Hip arthrodesis in children : a review of 26 cases with a mean of 20 years' follow-up.

AIMS: To examine the long-term outcome of arthrodesis of the hip undertaken in a paediatric population in treating painful arthritis of the hip. In our patient population, most of whom live rurally in hilly terrain and have limited healthcare access and resources, hip arthrodesis has been an important surgical option for the monoarticular painful hip in a child. METHODS: A follow-up investigation was undertaken on a cohort of 28 children previously reported at a mean of 4.8 years. The present study looked at 26 patients who had an arthrodesis of the hip as a child at a mean follow-up of 20 years (15 to 29). RESULTS: The mean Harris Hip Score (HHS) increased from 39.60 (SD 11.06) preoperatively to 81.02 (SD 8.86; p = 0.041) at final review. At latest follow-up, the HHS was found to be excellent in four patients (15%), good in 11 (42%), and fair in 11 (42%). A total of 16 patients (62%) reported mild low back pain, five (19%) had moderate pain, and five (19%) patients had no back pain. Mild ipsilateral knee pain was reported by 19 (73%), moderate pain by one (4%), and no pain by six (23%) patients. Mild contralateral hip pain was reported by ten patients (38%), and no pain by 16 (62%). The 36-Item Short Form Health Survey scores were very good in four patients (15%), good in 18 (70%), and poor in four (15%), with a mean score of 70.92 (SD 12.65). Of 13 female patients who had given birth, 12 did so with uncomplicated vaginal delivery. All patients had to modify their posture for toileting, putting on lower body clothes, foot care, and putting on shoes. CONCLUSION: Our results show that with hip arthrodesis, most patients have relatively good function at long-term follow-up, although some pain is experienced in adjacent joints, and modification in some activities of daily living is common.Cite this article: Bone Joint J 2022;104-B(9):1089-1094.

Outline of Hand and Wrist Injuries Presenting to an Emergency of a Tertiary Care Centre in Nepal.

BACKGROUND: Hand and wrist injuries are getting commoner with increasing incidence of injuries and accidents. This study aims to identify the prevalence and pattern of hand and wrist injuries presenting to the emergency department of a tertiary care center of Nepal. METHODS: The study was conducted through review of electronic data of the patient in the emergency department database for the period of 1 Nov 2005 till 31 Oct 2015.Data was extracted in Microsoft Excel 2007 andanalyzed to measure incidence and pattern of the hand and wrist injuries. RESULTS: There were2899 number of patients with hand and wrist injuries during the period. Most were males (80%) and commonest age group was 20-29 years. Majority of the injuries were due to road traffic accident (n=786, 27.11%), fall injury (n=696, 24.09%), cut injury with sharps (n=404, 13.94%) and machinery injury (n=319, 11%). The commonest presenting injuries were hand fractures (n=1820, 62.8%) followed by distal radius fracture (n=613, 21.1%), crush injury of hand (n=409, 14.1%), and cut injury (n= 406, 14%). Almost half, 48.84 % cases were discharged from the emergency department with preliminary or definitive management. CONCLUSIONS: Hand and wrist injuries constitute a substantial number of casesseen and managed in the emergency department.Therefore, public health measures should be taken to reduce RTI, fall injury and occupational accidents. Andit is of paramount importance that emergency care giver attends these injuries properly and timely and establishes a good referral system as and when necessary.

Socioeconomic Status Influences Functional Severity of Untreated Cerebral Palsy in Nepal: A Prospective Analysis and Systematic Review.

