Outcome of a Simple Novel Technique to Reduce Soft Tissue Complications in Open Tendoachilles Injury: A Series of 20 Patients

Introduction

Open tendoachilles injuries are rare and associated with significant soft tissues complications. The objective of the present study was to assess the clinical outcome and safety of a simple and minimally invasive technique, with a goal to assess if it may help minimise flap and wound related complications in open tendoachilles injuries.

Materials and methods

This prospective study of four years duration included 20 patients with open tendoachilles injuries managed with a simple minimally invasive tunnel technique. The primary outcome variable was occurrence of a major soft tissue complication. The secondary outcome variables included functional outcome measured using AOFAS Ankle hind foot score, re-rupture of tendoachilles and need for revision surgery.

Results

None of the patients in the present series developed a serious soft tissue complication. Based upon the AOFAS hind foot scoring system, good to excellent outcome was achieved in 19 (95%) patients. All the patients were able to perform tip toe walking at six months post-surgery. None of the patients had a re-rupture of the tendoachilles and no patient needed a revision surgery. The complications encountered include thickening of the tendon at the repair site (15%), superficial wound infection (5%), stitch granuloma (5%) and hypertrophic scar (5%).

Conclusion

This technique seems to be promising in reducing the soft tissue complications associated with the surgical management of open tendoachilles injuries. Most patients had a good final clinical outcome. The technique is safe, simple and reproducible. However, further randomised control studies with a larger sample size assessing the technique are recommended.

Molecular phylogeny, pathogenic variability and phytohormone production of Fusarium species associated with bakanae disease of rice in temperate agro-ecosystems

Bakanae is the emerging disease threating the rice cultivation globally. Yield reduction of 4-70% is recorded in different parts of the world. A total of 119 Fusarium isolates were collected from rice plants at different geographical locations and seeds of different rice cultivars. The isolates were evaluated for morphological, biochemical and pathogenic diversity. The amplification of TEF-1α gene was carried out for exploring the species spectrum associated with the cultivated and pre-released rice varieties. The production of gibberellin varied from 0.53 to 2.26 µg/25 ml, while as that of Indole acetic acid varied from 0.60 to 3.15 µg/25 ml among the Fusarium isolates. The phylogenetic analysis identified 5 different species of the genus Fusarium viz. Fusarium fujikuroi, F. proliferatum, F. equiseti, F.oxysporum and F. persicinum after nucleotide blasting in NCBI. Only two Fusarium spp. F. fujikuroi and F. proliferatum were found to be pathogenic under virulence assays of the isolates. The isolates showed a considerable variation in morphological and pathogenic characters. The isolates were divided into different groups based on morphology and pathogenicity tests. The isolates showed a considerable variation in morphology, phytohormone profile and virulence indicative of population diversity. Three species F. equiseti, F.oxysporum and F. persicinum which have not been reported as pathogens of rice in India were found to be associated with bakanae disease of rice, however their pathogenicity could not be established.

Bracka verses Byar's two-stage repair in proximal hypospadias associated with severe chordee: a randomized comparative study

INTRODUCTION

Proximal hypospadias associated with severe chordee represents a major surgical challenge and the debate over its optimal treatment is ongoing. The objective of this study is to compare the outcome of two-stage Bracka and Byar's repair in proximal hypospadias.

MATERIALS AND METHODS

This study was conducted from January 2013 to February 2018 in a tertiary care centre. Patients of hypospadias with severe chordee who required urethral plate transection were included in the study. Patients were randomly divided into two groups by simple randomization method. Bracka staged repair was done in Group A and Byar's staged repair in Group B. Postoperatively complications including graft loss, flap necrosis, fistula formation, meatal stenosis, stricture, diverticula formation, residual chordee were noted in both the groups and compared. p value of < 0.05 was considered statistically significant.

RESULTS

Over a period of 5 years, 74 patients in group A and 68 patients in group B were operated. Fistula occurred in 6.8% and 10.2% in group A and group B, respectively (p value 0.629). Meatal stenosis was seen in 4% in group A and 3% in group B (p value 0.731). Stricture was seen in 1% in each group (p value 0.339). Diverticula formation was seen in 2% in group B and none of the patient in group A (p value 0.960). None of the patient had recurrence of chordee in either group.

CONCLUSION

Bracka and Byar's two-stage repair have similar postoperative outcome and the choice between the two depends up on the surgeon's choice and experience rather than scientific evidence.

