Introduction: Pain management in total knee arthroplasty is aimed to minimize postoperative pain and improve functional outcomes in patients. Although there are many methods used for controlling the pain there has been no consensus on most appropriate or the best protocol. Adductor canal block (ACB) has the unique advantage of providing localized analgesia but it doesn't provide pain relief to the posterior capsule, it has been postulated that IPACK (interspace between the popliteal artery and the capsule of the knee) combined with ACB will provide better pain relief than ACB alone. Materials and Methods: 60 Patients were studied in two groups. Group A had those patients with ACB+ ipack and Group B had ACB. Group A -Patient were subjected to combined ACB block with IPACK. Group B -Patient in this group were given ACB. Patient were studied for pain score VAS on Day 0 and Day 1 morning and evening, range of movement at postoperative Day 1 and distance walked on Day 1. Results: Group B had better outcome as compared to Group A. The mean VAS score for the ACB+IPACK group was less than for ACB alone at end of Day 0 and Day 1 in morning and evening. The ROM for the ACB+IPACK group was better than ACB alone and number of steps walked by patients were more in ACB+IPACK as compared to ACB alone. The statistical difference was significant when Adductor +IPACK group was compared to Adductor group for VAS, ROM and number of steps walked. Conclusion: ACB+IPACK is better mode than ACB for control of postoperative pain in patient undergoing Total knee replacement. IPACK is relatively safe and combined with adductor canal block decreases posterior pain in TKR patients.

Multiple myeloma is a proliferative disease of plasma cells. The incidence of the disease increases with age. Objectives : To study different biochemical parameters and serum agarose gel electrophoresis patterns of patients consistent with clinical symptoms of multiple myeloma. Subject and Methods : A retrospective study was carried out in Department of Biochemistry, B.P. Koirala Institute of Health Sciences, from October 2008 to September 2009. Patients consistent with the symptoms of multiple myeloma were selected for the study. Alkaline phosphatase, total calcium, albumin and globulin levels were estimated. Bence Jones Protein, cell counts of bone marrow and x-ray of skull was carried out. Agarose gel electrophoresis was performed at buffer pH 8.6, 5 mili ampere current and the constant voltage of 200 volts was applied. Results : Serum electrophoresis patterns in all the patients showed M-Protein band (M-band) at gamma-region. Serum alkaline phosphatase levels were 216.0 ± 35.7 . Serum total calcium levels were 10.0± 1.5 , serum albumin levels were 4.1 ± 0.5 and serum globulin levels were 3.7 ± 0.9 respectively. Bence Jones Protein was present in urine of the 7 patients out of 14. Plasma cell counts were more than 10% and lytic lesions on skull were present. Conclusion : Patients with multiple myeloma showed consistently increased total calcium, decreased serum albumin and normal alkalline phosphatase levels. Electrophoretic patterns showed M-band in all the patients, giving the confirmation of the diagnosis. Though a conventional technique, electrophoresis remains as the gold standard for the diagnosis of multiple myeloma.

Traumatic Extensor Carpi Ulnaris (ECU) sublaxation is often missed and undiagnosed or wrongly diagnosed. ECU muscle plays a key role in active movement of wrist extension, ulnar deviation and also in providing suport to the ulnar side of wrist. Its position relative to the other structures in the wrist changes with forearm pronation and supination. As such it must be mobile yet stable. This structure can be injured in a variety of different athletic activity and following fall on outstretched hand. It lies subcutaneously and easily palpated and visualized, allowing early diagnosis and management. We in our study report a case of traumatic ECU sublaxation. An 18 year old female patient presented to our OPD with ulnar side wrist pain. MRI showed volar subluxed ECU tendon with ruptured ECU sheath. We had done open ECU sheath repair and excision of bursa. Very few literature shows traumatic ECU sublaxation report. The case is reported for the rarity of presentation and likely to misdiagnose in day to day clinical scenario.

Traumatic Extensor Carpi Ulnaris (ECU) sublaxation is often missed and undiagnosed or wrongly diagnosed. ECU muscle plays a key role in active movement of wrist extension, ulnar deviation and also in providing suport to the ulnar side of wrist. Its position relative to the other structures in the wrist changes with forearm pronation and supination. As such it must be mobile yet stable. This structure can be injured in a variety of different athletic activity and following fall on outstretched hand. It lies subcutaneously and easily palpated and visualized, allowing early diagnosis and management. We in our study report a case of traumatic ECU sublaxation. An 18 year old female patient presented to our OPD with ulnar side wrist pain. MRI showed volar subluxed ECU tendon with ruptured ECU sheath. We had done open ECU sheath repair and excision of bursa. Very few literature shows traumatic ECU sublaxation report. The case is reported for the rarity of presentation and likely to misdiagnose in day to day clinical scenario.