BACKGROUND: Cerebral palsy (CP) comprises a heterogeneous group of disorders whose clinical manifestations and epidemiologic characteristics vary across socioeconomic and geographic contexts. The functional severity of untreated CP in low-income countries has been insufficiently studied; a better understanding of how these children present for care in resource-constrained environments is important because it will better characterize the natural history of CP, guide clinical decision-making, and aid in the prognostication of children with untreated CP. QUESTIONS/PURPOSES: The purposes of this study were (1) to determine the etiologies, motor subtypes, topographic distributions, and functional classifications of a large cohort of Nepali children with untreated CP presenting to a large pediatric rehabilitation center in Nepal; and (2) to compare the Gross Motor Function Classification System (GMFCS), the Manual Ability Classification System (MACS), and the Communication Function Classification System (CFCS) scores of a subset of patients with spastic CP in the Nepali cohort with control subjects from high-income countries. METHODS: A cross-sectional study was conducted at the Hospital and Rehabilitation Centre for Disabled Children in Nepal. Two hundred six consecutive Nepali children (76 girls; median age 4.0 years [interquartile range {IQR}, 2.5-9.0 years]) were evaluated to determine the demographic, clinical, and functional characteristics of a cohort of Nepali children with untreated CP. A systematic review of the Medline and Cochrane databases was then performed to obtain reference classification scores from high-income countries. Cross-sectional, noninterventional studies reporting at least one functional classification system with a sample size of at least 50 participants were included. Only studies of patients with spastic CP were included to allow for compatible comparisons with a subset of our study sample with spastic CP. A random-effects analysis was used to pool functional scores from participants in the included studies. Among the 206 children in our sample, 102 had spastic CP (35 girls; median age 5.5 years [IQR, 3.5-9.0 years]). Functional scores from these children were compared with pooled scores obtained from the systematic review by assessing the proportions of children in each sample with GMFCS, MACS, and CFCS score categories of I or II versus III to V. RESULTS: Children with spastic hemiplegia from high-income countries were more likely to have a GMFCS score of I or II (96% [95% confidence interval {CI}, 92%-99%] versus 78% [95% CI, 62%-89%]) and a MACS score of I or II (83% [95% CI, 77%-88%] versus 50% [95% CI, 32%-68%]) relative to those from Nepal, but they were less likely to have a CFCS score of I or II (67% [95% CI, 51%-80%] versus 97% [95% CI, 87%-99%]). No differences were seen in children with spastic diplegia or quadriplegia. CONCLUSIONS: Children in Nepal with hemiplegic CP display less difficulty in communicating and social engagement (CFCS) despite more-severe upper- and lower-extremity impairments in gross motor function (GMFCS) and manual ability (MACS) than do children with hemiplegic CP from high-income countries. Targeted interventions, including perhaps simple orthopaedic interventions to treat soft-tissue contractures, may therefore provide more-substantial improvements in function and quality of life to Nepali children than could be achieved for the same deployment of resources in more-affluent settings. LEVEL OF EVIDENCE: Level II, prognostic study.

Neuroarthropathy of the hip following spinal cord injury.

We present the case of a 33-year-old male who sustained a burst fracture D12 vertebrae with spinal cord injury (ASIA impairment scale A) and a right mid-diaphysial femoral shaft fracture around 1.5 years back. The patient reported 1.5 years later with a swelling over the right buttock. Arthrotomy revealed serous fluid and fragmented bone debris. The biopsy showed a normal bony architecture with no evidence of infection and malignant cells. Hence, a diagnosis of Charcot's hip was made. Charcot's neuroarthropathy of the feet is a well-recognized entity in the setting of insensate feet resulting from causes such as diabetes or spina bifida. Although Charcot's disease of the hips has been described, it is uncommon in association with spinal cord injury, syphilis and even with the use of epidural injection. The present case highlights the fact that neuroarthropathy of the hip can occur in isolation in the setting of a spinal cord injury, and this can lead to considerable morbidity.

Hip arthrodesis in children: A review of 28 patients.

