Cytological Diagnosis Suggesting Candidal Infection of the Nasolacrimal Duct in an Uncontrolled Diabetic Patient With Gingival Abscess.

In this unique cytology case of a 64-year-old diabetic male who presented with left-sided facial swelling between the ala and lateral canthus of the left eye, conventional fine-needle aspiration cytology (FNAC) was done. FNAC of the swelling showed desquamated epithelial cells from the nasolacrimal duct and abundant proteinaceous material admixed with fungal organisms like that of budding yeast forms, morphologically resembling Candida on May-Grunwald-Giemsa stain. Special stain with periodic acid-Schiff revealed positivity for budding yeast forms. In this case report, we discuss the causes and clinical effects of nasolacrimal duct obstruction, cytological diagnostic features, and microscopic recognition of fungal organisms on routine staining as well as on special fungal stains.

Hyperglycemia and steroid use increase the risk of rhino-orbito-cerebral mucormycosis regardless of COVID-19 hospitalization: Case-control study, India.

BACKGROUND: In the ongoing COVID-19 pandemic, an increased incidence of ROCM was noted in India among those infected with COVID. We determined risk factors for rhino-orbito-cerebral mucormycosis (ROCM) post Coronavirus disease 2019 (COVID-19) among those never and ever hospitalized for COVID-19 separately through a multicentric, hospital-based, unmatched case-control study across India. METHODS: We defined cases and controls as those with and without post-COVID ROCM, respectively. We compared their socio-demographics, co-morbidities, steroid use, glycaemic status, and practices. We calculated crude and adjusted odds ratio (AOR) with 95% confidence intervals (CI) through logistic regression. The covariates with a p-value for crude OR of less than 0·20 were considered for the regression model. RESULTS: Among hospitalised, we recruited 267 cases and 256 controls and 116 cases and 231 controls among never hospitalised. Risk factors (AOR; 95% CI) for post-COVID ROCM among the hospitalised were age 45-59 years (2·1; 1·4 to 3·1), having diabetes mellitus (4·9; 3·4 to 7·1), elevated plasma glucose (6·4; 2·4 to 17·2), steroid use (3·2; 2 to 5·2) and frequent nasal washing (4·8; 1·4 to 17). Among those never hospitalised, age ≥ 60 years (6·6; 3·3 to 13·3), having diabetes mellitus (6·7; 3·8 to 11·6), elevated plasma glucose (13·7; 2·2 to 84), steroid use (9·8; 5·8 to 16·6), and cloth facemask use (2·6; 1·5 to 4·5) were associated with increased risk of post-COVID ROCM. CONCLUSIONS: Hyperglycemia, irrespective of having diabetes mellitus and steroid use, was associated with an increased risk of ROCM independent of COVID-19 hospitalisation. Rational steroid usage and glucose monitoring may reduce the risk of post-COVID.

Bilateral Traumatic Nightstick Fracture of the Ulna - A Rare Case Report and Review of the Literature.

INTRODUCTION: Unilateral isolated ulna fracture secondary to trauma are common but the bilateral nightstick fractures are quite rare in the clinical scenario. These are managed conservatively or surgically depending upon the degree of displacement, location of the fracture, fracture pattern and associated injury to other bones. Proper management of these fractures helps in getting a better outcome. The purpose of the study was to present a case of bilateral traumatic isolated ulna fracture and its management. CASE REPORT: A 33-year-old male presented to the emergency department with complaints of pain and swelling over the dorsum of both forearms with a history of assault with a bamboo stick. The mechanism of the injury was, the patient placed his both the forearms in front of the face as a defense during the assault and sustained injury to both forearms. On examination, the patient had bilateral forearm swelling with tenderness. Bony crepitus was present over both the ulna on palpation. X-ray of both forearms (radius and ulna) revealed the fracture of both right and left ulna without any associated fractures/injuries. The patient was managed surgically with open reduction and internal fixation using a 3.5 mm locking compression plate. At present, 1-year follow-up, the patient is having complete wrist, elbow ROM and supination, pronation without any pain. CONCLUSION: Bilateral traumatic Nightstick fractures of the ulna are rare and this is the first reported case of traumatic bilateral isolated ulna fracture according to author's best knowledge and literature review. Open reduction and stable internal fixation using the principles of fracture fixation along with early mobilization helps in getting better functional outcome and prevents further complications and secondary procedures. This case is unique as it helps in identifying the mode of trauma in medico legal cases like assault in cases of bilateral ulna fracture. The mode and the mechanism of injury are different in this case.

