Proximal Fibular Osteotomy: Is it Really an Option for Medial Compartmental Osteoarthritis Knee? Our Experience at Tertiary Centre.

INTRODUCTION: The medial compartment is commonly involved in age-related osteoarthritis knee because weight-bearing axis passes close to the medial condyle and its large surface area. Various treatments have been proposed ranging from conservative to total knee arthroplasty which is an expensive and complex treatment. Recently, proximal fibular osteotomy (PFO) for medial compartment knee osteoarthritis became popular as a treatment modality. Although, the mechanism of PFO is not clear. So, we conducted a prospective study to assess the clinico-radiological outcome of proximal fibular osteotomy in medial compartment osteoarthritis knee. MATERIALS AND METHODS: We conducted a prospective study from November 2017 to November 2019 on 32 (47 knees) patients with degenerative medial compartmental osteoarthritis knee, varus deformity < 15 and Kellgren and Lawrence grade II and grade III (K-L Grade). We recorded the visual analogue score (VAS) and knee society score (KSS) pre-operatively and post-operatively of all patients.  We got weight bearing anterio-posterior and lateral radiograph of knee done. We assessed joint space ratio and lateral tibio-femoral angle (FTA) pre-operatively, post-operatively and at each follow-up. RESULTS: Mean age was 48.4 (35-65) years and the mean follow-up was 18 months. Mean duration for unilateral PFO was 37 min and for bilateral, 55 min. The VAS was improved from 7.33 ± 0.72 to 7.13 ± 1.64 at 3 months and remained the same at final follow-up (p > 0.05). The mean pre-operative clinical and functional KSS was statistical insignificantly improved at 3 months and final follow-up (p > 0.05). The mean pre-operative lateral and mean pre-operative joint space ratio was also improved statistically insignificant (p > 0.05). Extensor hallucis longus (EHL) weakness was documented in five knees (10.6%) and paraesthesia was documented in seven (14.8%) knees. CONCLUSION: Although, PFO is a simple, less invasive and affordable procedure, we could not reproduce the favourable results in medial compartmental osteoarthritis knee. This procedure is also associated with reversible but noticeable complications. So, we would not consider PFO as an alternative option in the treatment of medial compartmental osteoarthritis knee.

Limb length discrepancy after total knee arthroplasty: Unilateral versus bilateral, a comparative study at tertiary centre.

INTRODUCTION: We conducted a prospective study to find out change in limb length (lengthening/shortening) after total knee arthroplsty in unilateral and bilateral total knee arthroplasty (TKA) because few literature is available regarding limb length discrepancy in TKA in comparison to total hip arthroplasty. Limb length discrepancy (LLD) may lead to low back pain and gait abnormalities. MATERIAL AND METHODS: We divided 58 patients into two groups: Group A (28 patients) includes patients who underwent unilateral TKA and Group B (30 patients) includes patients who underwent bilateral TKA. We assessed the patients clinico-radiologically in terms of limb length (supine position), deformity, Sagital-flexion deformity/extensor lag, coronal - varus/valgus, range of motion, knee stability, patellar tracking and Hip-knee-ankle angle preoperatively and postoperatively. RESULTS: In group A, mean limb length difference (operated limb gained length as compared to unoperated limb) was 1.11 cm. Out of 22 patients (78%) in whom limb length discrepancy was present, only 7 patients (31%) having limb length discrepancy perceived it. In group B, mean limb length difference was 1.03 cm. Fourteen patients (47%) in group B had LLD but none of them perceived it. Clinically 22 patients (78%) in group A and 14 patients (47%) in group B had LLD. Radiologically 25 patients (89%) in group A and 22 patients (73%) in group B had LLD. Out of the 7 patients who perceived LLD, all had LLD radiologically too. CONCLUSION: We reckoned that limb length discrepancy is more common in unilateral TKA. Limb length discrepancy of 2 cm or more is perceived by the patients operated for unilateral TKA. But in bilateral TKA, none of the patient perceived LLD because in this group LLD was less than 2 cm. Limb length discrepancy may leads to dissatisfaction of the patients and poor functional outcome.

