Search

Background: Nowadays, Wide Awake Local Anesthesia No Tourniquet (WALANT) technique has gained popularity among surgeons because of its use in variety of surgical procedures because it provides excellent hemostasis, eliminating the need of tourniquet, sedation and the risk and cost of general anesthesia. Aims and Objective: In this study, we wanted to evaluate its efficacy and the experiences of the patients and surgeons in different hand surgeries. Materials and Methods: We had 108 patients who underwent various hand surgeries under WALANT technique. Patients and surgeons were requested to fill a questionnaire after the procedure. The procedure was evaluated in terms of the pain compared to a dental procedure, duration of the anesthesia, amount of bleeding and patients’ satisfaction. Results: The mean age of our patients was 42.7 years. A variety of hand surgery was performed in our study. The mean local anaesthetic volume used was 16.5 ml. The Tang grading system was used to evaluate the levels of surgeon’s experience; 75% of surgeons were a Level 2, 18% Level 3 and 7% Level 4. Sixty-four patients experienced WALANT to be less than, 30 patients equivalent to and 8 had more pain compared to a dental procedure. There was a significant correlation between volume of local anesthetic used, duration of surgery and number of procedural components repaired. Both pain and anxiety levels were significantly less intra-operatively and postoperatively as compared to the level at the time of injection. Eighty-seven patients considered it to be better than expected, and would prefer it in the future in case they have to undergo surgery. Conclusion: We observed that our patients were satisfied with their experience on WALANT technique and the surgical procedures, and we recommend the use of this for a variety of hand surgery procedures.

Background: The incidence of peritrochanteric fractures are increasing worldwide. Early mobilization in these fractures prevents from other medical complications. There are many methods of treatment but the ideal method should be less invasive procedure, intramedullary device and stable fixation of fracture. Proximal femoral nail antirotation (PFNA) is biomechanically considered one of the most effective methods of treatment with promising results. Aims and Objectives: The aim of our study was to evaluate the clinical and radiological outcomes in patient who were treated with PFNA in peritrochanteric fracture. Materials and Methods: This study was a prospective study which included 37 patients, conducted in Manipal Teaching Hospital from 1st October 2019 to 30th September 2020. All the patients were clinically evaluated and detail history was obtained. After the anaesthesia clearance the patients were operated. Operating time, intraoperative blood loss and complications were noted. Postoperatively the duration of hospital stay, time of partial and full weight bearing, time for radiological union and complications were noted. At the final follow up Harris Hip Score was used for functional outcome. Results: The mean age of the patient in this study was 64 years (45-88 years). The average time to complete the surgery was 62.49 minutes (45-75 minutes) and the average blood loss was 129.32 ml (65-210 ml). Partial weight bearing was started at the mean time of 8.57 weeks (6-12 weeks) whereas full weight bearing was done at the mean of 14.43 weeks (10-20 weeks). Fracture union was seen at the average of 11.41 weeks (8-18 weeks). The mean Harris Hip score at final follow up was 84.73 (65.8-95.0) with the functional status of 35.1% excellent result, 45.9% good, 13.5% fair and 5.4% poor. Conclusion: Proximal femoral nail antirotation in peritrochanteric fracture is a good method of fixation. The procedure is easy with reduced operative time and radiation exposure. Since this is minimally invasive procedure the blood loss is very less compared to DHS or plate fixation. The patient could be mobilized early from the bed that reduced the complication of immobilization. So we strongly recommend using PFNA for fixation of peritrochanteric fracture of hip.