Disorders of Sex Development: A 10 Years Experience with 73 Cases from the Kashmir Valley

PURPOSE

To present the clinical data, investigative profile, and management of patients with disorders of sex development (DSD) from the endocrine unit of a tertiary care university hospital.

MATERIALS AND METHODS

This retrospective study included 73 cases of DSD, evaluated and managed at Department of Endocrinology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Kashmir, over a period of 10 years from September 2008 to August 2018.

RESULTS

Twenty-nine patients (39.7%) had 46 XY DSD and twenty-nine patients (39.7%) had 46 XX. Sex chromosome DSD was diagnosed in 15 (20.5%) patients. Of 29 patients with 46 XY DSD, 17 (58.6%) had 5α-reductase type-2 deficiency (5α-RD) and 6 (20.7%) had complete androgen insensitivity syndrome. In our patients with 5α-RD, the history of consanguinity was documented in nine (52.9%) patients. Two patients had testosterone biosynthetic defect and one patient had partial androgen insensitivity syndrome. Of 29 patients with 46 XX DSD, 16 (55.1%) had congenital adrenal hyperplasia (CAH). Of 15 patients with sex chromosome DSD, 7 patients had Turner's syndrome, 7 had Klinefelter's syndrome, and 1 patient had mixed gonadal dysgenesis.

CONCLUSION

In our study, equal number of patients had 46 XY DSD and 46 XX DSD. We are for the first time reporting from India that the most common cause of 46 XY DSD is 5α-RD, whereas CAH is the most common cause of 46 XX DSD as reported previously.

Posterior Reversible Encephalopathy Syndrome after Augmentation Cystoplasty in a Child with Neurogenic Bladder

Posterior reversible encephalopathy syndrome (PRES) or leukoencephalopathy syndrome was introduced into clinical practice in 1996 by Hinchey et al., to describe unique syndrome, clinically expressed during hypertensive and uremic encephalopathy, eclampsia, and immunosuppressive therapy. Hyperperfusion with resultant disruption of the blood–brain barrier results in vasogenic edema, but not infarction, most commonly in the parieto-occipital regions. The severity of this clinical symptom varies. For example, the visual disturbance can manifest as blurred vision, homonymous hemianopsia, or even cortical blindness. Patients may be mildly confused or agitated but can become comatose. Other symptoms less commonly seen include nausea, vomiting, seizures, and brainstem deficits. Chronic kidney disease (CKD) and acute kidney injury are both commonly present in patients with PRES. We are presenting a rare case of neurogenic bladder who developed PRES after augmentation cystoplasty due to underlying CKD.

Buck's fascia repair with glanuloplasty in hypospadias surgery: A simple approach with excellent outcome

BACKGROUND

Hypospadias is a common problem encountered in surgical practice and its repair is challenging because of various complications. Urethro-cutaneous fistula is the most common postoperative complication (incidence of 0-33%). Different types of intermediate protective layers have been used in attempts to decrease UCF formation; however, no single surgical technique is ideal.

OBJECTIVE

The aim of this study was to compare use of dartos fascia and Buck's fascia as intermediate layers in prevention of the formation of UCF.

STUDY DESIGN

This was a prospective, comparative study conducted over a period of 2 years from January 2014 to December 2015. Patients with primary hypospadias without or with mild ventral penile curvature were included in the study. Patients were categorised into two groups, A and B, with alternate patients assigned to each group. Patients in group A underwent Snodgrass repair with urethroplasty by two-layer subepithelial closure and dartos tissue as an intermediate layer. Patients in group B underwent a urethral repair followed by Buck's fascia repair as intermediate layer and glanuloplasty after excision of a triangular skin strip on either side of the urethral plate. Patients were followed at regular intervals for a minimum of 6 months and complications were noted.

RESULTS

Over a period of 2 years, 160 patients were included in the study: 80 patients in group A and 80 patients in group B. The age of patients ranged from 1 year to 4.6 years, with a mean age of 1.8 years. Postoperative complications are listed in the summary table.