Isolated Talonavicular Joint Tuberculosis in a Child - Rare Location of Koch's Bacillus: A Case Report.

Tuberculosis of the foot is an uncommon entity and the reported incidence is 0.1% to 0.3%. The isolated tuberculosis of talonavicular joint is exceptionally rare. In tuberculosis of the foot and ankle, the presentation is usually nonspecific. The diagnosis of tuberculosis affecting foot is difficult, especially when it is isolated. In doubtful cases, diagnosis should be confirmed by histopathological examination. Unlike pulmonary Kochs, osteoarticular tuberculosis should be treated with antituberculous drugs for a longer duration, preferably for 18 months. We are reporting a case of a 9-year-old boy with tuberculosis of the isolated talonavicular joint and the diagnosis was suggested on plain radiography, which was further confirmed by histopathological examination. He was treated with first-line antitubercular drugs. A good recovery was seen following the commencement of anti-tuberculosis treatment. After two years of follow-up, he was pain-free and doing all of his routine activities. In tuberculosis of the foot, diagnosis is usually delayed or missed due to vague presentation.

An outbreak of Middle East Respiratory Syndrome (MERS) due to coronavirus in Al-Ahssa Region, Saudi Arabia, 2015.

Between 19 April and 23 June 2015, 52 laboratory-confirmed cases of Middle East Respiratory Syndrome due to coronavirus (MERS) were reported from Al-Ahssa region, eastern Saudi Arabia. The first seven cases occurred in one family; these were followed by 45 cases in three public hospitals. The objectives of this investigation were to describe the epidemiological characteristic of the cluster and identify potential risk factors and control measures to be instituted to prevent further occurrence of MERS. We obtained the medical records of all confirmed cases, interviewed the members of the affected household and reviewed the actions taken by the health authorities. All the cases were connected. The index case was a 62-year-old man with a history of close contact with dromedary camels; three of the seven infected family members and 18 people in hospitals died (case-fatality rate, 40.4%). The median incubation period was about 6 days. The cluster of cases appeared to be due to high exposure to MERS, delayed diagnosis, inadequate risk communication and inadequate compliance of hospital health workers and visitors with infection prevention and control measures.

Unusual cause of anterior knee pain.

[No Abstract Available].

An outbreak of Middle East Respiratory Syndrome (MERS) due to coronavirus in Al-Ahssa Region, Saudi Arabia, 2015

Between 19 April and 23 June 2015, 52 laboratory-confirmed cases of Middle East Respiratory Syndrome due to coronavirus [MERS] were reported from Al-Ahssa region, eastern Saudi Arabia. The first seven cases occurred in one family; these were followed by 45 cases in three public hospitals. The objectives of this investigation were to describe the epidemiological characteristic of the cluster and identify potential risk factors and control measures to be instituted to prevent further occurrence of MERS. We obtained the medical records of all confirmed cases, interviewed the members of the affected household and reviewed the actions taken by the health authorities. All the cases were connected. The index case was a 62-year-old man with a history of close contact with dromedary camels; three of the seven infected family members and 18 people in hospitals died [case-fatality rate, 40.4%]. The median incubation period was about 6 days. The cluster of cases appeared to be due to high exposure to MERS, delayed diagnosis, inadequate risk communication and inadequate compliance of hospital health workers and visitors with infection prevention and control measures

