treated promptly after the event in other series. Nine of the 15 fractures had developed avascular necrosis at final follow-up. Overall, there were four excellent, three good, and eight poor results (based on the Ratliff criteria). CONCLUSIONS: Children whose transcervical fractures of the femoral neck were surgically treated after a delay of 1 week or longer had a high avascular necrosis rate and a relatively poor outcome. Reduction and internal fixation as the initial treatment should be implemented shortly after injury in order to enhance treatment outcome.

Treatment of ipsilateral high energy tibial plateau and calcaneal fractures by a circular wire fixator: a case report.

INTRODUCTION: High energy tibial plateau fractures along with calcaneal fractures individually produce several challenges for the orthopaedic surgeon. The principles of bony reconstruction include anatomic reduction and rigid internal fixation of intra-articular fractures and accurate restoration of the coronal, sagittal and transverse mechanical axes. Due to the tenuous nature of the soft tissue and devitalisation of the comminuted fragments with open reduction, external fixation of type 6 tibial plateau fractures is recommended. We report a case with ipsilateral high energy tibial plateau and calcaneal fractures both of which were managed with an ilizarov ring fixator. CASE PRESENTATION: A 55-year-old Kashmiri female presented to our department with an ipsilateral fracture of the tibial plateau and the calcaneum. Both were closed reduced and stabilized with an ilizarov ring fixator. CONCLUSION: The circular wire fixator provides a viable method to manage such fractures especially if they are co existent. This is especially true in situations where the soft tissue is compromised.

The role of composite technique in managing peri implant re-fractures in a case with supracondylar fracture of the femur: a case report.

INTRODUCTION: Osteoporosis of the long bones challenges the orthopaedician in several ways. Amongst the difficulties encountered are the reduced bone mass, increased bone brittleness and medullary expansion, which must be factored in when deciding the type of surgical method to be used. One of the commoner complications of fixation of fractures in such bone is the occurrence of peri implant fractures with subsequent management requiring significant surgical acumen and judgment. CASE PRESENTATION: We report a case who sustained a supracondylar fracture of the femur, which was managed initially by a dynamic condylar screw assembly. The patient sustained a peri implant fracture during her rehabilitation, which was managed by the application of a longer side plate. 4 months postoperatively the patient sustained another peri implant fracture. Using a minimally invasive method we removed the screws from the plate and passed an intramedullary implant. The whole assembly was rotationally stabilized using an Ilizarov fixator. The union proceeded uneventfully. CONCLUSION: Use of such minimally invasive methods can be beneficial in such complicated situations.

Delayed manifestations of the "Nail-Slipper injury".

Penetrating injuries of the foot are a common presenting complaint in the emergency department. The residents of the underdeveloped world are especially prone to suffer such injuries as barefoot walking is still common. However, a relatively common injury that occurs in the shod feet is the "Nail-Slipper injury". A metal nail penetrates through the rubber sole of the footwear introducing the rubber piece into the soft tissue of the foot. As the nail is removed the piece remains behind often leading to delayed manifestations. This article describes the various delayed manifestations of this injury. A leading question for the antecedent injury of this kind should be asked from all patients with such presentations, especially in the urban setting.

Draining infected non union of the distal third of the tibia. The use of invaginating docking over short distances in older patients.

BACKGROUND: The distal third of the tibia is unique in the sense that it has a minimal muscle cover and consequently the blood supply is easily compromised after a fracture in this area. Infected non union in this area provides a challenge to the orthopaedic surgeon. These difficulties are especially profound in the geriatric age group. MATERIAL AND METHODS: 12 cases with an infected non union of the distal third of the tibia were managed with acute docking over a distance of up to 2.5 cms. The age of these patients was more than 55 years. RESULTS: The average shortening at final follow up was 1.8 cms. The bone results were assessed according to the protocol laid down by the association for the study and application of the method of Ilizarov. Accordingly we had 3 excellent, 8 good and 1 fair result. The functional result was calculated as per the Ilizarov criteria [1]. On this basis we had 7 excellent, 4 good and 1 fair result. CONCLUSION: The acute docking modality is applicable to the distal tibia in such situations even in the geriatric population with predictable results.

Differentiating mass disasters. The barzullah classification.

BACKGROUND: To assess the pattern of mass casualty incidents managed at our hospital over the last eight years, and evolve a differentiating classification based on this pattern. A combination of retrospective and prospective assessment was made. MATERIAL AND METHODS: All patients receiving injuries in mass casualty incidents and managed at our hospital. Patients with an injury severity score above 9. Management of injuries as per the trauma management protocol. Classification based on the data collected during the study and application of this classification to the subsequent mass casualty incidents to allow comparison between similar incidents in different settings. RESULTS: A classification system that mainly differentiates mass casualty incidents on the hospital basis, the criteria being: the time interval between the first information to first reception, and the percentage of admission above the maximum normal intake. CONCLUSIONS: The Barzullah classification system is the first attempt at developing a hospital based differentiation in mass casualty incidents. It provides a valid and easy method of comparing such incidents between hospitals and perhaps a basis for developing protocol for mass disaster management.

A reciprocating ledge technique in closing wedge osteotomy for genu valgum in adolescents.

PURPOSE: To describe a technique that preserves anterior and posterior alternate ledges in a closing wedge osteotomy. METHODS: Five patients aged 14 to 19 years underwent a closing wedge osteotomy for genu valgum in 8 limbs using a reciprocating ledge technique. A unicortical wedge of bone was removed, with the anterior and posterior cortices spared. The anterior cortex at the proximal level and the posterior cortex at the distal level were cut through. With a wobbling action, the osteotomy site was rotated, and the distal fragment externally rotated. Manual force was applied to close the osteotomy site ensuring overlapping of the reciprocal ledges. The distal fragment was translated laterally to prevent club deformity. The osteotomy site was held with one or 2 staples. Stability was tested by flexion and extension of knee. RESULTS: All 8 limbs attained bone union within 12 weeks, and full range of motion within a mean of 13 (range, 12-15) weeks. The mean correction of the tibiofemoral angle was 13 degrees. At a mean follow-up of 12 months, all patients were pain-free and none developed club deformity. CONCLUSION: Sparing reciprocal ledges in a closing wedge osteotomy for genu valgum may increase stability in the flexion-extension axis, enable early range-of-motion exercises, and facilitate early bone union.