Background: Lateral condyle fracture of the distal humerus is the second most common injury around the elbow. Aims and Objective: The purpose of the study was to compare Kirschner wires (K-wire) and Cannulated cancellous (CC) screw for internal fixation of displaced lateral humeral condyle fracture in children. Materials and Methods: Forty-six patients with a displaced lateral condyle fracture of humerus were included in the study. Patients were treated with open reduction and internal fixation either with two 1.8mm K-wires or one 4mm CC screw. Fractures were classified according to Milch classification and clinical outcomes were evaluated according to criteria of Hardacre et al. Results: There were 23 patients in each group with the mean age of 6.57 years (range 2 to 12 years). Milch type II was common (n= 34) than Milch type I (n=12). Fracture union was observed at mean 4.13 weeks in the CC screw and 4.61 weeks in K-wire group.(p value = 0.026). On an average the CC screws were removed at 13.57 weeks and K-wires were at 4.57 weeks. The mean follow-up was 13.83 months in CC screw and 12.52 months K-wire group. Three patients (6.5%) had superficial pin site infection and 2 patient (4.3%) had lateral condyle prominence in the K-wire group and only one lateral condyle prominence (2.2%) was observed in the CC screw group. According to the Hardacre et.al criteria CC screw group were excellent in 20 (87%) and good in 3 (13%) patients whereas 13 (56.5%) excellent and 10 (43.5%) good results were found in the K-wire group. (p value = 0.022). Conclusion: Open reduction and internal fixation with either K-wires or cannulated cancellous screw for displaced lateral condyle fracture of humerus are both effective treatment methods but screw fixation provides absolute stability at the fracture site enhancing the fracture healing, reduces the probability of lateral prominence and allows early range of motion and activity in the affected elbow.

Background: Fracture clavicle is a common fracture around the shoulder joint accounting about 2.6% of all fracture and 44% in shoulder region. Mid shaft clavicle fracture accounts about 81% of total clavicle fracture. Open reduction and plate fixation is a good treatment method for displaced mid shaft clavicle fracture with benefit of early pain free movement of shoulder joint and early return to work. The anatomical contoured clavicular plate maintains mechanical strength and has less soft tissue complications. Aims and Objective: The aim of the study was to evaluate the clinical and radiological outcome, time for fracture union and complications in midshaft clavicle fracture managed with anatomical contoured clavicularlocking plate. Material and Methods: This study was done in Manipal Teaching Hospital, Pokhara, Nepal.There were a total of 30 patients (19 male and 11 female) who had displaced mid shaft fracture. All patients underwent plate osteosynthesis with anatomical contoured locking plate. The patients were followed up at 3 weeks, 6 weeks, 3 month and 6 months’ time. Results: There were 30 patients among whom; one patient had bilateral clavicle fracture. The mean age of the patient was 37.19 (11.96) years. The mean time for clinical and radiological union was 8.77 (1.17) weeks and 17.03 (3.06) weeks. All patients in our study had union of fracture with only one patient having superficial surgical site infection. Conclusion: Open reduction and plate fixation is a good option for displaced mid shaft clavicle fracture which help the patient for early pain-free movement of shoulder. Use of anatomical contoured clavicle plate provides fixation of clavicle to its normal contour and provides better fixation and stability.

Background: Distal radius fractures are one of the commonest injuries only after clavicle fractures. These fractures poses challenges to the treating surgeons as a result of which these fractures are sometime treated unacceptably and leads to poor outcome. Among various treatment options for these fractures wrist sparing Cobra external fixator is one of the options with an impressive stability and outstanding functional outcomes.Aims and Objectives: To determine whether this system can achieve adequate reduction of a variety of DRF, is able to maintain reduction despite hand and wrist movements, whether it compromises hand and wrist functions and leads to long term problems.Materials and Methods: From July 1, 2016 - June 30, 2017, all skeletally matured patients with acute distal radius fractures (AO-A2, B1, C1, C2) were adequately reduced and fixed with Cobra ex-fix. Immediately post-op patients were encouraged to start range of motion of the wrist as the pain decreased. The patients were followed up in 2,4 and 8 weeks and were analyzed clinically, radiologically, their functional outcomes and any complications.Results: Twenty-two patients were included in our study. Nine were males and 13 were females. Using the AO classification, 15 were classified as A2, 2 were B1, 3 were C1, and 2 were C2. The mean number of weeks the cobra fixator was maintained was 5.3 weeks. The Cobra ex-fix was able to achieve excellent maintenance of radial height and radial inclination and good maintenance of dorsal tilt. Recovery of functional activities according to Gartland and Werley’s functional scoring system was good to excellent in all patients at 8 weeks follow-up.Conclusion: The Cobra external fixation system is an outstanding device for use in fractures of the distal radius. It achieves superior anatomic correction and is dependable in maintaining fracture reduction even with hand and wrist use.Asian Journal of Medical Sciences Vol.9(6) 2018 84-89