Entre le 19 avril et le 23 juin 2015, 52 cas confirmés en laboratoire de syndrome respiratoire du Moyen-Orient [MERS] causé par le coronavirus ont été notifiés dans la région d'Al-Ahssa, partie orientale de l'Arabie saoudite. Les sept premiers cas sont survenus dans une seule famille ; ils ont été suivis de 45 cas déclarés dans trois hôpitaux publics. Cette investigation avait pour objectifs de détailler les caractéristiques épidémiologiques de ce groupe de cas et d'identifier les facteurs de risque potentiels ainsi que les mesures de lutte à mettre en place afin d'empêcher la survenue de nouveaux cas de MERS. Nous avons consulté les dossiers médicaux de l'ensemble des cas confirmés, avons interrogé les membres des foyers touchés et passé en revue les interventions entreprises par les autorités sanitaires. Tous les cas étaient reliés entre eux. Le cas indicateur était un homme de 62 ans ayant eu des contacts étroits avec des dromadaires ; trois des sept membres infectés de la famille et 18 patients hospitalisés sont décédés [taux de létalité : 40,4%]. La période d'incubation médiane était d'environ 6 jours. Le groupe de cas était vraisemblablement dû à une forte exposition au MERS, associée à un diagnostic tardif, une communication sur les risques inappropriée et une mauvaise observance des mesures de prévention et de lutte contre les infections par les personnels de santé de l'hôpital et les visiteurs

Prediction of quadruple hamstring graft diameter for anterior cruciate ligament reconstruction by anthropometric measurements.

BACKGROUND: The literature is scanty regarding the anthropometric predictors on the diameter of quadruple hamstring graft obtained in anterior cruciate ligament (ACL) reconstruction in Indian population. Minimum diameter of the graft for ACL reconstruction should be >7 mm to preclude failure. The objective of this study was to assess the prediction of the hamstring graft diameter by several anthropometric parameters including age, thigh circumference, weight, height and body mass index (BMI). MATERIALS AND METHODS: 46 consecutive patients who had undergone ACL reconstruction by the same surgeon using quadruple hamstring grafts were evaluated. The age, thigh circumference of the normal side, height, weight and BMI were recorded preoperatively and Pearson correlation was done using these parameters with graft diameter measured intraoperatively. Regression analysis in a stepwise manner was undertaken to assess the influence of individual anthropometric parameters on the graft diameter. RESULTS: There were 44 males and 2 females. Mean age was 29.4 years, mean height was 172.6 cm, mean weight was 70.9 kg, mean BMI was 23.8 kg/m(2), mean thigh circumference was 47.1 cm and mean graft diameter was 7.9 mm. There was a positive correlation individually between the thigh circumference and graft diameter obtained (r = 0.8, P < 0.01, n = 46), and between the height and graft diameter (r = 0.8, P < 0.01, n = 46). On the regression analysis thigh circumference and height were found to be significant predictors of graft diameter giving the following equation: Graft diameter (mm) = 0. 079 height (cm) +0.068 thigh circumference (cm) -9.031. CONCLUSION: Preoperatively using the above equation if graft diameter came out to be <7 mm then alternate options of graft material must be kept in mind in order to prevent failure.

A middle aged lady with recurrent low trauma fracture due to parathyroid adenoma.

A 48 year old lady was referred to BIRDEM Hospital, Dhaka, Bangladesh by her local physician for evaluation of hypercalcaemia and increased serum parathyroid hormone (PTH) in the background history of low trauma fracture. Ultrasound of neck and parathyroid scintigraphy with 99mTc-MIBI revealed a parathyroid adenoma. Parathyroidectomy was done. Histopathology report showed features consistent with parathyroid adenoma. Primary hyperparathyroidism should be kept in mind in all patients presenting with history of bone problems ranging from simple bone pain to spontaneous or low trauma fracture associated with hypercalcemia. By the help of appropriate localization technique it can be localized and cured by parathyriodectomy.

Clinical effectiveness and safety of vildagliptin in >19 000 patients with type 2 diabetes: the GUARD study.

The present GUARD study was a prospective, non-interventional study evaluating the clinical effectiveness, safety and tolerability of vildagliptin with or without metformin in adult patients with type 2 diabetes mellitus (T2DM) studied in routine clinical practice. Patients were enrolled from countries across four geographical regions. The primary endpoint was change in glycated haemoglobin (HbA1c) concentration from baseline after 24 weeks of treatment with vildagliptin with or without metformin. Of 19 331 patients analysed, 3511 received vildagliptin and 15 820 received vildagliptin plus metformin. At week 24, the mean HbA1c was reduced significantly from baseline by -1.27% (vildagliptin: -1.17%; vildagliptin plus metformin: -1.29%; p < 0.0001). Significant reductions in HbA1c from baseline were consistently reported regardless of patient age, body mass index (BMI) or baseline HbA1c. Weight and BMI were also significantly reduced from baseline. Vildagliptin treatment with or without metformin was generally well tolerated. It provided clinically relevant glycaemic and weight control, and was well tolerated in a large multi-ethnic population of patients with T2DM studied in routine clinical practice.

