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   Table of Contents - Current issue
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April-June 2018
Volume 15 | Issue 2
Page Nos. 49-120

Online since Thursday, July 5, 2018

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EDITORIALS  

Editorial Highly accessed article p. 49
RN Srivastava
DOI:10.4103/am.am_55_18  
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Innovations and new technology in orthopedic and trauma surgery Highly accessed article p. 50
Raju Vaishya
DOI:10.4103/am.am_54_18  
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INFOCUS ARTHROPLASTY - REVIEW ARTICLES Top

Three-dimensional printing for complex orthopedic cases and trauma: A blessing p. 51
Raju Vaishya, Vipul Vijay, Abhishek Vaish, Amit Kumar Agarwal
DOI:10.4103/am.am_51_18  
Three-dimensional (3D) printing technology is penetrating the health-care field at an astonishing rate. In the clinical settings, 3D printing, as a novel additive manufacturing technique, is mainly applied in orthopedics. A group of 3D printing-based patient-specific osteotomy instruments, orthopedic implants, and dental implants have been available for clinical use. The uses of 3D printing have been explored in the field of arthroplasty, sports medicine, spine, pediatric orthopedics, and trauma. The 3D printing technology may provide a chance for the Indian orthopedists and technicians to independently develop innovative medical devices to catch up with their Western counterparts. Its role in patient as well as medical education is also worth exploring. With these myriad applications, 3D printing holds great promise to improve patient as well as surgeon satisfaction in the near future. We discuss the process, applications, and advantages of 3D printing in this review article.
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Knee replacement surgery imbibes aviation technology p. 55
Yash Gulati
DOI:10.4103/am.am_50_18  
Knee replacement is a well-established procedure and has brought relieved to millions of people. Efforts are on to increase the survival replaced joint. If the implant is positioned in perfect position, they will last for a very long time. Gyroscope and accelerometer are used in aviation technology and in our smartphone for locating exact position. This technology has now been used in knee replacement giving perfect positioning of the implant.
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Knee replacement in obese patient p. 57
Yash Gulati
DOI:10.4103/am.am_49_18  
There is no doubt that conservative treatment is preferred by a patient and doctors for knee pain. However, if the patient develops severe arthritis with disabling pain, the only choice left is knee replacement. This applies to patient with average weight as well as obese. The author in this article has given his views on doing knee replacement in obese patient with severe disabling pain. The result of knee replacement in obese patient is very encouraging, and they should not be denied this surgery just because of their weight.
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Chemical thromboprophylaxis in total knee replacement: A critical review p. 59
Raju Vaishya, Amit Kumar Agarwal, Pratik Desai, Vipul Vijay
DOI:10.4103/am.am_27_18  
Venous thromboembolism (VTE) remains a devastating and potentially lethal complication following total knee replacement (TKR) surgery. Studies have shown that 40%–85% of patients develop venographically confirmed deep vein thrombosis after TKA if they do not receive any form of thromboprophylaxis (TP), and approximately 0.1%–1.7% also suffer from fatal complication such as pulmonary embolism (PE). There are various chemical-TP (CTP) recommendations in the literature for patients having TKR surgery. The present review provides the current evidence for CTP in post-TKR surgery. All guidelines provided by the American Academy of Orthopedic Surgeons, American College of Chest Physicians, and National Institute for Health and Clinical Excellence are reviewed and analyzed in detail. Newer oral anticoagulants results are also studied as well, in the quest for an effective and safe VTE prophylaxis after TKR surgery.
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INFOCUS TRAUMA - ORIGINAL ARTICLE Top

A study of open tibia and fibula fractures in fifty patients p. 69
Priyank V Kalaria, Chirag S Kapoor, Paresh P Golwala
DOI:10.4103/am.am_35_17  
Introduction: The incidence of high energy trauma is increasing with increase in traffic. Due to its subcutaneous anatomical location, tibia is vulnerable to direct blow in high energy trauma. Open tibial fractures are true surgical emergencies because of the risk of extensive infection to bone and devitalized soft tissue. The most serious consequence of open tibial fractures is amputation-which usually can be prevented by prompt early surgical intervention. Materials and Methods: Open tibial fractures often are the result of trauma from motor vehicle collisions, farm accidents, falls from heights, or fall of heavy objects. We studied 50 patients with compound tibia-fibula fractures for their mode and grade of injury, methods of stabilization, rate of union, rate of infection, method of soft tissue coverage used, requirement of change of implants, requirement of secondary procedures, amputation & postoperative rehabilitation. Result: Majority of the patients belonged to the age group of 41-50 years with a male preponderance and the commonest mode of injury was road traffic accidents. Bone grafting was required in 38% patients. The average time of union for the patients who required bone grating was 43 weeks and in those who didn't need was 26.12 weeks. Six patients required amputation and two patients died. Conclusion: As the Gustilo-Anderson grade increases, the chances of infection and non-union also increase and outcome is poorer. So we feel that more aggressive treatment has to be carried out for Grade III injury within first 48 hours to achieve optimum outcome.
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INFOCUS TRAUMA - CASE REPORT Top

