A retrospective cohort study of diabetic foot disease during the covid pandemic in a tertiary care hospital in Kerala

Introduction: Diabetes affects 88 million people in south-east Asia with a regional prevalence of8.8%, and of them, 77 million live in India. Diabetic Foot Disease is an important complication thataccounts for significant morbidity and mortality in a diabetic individual. Aim: This study wasconducted to study the presentation stage of diabetic foot disease during the pandemic period asseen at a tertiary care hospital in North Kerala. Methods: This was a retrospective cohort studycarried out on patients diagnosed with diabetic foot and admitted to the Department of Surgery of atertiary care hospital in North Kerala during the study period of 6months from July 2020 toDecember 2020. A sample size of 63 was calculated. Data were collected from the case records ofthe patients, and the stages of presentation, relevant blood investigations, culture reports,radiological imaging and arterial doppler ultrasound findings were noted. Results: In this study, atotal of 63 patients were included. Of the 63 patients, 51(80.9%) were males, and 12 (19.0%) werefemales with a male to female ratio of 4.25:1. The mean age of the patients was 57.74 years. In thisstudy, as per the Wagner-Meggitt Classification of diabetic foot, the most common stage ofpresentation of diabetic foot encountered was Grade III (42.9%) followed by Grade IV (28.6%),Grade II (19.0%) and Grade V (9.5%).Conclusion: This is in part may be due to financialconstraints of the patient's families due to lack of job, transportation difficulties, shortage ofmedicines, shutting down of small scale health care facilities and pharmacies, prolonged neglect ofwounds, discontinuing of regular medications and poor home wound care which in turn are due tothe frequent regional lockdowns as a result of the covid pandemic.

A Comparative Study on flap necrosis following Karydakis Flap Reconstruction and Z-Plasty in Patients with Sacrococcygeal Pilonidal Disease – Our experience

Aim: The purpose of this study was to evaluate patients with sacrococcygeal pilonidal sinus disease(SPSD) who underwent the Karydakis procedure and Z plasty at our centre concerning theperioperative findings, late postoperative results and recurrence. Patients and Methods: A total of30 patients presenting with SPSD at our centre underwent Karydakis flap repair and Z plasty fromMay 2019 to June 2021. These patients were then followed up and evaluated concerning operativetime, drain use, hospital stay, suture removal, complications, and recurrence. The adipocutaneousflap of Karydakis was devised to shift the natal cleft, while Z-plasty involves a fasciocutaneous flap.Results: The mean operative time was 60 min with a median hospital stay of 4 days. Drains wereremoved at a median of 5 days and sutures at a median of 15 days. The duration of hospitalisationfor the Karydakis procedure was found significantly lesser than that for Z-plasty Patients who werefollowed up for a median of 12 months. The overall complications were more in Z-plasty. Flapnecrosis developed in 30 % of the cases in the Z-plasty group, comparable to no recurrence seen inthe Karydakis procedure. Conclusion: Karydakis flap was found superior to Z-plasty, having lessseroma formation, no flap necrosis and no local hematoma Karydakis flap procedure is a relativelysimple procedure for SPSD and has advantages over Z-plasty technique like keeping scar away fromthe midline and flattening of the natal cleft, thus reducing local recurrence rates.

A prospective study of outcome of resection anastomosis in elective GI surgeries.

Background: Bowel anastomosis is successful when there is accurate union with no tension.Previous literature has compared between hand suturing and stapling devices in retrospective andprospective designs with varying outcomes. In this study a comparison between hand suturing andsurgical stapling in patients undergoing bowel surgery is done. Methods: A prospective study designover a period of 12 months was conducted in 40 patients undergoing elective resection andanastomosis. Different time parameters for anastomisis procedure, time taken for bowel sounds toreturn, resumption of oral feeds, postoperative hospital stay were collected. Follow up for 30 dayspost-operative was done. Results: In total forty patients were studied out of which twenty patientsunderwent hand sewn and twenty patients underwent stapler anastomosis. Main group analysis inmean time durations between hand sewn and stapler anastomosis were respectively; 35.25 minutesand 12 minutes for anastomosis, 3.4 days and 3.35 days for return of bowel sounds, 4.08 days and4 days for resumotion of oral feeds, 9.35 days and 8.50 days for post-operative hospital stay. A sub-group analysis was also done.Conclusion: Stapler anastomosis had shorter anastomosis time andtotal duration of operation compared to hand sewn anastomosis. However no difference was seen inreturn of bowel activity, resumption of oral feeds and duration of hospital stay.