Femur Neck Osteoid Osteoma Managed with Radiofrequency Ablation - A Case Report.

INTRODUCTION: Osteoid osteoma is a benign tumor of bones involving mainly the tubular bones and rarely axial skeletons. The patient mainly complains of night pain in the affected region or the joint nearby. Pain always subsides with analgesics and gradually increased over the period of time. It is mostly missed on the plain radiograph so magnetic resonance imaging or computed tomography (CT) scan are preferred for accurate and early diagnosis of the tumor. CASE REPORT: A 20-year-old male presented with pain in the left hip region which was gradually increased over the period of 6 months and was experiencing pain more in the night, used to relieve on medications. CT scan of the left hip showed the presence of osteoid osteoma of 0.5 cm diameter, which was managed with radiofrequency ablation. Moreover, the patient had pain relief immediately after the procedure. At present 1-year follow-up, the patient is symptomless with no recurrence. CONCLUSION: The neck of femur osteoid osteomas is best managed with radiofrequency ablation as it causes less morbidity to the patient and helps in early return to normal activities with fewer complications as compared to open procedures.

Giant Cell Tumor (GCT) of the Third Metatarsal in an Elderly Patient: A Rare Case Report.

INTRODUCTION: Giant cell tumour (GCT) is a benign osteolytic, locally aggressive lesion. Seen in young adults at the epiphysis. The most common site is long bones (85-90%). GCT of the metatarsal in elderly patients is very rare. CASE REPORT: A 60-year-old male came with complaints of pain and swelling over right foot dorsal aspect since for the last past one 1 year. There was no history of trauma. X-ray foot showed an osteolytic lesion in the right third metatarsal with thinning of the cortex. MRI and fine-needle aspiration cytology confirmed the diagnosis of GCT. The patient was managed by excision with the 3rd ray amputation. At present, 1.5 years follow-up, the patient is having no pain, difficulty in walking and no evidence of clinical and radiological recurrence . CONCLUSION: Giant cell tumours could also present at uncommon sites, and they should be considered in the differential diagnosis of lytic lesions of the metatarsals. Excision with ray amputation of the involved metatarsal helps in complete removal of the lesion and helps in early weight-bearing. This is the viable alternative treatment option in managing the metatarsal GCT in elderly patients.

Primary Total Hip Replacement in a Case of Unilateral Hypo Plastic Proximal Femur - A Case Report.

INTRODUCTION: Primary total hip replacement in hypo plastic proximal femur is difficult due to the presence of a small canal, soft- tissue contracture, fragility of bone, and poor femoral cement mantle when used. Intraoperatively, there could be occurrence of fracture of the femur, inadequate fit, and fill with cement less femoral component.It is found unilaterally in cases of osteonecrosis of femoral head, post- traumatic, and in sequelae of childhood septic arthritis. CASE REPORT: A 45-year- old male patient presented to the OPD with complaints of pain in the left hip and difficulty in walking since for 4 years. The patient had a history of fever and swelling over the left hip in childhood with no treatment taken for the same. X-ray of pelvis with both hips showed deformed femoral head, short neck, narrow femoral canal (Grade 1 Dorr), and arthritic changes in acetabulum. We managed with total hip replacement using Wagner cone stem. Postoperatively, the patient is having good range of motion and having no difficulty in walking and weight- bearing. Functional outcome is good as per Harris hip score. CONCLUSION: Total hip replacement in hypo plastic femur with arthritis is always a challenging problem. It requires surgical expertise and proper implant selection and pre-operative planning, which prevents intraoperative and post-operative complications. Wagner cone stem is a very good option in managing this type of patients.

Synovial Chondromatosis of Hip in a Young Patient Salvaged With Mini Arthrotomy Without Hip Dislocation - A Case Report.

