Management of Primary AVN with Total Hip Replacement

Introduction: Avascular necrosis (AVN) of femoral head is a dreadful and disabling condition. Total Hip Replacement (THR) is an effective solution. In this study we have analyzed the results of total hip replacement performed in ShSMCH, Dhaka for AVN of femoral head from July 2018 up to June 2020. Patients and Methods: In this prospective study, 19 total hip replacement were done. All patients were diagnosed as primary AVN of Ficat and Arlet Grade III and IV. Out of 19 patients, 15 patients operated with cementless pressfit implants and 4 patients with cemented implants. Results: Among the 19 patients 12 were male (63.15%) and 7 were female (36.85%). Mean age was 35.57 year. Operation done on right hip in 10 patients (52.63%) and on left hip 9 patients (47.37%). All the patients were evaluated pre-operatively and Harris Hip Score was poor ie, average 41.84. Three months post operatively Harris Hip Score improved significantly 47.36% patients value was 90-100 ie, excellent, 31.57% patients value was 80-90 ie, good and 21.05% patients value was 70-80 ie, fair. None documented as poor. In complication, 1 patient (5.26%) developed serous discharge which resolved with antibiotic treatment after culture and sensitivity. Conclusion: THR is the most effective method of removing pains and distress of end stage AVN of hip. J Shaheed Suhrawardy Med Coll 2020; 12(2): 87-89

Outcome of Partial Nail Avulsion Followed by Matricectomy Either With Phenol (80-88%) or With Electro Cautery for Toenails

Aim: To compare partial nail avulsion followed by matricectomy either with phenol (80-88%) or with electro cautery for Stage 2 & 3 ingrown toenails for early and late postoperative complications. Methods: This study was conducted at department of surgery Nawaz Sharif social security teaching hospital Lahore for one year from 01-01-2018 to 31-12-2018. One hundred patients full filling inclusion criteria were included in the study and divided into two equal groups A and B. Partial nail avulsion done in both groups followed by chemical matricectomy with phenol (80-88%) in group A and patients in group B matricectomy done with electrocautry. Results: The mean age in group A is 19.7± 8.08 years and in group B is 20.20± 6.9 years, both groups comparable p-value (0.74).In early post-operative complications in group A 17(34%) patients and 14(28%) patients in group B experienced mild pain p-value is (0.66). 6(12%) of group A patients and 6(12%) of group B patients experienced moderate pain p-value (01). 1(2%) of group A patient and 2(4%) of group B patients experienced severe pain p-value (01). 02(4%) patients of group A and 02(4%) patients of group B had serous discharge p-value(01). 1(2%) of group B patients have purulent discharge, however, no patients in group A patients have purulent discharge p-value (01). 1(2%) patients of group A and 2(4%) patients of group B had recurrence at three months follow up p-value (01). 2(4%) patients of group A and 4(8%) patients of group B had recurrence at six months follow up p-value (0.68). Conclusion: Partial nail avulsion followed by matricectomy either with Phenol 80-88% or with electrocautry are comparable in early and late complications. Keywords: Ingrown toenails, partial matricectomy

A case report on pemphigus foliaceus

Pemphigus Foliaceus (PF) is second most common autoimmune vesicular disease in the pemphigus family characterized by superficial blisters of the skin and rarely mucous membranes which rupture to produce scaly, crusted lesions. A 54 year old female patient admitted in female derma ward in tertiary care hospital, with the chief complaints of painful ruptured blisters all over the body with crusty, scaly patches associated with serous discharge and itching since 15 days. A positive Nikolsky’s sign is when the skin shears off easily when the surface is wiped sideways with a cotton swab or a finger. Based on both subjective and objective evidence, this case is assessed as Pemphigus Foliaceus. The plan incudes Corticosteroids, Immunosuppressants, Antibiotics, Vitamin A & D supplements, IV fluids, calcium and aminoacids supplements, antivirals and antifungals (if needed), proper wound management and finally plasmapheresis.

A study to compare the effect of topical phenytoin dressing and conventional saline dressing in chronic non-healing ulcers

Background: Chronic non-healing ulcers; particularly diabetic and venous ulcers impose a major healthcare burden and affect quality of living. Efficacy of conventional strategies used for treatment of chronic non-healing ulcers is limited due to factors like microbial infection, necrotic tissues, tissue hypoxia, and other prevailing co-morbidities. The aim of the study was to compare efficiency of topical phenytoin-based dressings to conventional saline-based dressings for treatment of chronic non-healing wound ulcers.Methods: A prospective observational study was conducted on 60 patients who were divided in two groups. First group received conventional saline dressing-based treatment and second received topical phenytoin dressing based treatment for chronic non-healing ulcers. Efficiency of the treatment strategy was determined by statistically comparing parameters like duration of hospital stay, nature of discharge, appearance of healthy granulation tissue, and pus culture evaluation upon admission and post one and two weeks of treatment.Results: Diabetes and trauma were observed to be two major causes of chronic non-healing ulcers. No cases of venous impairment and osteomyelitis were observed in participating patients. Topical phenytoin dressing based treatment significantly reduced the duration of hospital stay and number of patients with serous discharge and aided in rapid formation of healthy granulation tissue in comparison to conventional saline based dressings. Topical phenytoin dressings also prevented microbial infection and colonization on chronic non-healing ulcers.Conclusions: Topical phenytoin-based dressing was concluded to efficiently and rapidly heal chronic ulcers while preventing microbial infection in comparison to conventional saline-based dressings.

