Operative treatment of femoral fractures using intramedullary nailing is considered as the gold standard technique; despite safety and minimal invasiveness, it is prone to some complications, of these is the persistent abductor lurch even after complete fracture healing. In this review, we are discussing the possible factors which may endanger the superior gluteal nerve during cephalomedullary nailing of the femur.
Tuberculosis of the wrist is an uncommon clinical entity and mostly presents as insidious pain and swelling. Presentation of singular carpal bone involvement is rare as the presenting feature. A case of scaphoid fracture was evaluated in a 20-year-old male patient, and underlying tuberculosis was diagnosed on magnetic resonance imaging and culture of joint fluid. Antitubercular therapy under appropriate supervision resulted in clinical improvement and optimal regain of function. No reactivation of the disease was noted in a follow-up of 2 years. This case highlights a rare presentation of tuberculosis presenting with a fracture of scaphoid.
BACKGROUND: Calcaneal fractures are one of the most difficult and challenging fractures to treat by the orthopedic surgeon. Most of these fractures (i.e., almost 75%) are intra-articular. Furthermore, majority of these fractures are highly comminuted. Hence, open reduction and internal fixation (ORIF) with anatomical plate gives the best possible opportunity to bring about near-anatomical joint surface reduction and prevention of subsequent arthritis. This article studies the functional outcome after ORIF of such fractures. METHODS: Thirty patients, having intra-articular displaced calcaneum fractures, were admitted and included in the study after obtaining valid consent and permission from the ethical committee. All the patients were investigated with X-ray and computed tomography scan and classified according to the Sanders classification system. The functional outcome after surgery was measured using the American Orthopaedic Foot and Ankle Society (AOFAS) score. RESULTS: All patients had joint depression-type fractures with a similar history of trauma due to fall from height. Out of the 30 patients, 26 were male and 4 were female. After surgery, 20 patients out of 30 had good results with a mean AOFAS score of 82.6, 7 patients had fair results with a mean AOFAS score of 70.4, while the remaining 3 patients had poor results with a mean score of 50. Postoperatively, wound complications were seen in 2 patients which settled after debridement and medications. No other complication was encountered. CONCLUSION: Open reduction and rigid internal fixation of calcaneum fractures allows anatomical reduction of fracture, restoration of joint surface, and prevention of subtalar joint arthritis and helps in early mobilization after surgery.
PURPOSE: To assess the interobserver reliability and intraobserver variability of the visual analog scale (VAS) for visualization in shoulder arthroscopy and compare it to a less variable, more objective novel grading scale, the shoulder arthroscopy grading scale (SAGS). METHODS: Twenty separate 30-s length video clips were created from a library of shoulder arthroscopies. Video clips were randomized and distributed to six sports medicine fellowship-trained surgeons at two time points with a 1-month interval. Each rated visualization according to an adapted VAS and a novel grading scale, the SAGS. RESULTS: The VAS and SAGS both showed an excellent degree of consistency with interobserver reliability among raters with intraclass correlation coefficients (ICCs) of 0.96 and 0.97, respectively. Five of six raters demonstrated strong intraobserver variability with the VAS and SAGS with ICC ranging from 0.87 to 0.97 and 0.61 to 0.93, respectively. CONCLUSION: Given the strong-to-excellent degree of consistency in using the VAS and the SAGS, either can be reliably used as a measurement of visualization in shoulder arthroscopy.
Skeletal involvements are less likely in Mycobacterium tuberculosis (TB), and it is even rarer in the hand. Flexor tenosynovitis from M. tuberculosis concomitant with median nerve involvement has been rarely reported, and it usually presents with symptoms of carpal tunnel syndrome (CTS). In this report, we introduced a patient with symptoms of CTS with rice body in the volar wrist synovium membrane and extrapulmonary tuberculosis (TB). Rice bodies were presented in synovium and histological study indicated the inflammatory granulomatous with necrosis caseous. Surgical debridement with excision of the involved synovium and irrigation was performed. Twelve-month treatment with anti-TB medication regimen was successful.
Osteofibrous dysplasia is an uncommon benign fibro-osseous lesion of childhood, more often seen in maxilla and mandible. Among a long bone, it is usually encountered in the tibia as a painless swelling or anterior bowing. Osteofibrous dysplasia mimicking exostoses has never been reported in the literature, to the best of our knowledge. Here, we would like to present an unusual case of osteofibrous dysplasia of the tibia clinically mimicking exostoses.
