A 30 year old lady was tbrought to the unit ll of Lokmanya Hospital following a fall from a speeding train. she had sustained.
a) left sided compond comminuted fracture of calcaneum with avulsion of tendo-achillies partial loss of calcaneum and complete avulsion of hill pad and sole with exposed ankle joint. the wound was severly contaminated with sand oil,grass etc.

b) cerebral concussion with history of convulsion she was brought in hypovolaemic shock

The shock was managed on emergency basis. the management of the problem was challenging as the heelpad is a specialised tisue designed to bear weight and the calcaneum bone is also designed for the some purpose

In all, 5 surgeries were necessary to reconstruct the heel and stabilise the foot. On 6/11 95 she was oprated and thorough wound debridement was done.All the sand, oil and dead necrosed tissue was removed The fracture of calcaneum was fixed. with K wires.External fixator was applied with two schantz screws in first and fifth metatarsals.

The patient was givan broad spectrum antibiotic cover. After this surgery redebrident had to be done,two time,under anaesthesia to clear the infection. Now the Calcaneum was exposed directly to the exterior.There was no infection. Split thickness skin graft could not be used fortwo reasons. Firstly it cannot be directly appiled on bare done and secondly it is not suitable to bear weight. If applied it will be painful, wear out and produce nonhealing unlcers. Therefore full thickness fascio-cutaneous cross leg flap was an ideal choice which was done on 21/11/1996.in this sugery skin subcutaneous tissue and the fascio over gastrocnemiun muscle were elavated from three sides and were sutured to the wound edges,left side. One side of the flap remained attached to the doner right leg. The raw area over right leg was covered with S.S.G.To releive the tension on suture line of the flap of the fixator assembly was extended to right leg. Two leg of the patient were joined together resembling. Natraj Position.The legs where kept in this position for aperiod of the blood supply to the flap was established from the recipioent,i.e left leg.Therefore, the flap was datached from right leg and leg was sperarated.

No flap necrosis was observed. After2 week the patient was made to walk non weight bearing on crutches and progreessive weight bearing was then started. At present the patient is walking on the flap full weight bearing with one stick and without any pain.

The fixator and technique of flaps is thus enabling us to save many a amputation, it must be mentioned here that without cooperation of our really'patient' this would not have been possible.

A 60 year old lady presented herself in our clinic with history of pain in both knees on and offsince last 4-5 year aggravated since last 4-5 months.

She was crippled to the extent of being unable to walk since last 2 months and experinced excruciating pain on sightest movement of the knee-joint.

There was no history of Trauma of Fever and T.B. and no symptoms of T.B. she was a known case of DM with HT with RA of both knees with left knee more painful than the right one.

she had pain at rest with servere tenderness to touch or an attempt to move the knee she had not taken any acute treament for the problem and was physically and mentally crippled and was tied down to the bed.

Local examination revealed that both the knees were tender with case of Synovities.Right knee had FFP OF 10 and left knee had FFD of 50 No swelling was observed on the back of the knees, with no appearance of previous scaror sinus.

Her both hips and ankles were apparently normal with good distal plusations. Her Lab finding were WNL except for the hb cound which was only 8gm%.

Six transfusion were given to elevate her hb count,but her hb count could be raised by only 0.5gm%.T3 ,T4,THS,total count,sickling test,hanging drops, peripheral smear was done to find out the cause of anaemla but we could not reach the diagnosis.Her bone scan was also normal.A thorought cheak-up was done to rule our any source of infection ,her throat Swab, nosal sweb,urine clutere,dental cheak-up,ENT cheak-up were carried out.Preoperative psychiatric counselling was also done to boast the patient morale.owing to RA+DM + Anaemia she was labelled as high risk case for infection.She was given cover of oral antihypertensives and insulin, preoprratively fill both the values were under control. Prophylactic heparine was given one night prior to sugery. Total condylar knee replacement was doneon left knee 17/2/1989, under epidural anaesthesia and midine approach. The post operative stability and position was excellent. The sutures were removed on the 13th day.Static quadriceps , calfmuscles,pump exercises,CMP wasstrated from 2nd post operative day. she was given knee traction at rest.The patient was made to walk fully weight bearing,with the help of waker from the 14th post opearing day.There was no pain in the left knee with rotation flexion of 0-90 with good active SLR and no extension lag.Her intire recovery was rapid and uneventful without problem Like wound dehiscence ,D.V.T.,infection etc,

 

FUTURE PLAN:Her other knee is now showing swelling with case of synovities.We plan to do Total Knee Replacement of right knee within a minimal time of 3 month.

A 60 year old lady presented herself in our clinic with history of pain in both knees on and offsince last 4-5 year aggravated since last 4-5 months.

