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Introduction: The posterolateral tibial plateau fractures remain a challenge and usually a tough nut to crack even for experienced surgeons. The proximity of the neurovascular structures and difficulty owing to the presence of the fibular head demands surgical skills and expertise. The purpose of this study is to understand the technical difficulties such as difficult exposure, limitation of distal extension of approach, limited implant choices. Material and Methods: 14 consecutive cases of isolated posterior fractures of the posterolateral tibial plateau were operated with a modified posterolateral approach without exposing the CPN between September 2016 and September 2019. Articular reduction quality was assessed according to the intraoperative fluoroscopy and immediate postoperative radiographs. Patients were followed up at 2 weeks, 4 weeks, 2 months, 4 months and 6 months. International knee score was assessed online, at the end of 6 months. Results: All patients were followed up, with a mean period of 8 months (range 25–40 weeks). Bony union was achieved in all patients. The average range of motion arc was 126° (range 110°–135°) and the mean postoperative IKS was 94.2 (range 81–97) at 6 months follow-up. None of the patients sustained neurovascular complications. Conclusions: The modified posterolateral approach could help to expand the surgical options for optimal treatment of this kind of fracture, and plating of posterolateral tibial plateau fractures would result in restoration and maintenance of alignment. This approach demands precise knowledge of the anatomic structures of this region but the results are gratifying.

Background There is paucity of literature on early tendon transfer in surgical rehabilitation of hands with median nerve injuries. Since the single most important functional deficit in median nerve palsy is the loss of thumb opposition, we evaluated the results of early tendon transfer in restoration of thumb opposition. Methods This prospective study involved 10 cases of isolated median nerve paralysis (axonotmesis or neurotmesis) that underwent early tendon transfer for restoration of thumb opposition. A pre- and post-operative evaluation in terms of power and precision grip strength and range of opposition of thumb was done. Median nerve exploration was performed in 4 cases and was supplemented by a tendon transfer for thumb opposition. The extensor indicis proprius (EIP) opponensplasty was performed in nine out of ten cases. In one case where the patient had scarring over the EIP tendon, palmaris longus (PL) opponensplasty was performed. Results The median age at injury was 29 years (range; 8 years–57 years). Minimum period of follow-up was 6 months. Six patients who underwent EIP transfer had excellent opposition while 3 had good opposition. The patient, in whom PL opponensplasty was done, had an excellent opposition. The median time for return to work was 2.75 months. There was significant improvement in the power grip and all three types of precision grip at 6 months follow-up. The percentage deficit in the affected hand compared to the normal hand was significantly reduced. There was no case of tendon pull out in our study, nor did any of our patients have an extensor lag following EIP transfer. Conclusion Early tendon transfer has a unique role in the management of median nerve palsy hand and we suggest this procedure should be considered in both high and low lesions.

Distal radius fracture is usually associated with ulnar styloid fracture. Whether to fix the ulnar styloid or not remains a surgical dilemma as some surgeons believe that their repair is imperative while others feel that they should be managed conservatively. This prospective study involved 47 patients with unilateral fracture of the distal radius who met the inclusion criterion and underwent open reduction and internal fixation with volar locking plates; 28 patients (12 males and females = 16) had an associated ulnar styloid fracture (Group A) while 19 (7 males; 12 females) did not have any ulnar styloid fracture (Group B). At the time of final evaluation both the groups were compared clinically by measuring the grip strength and range of motion around the wrist and the radiologically by measuring radial angle, radial length, volar angle and ulnar variance. Subjective assessment was done using DASH score and final assessment using Demerit point system of Saito. In Group A, average time for consolidation was 9.4 weeks, 17 patients developed non-union of the ulnar styloid, average DASH scores was 4.4 and according to Demerit point system of Saito, there were 78.5 % excellent, 17.9 % good and 3.6 % fair results; there were 2 cases of loss of reduction out of which one had persistent ulnar sided wrist pain. In Group B the average time for consolidation was 10.2 weeks, average DASH score was 3.8.and Demerit point system of Saito yielded 78.9 % excellent, 15.8 % good and 5.3 % fair results. There was one case of loss of reduction and one case of carpal tunnel syndrome which was managed conservatively. Both groups attained excellent range of motion, grip strength and well maintained the post operative radiological parameters. The comparison of clinico-radiological parameters in both groups was found to be statistically insignificant. To conclude, ulnar styloid fracture or its non union does not affect the outcome of an adequately fixed distal end radius fracture. We urge caution in electing operative treatment of non-united fracture of the ulnar styloid until better scientific report for treatment of pain associated with these fracture is available.