Posterior fracture dislocation of shoulder with anatomical neck fracture p. 75
Yashwant Singh Tanwar, Atin Jaiswal, Yatinder Kharbanda, Anil Panda
DOI:10.4103/am.am_42_18  
Posterior fracture dislocation of anatomical neck of humerus is a rare injury and possesses challenges in management due to the scarcity of literature and absence of any recommended guidelines for such injuries. Treatment options available are internal fixation and hemiarthroplasty depending on injury pattern, duration of injury, bone stock available for secure fixation, and vascularity of the head fragment. We present a case report of posterior fracture dislocation of anatomical neck humerus in a 35-year-old male patient treated by open reduction and internal fixation by deltopectoral approach. This case report is unique as the fixation method (Herbert screws) used in this case resulted in a good functional outcome and has not been described previously in literature for this injury pattern.
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REVIEW ARTICLE Top

A review of sports-related injuries: Head to toe spectrum p. 79
Reddy Ravikanth, Jyotin Kshitiz Singh, Anegh Pavithran, Anoop Pilar, Anush Nagotu, Parthasarathi Sarkar, S Sandeep, Denver Steven Pinto, Mathew David, John Joshy, Manu Jacob Abraham, Ashok Alapati, Robert Patrick Selvam, Sunil Mathew
DOI:10.4103/am.am_39_18  
All sports come with a risk of injury, and in general, the more contact involved in the sports, the higher the risk of a more significant or traumatic injury. The most frequent types of sports injuries are sprains (ligament injuries), strains (muscle injuries), and stress fractures (bone injuries). In sports medicine, a catastrophic injury is defined as severe trauma to the human head, spine, or brain. Concussions in sports became a major issue in the 2000s as evidence connected repeated concussions and subconcussive hits with chronic traumatic encephalopathy and increased suicide risk. Overuse and repetitive stress injury problems associated with sports include jumper's knee, tennis elbow, and tendinosis. In this review article, we have made an attempt to describe the head to toe spectrum of sports-related injuries including traumatic injuries of the head and face, extremity injuries, soft-tissue injuries, and contact sports-related injuries.
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ORIGINAL ARTICLES Top

Extranodal nasofacial natural Killer/T-cell lymphoma: Our experiences at a tertiary care hospital of Eastern India p. 88
Santosh Kumar Swain, Mahesh Chandra Sahu, Manash Ranjan Baisakh
DOI:10.4103/am.am_10_18  
Background: Natural killer (NK)/T-cell lymphoma is a rare nonHodgkin's lymphoma originating in the nasofacial area including nasal cavity and paranasal sinuses. NK/T-cell lymphoma has an aggressive clinical course with unfavorable prognosis. Objective: Analysis of the etiopathogenesis, clinical profile, diagnostic difficulties, treatment options, and outcome in patients with NK/T-cell lymphoma of the sinonasal area. Materials and Methods: This is a retrospective observational study conducted over the period January 2012–December 2017. Age, gender, clinical presentation, histological diagnosis, radiological presentations, and immunophenotype characteristics were taken into consideration. Results: There were six patients, i.e., four males and two females with the common symptom were nasal obstruction (78%), nasal discharge (68%), and nasal bleeding (58%). The diagnosis was established by histopathological examination and immunohistochemistry. Computed tomography scan was done in all patients. Five patients were treated with chemoradiation one patient died after 6 months of treatment. Conclusion: Nasofacial NK/T-cell lymphoma is a rare clinical entity. Diagnosis is based on histopathological examination, immunophenotype, and molecular characteristics. It is an aggressive lymphoma which needs multidisciplinary approach. Its prognosis is poor. Optimal management of NK/T-cell lymphoma in the nasofacial area should be based on multidisciplinary approach among best outcome. Practicing physicians need to be aware of this nonspecific presentation of this lesion.
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Comparative burdens of atherosclerosis in rural and urban communities in South India: Insights from the Kovai Medical Center and Hospital-noncommunicable disease studies p. 94
Ganesh Veerasekar, Krishnan Swaminathan, Mohanraj Sundaresan, Chitra Ramanathan, Ganesan Velmurugan, Thomas Alexander, Nalla G Palaniswami, Mathew Cherian
DOI:10.4103/am.am_13_18  
Aim: The aim of this study was to describe the distribution and comparison of carotid intima thickness in two completely different demographics in South India. Materials and Methods: Data were obtained from 865 participants in rural Nallampatti and 1081 participants from urban Kalapatti in the state of Tamil Nadu. Local ethics committee approval and written and informed consent were obtained from all participants. Carotid intima thickness was measured on all participants using high-resolution B-mode ultrasound. Atherosclerosis was defined as a carotid intima-media thickness of ≥1 mm. Results: The prevalence of atherosclerosis was 10.3% in rural Nallampatti compared to 7.8% in urban Kalapatti. On binary logistic regression analysis, diabetes and hypertension were associated with atherosclerosis in rural areas, but this significance disappeared after adjustment for confounding factors. In urban areas, diabetes appeared to be significantly associated with atherosclerosis even after adjustment for confounding factors. Conclusion: Our data suggest a surprisingly increased prevalence of atherosclerosis in a rural farming population even though traditional risk factors for atherosclerosis such as diabetes and hypertension did not show a significant association after adjustment for confounding factors. If confirmed, this provides a rationale to do large-scale studies to explore the role of nontraditional risk factors in rural India that could have an impact on atherosclerosis and cardiovascular disease.
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CASE REPORTS Top