INTRODUCTION: The authors report a descriptive analysis of spine computed tomography (CT) scan to describe the anatomy of the laminae of T2 and T3 vertebrae. The aim of the study was to establish reference data in the adolescent population. These data could be useful to improve the effectiveness of laminar hooks. Hook-claw anchorage has been considered as one of the best choices in terms of safety and durability in the spine surgery. MATERIALS AND METHODS: We systematically reviewed CT scans of 14–16-year-old healthy individuals who underwent CT scans in other indications than scoliosis during a 2-year period. Patients with spine, chest, or bone disease were excluded. The Risser sign was ≥ 2. CT scan data were converted into a three-dimensional reconstruction. RESULTS: Seven hundred and fifty measures were collected from 30 CT scans matching with the inclusion/exclusion criteria. The mean age was 15-years old. Gender was mixed. Mean T2 lamina's upper half height was 8.9 mm (8.2–9.6) corresponding to a thickness of 7.1 mm (6.6–7.7). Mean T3 lamina's lower half height was 9.0 mm (6.9–10.4) corresponding to a thickness of 7.3 mm (6.8 à 7.9). DISCUSSION: No previous study reported these data in adolescents. Laminae in adolescents appeared to be slightly oversized in this study relative to the previous reports in adults. It seems that the intracanal part length of the hook and depth of the gorge should be adapted in order to improve fitting of the implant with laminae. CONCLUSION: This study brings new data in the knowledge of anatomical characteristics of the vertebras that should help to improve safety and stability of implants as laminar hook and hook claw.
OBJECTIVES: Injuries are the leading cause of death in the first four decades of life and the third leading cause of death among all patients. Road traffic accidents (RTAs) is the most common cause of injury in India with varied reports of mortality ranging from 7% to 45%. There are several scoring systems to evaluate the severity of injury and predict mortality. However, the reliability of injury score as a mortality predictor is challenging. The purpose of this study was to assess the cause of trauma with its epidemiological correlates and to categorize patients of trauma using the New Injury Severity Score (NISS) and Injury Severity Score (ISS) with their comparison in terms of mortality prediction in the present scenario of trauma in India. MATERIALS AND METHODS: Between October 2015 and March 2017, 5122 injured patients meeting the inclusion criteria were enrolled in this prospective longitudinal study. Data of the patients were recorded as per the working pro forma; detailed description of injury, treatment given, ISS and NISS, and ultimate outcome (mortality occurring within 30 days) was documented at the time of arrival/admission and stay at the hospital. Patients were divided into the score groups of 0–8, 9–15, 16–25, 26–49, and ≥50. The patients who were discharged or referred to a higher center were also followed up to 30 days of admission and any mortality occurring was recorded. RESULTS: Totally 5122 patients were enrolled in the study, and injuries, NISS/ISS, and outcome as mortality were documented. The overall mortality was 525 (10.25%). RTA constituted 61.56% and mortality was two times higher than that in female. Patients arriving after 24 h had the highest mortality (16.22%) and time lag had a significant effect on outcome. Sensitivity and specificity of NISS/ISS in predicting mortality was 85.5%, 63% and 61.7%, 68.3%, respectively, and the sensitivity of NISS in predicting mortality is higher than ISS whereas the specificity of NISS is similar to ISS. CONCLUSION: The major cause of trauma in India is RTA and time lag has a significant effect on the prognosis of the patient, and NISS is a better scale and should be incorporated in management protocols and TRISS methodology.
Transforaminal endoscopic lumbar spine surgery has evolved leaps and bounds in the last 10 years, and as such, it is now not limited to simple contained herniation. It can now be successfully done for central, extraforaminal, extruded, and migrated herniations, which were considered bad indications when the procedure was limited to central intradiscal nucleotomy or debulking. With better understanding of the foraminal anatomy, more bold approaches to intervertebral foramen are now being undertaken. Moreover, with further development in instruments, such as motorized burrs and lasers, we can now successfully treat the foraminal and lateral canal stenosis. With the advantages of Transforaminal endoscopic techniques, such as use of local anesthesia, minimal skin incision, no need for neuromuscular retraction, and no excessive bone removal, with minimal approach-related morbidity, allows it to be applied safely in extremes of age, with early return to normal life. The procedure of foraminoplasty is vital to achieve these extended targets in Transforaminal endoscopic surgeries. The term foraminoplasty is used among the spine endoscopists to broadly describe the expansion of the foraminal boundaries and it is reversibly used to describe foraminotomy. However, foraminotomy is performed for widening the foramen to reach far off and difficult targets, whereas foraminoplasty is performed for decompression of neural structures in the treatment of foraminal and lateral stenosis. In this article, we discuss both the procedures. To understand the principles and successfully employ the technique, let us first understand the foraminal anatomy.