Laparoscopic Anterior 180° Partial Fundoplication - Indian Perspective

Aim: To evaluate Laparoscopic anterior 180° partial fundoplication for its good long-term relief forsymptoms of gastroesophageal reflux disease and association with adverse effects. Methods:Study design: Prospectively evaluated case series. Settings: Tertiary care centers Patients: Theclinical outcomes were determined for all patients who had undergone a laparoscopic anterior partialfundoplication by us between January 1, 2013 to March 31, 2021. Interventions: Clinical outcome,complications, and follow-up after laparoscopic anterior 180° partial fundoplication was obtainedusing a structured questionnaire. Results and Discussion: 228 procedures were performed. Theoutcome at 0 to 8 years (mean, 4 years) follow-up was determined for 195 patients. 1 death waslinked to the laparoscopic procedure and 2 patients died during follow-up due to unrelated causes.For 186 patients (95%) with clinical outcome data at late follow-up, gastroesophageal refluxsymptoms were significantly improved following surgery and were well controlled in 9 patients(4.5%). In a subset of 85 patients with more than 5 years of follow-up, relief of heartburn was foundin 59 patients (69%). Incidence and severity of heartburn were reduced after surgery in 22 patients(26%), decreased dyspepsia in 80 patients (94%). Normal belching was preserved in 84 patients(99%) and almost all patients were able to eat normally. Conclusion: Laparoscopic anterior 180°partial fundoplication is an effective procedure for the surgical treatment of gastroesophageal refluxand is associated with a high rate of patient satisfaction at late follow-up. Compared to Nissen'sfundoplication it is as good as control of recurrent reflux as well as reduced adverse effects. Thepatient goes home in 3-4 days. Hence we recommend it as the procedure of choice for refluxsymptoms.

Corrective Osteotomy in cubitus varus deformity in children: A prospective study

Background and Aim: Cubitus varus deformity is the most common late complication aftersupracondylar fracture of the distal humerus in children, incidence varying from 4% to 58%. Thepresent study was done to evaluate the results of dome osteotomy. Material and Methods: Thisprospective study was conducted in a tertiary care hospital over 16 months. In all patients humerus-elbow wrist angle was measured on both sides and the correction needed was calculated. The lateralcondyle prominence index (LCPI) was calculated by anteroposterior view radiographs of thedeformed and the normal elbow in full extension by (AB-BC)/AC. Dome osteotomy with para tricepsapproach was used. Pre and post-operative carrying angle of elbow, range of motion and lateralprominence indices were compared. Results: The age of patients ranged from 3 to 15 years with amean age of 8.47±3.14 years. Preoperative carrying angle of normal side ranged from 80 to 140and that of effected side ranged from -23 to -13 and the difference was statistically significant(p<0.05). LCPI ranged from -8.4 to 5.9%. The majority of cases had LCPI >2.7%. As compared to,an improvement in carrying angle at defect side was observed to be 28.41±2.15 which wassignificant (p<0.05). At baseline mean LCPI was 0.39±3.87% which changed to -0.86±3.47%, themean change of this was significant (p=0.01). baseline Conclusion: Dome osteotomy is a relativelytechnically demanding technique for correction of cubitus varus deformity but with a betterfunctional outcome without being associated with lateral condyle prominence.

Comparison of functional outcome and complications in Gartland’s Type III fracture Supracondylar Humerus in paediatric population by different pinning technique

Background: Fracture Supracondylar humerus is one among common fracture in children betweenage 5-7 years. Boys are frequently affected than girls. Extension variety is more common. Theconventional approach to treat fracture supracondylar humerus (Type III) is a close reduction withpercutaneous fixation. There have been controversies as to which surgical technique should be used,cross pinning or two-wire lateral pinning. This study aims to find which method of pinning is mostappropriate to fix fracture supracondylar humerus. Method and material: A Retrospectivecomparative study was designed to analyze the outcome of the cross pinning and lateral pinningmethod. A total of 60 patients were included in the study. They were divided into two groups of 30each. Group A comprised of fixation by cross pinning method. Group B comprised of fixation by two-wire lateral pinning method. Results of both groups were analysed about Flynn’s criteria andcomplications. Result: The mean age in Group A was 5.1 years and in Group B was 4.8 years. Onepatient was lost to follow up in Group A. On the final follow up, there was statistically no differencein terms of outcome according to Flynn’s criteria in both groups. According to Flynn’s criteria>95%of patients had a satisfactory outcome in both groups. Among Group A, there were 2 cases ofiatrogenic ulnar nerve praxis whereas in group B there was one case of pin loosening. Conclusion:On comparing both techniques there was no significant difference in the outcome. However, there isa slight increase in the chances of iatrogenic ulnar nerve injury in the cross pinning method.