Bilateral idiopathic granulomatous mastitis

A 35-year-old woman presented to the surgery outpatient department with a lump in her right breast for 2 months and pain for 1 month. After clinical examination and relevant investigations, we kept a working diagnosis of antibioma. The lump was excised under local anaesthesia and biopsy was sent. However, histopathological examination reported multiple non-caseating granulomas without acid-fast bacilli. Two months later, she developed a sinus with serous discharge at the scar site. At the same time, she developed pain in the left upper breast, which subsequently progressed to an abscess. Incision and drainage of the abscess was done, but the wound did not heal, and a discharging sinus appeared at the site. Finally, a diagnosis of idiopathic granulomatous mastitis was made, after excluding all other causes, and the patient was prescribed oral steroids. She recovered fully after 8 months and there is no recurrence till date.

Role of prophylactic antibiotics in elective surgeries and postoperative surgical infections

Background: Health care associated infections (HAIs) present a significant source of preventable morbidity and mortality. More than 30% of all HAIS are represented by surgical site infections (SSIs) making them most common sub types between 1.9% and 2.7% of all surgical patients. Joseph Lister “the man who made surgery safe” introduced antiseptic method for safe surgeries. As many are now considering antibiotics “wonder drug” which covers the surgical techniques and having asepsis. Extensive indiscriminate use of antibiotics has resulted in developing resistance.Methods: Study conducted in about 100 cases in various surgical units having various surgical procedures. Only clean cases are taken. A single stat dose of first generation cephalosporin 1gm given IV at the time of giving anesthesia. Postoperative any signs and symptoms like infections, fever with chills, wound discharge are observed. If any evidence of wound infection is present, accordingly sent for culture and sensitivity and suitable antibiotics are given.Results: In our study 5 patients had fever with serous discharge 2 patients showed no growth, 3 patients had got growth positive (2- staphylococcus aurous, 1- pseudomonas). Hence our infection rate is 3%.Conclusions: Single dose prophylaxis has got definite advantage to overcome the postoperative wound sepsis. Prolonged antibiotic therapy should be avoided as it has got no added advantaged over single dose antibiotic.

A rare case of varicella gangrenosum in adult

Varicella gangrenosum is a gangrenous ulceration of varicella lesions involving the skin and soft tissues of the body. It most commonly occurs in children less than 5 years of age and life threatening. This is a very rare complication of chicken pox in adults which deserves early diagnosis and management. 21-year-old male presented with blackish discoloration in the lateral aspect of right thigh for 5 days. He has positive history of chicken pox for his brother and sister following which he acquired it 15 days back. During that episode he had fever, headache and blisters which ruptured to heal by scab. But scab in right thigh coalesced to form the gangrenous area with serous discharge. On presentation he had no fever with local lesion and surrounding erythema. Patient underwent radical surgical debridement and regular dressing. Pus culture was sent which showed no growth. He gradually improved and the ulcer granulated well and split skin graft is done. Varicella gangrenosum is a life-threatening condition which can be either wet, moist or purpura fulminans. Patients who develop disseminated intravascular coagulation and have a grave prognosis. Surgical debridement is the only proven treatment which has led to better outcome. Only about 10 cases reported in literature so far regarding this condition.