BACKGROUND: The best method of treating intractable hip pain in an unsalvageable hip joint in a child is still a subject open to debate. We believe that hip arthrodesis in such patients provides a painless and stable hip for most activities of daily living in our challenging rural terrain. Therefore, we conducted this study to assess the functional ability of children with painful hip arthrosis treated by arthrodesis of the hip. MATERIALS AND METHODS: A retrospective evaluation of 28 children (out of 35) who had an arthrodesis of the hip performed between 1994 and 2008 was carried out. The average age was 14 years, with 12 males and 16 females. There was involvement of the right hip in 13 and left in 15 cases. The average duration of follow-up was 4.87 years. The preferred position of the hip for arthrodesis was 20-30 degrees of flexion, neutral abduction-adduction, and neutral rotation, irrespective of the method of fixation. RESULTS: The average duration of clinical and radiological arthrodesis was found to be 4 months (2-6 months). At the last follow-up, all patients were painfree and had good ambulatory capacity. The average Modified Harris Hip Score increased from 53 to 84 and the average post-surgical limb length discrepancy was 1.3 cm, which was well tolerated in all cases. Patients, however, had difficulty in squatting and had to modify their posture for foot care, putting on shoes, etc. Also, some patients complained of ipsilateral knee, contralateral hip, or low back pain with prolonged activity, but this was not severe enough to restrict activity except in one case that was known to have juvenile rheumatoid arthritis and needed ambulatory aid. CONCLUSION: In an environment where pathology generally presents very late and often in a dramatic manner, where the patient's socioeconomic status, understanding, compliance, and the logistics of follow-up are consistently a challenge in management, hip arthrodesis has been an important procedure for our patient group, with good short-term results and promising midterm, and, hopefully, long-term prospects. In our series of patients, we have been successful in restoring painfree mobility.

Ponseti method for untreated idiopathic clubfeet in Nepalese patients from 1 to 6 years of age.

UNLABELLED: Although the Ponseti method has been effective in patients up to 2 years old, limited information is available on the use of this method in older patients. We retrospectively reviewed the records of 171 patients (260 feet) to determine whether initial correction of the deformity (a plantigrade foot) could be achieved using the Ponseti method in untreated idiopathic clubfeet in patients presenting between the ages of 1 and 6 years. A mean of seven casts was required, and there were no differences in the number of casts between the different age groups. Two hundred fifty (95%) of the 260 feet were treated surgically for residual equinus after a plateau in casting, and procedures included percutaneous tendo-Achilles release (n = 205 [79%]), open tendo-Achilles lengthening (n = 8 [3%]), posterior release (n = 21 [8%]), and extensive soft tissue release (posteromedial release, n = 16 [6%]). The mean dorsiflexion after removal of the last cast was 12.5 degrees for the entire group and was greater in 1 year olds compared with 3 year olds. Although all patients achieved a plantigrade foot, the importance of the mild loss of passive dorsiflexion remains to be determined. An extensive soft tissue release was avoided in 94% of patients using the Ponseti method. We intend a followup study to ascertain whether the correction is maintained. LEVEL OF EVIDENCE: Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Musculoskeletal training for orthopaedists and nonorthopaedists: experiences in Nepal.

Orthopaedic surgical training in Nepal began in 1998, and four major centers now produce between 15 and 20 graduates annually. The duration of the training is four years in one center and three years in the remaining centers. Trainees have adequate trauma exposure. The major challenges include: tailoring training to suit local needs, avoiding the dangers of market driven orthopaedic surgery, adequately emphasizing and implementing time honored methods of closed fracture treatment, and ensuring uniformity of exposure to the various musculoskeletal problems. Training in research methods needs to be implemented more effectively. The evaluation process needs to be more uniform and all training programs need to complement one another and avoid unhealthy competition. Training for nonorthopaedists providing musculoskeletal care is virtually nonexistent in Nepal. Medical graduates have scant exposure to trauma and musculoskeletal diseases during their training. General surgeons provide the majority of trauma care and in the rural areas, health assistants, auxiliary health workers and physiotherapy assistants provide much needed basic services, but all lack formal training. Traditional "bone setters" in Nepal often cater to certain faithful clientele with sprains, minor fractures etc. A large vacuum exists in Nepal for trained nonorthopaedists leading to deficiencies in prehospital care, safe transport and basic, primary emergency care. The great challenges are yet to be addressed.