Comparison of two techniques of steroid injections in the management of Frozen shoulder

Background: Frozen shoulder is a condition in which movement of the shoulder becomes restricted.It can be described as either primary (idiopathic) whereby the aetiology is unknown, or secondary,when it can be attributed to another cause. It is commonly a self-limiting condition, of approximately1 to 3 years' duration, though incomplete resolution can occur. The aetiology of shoulder pain isdiverse and includes pathology originating from the neck, glenohumeral joint, acromioclavicularjoint, rotator cuff, and other soft tissues around the shoulder girdle. The most common source ofshoulder pain is the rotator cuff, accounting for over two-thirds of cases. Material and methods:This was a prospective study with 50 patients coming to our OPD. Patients of all stages wereincluded and randomized into two groups. Group 1: Single Site Injection (SSI) group receivedsteroid injection through posterior approach and Group 2: Novel three-site ( NTS )group receivedthe same dose of steroid in diluted doses at three sites (posterior capsule, subacromial andsubcoracoid). The second sitting was repeated after 3 weeks. Both groups had received the samephysiotherapy. The patients were evaluated by the CONSTANT score at initial, 3 weeks, 6 weeks and6 months. Results: Patients of Group 2 (NTS group) had significant pain relief and earlyimprovement in activities of daily living (p < 0.005) as compared to Group 1 (SSI Group). Also,although there was an improvement in shoulder movements in both the groups but in Group 2 (NTS)patients, early near-normal scores were attained and sustained even after 6 months. About 40% inGroup 1 (SSI) could not attain near-normal levels and had relapses. Conclusion: The Novel three-site approach of steroid injections in frozen shoulder provides early recovery, better pain relief andbetter improvement in shoulder function with fewer relapses.

Open versus closed reduction and K-wire fixation for supracondylar fracture of the humerus (Gartland type 3) in children

Background: The purpose of the study was to compare the presentation and postoperative resultsof children treated by open reduction and closed reduction for completely displaced Gartland type IIIsupracondylar humerus fractures (SCFs). Method: Supracondylar fracture of the humerus is acommon paediatric fracture seen in our OPD. Among them Type III fractures are displaced with nocortical contact, and reduction is difficult, and maintaining reduction is almost impossible withoutsome form of internal fixation. Therefore during surgery of type 3 fractures, fixation is done by twomethods. 1 open reduction and fixation with 2 cross k-wire 2. closed reduction and fixation with 2cross k-wire fixation. Following pinning, the elbow was immobilized in an above elbow slab inpronation with the elbow at 75 degrees of flexion. Result: The average age of patients was 5 years(age range, 3 to 10 years). The test population consisted of 18female (36%) and 32 male (64%)patients. There were 31 fractures (62%) in the right elbow and 19 fractures (38%) in the left. Group1 patients stayed in the hospital for 5 days while Group 2 stayed for only 2 days in the hospital. Alsogroup 1 patient required follow-up at eight postoperative days (for check dressing) and 11postoperative days for stitch removal while group 2 patients were directly called for k-wire removalat 3 weeks postoperatively. Both groups of patients were called after three weeks for k-wireremoval. Mean clinical follow-up for both groups was 6 months. Conclusion: The closed reductiontechnique was preferred because it required less hospitalization time, less number followup, andresulted in almost no visible surgical scars.

Retrospective analysis of Intramedullary K-Wire fixation of Metacarpal Fractures

Introduction: The majority of fractures of the metacarpal bones occur at a young age.Most of thetimes these metacarpal fractures can be treated conservatively in a POP slab(cock up slab)producing good functional results.Surgery was indicated in patients with palmar dislocation of >30°and shortening of >5 mm.Our study aimed to evaluate the clinical results of all metacarpal fracturestreated surgically by intramedullary Kirschner-wire fixation presented in our hospital.Materials andMethods: It was a retrospective study in which we included 50 patients with metacarpalfractures(both open andclosed) that came in our hospital, treated surgically by closed reduction andwere fixed with two intramedullary k-wires. Result: K-wires were removed after 4 weekspostoperatively,under local anaesthesia in the OPD. Metacarpal joint functions (flexion, extension,rotation) were clinically followed up in all patients, on the median periodof6 months (3 months to 9months). In our study, we found in all patients,flexion and extension were normal on bothsides.Conclusion: Closed reduction and intramedullary k-wire fixation of metacarpal bone fracturesproduce good functional results in the longterm. We found a very low rate of complication and thusrecommendthis surgical method for the stabilization of all these types of fractures.

“Clinical Profile and Outcome of Diabetic Foot Ulcer in South Indian Tertiary Care Centre”

Aim: To study the clinical profile and outcome of diabetic foot ulcer in a Tertiary Care Centre. Theclinical profile of 200 patients with diabetic foot ulcer was studied. Methods: Patients with diabeticfoot ulcer of both genders with age above 18 years willing to participate were included in the study.All patients were subjected to routine diabetic work up with Doppler study and X-ray foot to rule outbone involvement. Results & discussion: The majority of patients with diabetic foot ulcers were ofage group 51 to 60 years, male predominant, mostly with a duration of diabetes mellitus more than6 years had intermittent claudication and most population with a single ulcer. Conclusion: Ourstudy gives important information that diabetic foot ulcer is more common among middle-agedpeople with male predominance which gives the importance of screening diabetic patients forneuropathy and peripheral vascular disease.