Superior mesenteric artery thrombosis: A rare complication after pancreaticoduodenectomy p. 99
Satyaprakash Jindal, GK Adithya, Varun Madaan, Vivek Tandon, Deepak Govil
DOI:10.4103/am.am_11_18  
Pancreaticoduodenectomy (PD) is the treatment of choice for malignant and some benign diseases of the pancreas and periampullary region. Common complications after PD include delayed gastric emptying, pancreatic fistula, anastomotic leak, and intra-abdominal collection. Postoperative medical complications include arrhythmia, renal failure, pulmonary complications, urinary tract infection, and deep vein thrombosis. Superior mesenteric artery (SMA) thrombosis is rarely been reported after PD. SMA thrombosis is difficult to diagnose in postoperative period due to nonspecific symptoms and associated with high mortality rate up to 80%–90%. The patient was a 68-year-old female with lower end cholangiocarcinoma without any other comorbidity. She underwent PD without any intraoperative complications. Postoperatively, she developed SMA thrombosis. Unfortunately, the patient could not be salvaged, and she succumbs to death.
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Successful myomectomy in early pregnancy for a large asymptomatic uterine myoma p. 102
Juhul Patel, Sumana Manohar
DOI:10.4103/am.am_21_18  
The decision of myomectomy is not usually taken by OBG specialist for uterine fibroids during pregnancy because of its complications which become life threatening at times. This is why it is generally delayed until after delivery. The current case was a large, asymptomatic subserous uterine myoma of 17 cm diagnosed during pregnancy by ultrasound and successfully managed by antepartum myomectomy retaining the fetus alive in utero at 13–14 weeks' gestation. This case demonstrates that myomectomy during pregnancy in special circumstances in selected cases to prevent forthcoming events adversely affecting mother and fetus can be considered.
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Effect of sleep counseling and parental education for management of sleep-related problems in special need children: A case study p. 104
Meenakshi Khorana Saha, Anjan Bhattacharya
DOI:10.4103/am.am_24_18  
The aim of this case study is to describe how parental sleep counseling and education can help to manage children from developing sleep disorder and improve the quality of sleep. In this case study, semi-structured behavioral intervention has been used. Children and parents of children with special needs and sleep-related difficulties were picked up from detailed developmental history taken in our center as a routine and were referred to the developmental psychologist for sleep counseling by the developmental pediatrician. The child already had a diagnosis of Cornelia de Lange Syndrome, autism spectrum disorder (ASD), profound global developmental delay, and attention deficit hyperactivity disorder (ADHD). Sleep disorders are commonly associated with Cornelia de Lange Syndrome, ASD, and ADHD. Parents were given a semi-structured sleep counseling session and were advised to sit for a review after 2 weeks post the intervention/counseling. The major disturbances in sleep were significantly reduced along with that parents reported child's behavioral issues have improved and are more attentive now. Our case study highlights that even though a single parental education and counseling session, many of the sleep-related problems can be managed successfully enough preventing downward spiraling. This is important knowledge since sleep disorders are common in neurodevelopmental disorders described, and our simple intervention strategy seems to alleviate a number of these problems. Thus, the role of parental education and counseling can be a potentially useful tool in the management of children with special needs, some of which may be even in the form of a single semi-structured session only.
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Partial molar pregnancy at uncommon site as intramural molar ectopic pregnancy p. 107
Vandana Gite, Maruti Dhakane
DOI:10.4103/am.am_28_18  
Intramural partial molar ectopic pregnancy is among the rarest sites of molar changes, may mimic intramural myoma and seriously threaten maternal life. The diagnosis and treatment of this unusual site molar ectopic pregnancy present a clinical challenge. We report the case of a partial molar intramural ectopic pregnancy in a 44-year-old patient presented with multiple intramural myoma and confirmed on final histopathology examination.
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Anesthetic challenges in a cardiac patient undergoing noncardiac surgery p. 110