Trapping of fingers in metallic bands is a commonly encountered situation. The children, elderly people, and psychiatric patients are the usual victims. The constricting object in the digit causes obstruction to lymphatic and venous drainage leading to oedema distal to the constriction, which leads to further neurovascular compromise and presents as a surgical emergency. A 7-year-old boy presented to us with his right middle finger being stuck in a steel door latch. Multiple attempts were made to remove the trapped finger with conventional methods, and subsequently, it was removed by electric-driven metal cutting saw, which was not previously described in medical literature to the best of our knowledge.

Purpose. To review outcome of early reimplantation for open total talar extrusion in 7 patients. Methods. Medical records of 5 men and 2 women aged 19 to 53 years who underwent reimplantation for open total talar extrusion within 6 hours after road traffic accident (n= 6) or industrial injury (n=1) were reviewed. The talus was first irrigated with 9 to 10 litres of saline solution, followed by 10% povidone iodine. It was then reduced after thorough debridement and fixed with tension band wiring or external fixation. Ankle mobilisation exercises were started at week 6 and full weight bearing at week 14. Outcome was assessed using the American Foot And Ankle Society score. Results. After a mean follow-up of 31.9 (range, 24–46) months, the mean American Foot and Ankle Society score was 81, and the mean dorsiflexion-plantar flexion arc was 36.9° (range, 25°–45°). All patients were able to walk with a balanced, unaided gait with mild-to-moderate pain (n=3) or pain-free (n=4). No patient developed deep infection or instability. Three patients developed avascular necrosis of the talus; restriction of motion was moderate at the ankle joint and severe at the subtalar joint. None of these 3 patients opted for revision surgery, as the pain was tolerable and did not limit their daily activities, but their condition was expected to deteriorate with time. Conclusion. Early reimplantation is recommended for open total talar extrusion, as it restores (to some extent) hind foot mechanics, heel height, and bone stock for activities of daily living and future reconstructive options.

Background Since complete functional restoration after spinal cord injury may not always be possible, the major focus in such cases has to be on rehabilitation. We performed surgery in such patients to reconstruct important absent hand functions viz. pinch and hook using various methods described in literature and compared their outcome. Methods A total of 29 procedures were performed in ten patients (18 upper limbs) with tetraparesis consequent to cervical spine injury distal to C6 level who had at least grade 3 power of elbow extension but had not documented any significant improvement in hand function, at least 6 months post injury. Key pinch was reconstructed in 14 upper limbs using brachioradialis (BR) to flexor pollicis longus (FPL) transfer in 11 and pronator teres (PT) to FPL transfer in three limbs. Hook was reconstructed in 15 upper limbs: PT to flexor digitorum profundus (FDP) ( n=7), BR to FDP ( n=2), and FDP tenodesis ( n=6). The gains achieved were measured at intervals of 4 weeks, 3 months, and 6 months postoperatively and at a final possible follow-up of every patient, the average follow-up being 32 months. The functional outcome was assessed by the modified Lamb and Chan score. Results For key pinch reconstruction, both BR and PT turned to be equally efficacious donors, while for hook reconstruction, PT and BR transfer to FDP turned out to be superior to FDP tenodesis. The functional outcome as assessed by the modified Lamb and Chan score revealed good to fair outcome in 70 % of patients while poor in 30 %. Complications resulted from stretching of transfer, rupture of tenodesis, and maltensioning. Conclusion Surgery can routinely be offered to suitable tetraplegics with deficient hand function in whom no useful recovery of any function is expected with at least 6 months elapsed post injury. Single-staged bilateral procedures enable maximal possible rehabilitation in minimal possible duration.