INTRODUCTION: Synovial chondromatosis is a rare, benign disorder of the synovium, which leads to loose body formation due to metaplastic transformation. It presents as multiple cartilaginous bodies in the synovial joints, bursae and in tendon sheaths. The diagnosis often delayed in hip involvement due to insidious onset of symptoms. Surgical management is essential to manage synovial chondromatosis, which includes hip dislocation and debridement, arthroscopic removal or using arthrotomy. CASE REPORT: A 20-year-old male patient presented with complaints of pain in the left hip since 1 year and difficulty in walking for 6 months. On examination, the patient had mild tenderness over the left hip with the restriction of joint movements. He had flexion deformity of 30°, adduction and external rotation deformity of 10 and 15°, respectively. X-ray of the pelvis with both hips anteroposterior and left hip lateral view revealed calcified nodular mass over superior, inferior part of the femoral head, and anterior part of the neck with decreased joint space. As the patient was disabled with pain, stiffness especially restricted flexion and abduction and difficulty in daily routine activities, we planned for surgical excision of the loose bodies. Using lateral approach to the hip, intra-articular loose bodies were removed through arthrotomy without hip dislocation. At present 2-year follow-up, the patient is having full hip range of motion with no difficulty in squatting, sitting cross-legged, and radiological examination showed no evidence of recurrence. The patient is fully satisfied with the chosen treatment and participating in running and other sports. CONCLUSION: Although hip synovial chondromatosis are rare, early surgical intervention with complete removal of loose bodies, joint distraction for 6 weeks to allow healing, and early initiation of hip physiotherapy helps in getting better outcome even in patients with early stages of hip arthritis. The early surgical intervention also prevents the progression of the joint degeneration, which in turn helps in postponing replacement surgeries in young patients. Satisfactory outcomes can be achieved by salvaging the natural hip joint.

Subtrochanteric Femur Fracture in Monostotic Pagets Disease and its Management - A Case Report and Review of Literature.

INTRODUCTION: Paget disease of bone is a chronic progressive disease of the bone of uncertain etiology, characterized initially by an increase in bone resorption, followed by a disorganized and excessive formation of bone, leading to pain, fractures, and deformities. It can manifest as a monostotic or polyostotic disease. Pathological fracture secondary to Paget's disease requires surgical management. CASE REPORT: A 60-year-old male patient came with complaint of pain and swelling over the left hip for 30 days. The patient had a history of a trivial fall. Radiological investigations were suggestive of pathological subtrochanteric femur fracture with Paget's disease of the left femur. We managed with the long proximal femoral nail (PFN). Histopathological examination confirmed the diagnosis of Paget's disease. At present 1-year follow-up, the patient is having good radiological and functional outcome with no implant failure. CONCLUSION: Subtrochanteric pathological femur fractures in Paget's disease are best managed with the long PFN with good outcome and fewer complications, which help in early mobilization and weight-bearing. Long PFN spans the entire pathologic femur and prevents the secondary fractures.

Closed Humerus Shaft and Distal Humerus Fractures with associated Brachial Artery Thrombosis in Adult Patients and its Management -A Case Series.

Introduction: The humerus fractures can present as isolated or associated with other injuries and these fractures can be associated with both primary and secondary iatrogenic or traumatic neurovascular injuries. The timely management of these injuries helps in preventing catastrophic consequences. Case Presentation: Two cases of humerus fractures were presented with brachial artery thrombosis. First case is 56-year-old female with distal humerus fracture and second is 32-year-old female with humerus shaft fracture. Both the patients had feeble pulse at the time of presentation. Urgent CT angiography of the upper limb was performed and vascular surgeon intervention was taken. First case showed complete non opacification of distal brachial artery due to thrombosis, which was managed with bicolumnar plating with embolectomy. The second case of humerus shaft fracture showed non contrast opacification at the fracture, which was managed with intramedullary nailing with removal of the bony fragment impinging on the artery and embolectomy. Postoperatively, both the patients are having good functional and radiological outcome without any complications. Conclusion: Proper early clinical evaluation for vascular deficits helps to prevent the delayed diagnosis and radiological investigations helps to identify the cause and location of the vascular insults. Early surgical intervention in association with vascular surgeons helps in getting better outcome and prevents complications related to vascular injuries.

The Neck of Femur Fracture in an Elderly Patient with Schizophrenia and Parkinsonism Managed with Dual Mobility Total Hip Replacement- A Rare Case Report.