Background: The treatment of proximal and distal diametaphysealtibial fractures remains controversial. This study was performed to evaluate the results of Locking compression plate using MIPO technique in the management of proximal and distal diametaphysealtibial fracture.Aims and Objective: To analyse and observe the result of management of metaphyseal fractures of tibia with respect to operative technique, stability of fixation, union of fracture, post-operative range of motion and complication. Materials and Methods: The study was prospective study. Forty two patients who sustained fractures of proximal and distal dia-metaphyseal tibial fractures with or without articular involvement were included in the study and treated by employing the concept of Minimally invasive plate osteosynthesis during period of August 2015 to December 2017 and followed up at regular interval with minimum six months to thirty months. Intervention: Surgical reduction and fixation of fracture using proximal and distal anatomical locking compression plate followed by rehabilitation. Main outcome measure: Radiological outcome, perioperative and postoperative complication, postoperative alignment, range of motion.Results: All fractures got united with the average duration of 22.7 weeks for proximal metadiaphyseal tibia and 19.9 weeks for distal diametaphysealtibia. There were 3 delayed union cases which got united without any surgical intervention. Deep peroneal nerve palsy was seen in 2 cases with proximal tibia fracture treated with longer plate. 2 cases of superficial infection and one deep infection seen with proximal diametaphyseal fracture and 2 superficial infection with one case of wound dehiscence and implant prominent seen with distal diametaphyseal tibia fracture. No malalignment or angulation of more than 10 degree occurred in any plane for both proximal and distal diametaphyseal fractures.Conclusion: MIPO provides stable fixation with excellent union rate with minimal complication for both proximal and distal diametadiaphysealtibial fracture.Asian Journal of Medical Sciences Vol.9(6) 2018 76-83

Background: Distal tibia fracture is one of the difficult fractures to manage. There are many treatment options from conservative management to operative management. Each treatment methods have its advantages and disadvantages. Minimally invasive percutaneous osteosynthesis (MIPO) in distal tibia fracture has better outcome due to the advantages of minimal soft tissue dissection, preservation of periosteum and fracture hematoma. There is indirect reduction of fracture with correction of axial and rotation malalingement.Aims and Objective: The aim of the current study was to evaluate the functional and clinical outcome of distal tibia fracture treated with distal tibia anatomical contoured plate by MIPO technique.Materials and Methods: This was a prospective study that included 56 patients of which 37 were males. 31 patients had right sided distal tibia fracture. The most common mechanisms of injuries were road traffic accidents and fall injury. There was 6 cases of type I open fracture and 3 cases of type II open fracture. The patients were followed up at2 weeks, 6 weeks, 3 months, 6 month and 12 months’ time.Result: The mean age of the patients was 45.89 years. The mean time for partial and full weight bearing was 7.29 weeks and 14.29 weeks respectively. Radiological union was seen at 17.75 weeks. There was no case of nonunion or delayed union. The most common complication was ankle stiffness (5/56). Conclusion: MIPO is a good treatment option for unstable distal tibia fracture because of minimal soft tissue dissection and preservation of periosteum and fracture hematoma.Asian Journal of Medical Sciences Vol.9(5) 2018 73-76