DISCUSSION

A protective intermediate layer between the neourethra and the skin can be used to reduce fistula formation. We describe a technique of urethroplasty using Buck's fascia as intermediate layer and glanuloplasty, with excellent results. Buck's fascia over the corpora spongiosum which is deficient ventrally in hypospadias is not completely absent, and can be easily used to cover the neourethra, needs minimal dissection and hence vascularity of tissues is preserved (summary Fig.). We used this Buck's fascia as a second protective layer over the neourethra in an attempt to decrease UCF formation, and compared it with use of dartos fascia. In our study, UCF occurred in 2.5% of patients in the Buck's fascia group and 12.5% of patients in the dartos group, a statistically significant difference. We believe that the native Buck's fascia lateral to spongiosum is a more appropriate, natural, and strong layer to cover the neourethra.

CONCLUSION

Use of Buck's fascia as an intermediate layer along with glanuloplasty is simple and very effective in preventing UCF formation and glanular dehiscence. We recommend the use of Buck's fascia as an intermediate layer to cover the neourethra to reduce incidence of postoperative complications and improve results.

Meckel’s Diverticulum with Multiple Ileal Ulcers as a Source of Massive Gastrointestinal Haemorrhage in a Three Year Old Child

Meckel’s Diverticulum (MD) is a frequent congenital anomaly of small bowel often difficult to diagnose. It is usually asymptomatic and can present as bleeding, obstruction and inflammation. We report a case of MD in a 3 year old male child, diagnosed by 99mTc pertechnetate scan and confirmed on laparotomy. Excised specimen revealed a large MD with multiple ileal ulcers, as a source of massive bleeding per rectum. The clinical features and need for early diagnosis and treatment are discussed. DOI: http://dx.doi.org/10.3126/jnps.v33i3.7802   J. Nepal Paediatr. Soc. 2013;33(3):227-229

Primary Hydatid Cyst Posterior Triangle of Neck in a Child of 10 Years of Age

A case of hydatid cyst involving posterior triangle of neck in a 10 year old male child is reported. Diagnosis was confirmed by MRI. Surgical excision of the cyst was done. Hydatid cyst in posterior triangle should be considered one of the possibilities in evaluating a cystic swelling in this region. DOI: http://dx.doi.org/10.3126/jnps.v32i3.5768 J. Nepal Paediatr. SocVol.32(3) 2012 261-262

Congenital Descending Colonic Stenosis with Perforation of Transverse Colon in a Neonate: A Case Report

Colonic atresia and stenosis are rare causes of intestinal obstruction in the infant. Only 10 cases have been reported in Literature since 1966 and only one late-onset case has been reported in Literature until now. We describe the case of a 3 day old baby presenting with abdominal distension, failure to pass meconium and vomiting. X-ray of the abdomen showed dilated gut loops. Exploratory laparotomy was performed. At the junction of descending and sigmoid colon a stenosis was found, laparotomy also revealed a perforation of transverse colon. Transverse colostomy and a mucous fistula of sigmoid colon was performed after resecting stenosing segment and colon distal to perforation site upto stenosing site. Diagnosis was confirmed on histopathology. Colostomy was close after six weaks with uneventful recovery. Considering both the Literature and our case, congenital colonic stenosis should be considered one of the rare differential diagnoses in a neonate presenting as complete or partial intestinal obstruction. Key words: Colonic Stenosis; Perforation; Obstruction DOI: http://dx.doi.org/10.3126/jnps.v32i1.5446   J. Nepal Paediatr. Soc. Vol.32(1) 2012 73-75  

Congenital duodenal diaphragm and enteroliths: A Unique complication

We report an unusual case of duodenal diaphragm (DD) with “wind-sock” anomaly in a 6-year-old male. The child presented with an acute duodenal obstruction precipitated by multiple pigmented stones completely blocking the duodenum.

Pre-operative manometry of the blind rectal pouch to predict post-operative potential for continence in anorectal malformation

AIM

Despite technical advances in the surgical repair of anorectal malformation, many children suffer post-operative faecal incontinence. There are many ways to assess postoperative continence in these patients but there is no manometry-based method to assess and make predictions pre-operatively. In this pilot study an attempt was made to correlate the pre- and postoperative manometry and electromyography findings in order to use the pre-operative findings to predict the postoperative potential for continence.

METHODS

Ten patients aged 12 to 54 months were subjected to pre-posterior sagittal anorectoplasty manometry by introducing the balloon catheter probe through the distal colostomy into the blind rectal pouch. Electromyography activity in the striated muscle complex was also studied by placing electromyography needles in the midline in the anal dimple. A second study was repeated after posterior sagittal anorectoplasty (PSARP), the probe was introduced into the rectum via the neo-anus and the electromyography needles were placed on either side of the neo-anus. A third study was done, similar to the second study, after colostomy closure along with Kelly's scoring. Results of the three studies were compared.

