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BACKGROUND: Infrapatellar branch of the saphenous nerve lies subcutaneously and supplies the anterolateral aspect of knee below the patella. It is extremely susceptible to iatrogenic injuries during the surgeries around the knee, mainly total knee replacements (TKRs). Post operatively the patients present with localised area of numbness and in some instances a traumatic eczematous reaction termed autonomous denervation dermatitis (ADD) is witnessed, leading to skin manifestations that range from a simple rash to extensive lesions. METHODOLOGY: A review of literature was conducted with search of relevant articles from Medline (PubMed), Embase, and Scopus which discussed eczematous skin lesions secondary to total knee replacements. Additionally, we noted studies which described these lesions in other surgeries around the knee like arthroscopies and fracture fixations. RESULTS: Eight studies including atleast one case after TKR were reviewed. There was only one cohort study while the remaining included case reports and small case series. There were 69 cases of ADD appearing after TKR. The appearance of the skin lesions was lateral to the incision in 30/34 operated knees and on both sides of the incision in four knees after TKRs. Bilateral lesions were seen in only six patients of TKRs. There was no functional limitation caused by these lesions and they resolved either spontaneously or after using topical steroids. CONCLUSION: ADD is a relatively uncommonly reported complication of TKRs, which can reduce patient satisfaction and increase surgeon apprehension. Although all cases of nerve damage do not manifest as cutaneous lesions, steps to minimise the damage to the nerve intra operatively should be taken. The diagnosis requires a high index of suspicion, and should not be dispelled as a simple allergic reaction without adequate investigations. Patients should be counselled to alleviate unnecessary fear and apprehensions.

Involvement of toe phalanges by giant cell tumor (GCT) is extremely rare; tumors in these locations tend to be aggressive. Whereas aggressive GCTs of the distal phalanx may be managed successfully by en-bloc resection without reconstruction or amputation, management of these lesions, when they involve the proximal phalanx, can be challenging. We present a Campannaci grade III GCT of the hallucal proximal phalanx in a 14-year old girl that had breached into the dorsal soft tissues and the metatarso-phalangeal joint. Wide local resection of the proximal phalanx along with reconstruction arthrodesis with an autologous, non-vascularized fibular strut graft was performed. There was no recurrence at 3 years of follow-up. The patient had an excellent functional outcome. To the best of our knowledge, this is the first case reporting the outcomes of fibular strut arthrodesis for salvage of GCT of the hallucal proximal phalanx.

Background Regeneration potential of Hamstring tendons after harvest assumes significant clinical relevance as its use has become widespread today. Methods which best assess the regeneration, extent and type of regeneration, plus issues related to functional loss are important for the surgeon to know. This review looks at the literature to find answers to the above questions. Purpose To summarize the evidence in support of hamstring tendon regeneration, and the most appropriate modality for evaluation of regeneration. Additionally, to evaluate the regeneration in terms of complete or partial, extent and its impact on strength deficit and functional outcomes. Methods We did a systematic review of literature through specified search engines and identified 30 of 285 studies to be relevant (19 prospective and 11 retrospective). Results Evaluation of above data suggests tissue regeneration at harvest sites does occur (78.9% of semitendinosus and 42.7% of gracilis tendons), but this regeneration is variable. No established definition of regeneration exists; MRI is an adequate tool to identify regeneration, while biopsy is confirmative. USG is a cost-effective screening method and can document distal progress of regenerate. Semitendinosus and gracilis tendons regenerate at different rates and extents, and often fuse together, but there is no evidence to state that one regenerates better than the other. Proximal retraction of the muscle-tendon junction occurs, along with some atrophy, which affects function to a variable extent. Strength deficits may persist, but they may not convert to significant functional deficits. Conclusion There is variable hamstring regeneration after harvest, with poorly defined definition of “regeneration”. Some changes in the muscle itself, abnormal distal insertion and absence of regeneration in some are documented, along with strength deficits. Although overall functional deficits have been reported to be minimal, a definite change in the anatomy of the medial hamstrings is a factor to be kept in consideration. More information is needed about the long-term consequences.