Abdominal Ultrasonography was done by the radiologist in which mild hydronephrosis & hydrueter on left side was noted.

There was no calculas.The radiologist advised him plain X-Ray a large calcified tumour arising from Quadrilateral plate of illeumwas noted.

The case was referred to Department of Othpeadics,Lokmanya Hospital Nigdi.

Chief Complaints

On examination:

Local examination

Investigation

Differential Diagnosis

Operative notes

Incision over left iliac crest extending from anterior superior iliac spine extending along crest 15cm distal & medial to anterior superior iliac spine.

Gluteus & iliac muscle elevated subperiousteally from outer & inner table of ilium respectively. Hard osteocartilagenous,welldefined encapsulated lated lobulated roughly spherical tumour arsing from quadrilateral plate of acetabulum.no sign of any soft tissue or any other tissue invastion. Tumourattached to iliac wing superior pubic rami & anterior. inferior iliac spine. Tumber excised in toto. sent for histopathology.

Post OP unventful

Patient was mobilised partial weight bearing on 4th post operative day & full weight bearing from 5th post operative & was discharged on 6 th post operative day. wound heald with primary intention.

A 24 YR old male patient presented with complaints of heaviness and numbness and both lower limbs, left more than right,since 2 yrs. History of back pain, no history of radiating pain. History of claudication. No history of trauma,fever,wt.loss,anorexia.

ON EXAMINATION

Thin built averagely nourished. Afebrile,Haemodynamically stable.No pallor,cyanosis,clubbing,icterus, lympadenopathy.

SYSTEMIC EXAMINATION

PER ABDOMINAL :No distension, scar soft non tender.

RESPIRATORY SYSTEM :Chest expanssion good. Air entry equal both sides. No wheeze crept.

C V S EXAMINATION :Normal.

Spasticiy both lower limbs. ankle and pateller clonus. Hyperreflexia both lower. Spastic gait

LOCAL EXAMINATION

Scoliosis- upper dorsal spine

INVESTIGATION

X-RAY Chest : Socoliosis with concavity to left side upper dorsal region
X RAY Cheat : Mediastinal windening on right side,post. Mediiastinal mass.

C T SCAN THOREX

A large well defined soft tissue mass measuring 9.8 X 5.5 X12.5 cm at D1 to D8 level in right side.

CONTRAST C T SCAN DORSAL SPINE

Mild scoliosis in upper dorsal spine A large extradural tumor extending through righ side intervertebral formen at D2 D3 & D3 D4 Level extending from D2 TO D6 level causing marked cord compression & displacement toword left side in spinal canal.

MANAGEMENT

Excision of tumor was planned in two stage

a.Excision of intru spinal tumor was planned immediately because of rapidly progressing Neurodeficit.

b.Excision of mediastinal mass bythoracotomy.

29/06/2000 intra spinal tumor was excised. prone position on wilsone spinal sugery frame posterior mid line skin incision . Laminectomy D2-D6 done.Extra dural fleshy tumor arsing from epidural space pushing the dural tube to left side excised . Two nerve roots which were engulfed in the tumor were scrificed. Tumor excised totally. Total decompression achived.Post op neuro recovery was good.i week later on 06/07/2000 Throcotomy was done. The tumer was adherant to transverse processes, vertebral bodies of D2 TO D5 vertebrae. The fumor was found to be extending form 2nd rib on R side to about 8th rib caudally. it was crossing the midline anterior to D4,5 vertebrae pushing great vessels viz vena cava & aorta anterioly & was in close proximituy of these structures. The dissection in this region was extremely tricky. While performing this dissection a small rent in vena cava occurred which was repaired. The tumor was excised in toto. Haemostasis achieved. Closure in layer over 2 ICDs & suction draims.

The ICD were kept for a period of 12 days was daily collection of about 150cc fluid in ICD. The lung expasion was partial on R side. The patient all the time was comfortable, not having hypoxia/dypnea. it was thought that there is an organised heamatoma which is preventing full lung expansion, with consultation of throacic surgeon repeat thoracotomy was done. A large organised haematoma was evacuated. Pleural adherions released. Good total lung expansion on table. Haemostomis & closure in layers over ICD in thorax & suction drains in parieties.

Postop small residual pneumothorax in apical rdgion which required no active intervention. At present 3 months postoperatively the patient has full neurological recovery with no spasticity having normal lung function, is living totally normal life.

Further course : We will be monitoring the localized scoliosis which may need fusion at later stage.

At the NEWVISIONS Centre for joint Replacement.A 54 yr.Old male Teacher by occupation presented with excruciating pain in right Elbow since 15 yrs. Patient had old history of trauma to right Elbow details unavailable about the trauma.

History of Patient :

On Examination

Systemic examination

Respiratory system :