RESULTS

Pre-posterior sagittal anorectoplasty rectal pouch pressures were in the range of 18.3-93.3 cm H2O and electromyographic activity was between 43.6 and 383.0 microv. Post-posterior sagittal anorectoplasty studies showed anal canal pressure in a similar range of 16.0-95.5 cm H2O and electromyographic activity between 57.0-340.7 microv. The post-colostomy closure anal canal pressures ranged from 22.7 to 99.1 cm H2O and electromyographic activity ranged from 65.7 to 335.7 microv. The Kelly's score ranged from 1-6.

CONCLUSION

Since, the pre-and postoperative manometry findings are quite similar and they correlate well with the surgical outcome, it may be possible to predict such an outcome before PSARP. Also, the pressure profiles and EMG activity in post-operative assessments suggest intact neural pathways despite blind pouch mobilisation.

Congenital pouch colon syndrome: a report of 17 cases

BACKGROUND

Congenital pouch syndrome (CPC) is a rare condition seen in association with anorectal malformation that occurs almost exclusively in northern India. We reviewed cases seen in our institution to study aspects of clinical presentation, diagnosis, embryogenesis and management and raise awareness of this relatively infrequent entity.

PATIENTS AND METHODS

From March 2002 to September 2004, 17 neonates/infants (11 males and 6 females) treated for CPC associated with anorectal malformations included 13 with type IV and 4 with type I CPC. Diagnosis was made by a single large air-fluid level on the infantogram occupying more than 50% of the entire abdominal dimension.

RESULTS

In all patients, the pouch had fistulous communication with the genitourinary system, and there were other associated anomalies as well. Of 13 patients with pouch colon type IV, 11 neonates underwent laparotomy, ligation of the fistula, excision of the colonic pouch and end colostomy as a stage 1 procedure. Subsequently, these patients underwent definitive surgery, i.e. abdominoperineal posterior sagittal anorectoplasty (AP-PSARP), with or without covering colostomy. Two of 4 patients with type 1 CPC underwent laparotomy, ligation of the fistula and colorrhaphy as a first-stage operation before AP-PSARP. In our series, 4 patients were diagnosed intraoperatively and were treated in accordance with their operative findings. Post-operatively, there were no major complications except wound infection in some patients. There was one death that was not related to surgery.

CONCLUSION

There are variants of the anomaly, but the possibility of CPC needs to be kept in mind as a possible association with anorectal malformations.

Manometric evaluation of postoperative patients with anorectal anomalies

AIM

To evaluate the outcome of surgical treatment in patients with anorectal malformations and to correlate the clinical, manometric and electromyographic studies in assessment of postoperative continence in these patients.

METHODS

Forty-one patients operated on for anorectal malformations were evaluated retrospectively. These included 13 patients with low anomalies, 24 with high anomalies, and 4 with congenital pouch colon. Functional results after surgical correction were assessed on clinical basis using the Kelley's scoring system and by anorectal manometry. In addition, the electrical activity of contraction of the external sphincter muscle was studied using electromyography.

RESULTS

There was direct correlation between anal canal pressures and Kelley's score in patients with both high and low anomalies; Kelley's score of 6, 5, 4, 3 and less had pressures ranging between 60-75, 45-59, 30-44, 15-29 and less than 15 cm H2O, respectively. However, the electromyographic activity did not correlate well with Kelley's score.

CONCLUSIONS

Anorectal manometry correlates well with Kelley's scoring system and may be a more objective method of analyzing the results of surgery. Poor correlation between Kelley's score and electromyography may be a reflection of poor compliance with instructions to voluntarily contract the muscles of continence.

Sacrococcygeal teratoma with anorectal malformation

A 7-month-old child presented with imperforate anus, penoscrotal hypospadias and transposition, and a midline mucosa-lined perineal mass. At surgery the mass was found to be supplied by the median sacral artery. It was excised and the anorectal malformation was repaired by posterior sagittal anorectoplasty. Histologically the mass revealed well-differentiated colonic tissue. The final diagnosis was well-differentiated sacrococcygeal teratoma in association with anorectal malformation.