INTRODUCTION: Shoulder arthroscopy can be performed under regional blocks or general anesthesia. General anesthesia using laryngeal mask airway (LMA) can be an alternative to regional techniques. Insertion of LMA within the hypopharynx mandates a depth of anesthesia apt enough to relax the jaw and obtund the laryngeal reflexes. Various adjuncts are combined with the induction agent propofol to facilitate improved insertion conditions of LMA and improved pain scores in shoulder surgeries. AIM: The aim of this study was to a comparison of insertion conditions of LMA and postoperative pain scores in shoulder arthroscopies using either intravenous (IV) butorphanol or IV fentanyl in combination with IV propofol. METHODS: A total of 100 patients scheduled for various elective surgical procedures were randomly selected and divided into two groups of 50 each, that is, Group F (propofol and fentanyl) and Group B (propofol and butorphanol). Coinduction was done in Group B with IV butorphanol (30 μg/kg) and in Group F with IV fentanyl (1.5 μg/kg). One minute after coinduction, the induction was achieved with IV propofol 2.5 mg/kg, jaw relaxation was assessed, and LMA was inserted. The postoperative pain scoring was done with visual analog scale (VAS). RESULTS: With the observations made and analyzed, we found that the LMA insertion conditions were significantly better with butorphanol (jaw relaxation [90% vs. 34%; P < 0.0001] and ease of insertion [96% vs. 66%; P = 0.0001]) than fentanyl. Comparison of average VAS score of patients postoperatively during the study showed low VAS score in both groups at 1 h, but Group B showed significantly lower score as compared to Group F. Group F showed a higher mean score of VAS at 2 h and 4 h and signified first analgesic need in the majority. CONCLUSION: The use of propofol-butorphanol combination produces excellent LMA insertion conditions as compared to propofol-fentanyl combination. Lower VAS scores due to analgesic effects of fentanyl and butorphanol contribute to painless shifting of patients undergoing shoulder arthroscopy.
Endoscopic spine surgeons bridge the major gap between fusion-oriented spinal surgeons and pain management physicians. Current surgical philosophy by traditionally trained spinal surgeons focuses on decompression with or without fusion as the “ultimate cure” for a painful spinal segment, while pain management uses spinal injections and techniques such as peripheral nerve and spinal cord neuro-modulation to relieve pain. Endoscopic surgery is the least invasive of current minimally invasive surgical options-focuses on treating the patho-anatomy of the pain generator. This represents a path between traditional open decompression with or without fusion and the more temporary techniques of pain management.
AIMS: The current orthopedic treatment of geriatric hip fracture is inadequate as per the British Orthopaedic Association guidelines and hence to know whether there is a need of orthogeriatric unit in the tertiary hospital setups in India for the management of hip fracture. METHODOLOGY: This is a retrospective cross-sectional study, held in tertiary care teaching hospital. The data of patients with age >60 years admitted with hip fracture of 2016–2017 were recorded from medical record section. Age, sex, type of fracture, total duration of admission, delay in surgery, and associated comorbidities were recorded. Patients who had undergone hip surgery electively for other hip or acetabular fracture were excluded from the study. OBSERVATION: There were a total of 81 cases of hip fracture, of which there were 39 males and 42 females. Seventy-one percent of patients were from the age group of 60–70 years. Maximum number of (54.3%), 44 Patients were having intertrochanteric fracture, followed by fracture of the neck of the femur (35 patients) and subtrochanteric fracture (7 patients). These patients were treated with bipolar hemiarthroplasty, total hip replacement, or with proximal femoral nail fixation or with dynamic hip screw fixation. Hypertension, diabetes mellitus, asthma, and hemiparesis were associated diseases. The maximum stay was 65 days, the minimum stay was 8 days, and the average stay was 13 days.The average delay between admission to surgery was 7 days, maximum of 24 days. We could not analyze the exact cause for delay due to lack of proper data in most of the cases. CONCLUSION (IMPACT OF STUDY): Hip fractures in the elderly in India are increasing and not getting the quality of care required. There is an urgent need to the implementation of orthogeriatric unit, and team approach is required to curtail the delay in treatment. This may lead to decrease in the cost of treatment, reduced postfracture morbidity, and mortality. Formation of hip fracture registry would also help us to analyze the present status of care for hip fractures in the elderly.
