Neglected medial swivel dislocation of talonavicular joint with calcaneus,cuboid and 5th metatarsal fractures – A case report

Talonavicular dislocation is a rare injury. Isolated medial or lateral talonavicular dislocations without disruption of subtalar joint are known as medial or lateral swivel dislocations respectively, both being extremely rare. We describe a rare case of neglected medial swivel dislocation with concomitant calcaneus, cuboid and 5th metatarsal fracture, which was managed with open reduction and fixation of talonavicular joint with k-wires and an external distractor. At 1 year follow up the patient was mobilizing full weight bearing without any pain or deformity, the radiographs showing well located talonavicular joint and healed calcaneus, cuboid and 5th metatarsal fractures. This is the first reported case of medial swivel talonavicular dislocation with associated calcaneum, cuboid and 5th metatarsal fracture to the best of our knowledge. This case report highlights the importance of maintaining high level of suspicion for diagnosing midfoot injuries in a polytraumatized patient as well as need of accurate and timely reduction of dislocation for good functional outcome.Level of clinical evidenceLevel 4.     

Management of Neglected Upper Cervical Spine Injuries

BackgroundInjuries involving upper cervical spine are serious and fatal injuries which are associated with alteration of normal occipital–cervical anatomy. These injuries may result in permanent neurologic deficits or neck deformity if not treated in a timely and appropriate manner.ObjectiveTo evaluate the outcomes of neglected upper cervical spine injuries treated by various methods.Study designRetrospective study.Materials and methodsTwelve patients attending ER or OPD with a history of neck trauma and who were diagnosed with fractures and fracture dislocations C1 and C2 were included in the study. Fresh injuries sustained within a week were excluded from study. The outcomes were measured in terms of improvement in VAS, ODI Scores and correction of the neck deformity. Surgical parameters like duration of surgery and blood loss were also observed.ResultsEleven males and one female. The mean age was 40.9 ± 16.9 (07–67 years). Eleven patients underwent posterior instrumentation, while one patient was treated anteriorly. The mean delay in presentation was 28 ± 8.67 days (15–42 days). The mean duration of surgery was 188.3 ± 34.35 min (120–240 min), average blood loss was 350 ± 111.8 ml (150–600 ml). The mean VAS improved from 8.45 ± 0.89 to 3.9 ± 0.51 (p < 0.05). The mean ODI Pre-operatively was 88.45 ± 5.89 which improved to 31.9 ± 4.01 (p < 0.05). The neck deformity/torticollis was corrected in all the patients.ConclusionsNeglected upper cervical spine injuries are difficult to treat and a posterior approach is helpful in reducing the subluxations indirectly and to obtain a posterior fusion.     

Marjolin’s ulcer of the forearm from 30-year-neglection of external fixator

BackgroundMarjolin’s ulcers are a rare form of malignancy that present at regions exposed to chronic infection. They present with a clinical triad of nodularity, induration, and ulceration greater than 3 months.Case reportWe present herein, an extremely rare case of Marjolin’s ulcer of the forearm, secondary to osteomyelitis, resulting from a 30-year neglection of external fixator used to treat a war injury of the forearm.DiscussionMarjolin’s ulcers are classically encountered in lower extremities at sites of burns, trauma or complicated wounds. In the upper extremity however, they are seldom mentioned in literature. The presence of risk factors raise the suspicion of the disease.ConclusionMarjolin’s ulcer is rare sequelae of chronic wound infection. Patients often present after a latency period with exacerbated pain, discharge, and exophytic mass. This disease should be suspected in every case of chronic ulcer, where histological studies of the lesion must be conducted to exclude or confirm the diagnosis.     

Heterotopic Ossification of annular ligament: A case report and review of literature

Heterotopic Osification (HO) commonly occurs in the hip and elbow joint post, trauma, surgery or dislocation. HO can occur anywhere in the body, and the term Heterotopic Ossification of Ligaments and Tendon (HOTL) is specifically used to denote HO occurring in ligaments and tendons. HOTL of an annular ligament is reported rarely in the literature. Here we describe a case of calcified annular ligament in a neglected monteggia fracture (Bado Type – 1), which was managed by excision and reconstruction of the same using triceps fascia. Post-op review after 2.5 years showed a stable elbow, with some restriction in pronation.     