Background: Distal Radius Fractures (DRF) are common fractures with variety of complications if treated inadequately. Among them, Distal Radio-Ulnar Joint (DRUJ) instability is one of the common residual disabilities leading to chronic and persistent subluxation or dislocation of the DRUJ which causes arthritis, pain and limitation of the hand functions. Aims and Objectives: This study aims to identify the factors either clinical of radiographic, indicative of DRUJ instability patients in acute DRF which may help the orthopedic surgeons to correctly diagnose and allow proper treatment.Materials and Methods: All patients from Aug 1, 2016-July 31, 2017 with acute DRF who were treated at Manipal Teaching Hospital were examined and evaluated for DRUJ instability. The demographic, clinical and radiological parameters of all the patients were analyzed and compared with those with stable DRUJ. Preoperatively all the fractures were classified using AO classification. Based on the classification, the association of fracture comminution, and intra-articular involvement with DRUJ instability, as well as its relation to the osteoporotic age was analyzed. Associated ulna styloid fracture and sigmoid notch involvement if present was noted with its size and displacement.Results: Out of 74 wrists, there were 30 males and 44 females, with a mean age of 44 (range 18-79). Most of the females (72%, n=32/44) sustained low energy trauma, while most of the males (77%, n=23/30) sustained high energy trauma. Irrespective of the sex, it was noted that DRUJ instability was significantly higher in males (p 2mm and 28 (80%) was undisplaced.Conclusion: Factors associated with DRUJ instability in DRF were young male patients, high energy trauma, displaced ulnar styloid base fractures, sigmoid notch involvement, AO type C.Asian Journal of Medical Sciences Vol.9(5) 2018 62-66

Objective: The objective of this study was to compare the outcome of intramedullary nailing to plating for both-bone forearm fractures in early and mid-adolescent age group. Design: This was a retrospective, comparative study. Methods: A total of 76 skeletally immature adolescents with a mean age of 12.5 years; range 10–17 years treated operatively for both-bone forearm fractures from 2012 to 2017. Patient with fixation of only one bone, hybrid fixation, bilateral forearm injuries, previous forearm injuries, Galeazzi, Monteggia and radial head fracture, underlying bone pathology, and fracture associated with neurovascular injury were excluded from the study. Intervention: Forty-six patients (mean age, 12.33 years) underwent intramedullary nailing and 30 patients (mean age, 12.77 years) underwent plating. Main Outcome Measure: Time to fracture union, magnitude and location of maximum radial bow (both as a percentage of radial length), forearm rotation, and complications. Results: The mean union time for nail was 7.86 weeks and for the plate was 7.33 weeks which showed no statistically significant differences between the groups for the union of fracture at 3 months (P = 0.780). There were no significant differences between the two groups for the value of maximum radial bow magnitude and its location (P = 0.60). The maximum radial bow magnitude was significantly different from normative values in both groups (P = 0.003 nail and P = 0.001 plate); however, no statistically significant differences for the location of maximum radial bow (P = 0.370 nail and P = 0.632 plate). There were no residual angulation, displacement, or malrotation. Nearly 88% of patients in both groups regained full forearm rotation. There were one major complication and seven minor complications in the intramedullary nailing group and one major complication in plating group. Conclusion: Based on similar functional and radiographic outcomes, intramedullary nail and plate fixation in early and mid-adolescent age group patients for both-bone forearm diaphyseal fractures are equally effective treatment.

Background: Intramedullary interlocking nail is commonly accepted standard treatment in fracture shaft of femur. Its cost, technique, necessity of fracture table and image intensifier make it difficult in using for such cases where facilities are not available. In developing countries like Nepal open Kuntscher nailing is still an option for treating fracture shaft of femur. Its results and outcomes are comparable to that of intramedullary interlocking nails.Aims and Objectives: This study was undertaken to evaluate the outcome of Kuntscher nailing in fracture shaft of femur with regards to operative duration, union, infection, limb-length, and range of motion of knee and hip joints.Materials and Methods: This retrospective study included seventy-six patients with fracture shaft of femur. This study was conducted for a period from December 2014 to December 2017. The study outcome was assessed in terms of operative time duration, union, infection, limb-length, and range of motion of knee and hip joints.Results: Seventy six patients with fracture shaft of femur with mean age of 32.36 years ranging from 15 to 65 years were included in the study. Operation duration ranges from 55 to 95 minutes, with average healing time of 17 weeks. Wound infection was seen in 5% cases, with not much limb length discrepancy and knee range of motion 100 -135 degree achieved by the end of 9 months in more than 95 % cases. Conclusion: Kuntscher nail is still a relevant option for treatment of fracture shaft of femur with good functional and clinical outcome.Asian Journal of Medical Sciences Vol.9(6) 2018 90-92