【Abstract】Dynamic hip screw fixation is a com-monly performed procedure for internal fixation of intertro-chanteric femoral fractures. Arterial injury following the operative fixation is a rare but serious event. We present a patient who developed pseudoaneurysm of profunda femo-ris artery after internal fixation of intertrochanteric fracture with a dynamic hip screw. The diagnosis was confirmed by angiographic study and it was successfully treated by coil embolization. Key words: Hip fractures; Bone screws; Arteries; Aneurysm, false

Background: Osteoarthritis of knee is a chronic degenerative joint disease which leads to pain, swelling and stiffness. Intra-articular hyaluronic acid or steroids are being used for its treatment. The purpose of the present study was to assess the effect of intra articular hyaluronic acid in comparison to steroids for knee osteoarthritis.Methods: A prospective randomized study including 70 patients (121 knees) diagnosed with osteoarthritis of knee, were randomly divided into two groups: 35 patients (58 knees) were given intra-articular hyaluronic acid and 35 patients (63 knees) were given intra-articular methylprednisolone. The outcome was evaluated with knee society score (KSS) and visual analog scale (VAS) before the injection and 1, 3 and 6 months after the injection.Results: The mean KSS pain and function scores increased while VAS decreased in both the groups. All the scores showed improvement at 6 months follow up. In both the groups, the scores at 6 months were significantly better than the pre injection values, and the scores of hyaluronic acid group were significantly better compared to steroid group.Conclusions: Intraarticular hyaluronic acid seems to be better for long term pain relief and preservation of function in comparison to intraarticular steroids in osteoarthritis of knee.

Background: Chronic plantar fasciitis is often a difficult to treat entity and platelet-rich plasma (PRP) is an upcoming modality instead of steroid in chronic cases of plantar fasciitis resistant to traditional non-operative management.Methods: Sixty patients with chronic plantar fasciitis were prospectively randomised into 2 groups and treated with either a single injection of 3 cc PRP or 40 mg DepoMedrol (Cortisone) injection and followed for a year. Immediately prior to PRP or cortisone injection American Orthopedic Foot and Ankle Society (AOFAS) hind foot scoring was done for all patients. These scores were repeated at 6 weeks, 6 months and 12 months.Results: Six weeks evaluation of AOFAS after PRP and corticosteroid administration, the mean visual analogue scale (VAS Score) showed a significant increase in corticosteroid group (4.2) as compared to PRP group (5.8). But, the PRP group (1.8) showed significant improvement in mean VAS scores as compared to Steroid group (3.4) after a year of the treatment. Similarly, the AOFAS score improved significantly in the steroid group (64.4) at 6wks as compared to the PRP group (52.2) but at 12 months however, the PRP group sustained its effect with a mean AOFAS score of 92.2 while in the steroid group, the score dropped to a mean of 78.4.Conclusions: PRP was more effective than steroid for the long term treatment of chronic plantar fasciitis. Level of Evidence: Level I, prospective randomized comparative series.

Background: The purpose of this study is to evaluate neurological, functional and radiological outcome of the anterior reconstruction of spine by posterior approach in cases of unstable thoracolumbar burst fractures.Methods: Ten patients with acute unstable burst fractures at thoracolumbar junction (T-11 to L-3) with partial or complete neurological deficit in the age group of 18-50 years with McCormack’s score six or more and thoracolumbar injury severity score (TLISS) five or more were included. Neurological status, Japanese Orthopaedic association score (JOA score), visual analogue scale (VAS), angle of kyphotic deformity, McCormack’s score and TLISS score were evaluated.Results: The mean duration of surgery was 282 minutes. The mean blood loss was 1885 ml. Five patients with neurologic deficit recovered an average of 1.40 ASIA grades at last 24 months’ follow-up. The JOA score improved from -6 preoperatively to 11 at 24 months follow up. The mean kyphotic angle was 19 degrees preoperative improved to -0.6o postoperatively. Visual analogue score improved from 6.1 to 1.7.Conclusions: The familiar posterior approach is a safe and reliable surgical approach for reconstruction of all the columns of spine. It has the advantage of doing anterior decompression and reconstruction with posterior instrumentation in single stage, reducing the operative time and blood loss. It reduces the morbidity of anterior approach (isolated or two staged) in the hands of an average orthopaedic surgeon.