Clinical experience with BIAsp 30: Results from the Bangladesh cohort of the global A1chieve study.

The aim of A1chieve was to remedy the deficit of data on the efficacy and safety of insulin analogues in routine clinical care in less well-resourced developed countries. To present results from the Bangladesh cohort of the A1chieve study receiving BIAsp 30 ± oral anti diabetic drugs. A1chieve was a 6-month, observational study of 66,726 people with type 2 diabetes, started on insulin detemir, insulin aspart or biphasic insulin aspart (BIAsp 30) in 28 countries across four continents. A total of 1,093 subjects were recruited from 49 sites in Bangladesh and 580 subjects initiated on BIAsp 30 were studied. In the entire cohort, treatment with BIAsp 30 for 24 weeks significantly reduced mean HbA(1c) (2.8%, p < 0.001), fasting plasma glucose (4.0 mmol/L, p < 0.001) and post prandial plasma glucose (6.6 mmol/L, p < 0.001) levels from baseline. The rate of overall hypoglycaemic events in the entire cohort also reduced significantly at 24 weeks (1.86 to 0.02 events/person year, p < 0.0001). BIAsp 30 can be considered as a safe and effective option for initiating as well as intensifying insulin therapy for type 2 diabetes.

Androgen versus erythropoietin for the treatment of anaemia of pre-dialysis chronic kidney disease.

Chronic kidney disease is a microvascular complication of diabetes mellitus (DM). Anemia is an important clinical manifestation to treat chronic kidney disease. Many subjects with poor socio-economic status having chronic kidney disease (CKD) and anaemia in a developing country can not afford the treatment with erythropoietin. This study has designed to see the efficacy of Nandrolone, a cheaper alternative; in comparison with recombinant human erythropoietin for management of anemia of pre-dialysis diabetic chronic kidney disease. Sixty adult diabetic patients with anaemia of chronic kidney disease on conservative treatment [Not on Hemodialysis (HD)] were enrolled. Patients were divided into two groups (Group 1 and Group 2) of 30 patients each. Group 1 patients received nandrolone deaconate 50 mg deep intramuscular and Group 2 recombinant human erythropoietin 100 IU per kilogram of body weight subcutaneously once weekly. Patients of both group received oral supplements in order to maintain body iron stores. All the relevant haematological and renal parameters were evaluated at the end of 3rd & 6th months. There was a statistically significant rise in haemoglobin concentration, packed cell volume, in both groups. The rise in haemoglobin concentration, in Group 2 was more marked followed by Group 1, at the end of 3rd, and 6th months. Nandrolone, though not equally effective, may be considered as a valid alternative therapy for the treatment of anemia of pre-dialysis diabetic chronic kidney disease to that of erythropoietin.

Prevalence of diabetes among hypothyroid subjects.

Thyroid dysfunction affects a significant portion of the general population. Most studies have found a higher prevalence of hypothyroidism in women, increasing with age. Prevalence of hyperthyroidism has been found to range 0.5-3.0%. Type 2 diabetes is a major public health problem affecting approximately 4.8 percent of the Bangladeshi population. The study was designed to see the prevalence of type 2 diabetes in hypothyroid patients of any etiology. Four hundred forty two consecutive cases of diagnosed hypothyroidism were recruited in the study. All diagnosed hypothyroid subjects (sub-clinical or overt) reported in one year not known to be diabetic previously, underwent standard OGTT (FPG and 2-hour post 75 gram glucose) before initiation of thyroid hormone replacement. Newly detected diabetes among the subjects diagnosed as hypothyroidism is significantly higher 4.8 vs. 7.01% (p<0.01) and the prevalence of pre-diabetic state Impaired Glucose Tolerance (IGT) is also higher (11% vs. 12.6%) among hypothyroid subjects. Pure IFG (FPG ≥6.1 mmol/l but <7.0 mmol/l, and 2-PG <7.8 mmol/l) was found in 5.2% according to WHO criteria and the prevalence is higher (6.8%) with ADA criteria (considering normal FBG <5.6mmol/l). Diabetes was found in 7.01% among hypothyroid subjects which is higher than the existing known prevalence (4.8%). IGT was also found higher among hypothyroid subjects than population prevalence (8.6%). Further larger sample study is essential to establish the findings.