Introduction: Trigger Finger (TF) is frequently encountered problem by an orthopaedic surgeon which, if not managed, causes pain, discomfort and disability in hand function. Patient presents with pain at Metacarpo-phalangeal (MCP) or Proximal Inter-phalangeal (PIP) joint or clicking of the thumb, ring or long fingers. It is commonly caused by mismatch between the flexor sheath and the flexor tendon, which may be because of enlargement of the tendon or thickening of the fibrous flexor sheath of the first annular pulley. Aim: To compare percutaneous release with that of open surgery in terms of its effectiveness in releasing the A1 pulley and their complications and also to determine if the results are comparable with those observed in other studies. Materials and Methods: From January to December 2016, 56 patients presented to Manipal Teaching Hospital, Kaski, Nepal, with diagnosis of TF, were blindly randomised to two groups with 28 patients and 30 fingers each. One group was treated with percutaneous release while the other group was treated with open release. All the patients were followed up in OPD on two days, two weeks and eight weeks and were evaluated for postoperative pain, presence of infection, persistence or recurrence of triggering, presence of digital nerve injury and finger range of motion. Results: There was no statistical difference between the two groups with regard to the above parameters. Although, there was a trend to earlier return to full activities of daily living and full range of motion in the percutaneous group and also the complication rates were low and without any surgical scar, the difference was insignificant compared to the open release group. Conclusion: The present study recommend that both the open and percutaneous release is equally effective in treating TFs. Depending on the surgeon’s preference and experience the surgeon may opt to choose any of the surgical procedure for his patients.

Introduction: Low back pain is characterized by a range of symptoms which include pain, muscle tension or stiffness, and is localized between the shoulder blades and the folds of the buttocks, with or without spreading to the legs. Non-Steroidal Anti Inflammatory Drugs (NSAIDs) are the drugs of choice which provide an analgesic effect for acute low back pain. Aim: To study the factors affecting low back pain, efficacy and safety of different non-steroidal anti-inflammatory drugs (aceclofenac, diclofenac, naproxen and nimesulide) in low back pain. Methodology: Data collection form and numeric pain rating scale were used as study tools for studying patients’ demographies and severities of pain respectively. Patients prescribed with aceclofenac 100 mg , diclofenac 100 mg, naproxen 500 mg and nimesulide 100 mg for acute low back pain at Orthopaedics Outpatients Department of Manipal Teaching Hospital, Nepal, were enrolled in this study. The decrease in pain scores was recorded on 5th and 10th days of follow-up and pain scores were calculated. Descriptive statistics and Kruskal Wallis non parametric test were used for analysis. Results: Among 150 patients, 67.3% were females (n=101). Low back pain was more prevalent (24.7%) in age-group of 59-68 years and a positive correlation was seen. Similarly, low back pain was found to be high among people involved in agriculture, heavy weight lifters and non smokers. The decrease in average pain scores was more in the patients treated with aceclofenac (4.83 ± 0.537), followed by that in those who were treated with naproxen (4.13 ± 0.067) and diclofenac (3.84 ± 0.086). The decrease in pain scores was found to be lowest among patients who were treated with nimesulide (2.11 ± 0.148). Nimesulide presented more number of side-effects than the comparative drugs. Conclusion: Different factors affect low back pain, such as age, gender, personal habit, posture, occupation, weight lifting. Aceclofenac showed greater decrease in pain scores with lesser number of side-effects.

Background: Anterior dislocation of shoulder account for more than 50% of dislocation that occur in our body. Several methods of reduction are described in literature which are painful or require anaesthesia. Aim: This study was undertaken to compare the External Rotation Method and Milch method for reduction of anterior dislocation of shoulder. Materials and Methods: There were total 52 patients with anterior dislocation of shoulder, distributed randomly into 2 groups. Reduction was done by External Rotation Method and Milch Method for each group and their outcome were compared. Statistical Analysis: The data was analysed by using SPSS for Windows (version 16.0) by applying the Chi-Square test. p-values of