Background: Multimodal periarticular cocktail injection (MPCI) containing local anesthetics, adrenaline, and anti-inflammatory agents such as NSAIDS have been promising in terms of quick functional recovery. This study evaluates the efficiency of steroid as a component of MPCI in knee arthroplasty.Methods: This is a prospective, double-blind, RCT where 36 patients with osteoarthritis were included and randomized to receive MPCI either with steroid or without steroid. Pain was evaluated by visual analogue scale (VAS) at preoperative and postoperatively at rest, and during activity. The range of motion of the knee was looked for in a similar way. The amount of NSAIDs and the duration of NSAID usage were noted till the last follow-up.Results: Both non-steroid and steroid groups were similar with regard to VAS at rest and during activity, or range of motion, at all postoperative observations. The postoperative knee society knee score in the steroid group improved significantly as compared to that in non-steroid group at the one-month (84.1±13.1 and 65.9±12.1; pConclusions: The Study validates usage of steroid in MPCI due to faster rehabilitation and less consumption of NSAIDs and no additional risk of post-operative complications.

BACKGROUND: Indiscriminate use of intra-operative fluoroscopy can incur harm both to the patient as well as the surgeons. Orthopedic surgeons seldom do in skin marking prior to cleaning and draping of the operative site. This study aims to study the feasibility and utility of pre-operative skin marking with henna in conjunction with marker radiograph.METHODS: Out of 54 patients undergoing spine surgery, vertebral level localization was done by fluoroscopy in 26 patients. In the rest of the 28 patients, preoperative marker radiograph with steel wires was taken in conjunction with henna line markings on the skin. These were correlated for vertebral level localization. Difference in time taken for vertebral localization by these two methods, and the difference in the number of fluoroscopic images required was observed and recorded.RESULTS: Approximately 4 minutes were needed for level localization via fluoroscopic technique, whereas the henna marking technique did this in approximately 30 seconds. No adverse effects of henna application were observed during the study.CONCLUSIONS: The use of preoperative skin marking with henna along with the appropriate marker radiograph can reduce the surgical time and radiation exposure without increasing the chances of a wrong level surgery in the spine.

Background: Spontaneous epidural haematoma is a rare clinical presentation and may be associated with coagulation disorders. These hematomas present usually with rapidly developing paraparesis and any delay in diagnosis may be disastrous.Methods: We included five patients of spontaneous epidural hematomas in hemophilia A with neurological deficit. They were treated non-operatively with factor VIII replacement therapy with oral tranexamic acid and intravenous dexamethasone as per protocol. All patients were followed up for 6 months and assessed for signs of neurological recovery and radiological resolution of hematoma.Results: All patients had complete motor recovery within 3 months of initiating treatment and showed resolution of hematoma on MRI. Conclusions: Prognosis following early initiation of correction of factor deficiency is good.

Osteochondromas are the most common benign tumours of the bone. They are solitary or multiple, pedunculated or sessile exophytic outgrowths from the bone surface that are composed of cortical and medullary component with an overlying hyaline cartilage cap. Marrow and cortical continuity with the underlying parent bone is the characteristic of the lesion; they mostly arise from the metaphysis of the bone. Osteochondromas arising from the diaphysis are rare; and nerve palsy arising in the setting of a diaphyseal osteochondroma is even rarer. This is a report of solitary osteochondroma arising from diaphysis of left humerus in a 10 years old boy, which resulted in median nerve palsy. Surgical excision relieved the symptoms completely. The aim of this case report was to draw attention to an unusual etiology of median nerve palsy caused by an osteochondroma arising from the diaphysis of humerus which is a rare site, and to emphasize its importance.