Introduction: Neck of femur fractures is the most common fractures in elderly people as they present with osteoporosis. There is a higher chance of proximal femur fracture in a schizophrenic patient as there is a loss of bone mineral density due to a drug-induced increase in the level of prolactin and immobility. Patients with Parkinson's disease were at higher risk for the development of hip fractures due to gait disturbances and instability. Case Report: A 63-year-old male patient presented with complaints of the right arm pain, swelling, deformity of the right arm, and difficulty in extending the wrist for 3 days. The patient had a history of falls and trauma to the left arm at home. X-ray right arm showed distal one-third spiral humerus fracture for which intramedullary nailing was done. X-ray of the pelvis with both hips showed right neck of femur fracture with associated greater trochanter (GT) fracture. We managed with total hip replacement using a dual mobility cup and tension band wiring for GT fracture. Postoperatively, the patient has a good range of motion at the hip. The functional outcome is good as per Harris's hip score. Conclusion: Neck femur fractures in elderly patients with associated comorbidities such as schizophrenia and parkinsonism are best managed with total hip replacement using a dual mobility cup. It avoids the risk of dislocation in high-risk patients and prevents secondary procedures. Careful clinical and radiological examination of the pelvis is very essential even in asymptomatic patients with a history of trauma to prevent delayed diagnosis of these types of fractures in patients with schizophrenia and parkinsonism.

Tuberculosis of Calcaneus - A Case Report and Review of Literature.

INTRODUCTION: Osteoarticular tuberculosis (TB) constitutes 1-3 % of cases and about 10% of osteoarticular TB affects the foot and ankle. In foot, TB calcaneus is the most commonly affected bone. CASE REPORT: A 21-year-old male presented with pain, swelling in the right heel for 5 months and difficulty in walking for 2 months. Plain X-ray (axial) view of calcaneus showed a lytic lesion in calcaneus. Biopsy was done under local anaesthesia and histologic examination revealed a characteristic granuloma, caseous necrosis, and Langhans giant cells which confirmed our diagnosis. The patient was treated with anti-TB chemotherapy for 12 months. Radiographs at 18 months follow-up showed a healed lesion. At present, the patient is comfortable with no complaints. DISCUSSION AND CONCLUSION: TB calcaneus is rare condition and a high index of clinical suspicion along with imaging studies helps in diagnosis. Conservative management with anti-TB chemotherapy for adequate duration helps in complete resolution of the infection with good functional results.

Primary Total Knee Replacement in a Case of Lateral Tibial Condyle Delayed Union with Severe Grade 4 Osteoarthritis Knee - A Case Report.

INTRODUCTION: Tibial plateau fractures are not uncommon. These fractures occur in bimodal age distribution consisting of 8% of all geriatric fractures. They usually occur as a result of low-energy trauma in the elderly. The management options include closed/open reduction and internal fixation (ORIF) using screws and plates. The osteosynthetic treatment options cause malreduction, non-union, implant failure in elderly patients due to osteoporosis and this may lead to post-traumatic arthritis, requiring total knee replacement (TKR) as a secondary procedure later. CASE REPORT: A 76-year-old male patient presented with pain and swelling in the left knee with a history of trauma to the left knee. X-ray of the left knee showed the split fracture of the left lateral tibial condyle with severe Grade 4 osteoarthritis. On examination, tenderness was present over the lateral tibial condyle. We managed with cemented primary TKR using stemmed tibial component. Postoperatively, the patient is having good knee range of motion and having no difficulty in walking and weight-bearing. Functional outcome is good as per Oxford knee score. CONCLUSION: Primary TKR is a viable alternative treatment option compared to ORIF in elderly patients with preexisting osteoarthritis with tibial condyle fractures. It helps in early mobilization, weight-bearing and avoids secondary surgical procedures.

Management of Forearm Deformity by Limb Reconstruction System in Children with Multiple Exostosis - A case Report.