Background Primary amputation below the level of the knee joint is the most frequently performed amputation following trauma; however, data about incidence, patient profiling, and causative factors are seldom available in India. Objective To evaluate the profile and incidence of trauma-related amputations below the level of the knee joint at a level 1 trauma center. Methods An observational study over six months was conducted at a level 1 trauma center of north India. Epidemiological data such as age, sex, occupation, socioeconomic status, mechanism of injury, time of surgery, single or staged procedure, and complications were recorded from the admission files. Observations 125/3047 (4.1%) trauma patients underwent amputation, of which 32.8% (41 of 125) had amputation below the level of the knee joint. Unilateral transtibial amputation was the most common (85.3%) involving 40/41 males with a mean age of 37.2 years of low socioeconomic status. Road traffic accidents were the most common cause (85.36% of cases). 39 of 41 cases presented within 24 h of injury and underwent surgery within 24 h of presentation. Secondary surgery was needed in 24.4% of the patients and revision amputation was done in only 2.4% (n = 1/41). No patient developed medical complications, and the average hospital stay was 8.7 days with a range from 2 to 14 days. Conclusion We have documented a significant amputation rate in trauma cases (4.1%) reflecting on the seriousness of patients seen at our center. Most patients are young males at the peak of their productive lives, and from low socioeconomic status. Road Safety is essential, and specialized services for the amputees may be the need of the hour.

Background A mysterious cluster outbreak of pneumonia in Wuhan, China in December 2019 was traced to Severe Acute Respiratory Syndrome Coronavirus 2 and declared a Pandemic by WHO on 11th March 2020. The pandemic has spread rapidly causing widespread devastation globally. Purpose This review provides a brief understanding of pathophysiology, clinical features, diagnosis and management of COVID-19 and highlights the current knowledge as well as best practices for orthopaedic surgeons. These are likely to change as knowledge and evidence is gained. Results Orthopaedic surgeons, like other front-line workers, carry the risk of getting infected during their practice, which as such is already substantially affected. Implementation of infection prevention and control as well as other safety measures for health care workers assumes great importance. All patients/visitors and staff visiting the hospital should be screened. Conservative treatment should be the first line of treatment except for those requiring urgent/emergent care. During lockdown all elective surgeries are to be withheld. All attempts should be made to reduce hospital visits and telemedicine is to be encouraged. Inpatient management of COVID-19 patients requires approval from concerned authorities. All patients being admitted to the hospital in and around containment zones should be tested for COVID-19. There are special considerations for anaesthesia with preference for regional anaesthesia. A separate Operation room with specific workflow should be dedicated for COVID-19 positive cases. Conclusions Despite the magnitude of challenge, the pandemic offers significant lessons for the orthopaedic surgeon who should seek the opportunity within the adversity and use this time wisely to achieve his/her Ikigai. Electronic supplementary material The online version of this article (10.1007/s43465-020-00135-1) contains supplementary material, which is available to authorized users.

The management of Osteoporotic ankle fractures is still considered to be a challenge by many surgeons. One of the issues seems to be a lack of data focused on this special subgroup, with very little evidence of good quality. We did a narrative review of the literature in an attempt to identify the magnitude of the problem and to evaluate the evidence in support of management options. The current review of the literature has brought to light some interesting facts. Despite limited data there seems to be an in increase in the incidence of these fractures. Although we could not demonstrate any clear distinction between geriatric and osteoporotic ankle fractures from the available literature; it is clear that all geriatric fractures are not necessarily osteoporotic and neither is the reverse true. The evidence to associate osteoporotic ankle fractures with poor outcomes is weak, and factors other than osteoporosis may have a stronger influence. From this analysis, we could not establish a higher incidence of implant failure for this specific fracture group, although many modifications in technique have been proposed due to the fear of fixation failure. Hook plating and Tibia-pro fibula fixation have weak evidence in support, but posterior fibular plating is preferred due to soft tissue protection. There is weak evidence in support of Locking plates for these fractures, as publications focused on this are limited; nevertheless some advantages have been documented. Augmentation by calcium based bone graft substitutes has been reported to improve pull out strengths of screws, but again the evidence of its role in Osteoportic fractures is limited. Fibular nailing has been proposed with specific advantages in osteoporotic fibular fractures, but the concept is new and it is indicated only in a select a subgroup of cases. Some evidence exists for the use of trans-articular nails in geriatric subgroups with limited pre-injury mobility, but the technique has to be used with caution to prevent other complications. Inference More data needs to be accumulated before clear guidelines for management of osteoporotic ankle factures are defined; however the current literature supports the need for modifications in standard ankle facture fixation methods to improve outcomes.