Trypanocidal treatment of Chagas disease

Chagas disease is a neglected parasitosis caused by the protozoan parasite Trypanosoma cruzi. This infection is present in most Latin American countries, although, due to migratory movements, it is a growing cause for concern in non-endemic countries. The only two drugs currently available for its treatment—benznidazole and nifurtimox—were marketed 50 years ago. While they are very effective for acute and recent infection, and for the prevention of maternofoetal transmission, their efficacy declines in people who have chronic infection, especially those older than 18 years of age. In the presence of visceral involvement, parasiticidal treatment is of little or no value. The safety profile of both drugs is far from ideal, with frequent adverse events and high rates of drug discontinuation, mainly in adults. So far, new drugs and new strategies have not been shown to improve the results of the current nitroimidazoles, although the results are promising. In this review, we focus on the aspects that allow clinicians to make the best use of currently available drugs. In addition, we discuss new therapeutic options and ongoing research in the field.     

Surveillance and response: Tools and approaches for the elimination stage of neglected tropical diseases

The presentation of the World Health Organization (WHO)’s roadmap for neglected tropical diseases (NTDs) in January 2012 raised optimism that many NTDs can indeed be eliminated. To make this happen, the endemic, often low-income countries with still heavy NTD burdens must substantially strengthen their health systems. In particular, they need not only to apply validated, highly sensitive diagnostic tools and sustainable effective control approaches for treatment and transmission control, but also to participate in the development and use of surveillance–response schemes to ensure that progress made also is consolidated and sustained. Surveillance followed-up by public health actions consisting of response packages tailored to interruption of transmission in different settings will help to effectively achieve the disease control/elimination goals by 2020, as anticipated by the WHO roadmap. Risk-mapping geared at detection of transmission hotspots by means of geospatial and other dynamic approaches facilitates decision-making at the technical as well as the political level. Surveillance should thus be conceived and developed as an intervention approach and at the same time function as an early warning system for the potential re-emergence of endemic infections as well as for new, rapidly spread epidemics and pandemics.     

Contributions to the Improvement of Living Conditions among Neglected Populations with Trachoma

Objective: Trachoma (Chlamydia-triggered blinding infection) provoked irreversible visual impairment in about 8 million people in 2011, and the prevalence among children with dirty faces is more than three fold that among children with clean faces. In 250 villages with a high prevalence of trachoma (Kolofata district, Far North Region, Cameroon), the lack of water for facial cleanliness was reported during trachoma awareness campaigns. The objective of this study was to determine if the lack of water was linked with the absence of means to dig wells.Methods: Wells, waterholes, motorcycles, irrigation pumps, electricity, goats and oxen, cell phones and distance from waterholes were recorded in January 2011 in 50 randomized villages of Kolofata’s district.Results: The number of villages with <25 goats and <5 oxen was 0 and the number of adults owning <1 goat was 0. The cost of a pail of water was 0.01 USD. Motorcycles, cell phones and televisions have been reported in more than 66% of villages. The cost for the construction of lined shaft wells ranged between 15–35 goats and 0.5–3 oxen; the cost for drinking water wells ranged between 50–200 goats and 3–30 oxen.Discussion: No link between the means for digging wells at the village level and access to water was found. Social solidarity, which refers to a social debt owed by each person to his/her group, should be added to training guides to gauge its ability to release people from the dead end of having to wait for external assistance to gain access to water.     

Results of Modified Ponseti Technique in Difficult Clubfoot and a review of literature

IntroductionSerial Ponseti casting achieves deformity correction in early presenting idiopathic clubfoot cases normally in around 7 casts. However, there are resistant patients where correction requires more casts than usual. In such patients a modification in standard technique might be required right from the beginning. Such patients were collectively called as difficult clubfoot. The aim of this study was to assess the outcome of our modification to Ponseti technique in difficult clubfoot.MethodsAll idiopathic clubfoot cases who were 75th percentile or more in WHO age for weight chart (chubby infants) or untreated clubfoot patients presenting for first time to our clinic at more than 5 months age (late presenters and neglected cases) were included in the study. Patients who had been previously surgically intervened elsewhere, patients over 7 years of age, patients with syndromic clubfoot or clubfoot associated with neurological conditions were excluded from the study. The patients were treated by early tenotomy of tendoachillis and a plantar fascia release before starting serial casting by Ponseti technique. Post correction, strict bracing protocol was followed with regular follow up. Pirani scoring was done at each stage. Measurement of Talocalcaneal angle on AP radiograph, maximum degree of abduction and dorsiflexion was noted once every year.ResultsThere were total 28 patients in our study. In all, 47 feet were subjected to modified Ponseti protocol. There were 21 male patients. Median age at presentation was 4 months. Mean centile of weight for age as per WHO growth chart was 64. Mean Pirani score at presentation was 5.86 (S.D. ± 0.34). Mean number of casts required for correction was 3.75 ± 1.10. Maximum followup period was 25 months.ConclusionThis modification of Ponseti casting for difficult clubfoot patients achieves correction in shorter duration with less number of casts.