INTRODUCTION: Osteochondroma is the group of benign bone tumours, which are composed of spongy bone covered by a cartilaginous cap. Patients with distal ulnar osteochondromas frequently cause forearm deformities with relative ulnar shortening, wrist joint deviation, and varus bowing. Surgical ulnar lengthening is necessary to restore the carpal balance. CASE REPORT: We report the case of multiple exostosis in a 13-year-old male with the right distal ulna osteochondroma with long-standing and progressive ulnar shortening and radial bowing treated with a limb reconstruction system. Our case is Type I Masada managed with excision of distal ulna osteochondroma and gradual ulnar lengthening without osteotomy of the radius. CONCLUSION: Progressive ulna deformity can lead to increasing pain, joint instability, limited motion, and functional decline. For Type I, Masada ulnar lengthening is necessary, but over correction is inadvisable due to possible ulnocarpal impaction syndrome. As significant remodeling effects on the radius were observed, simultaneous radial correction can be delayed.

Cervical Myelopathy and Lumbar Spondylolisthesis in Elderly Patients with Diffuse Idiopathic Skeletal Hyperostosis (DISH) - A Case Series.

INTRODUCTION: Diffuse idiopathic skeletal hyperostosis (DISH) is a non-inflammatory disease, which causes the ossification of spinal longitudinal ligaments and enthesis leads to stiffness in the affected segment of the spine and neurological deficit due to compression of spinal cord or nerve roots by osteophytes. CASE PRESENTATION: We present three cases of DISH, presented with cervical myelopathy, lumbar spondylolisthesis, and dysphagia. All three patients had neurodeficit and radiological examination showed cord compression, canal stenosis, listhesis, and contiguous ossification in the spine with normal sacroiliac joints. The first patient had cervical myelopathy because of compression of cord by ossified posterior longitudinal ligament, which was managed with posterior laminectomy, decompression, and stabilization. The second patient had L4-L5 listhesis with canal stenosis, which was managed with decompression, instrumentation and fusion (TLIF). The third patient had cervical myelopathy due to C6-C7 listhesis and also had dysphagia because of compression of esophagus by anterior osteophytes, which was managed with removal of anterior osteophytes and anterior discectomy and fusion (ACDF). Postoperatively, all three patients recovered completely with no residual neurodeficit. CONCLUSION: DISH can present in various ways, which depends on the site of involvement in the spine. Early surgical intervention helps in getting a better outcome in patients with neurodeficit and prevents further complications.

Segmental Fibulectomy to Excise the Adherent Distal Tibia Osteochondroma in a Case of Hereditary Multiple Exostosis - A Rare Case Report.

INTRODUCTION: Hereditary multiple exostosis (HME) is an autosomal dominant disorder affecting the skeletal system, which is characterized by multiple osteochondromas in bones arising from osteochondral ossification and leading to skeletal deformities, short stature, soft tissue, and neurovascular compressive symptoms. CASE REPORT: A 10-year-old female a case of HME presented with painless multiple swelling around knees, wrist, and painful varus deformity in the lower third of the right leg. The large exostosis of the right distal tibia was symptomatic and indenting the fibula which required excision along with the segment of the fibula of about 2.5 cm above the syndesmosis adjacent to the exostosis as the mass was adherent to the fibula. CONCLUSION: Although distal tibia osteochondromas are rare, they can lead to deformity of the ankle and loss of function if not managed early and properly. Hence, early detection, proper planning, and management of periarticular distal tibia osteochondromas are essential to prevent the development or progression of the deformity. Segmental fibulectomy is required to remove the adherent osteochondromas completely and to prevent the recurrence and secondary surgical procedures. It is very essential to follow up the patient till the skeletal maturity to identify the delayed presentation and late progression of the ankle deformities.

Incisional Hernia Secondary to Iliac Crest Bone Graft: A Rare Case Report and Review of Literature.

INTRODUCTION: Autologous bone graft is a commonly used procedure in orthopaedic surgery. Autologous bone is used to promote bone healing in fractures and to provide structural support for reconstructive surgery. Iliac bone is one of the common sites for harvesting autologous bone graft. Hernia through an iliac crest defect following bone graft harvesting is a major but very rare complication. CASE REPORT: An 80-year-old female patient operated for left subtrochanteric femur fracture with dynamic condylar screw and iliac bone graft. Ten months after the surgery, the patient came with the complaints of reducible swelling in the left flank over the incision site. On the basis of clinical examination and investigations, the swelling was diagnosed as an incisional hernia from the defect in the iliac bone graft site. CONCLUSION: Hernia through an iliac crest defect following bone graft harvesting is very rare but a major complication. Attention should be paid while harvesting bone graft to avoid this complication.