Open total talus dislocation without concomitant malleoli fracture: a case report.

BACKGROUND: Total talus dislocation without ankle (malleoli) fracture is a very rare injury with prevalence of only 0.06% of all dislocations and only 2% of talar injuries, and are usually associated with common complications such as infection, avascular necrosis, and posttraumatic arthritis. The treatment usually involves debridement, reduction, stabilization of the ankle joint, and primary or secondary closure of the wound. CASE PRESENTATION: We present the case of a 40-year-old South Asian woman who was involved in an accident. She was rushed to our hospital, whereby subsequent examination revealed an open total talus dislocation with the talus being exposed in its entirety from a contaminated wound in the medial side. Furthermore, radiograph confirmed total talus dislocation without concomitant malleoli fracture. She was immediately taken to the operating theater whereby debridement and immediate reduction was performed under anesthesia, and the ankle was stabilized with external fixator for about 6 weeks. She is now able to bear weight on the affected ankle with minimal tolerable pain and has normal range of motion of the ankle. CONCLUSIONS: Open total talus dislocation without concomitant malleoli fracture is a rare injury. Reduction of the talus in combination with complete wound debridement potentially successfully avoids infection, provides early revascularization preventing avascular necrosis, and preserves the normal ankle anatomy.

Effectiveness of Fentanyl in Facilitating Cannulation of Ampulla of Vater during Endoscopic Retrograde Cholangiopancreatography.

BACKGROUND: Endoscopic retrograde cholangiopancreatography is carried out under moderate sedation mostly by use of propofol, opioids and benzodizepines. The aim of study is to assess difficulty in cannulation of ampulla of vater with the use of fentanyl. METHODS: A prospective randomized double blind comparative study was conducted at Bharatpur Hospital from August 2019 to August 2020 among patients undergoing Endoscopic retrograde cholangiopancreatography. Total 100 patients were enrolled in study and were divided in two groups - Group P (propofol and midazolam) and Group FP (propofol, midazolam and fentanyl). Ease of cannulation was determined using Freeman scale. Independent sample t-test was used to compare mean between two groups and Chi Square test was used to compare categorical variables. RESULTS: Mean age (51.36±17.750 years versus 56.74±16.995 years), weight (58.88±8.151 kg versus 57.32±8.431 kg) and gender distribution (14 versus 12 male patients and 36 versus 38 female patients) were comparable in both groups-Group P and Group FP. There were 34 patients in Group P and 37 patients in Group FP with easy cannulation and 16 patients in Group P and 13 patients in Group FP with difficult cannulation, which was comparable (p value=0.509) Conclusions: Cannulation of ampulla of vater is not affected by the use of fentanyl in combination with propofol when compared to propofol alone and can be routinely used during endoscopic retrograde cholangiopancreatography.

Ringer's Lactate Hydration and Incidence of Post ERCP Pancreatitis: A Descriptive Cross-sectional Study.

INTRODUCTION: Endoscopic retrograde cholangiopancreatography is one of the most frequently used treatment modality for various pancreatobiliary problems. Frequent complications of endoscopic retrograde cholangiopancreatography include pancreatitis, cholangitis, hemorrhage and perforation. This study was done to see the prevalence of post endoscopic retrograde cholangiopancreatography pancreatitis in patient aggressively hydrated with Ringer's Lactate solution. METHODS: A descriptive cross sectional study was carried out on patient undergoing endoscopic retrograde cholangiopancreatography at Bharatpur Hospital from June 2018 to August 2020. Ethical clearance was taken from Institutional Review Committee Bharatpur Hospital (reference number 16/076/77). The convenient sampling method was applied. Data were collected and analyzed in statistical package for the social sciences version 16. Point estimate at 95% confidence interval was calculated along with frequency and proportion for binary data. RESULTS: Pain abdomen was assessed using Visual Analogue Scale and it was found that 8.1% of patients (15 patients) complained of pain abdomen with visual analogue scale> 3. Serum amylase was sent only in those patients who complained of pain abdomen and only in three patients (1.6%) serum amylase was increased more than 3 times the upper limit of normal value suggestive of pancreatitis. All three patients who had pancreatitis had precut sphincterotomy. CONCLUSIONS: In this study we found that incidence of pancreatitis slumped after aggressive hydration with Ringer's lactate solution and adjunct use of other prophylactic measures for prevention of post endoscopic retrograde cholangiopancreatography pancreatitis might yield further better results.