Spondylodiscitis is on rise due to increasing elderly population and immunocompromised people and now gets early detected due to early imaging. Percutaneous Transforaminal Endoscopic Discectomy and Drainage (PTELDD), is simple procedure that yields high culture wihich helps in specific targeted antimicrobial bombardment. Dr. Satishchandra Gore has been pioneer in introducing transforaminal endoscopy in India way back in 1999. His persistent efforts has made inroads into traditional spine care treatments and endoscopy bandwagon is flying high and many surgeons are able to give results with the technique all over India. The available english literature of transforaminal endoscopy in spondylodiscitis is reviewed here with technical note of this simplistic procedure. The reported outcome in literature is excellent in majority of cases. Authors unpublished report of 16 cases is also comparable with literature. PTELDD is a simplistic most minimalist minimally invasive procedure that gives very positive outcome in early cases of spondylodiscitis.
INTRODUCTION: In the quest for better alternatives for open transforaminal lumbar interbody fusion (TLIF), minimally invasive surgery-TLIF (MIS-TLIF) has evolved, and feasibility studies of transforaminal endoscopic fusion are also getting reported in western literature. However, the cost of instrumented expandable cage may make it non-feasible for Indian setup whenever it will be commercially available.METHODS: This is a retrospective study of 13 patients of single-level percutaneous transforaminal endoscopic decompression and cageless percutaneous bone graft TLIF with percutaneous pedicle screw fixation under combined local with epidural anesthesia. The results of all patients as measured by validated tools of visual analogue score-Back and Leg, Oswestry Disability Index, patient satisfaction index, and fusion. The operating time, Estimated Blood Loss, Length of hospital stay and tolerance of patient for procedure was also scored.RESULTS: All the outcome measures were significant (P < 0.05) and fusion achieved in all with a mean follow-up period was 39 ± 6.36 months. Operating room time was 250.23 ± 52.90 min (187–327). Postoperative LOH hospital stay was 29.92 ± 4.94 h (24–39). The tolerance score was 2.30 ± 0.85 (1–3). One superficial bone graft site infection resolved with antibiotics. CONCLUSION: It not appealing to be recommendable to general population inspite of it being low cost and with negligible complications. Further research and engineered tools are needed to reduce the operating time.
We report the case of a 66-year-old female who sustained a closed ankle fracture dislocation of her right ankle (Weber B; AO 44-B3.2). She underwent an open reduction with internal fixation, complicated with a small, superficial wound dehiscence during the initial follow-up. One month after surgery, she developed inflammatory signs on her right ankle, but disregarded them. One week later, she was admitted into the emergency department with infection of her ankle's osteosynthesis, and a necrotizing fasciitis of her left upper limb, neck, and thorax. The patient underwent multiple surgical interventions for the removal of osteosynthesis hardware, fasciotomies, consecutive debridements, and finally a below-the-knee amputation. Streptococcus pyogenes was identified in several cultures as the responsible agent, and directed antibiotic treatment was performed. However, despite all treatments, the patient's clinical status progressively worsened until she eventually deceased, 1 month after admission.
Symptomatic lumbar facets manifest as low back pain located paraspinally of varying intensity. The pain may increase with extension and rotation and can be well localized or diffuse and associated with extension lag on prolonged sitting. This pain can be easily identified by facet or medial branch block and then treated by ablating under vision this medial branch. Results are gratifying and can delay need for fusion in patients.
OBJECTIVE: The objective of the study is to generate reference values of bone mineral density (BMD) in north Indian population using phantomless quantitative computed tomography (QCT). MATERIALS AND METHODS: Bone mineral densities were generated from the computed tomography (CT) scans of 691 patients (390 males and 301 females, ages 11–85 years) who underwent CT of the abdomen or thorax for indications unrelated to bone diseases. The individuals were divided according to age groups from 11–15 to 80–85 years. BMD was calculated by phantomless QCT software by assessing L1 and L2 vertebrae. RESULTS: For females, the maximum BMD was observed for the age group of 21–25 years (144.67 mg/cc). The overall bone loss per year from 26 to 85 years was 1.62 mg/cc. Greater bone loss was seen from ages of 36–55 years which was 2.18 mg/cc. With bone loss per year being 0.99 mg/cc in ages from 26 to 35 years and 1.41 mg/cc from 56 to 85 years. Regression analysis gave a better fit using third order polynomial of age than did a linear regression line. For males, the maximum BMD was observed for the age group of 21–25 years (147.67 mg/cc). The overall bone loss per year from 26 to 85 years was 1.2 mg/cc. Regression analysis gave the best fit using linear regression. CONCLUSION: In the study population, the males show a linear relationship between age and BMD with continuous bone loss after the age of 25 years while females demonstrate a more complex relationship between age and BMD with accelerated bone loss in perimenopausal age group.