Lisfranc injuries may occur in the form of fracture-dislocations or pure ligamentous dislocations or subluxations. These innocuous appearing injuries have the potential for significant morbidity and long-term sequelae resulting in permanent deformities. Ligamentous subluxations account for 20% of these injuries and cases with partial incongruity are amenable to percutaneous fixation. In this article, we present step-by-step percutaneous fixation of these injuries as well as the post-operative management.

Calcaneus malunion is a common sequela to calcaneal fractures and is a cause of pain and discomfort. Multiple approaches have been described to address the subtalar joint and the lateral wall. Type 2 malunion is the most commonly encountered problem, and is usually addressed by the sinus tarsi approach. This has some limitations, as exposure for lateral wall excision beneath the peroneal tendons maybe a problem. We have slightly modified the sinus tarsi approach by a more horizontal skin incision, which may even be extended proximally by 1–2 cm; this allows access to the lateral wall on either side of the peroneal tendons. The approach is described in detail.

Background There are few studies in the literature that correlates the level of IL-6 with fat embolism syndrome (FES). But there is no conclusive correlative evidence of its specific relation to the establishment of FES. Also it is a proven fact that polytrauma due to its associated multiple long bone fracture and/or associated shock can predispose an individual to FES. By hypothesizing that polytrauma induces Fat Embolism in the animal; it was considered worthwhile to study the association of IL-6 in polytrauma induced Fat Embolism (FE) and to compare it with induced FE by injecting fatty acids in rabbits. Materials and methods An animal study was conducted in 32 New Zealand white rabbits. The animals were divided into 3 groups: control, fat embolism and polytrauma group. We injected 6 ml of normal saline and 0.2 ml of linoleic acid in the control and fat embolism group respectively. In the polytauma group we created bilateral femur and tibial shaft factures which were stabilized with intramedullary K- wires. Blood was taken before and at 6, 12 and 24 h after the procedure to measure plasma IL-6 levels. The rabbits were euthanized at 24 h and lungs were removed and stained for fat globules. Results All rabbits in the fat embolism group and around 72.22% rabbits in polytrauma group had fat embolism. The IL-6 levels were raised in all the groups reaching a peak at 6 h after procedure with a decline in the values at 12 h for polytrauma and fat embolism group. IL-6 in the control group was stationary after an initial raise at 6 h. There was no statistically significant difference seen among the groups (p value > 0.05) at 6 h. Conclusion IL-6 is not a specific marker to fat embolism per se or polytrauma who later develop complications like FES. Even though the recent literature says that IL-6 is an early marker of fat embolism, still the diagnosis of fat embolism syndrome is clinical only and can be supplemented by laboratory markers. None of the laboratory markers individually is good enough to predict the development of FES in an individual.

The rising incidence of mangled extremity seen in modern trauma has lead to significant patient mortality. A lot of research is going on at microcellular level for a better understanding of tissue injury, repair and regeneration. PAX-7 is one such transcription factor, a marker of satellite stem cells in skeletal muscle. Though few studies have shown concrete evidence of increased expression of PAX-7 in the nearby injured zone in skeletal muscle post-injury, none has studied its expression in an event of mangled injury of limb in humans. We, hereby, attempted to identify whether PAX-7 expression of tissue near the zone of injury, after grievous trauma like mangled injury of extremities, actually increases, decreases or remains unaffected. A pilot study was conducted on 30 cases at a level 3 trauma centre; patients were segregated into two groups—group I with MESS score ≥ 7 and group II with score