Tubulopapillary Carcinoma of the Mammary Gland in a Mare

Background: Mammary gland neoplasia are often observed in bitches and cats, rarely in cows, goats, sheep, sows, and mares. Among the neoplasia that affect mares, breast tumors are rare, as they occur more frequently in older animals. In horses, mammary gland tumors occur more frequently in older animals. In this species there are reports of cases describing carcinomas and adenocarcinomas and several subtypes. Mammary neoplasms in equines tend to be locally aggressive and promote metastases to the regional lymph nodes and other organs, including the lungs, and may cause pleural effusion. The aim objective of the present case report was to describe the clinical-pathological and immunohistochemical findings of a tubulopapillary carcinoma of the mammary gland in mare.Case: Was received a biopsy of a tumor mass of the mammary gland of a 15-year-old Quarter Horse mare. According to the veterinarian, the mare presented an increase in volume with ulceration of the mammary gland three months before the biopsy. Macroscopically, the mass was firm to the cut with white surface measuring 12x12 cm. The fragment was fixed in 10% formalin, routinely processed for histology, paraffin embedded, and stained with hematoxylin and eosin. Microscopically, we observed proliferation of epithelial neoplastic cells arranged in tubules and papillary projections, some with two to three layers of cells. Neoplastic cells had oval, moderate and distinct cytoplasm. The nuclei were rounded with dense chromatin and an apparent nucleolus. There were two figures of mitosis per field of high magnification. Proliferation of neoplastic cells invaded adjacent tissues, and in lymph vessels of the region, neoplastic cells were observed as well as inflammation in adjacent tissue. In addition, the breast fragment was submitted to the immunohistochemistry technique using anti-pancytokeratin and anti-vimentin antibody. In immunohistochemistry for pancytokeratin, there was immunoreactivity with marked cytoplasm in neoplastic epithelial cells. In immunohistochemistry for vimentin, there was cytoplasmic labeling in cells of the supporting tissue (fibroblasts and endothelial cells). After approximately six months of the initial diagnosis, the mare died.Discussion: The diagnosis of tubulopapillary carcinoma of the mammary gland in a mare was based on the clinical-pathological and immunohistochemical findings. In mares, descriptions of breasts neoplasia are uncommon and found in animals aged over 12 years. In a study carried out in slaughterhouses in France, with approximately 40,000 horses slaughtered, only 45 breast neoplasms (0.11%) were observed, most of them consisting of carcinomas. In these equines, the absolute incidence of neoplasia of the reproductive system increases with age and tumors generally appear as deep, multifocal, and ulcerating skin nodules. Thus, important differential diagnoses include chronic mastitis and prepartum breast edema. In mares with neoplasia of the mammary gland, unilateral or bilateral volume increase, pain, warm area, redness and suppurative serous discharge are frequently observed. There are also reports of skin ulceration or necrosis. In the present report, the mare showed increased volume of the mammary gland, with focal hyperthermia, fistulated area and serum-blood secretion. The literature suggests a reserved prognosis for any mare presenting mammary neoplasia. Histopathology and immunohistochemistry were fundamental for the diagnosis of tubulopapillary carcinoma of the mammary gland in the present study. Mammary neoplasiss in mares are rare, but should be considered in the diagnosis of mammary pathologies in this species.

A rare case of peritoneo-cutaneous fistula after laparoscopy converted to open failed cholecystectomy: meticulously managed by laparoscopy

Peritoneo-cutaneous fistula can occur following cholecystectomy due to leftover stones. However, cholecysto-cutaneous fistula has been found to be associated with complication of acute cholecystitis. But never before a fistula associated with abandoned cholecystectomy without spillage of stone have been described in literature. We describe a case report of a 25-year-old female presented with right upper quadrant serous discharge from a previous incision site for the past 8 months. The patient had a history of failed cholecystectomy one year back. The patient was evaluated radiologically with computed tomography sinogram and magnetic resonance cholangiopancreatogram (MRCP) and found to have a tract communicating with subcutaneous tissue and gallbladder fossa with normal gallbladder anatomy and a single calculus. The patient was managed laparoscopically. Laparoscopic cholecystectomy was performed successfully with excision of peritoneo-cutaneous fistula tract. All difficult and failed cholecystectomies should be attempted at high volume surgical centres by an experienced laparoscopic surgeon only.

Prospective study on use of antibiotic prophylaxis on operative wound infections in south Indian population

Background: Antibiotic prophylaxis can help to reduce surgical site infections in operative wound infections. Present work was done to study the use of antibiotic prophylaxis on operative wound infection.Methods: A total of 120 patients under went various surgeries in the department of surgery, Fathima Institute of Medical Sciences, Kadapa, Andhra Pradesh utilized for the present study. Out of 120 patients utilized 86 were males and 34 females with elective surgeries and observed from their admission to discharge from the hospital and also followed up all the patients up to fifth week of post-surgery. Surgical wound types were observed and recorded.Results: We have noted clean wound cases were 91, contaminated cases were 5 and clean contaminated were 24 noted. 11 infected cases were observed in clean wound type, 3 infected cases in clean contaminated were observed. 3 patients out of 120 patients had post-operative fever and subsided within 2 days without antibiotics. Out of 91 clean wound cases, 2 patients (2.19%) had post-operative fever, 10 patients (10.9%) developed with serous discharge and purulent discharge was developed in 1 (1.09%) case in present study. Bacteriology revealed 4 cases (4.29%) showed growth of staphylococcus aureus organism, 1 case (1.09%) with pseudomonas organism was noted. 2 cases (8.3%) developed with serous discharge and 1 case (4.16%) with purulent discharge and also growth of E. coli in 1 (4.16%) case was noted in 24 clean contaminated cases in present study.Conclusions: Use of antibiotic prophylaxis has a vital role in pre and post-operative wound infections.