Vaishali S Badge, Pankaj Patil
DOI:10.4103/am.am_29_18  
We report a case of a patient with coronary artery disease (ejection fraction [EF] = 20%) with automatic implantable cardioverter-defibrillator (AICD) implanted, hypertension, diabetes mellitus, chronic kidney disease, and peripheral vascular disease for vitrectomy. This patient was diagnosed as a case of bilateral retinal detachment with proliferative vitreoretinopathy Grade III. He developed hyphema in the right eye due to long-standing uncontrolled diabetes with complete loss of vision. This case was very complex to manage as the patient had comorbidities with low EF. The case was done on an urgent basis thinking that the patient might lose eyesight if he is not operated quickly. A 55-year-old male presented with complaints of breathlessness, chest discomfort, and cough and diagnosed as left ventricular failure with cardiogenic shock. He complained of sudden onset loss of vision after 2 days of admission while in Intensive Care Unit. This patient had vitreous hemorrhage due to end-stage diabetic disease. The patient was suffering from triple vessel coronary artery disease (EF = 20%, regional wall motion abnormalities), AICD in situ, diabetes, hypertension since 10 years, and peripheral vascular disease with peripheral plasty. He was a chronic alcoholic and smoker as well. His renal function tests showed serum creatinine 1.8 mg/dl. Patient was planned for right eye vitrectomy to save vision. The patient was operated without any complications.
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Migraine-related vertigo in an elderly male p. 112
Santosh Kumar Swain, Sidhartha Mohanty, Mahesh Chandra Sahu
DOI:10.4103/am.am_30_18  
Migraine-related vertigo (MRV) is a distinct and common clinical entity which accounts for major vestibular symptoms among the adult and children. The pathophysiology for MRV is not completely understood and is always a puzzling dilemma. Patients often present with vertigo, headache, photophobia, and phonophobia. The clinical examinations and laboratory investigations are usually within normal limit. The diagnosis of MRV is often challenging as there are no confirmatory tests available. The treatment is often similar to the migraine headache. It is always a challenging disease for the clinician and often creates a puzzle for diagnosis and treatment. We are presenting a case of MRV in an elderly person which is rare in clinical practice.
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Mucinous cystadenoma of the appendix p. 116
Oktay Aydin, Faruk Pehlivanli, Gökhan Karaca, Gülçin Aydin, İsmail Özler, Çagatay Erden Daphan
DOI:10.4103/am.am_32_18  
Mucocele is a rare condition caused by the collection of mucus with in the lumen of the appendix. It accounts for 0.2%–0.3% of patients undergoing appendectomy procedure. In this article, we describe the case of a 53-year-old female patient who presented with pain in the right lower quadrant of the abdomen and a clinical pattern likely to a appendicitis. The patient was treated with appendectomy while avoiding perforation of the cyst. The histological specimen revealed mucinous cystadenoma with clear resection lines. The patient was discharged on the second day after surgery without any complications.
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A rare cause of retroperitoneal mass: Castleman's disease p. 118
Satyaprakash Jindal, GK Adithya, Varun Madaan, Rigved Gupta, Sandeep Vohra, Vivek Tandon, Deepak Govil
DOI:10.4103/am.am_35_18  
Castleman's disease is a rare lymphoproliferative disorder. It is a pathological diagnosis and rarely diagnosed before surgery. Presentation of disease may be unicentric or multicentric. We are reporting a case of unicentric Castleman's disease presenting as an asymptomatic retroperitoneal mass. The ultrasound-guided aspiration of the lesion was inconclusive. Complete en bloc resection was done and was reported as Castleman's disease after pathological analysis. Pathogenesis of Castleman's disease is not well defined, but interleukin-6 and vascular endothelial growth factor are thought to have a significant role. Two pathological variants have been described as follows: hyaline vascular and plasma cell type. The treatment of unicentric disease is complete resection. Multicentric disease may be associated with human immunodeficiency virus and human herpes virus-8 infection and requires systemic treatment in the form of steroids, chemotherapy, radiotherapy, or immunotherapy.
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