Resumo Justificativa e objetivos O alivio inadequado da dor apos a reconstrucao do ligamento cruzado anterior afeta a mobilidade, leva ao desenvolvimento de aderencias, insercao do ligamento enfraquecido e atrofia muscular. O bloqueio do canal adutor para analgesia pos‐operatoria preserva a forca do quadriceps. O presente estudo foi feito para comparar o periodo sem dor em pacientes de reconstrucao artroscopica do ligamento cruzado anterior, submetidos ao bloqueio do canal adutor guiado por ultrassom com ropivacaina isolada e ropivacaina + clonidina. Metodos Um estudo prospectivo, randomico e duplo‐cego foi conduzido com 63 pacientes adultos, estado fisico ASA I–II, submetidos a reconstrucao do ligamento cruzado anterior. Os pacientes foram randomizados em tres grupos: Grupo S, que recebeu bloqueio do canal adutor com 30 mL de solucao salina para controle; Grupo R, que recebeu bloqueio do canal adutor com 30 mL de ropivacaina a 0,375%; Grupo RC, que recebeu bloqueio do canal adutor com 30 mL de ropivacaina a 0,375% e 1 μg.kg−1 de clonidina. O desfecho primario do estudo foi comparar o periodo sem dor nos pacientes que receberam bloqueio do canal adutor com ropivacaina isolada ou ropivacina + clonidina. Os desfechos secundarios foram escores de dor em repouso e movimento, necessidade total de analgesicos, escore de sedacao, alem de nausea e vomito no pos‐operatorio. Resultados Os periodos medios sem dor foram 20 min, 384,76 min e 558,09 min para os grupos S, R e RC, respectivamente, e essa diferenca foi estatisticamente significativa (p Conclusao A adicao de clonidina a ropivacaina em bloqueio do canal adutor guiado por ultrassom levou a um prolongamento significativo do periodo sem dor, embora os escores de dor em repouso e movimento, e a necessidade de analgesico de resgate, nao tenham diferido.

Introduction COVID-19 has emerged as a medical threat to mankind, with a serious disruption of lifestyle in 2020. This has not only changed the way we live and work but has also changed the pattern of hospital admissions and medical care. To see if there was significant change in the pattern and management of trauma in our region, we evaluated data from our centre for the lockdown period and compared it with data from the previous year, and also with some available international data. Methods We collated data from our Tertiary care hospital for two periods, i.e. from 25th March 2020 to 3rd May 2020 signifying strict lockdown and then from 4th May to 31st May during which some conditional relaxations were given. This was compared to data from similar periods in 2019. We looked at patient demographics, fracture types, injury mechanisms, and even changes in treatment protocols. Results Significant reductions in caseloads were noted; open injuries were less, road accidents were infrequent, but cases due to falls, especially children and the elderly were still seen, although slightly reduced. The plan to minimize operative interventions could not be fully implemented due to complex nature of trauma seen by us. Only one case of bilateral amputation turned out to be positive, with no infectious consequences to the treating staff. Conclusions COVID-19 pandemic led to significant reductions in trauma caseload and change in injury patterns. Doctor responses and patient management needs significant alteration to prevent spread of disease.

Background: Osteogenesis imperfecta (OI) is a genetic connective tissue disorder characterized by skeletal deformity and increased risk of fracture. Independent mobility is of concern for OI patients as it is associated with the quality of life. The present study investigates the variation of kinetic and kinematic gait parameters of type IV OI subjects and compares them with age-matched healthy subjects. Materials and Methods: Gait analysis is performed on five type IV OI patients and six age-matched normal subjects. Spatiotemporal, kinematic, and kinetic data are obtained using Helen Hayes marker placement protocol. Results: The results indicate an imprecise double-humped profile for vertical ground reaction force (GRF) with reduced ankle push off power and walking speed for OI subjects. Moreover, a comparison of vertical GRFs in OI subjects with that of healthy subjects suggests lower values for the former. The results encourage and motivate for further investigation with a bigger set of subjects. Conclusion: This information may be useful in developing a better understanding of pathological gait in type IV OI subjects, which ultimately helps the design of subject-specific implants, surgical preplanning, and rehabilitation.

Background: Minimally invasive surgery (MIS) has a significant and evolving role in the treatment of displaced intra articular calcaneal fractures (DIACFs), but there is limited literature on this subject. The objective was hence to assess the clinicoradiological outcomes of DIACFs fixed with an innovative open-envelope MIS technique. Materials and Methods: 42 closed Sanders Type 2 and 3; DIACFs were included in this study. The Open-envelope approach was developed, which is essentially a limited open, dual incision, modified posterior longitudinal approach allowing excellent visualisation and direct fragment manipulation. The main outcome measures were American Orthopaedic Foot and Ankle Score (AOFAS) hindfoot score and preoperative and postoperative radiological angles. Results: The Bohler angle improved from a preoperative mean of 14.3° (range 0°–28°) to a postoperative mean of 32.46° (range 22°–42°). The Gissane angle improved from a preoperative mean of 135.83° to a postoperative mean of 128.33°. The postoperative improvement in Bohler and Gissane angles was highly significant (P < 0.001). The AOFAS scores at 6 months were excellent in nine patients, good in 15 patients, and fair in six patients. Three patients had residual valgus deformity of the heel. Conclusions: Open-envelope technique minimized soft tissue complications and achieved acceptable radiological reductions with good clinical outcomes.