Clozapine-induced late leukopenia.

A patient with a 28-year history of schizophrenia was treated with a wide range of antipsychotic medications since diagnosis. She had experienced no clinically significant symptomatic relief until she commenced treatment on clozapine. Her psychotic symptoms, self care, and general sense of well-being improved significantly. After 6 years of successful treatment, she developed leukopenia and clozapine was discontinued. The following issues will be discussed in the article: rechallenge with clozapine following leukopenia during previous therapy and the choice of and haematological monitoring needs with other antipsychotic medications after clozapine-induced blood dyscrasia.

Practical management of diabetes during Ramadan fasting.

Diabetes mellitus is a global epidemic including Bangladesh. It is a chronic, costly and deadly disease. Recent advancement gives us the opportunity to control diabetes and offer the patient to have a normal or near normal life. Fasting during Ramadan is one of the five pillars of Islam. Recent studies show that most of the type-2 diabetic patients can fast during the holy month of Ramadan safely. But they need pre-Ramadan counseling for assessment, education, motivation, dietary and drug adjustment. Ramadan is beneficial for health. Fasting improves metabolic control, reduces weight and helps to control hypertension. Fasting also associated with some risks like-hypoglycemia, diabetic ketoacidosis, hyper osmolar non ketotic coma and dehydration. All of these risks can be significantly reduced by pre-Ramadan counseling. Those who are at very high risks of hypoglycemia and acute diabetic or other complications they should not fast. After recovery they should complete their fast with the consultation of Islamic scholars. If there is hypoglycemia while fasting, fast must be broken. Islam allows us to have a regular blood sugar test during fast. Patient should follow a highly individualized management plan. Close monitoring is essential to prevent complications for safe Ramadan.

Evaluation of management, control, complications and psychosocial aspects of diabetics in Bangladesh: DiabCare Bangladesh 2008.

DiabCare Bangladesh 2008 evaluated the current status of diabetes care in Bangladesh as a continuation of similar cross-sectional study conducted previously in 1998. The current study recruited 1952 patients from general hospitals, diabetes clinics and referral clinics to study current scenario of diabetes management from 01 March 2009 to 31 March 2009. We report the results of type 2 diabetic population who constituted 95.3% (n=1860). Results showed deteriorating glycaemic control with mean HbAlc of 8.6 +/- 2.0% with only 23.1% of the patients achieving American Diabetes Association (ADA) target of <7%. 896 (47.0%) patients were hypertensive and 850 (94.9%) were on antihypertensive medication. 70.8% of patients had LDL levels >2.6 mmol/L; 43.8% had triglycerides >2.2 mmol/L; 44.1% had HDL<1 mmol/L despite 48% of the patients being on lipid lowering agents. Microvascular, macrovascular and severe late complications were reported in 39.2%, 9.9% and 12.1% patients respectively. The rates of diabetic complications were cataract 12.9%, microalbuminuria 15.7%, neuropathy symptoms 31.7%, leg amputation 1.2% and history of angina pectoris was 6.6%. Quality of life evaluation showed that about half of patients have poor quality of life. Also, there was poor adherence to diet, exercise and self testing of blood glucose. In conclusion, majority of the patients were still not satisfactorily controlled. There is an urgent need for effective remedial measures to increase adherence to practice guidelines and to educate both patients and healthcare personnel on importance of achieving clinical targets for metabolic control.