Optical pulse propagation in nonlinear photonic crystals

We present a formalism for optical pulse propagation in nonlinear photonic crystals of arbitrary dimensionality. Using a multiple-scale analysis, we derive the dynamical nonlinear Schrödinger equation obeyed by the envelope function modulating an underlying Bloch function. Effective coefficients appear in that equation characterizing the effects of Kerr nonlinearity, linear gain or loss, and material dispersion. They depend on how the underlying Bloch function "samples" these effects in the photonic crystal, and require for their calculation a specification of these effects throughout the photonic crystal, and the calculated bandstructure of the photonic crystals in the linear, nondispersive limit. We show that wave packets from different bands can experience significantly modified effective material properties.

Thoracoabdominal intestinal duplication with absent inferior vena cava

We report a rare case of thoracoabdominal intestinal duplication with absent inferior vena cava (IVC). The patient was initially explored with a mistaken diagnosis of diaphragmatic hernia on the basis of a chest radiograph and barium meal. However, a subsequent computed tomography scan revealed a mediastinal mass with an air-fluid level, a hugely dilated azygos vein, and an absent IVC. Thoracoabdominal exploration was required to excise the duplication cyst arising from the jejunum. We believe that this is the first report of this association.

Duplications of the alimentary tract in children

This study was conducted to assess the clinical, diagnostic and therapeutic approach in patients with alimentary tract duplication and review the relevant literature. A retrospective analysis of 28 patients of alimentary tract duplications treated between January 1990-December 1999 was carried out. There was a male preponderance (25:3); 71% of the patients were under 2 years of age. The presenting features were related to the anatomic location. Three patients were diagnosed antenatally. Real time ultrasonography and CT scan was undertaken for preoperative evaluation in the majority of patients. In selected cases a 99m-Tc-pertechnetate scan and barium meal follow through examination were also performed. Majority of duplications were in the jejunum and ileum. Twenty percent of our patients had thoracoabdominal duplication as compared to 2% reported in literature. Four patients required to be operated upon in the emergency for related complications. In the remaining patients complete excision of the cyst was done in 21 and only mucosectomy in 3 patients. Because these lesions are rare and can present with a wide range of clinical manifestations or may even be encountered intraoperatively, the appropriate surgical management requires the surgeon to be familiar with the anatomy and clinical characteristics of these lesions.

Retrospective analysis of surgical outcome, symptom changes, and hearing improvement following myringoplasty

This study examines the surgical and audiologic results of myringoplasty and what factors affect these outcomes. It also examines whether patients experience any improvement in their main symptoms following surgery. This was a retrospective analysis of case notes, patient questionnaires, and audiograms of all patients undergoing myringoplasty between 1990 and 1995 at Walsgrave Hospital, Coventry, UK. Overall success of myringoplasty for consultants was 81% and for trainees was 79%, with an overall success rate of 86% in children. Posterior and inferior perforations had a 90% success rate for repair, compared to only 67% of anterior perforations. There was a statistically significant reduction in air-bone gaps following myringoplasty, and the majority of patients felt that their ears were drier and had improved hearing. Myringoplasty is a successful procedure in the hands of consultants and trainees alike. The results are satisfactory enough to justify surgery purely for deafness and also in symptomatic children. There is a strong correlation between surgical success and resolution of symptoms and generally a satisfactory improvement in hearing.

Kikuchi's disease of the neck (histiocytic necrotizing lymphadenitis)

Histocytic necrotizing lymphadenitis (HNL), also known as Kikuchi's disease is a benign self limiting disease of unknown origin. It effects cervical lymph nodes, predominantly in young females. It is well described in the pathology literature, but little is written about this in the ENT literature, as few clinicians are probably aware of this condition. Five cases of cervical Kikuchi's disease are presented with a brief review of the literature.

An unusual foreign body in the larynx: a case report

Inhalation of a foreign body is a serious event. A small proportion of foreign bodies become impacted in the larynx, when urgent recognition is required to prevent disaster. The case of an 18-month-old baby with an impacted artificial finger nail in the larynx is described along with a brief review of the literature.

Tuberculous parotitis: a case report

Tuberculosis of the parotid gland is rare. It cannot be distinguished d form a parotid tumour by clinical examination alone, so surgical exploration has usually been required for diagnosis. We present a case with the same diagnostic dilemma.