The purpose of this study was to evaluate the effect of physiotherapeutic intervention to improve the deviated balance of pregnant women.A total of 174 subjects were included in the study out of which 62 had postural deviation. They were divided into three groups, two intervention groups and one control group. The target population consisted of women in the antenatal stage, randomly selected from Obstetrics and Gynecology OPD, PGIMER, Chandigarh. The study was conducted over a period of 3 years (2014-2017). They were advised exercises, postural correction, regular walking, and hot water fomentation. Six follow-ups were taken into consideration throughout the pregnancy and postnatal stage.The impact of the intervention package on both ante-natal and postnatal women with balance problems showed significant improvement.Postural deviations, pain, heaviness in the lower limb, incontinence, breathlessness, etc., are common complaints during and after pregnancy. The problem starts early in pregnancy and increased over time and may persist throughout life if treatment does not start early in the pregnancy. This intervention can be practiced in primary care setting after giving proper training to the health care workers by experienced physiotherapists.

The anterior end of calcaneum fractures can present as inversion injuries, stress fractures or as a part of displaced intraarticular calcaneum fracture. Rarely, these may occur due to abduction injury from a laterally directed force that crushes the anterior calcaneum instead of the cuboid, and has associated medial column injuries which are unrecognized. Compression fractures of the anterior calcaneum are actually lateral column shortening injuries with poor outcomes in the few published reports. We describe three patients with compression fractures of the anterior end of calcaneum resulting from foot abduction injury which were managed by reduction and column length restoration via distraction by external fixator. All three fractures showed good to excellent outcomes using the American Orthopedic Foot and Ankle Society midfoot score at followup >1 year. Awareness of this injury pattern is important, and appropriate measures to reduce and maintain the fracture reduction are needed to avoid long term disability.

In the modern era, rehabilitation after sports injury has become a domain for specialists, and its evolution has necessarily brought together the sports physiotherapist, the sports physician, and the orthopedic surgeon. The changing profile of sports related injury, as well as limited availability of facilities for rehabilitation in many areas of India, is a matter of concern. Elite sportspersons have some protection, but the average athlete is often left to fend for himself. Key factors in successful sports injury rehabilitation protocols are the application of modern rehabilitation protocols under appropriate supervision, appropriate and well timed surgical interventions, and judicious and need based use of pharmaceutical agents. Modern rehabilitation protocols emphasize teamwork and proper rehabilitation planning, and the rehabilitation team has to be lead by a trained sports physiotherapist, with an understanding of the protocols and interventions required at various stages. Injury specific rehabilitation protocols are being practiced worldwide but need to be introduced according to the nature of the sport as well as available facilities. Even in India, sports physicians are increasingly joining specialist rehabilitation teams, and they can help with medication, nutritional supplements, and specialized tests that could improve injury understanding. Inputs from surgeons are mandatory if surgical interventions have been performed. What is often missing in the underdeveloped world is psychological support and a clear understanding by the athlete of his/her rehabilitation protocols. World over, the primary aims are safe return to sports and minimizing reinjury on return to sport; this involves rehabilitation in stages, and current methodology clearly demarcates acute and chronic phases of injury. Close coordination with trainers and coaches is mandatory, and all need to understand that the reconditioning phase is crucial; skill assessment before progression has now become a specialized domain and needs to be introduced at all levels of the sport. A key factor in all sports injury rehabilitation protocols is injury prevention; this involves data maintenance by teams or trainers, which is still not fully developed in the Indian context. The injury and subsequent problems need to be comprehended both by athletes and their coaches. The current review is an attempt to clarify some of the issues that are important and routinely used world over, with the aim to improving rehabilitation after sports even in the underdeveloped world.

Background Minimally invasive surgery has a significant and evolving role in the treatment of DIACFs, but there is limited literature on this topic. Objectives To compare the clinico-radiological outcomes of DIACFs fixed with MIS technique with ORIF. Methods This randomised control trial (RCT) included 21 closed Sanders type 2 and 3 DIACFs which were selected from 70 who presented. Extensile lateral approach was used in the ORIF group; while MIS techniques included either percutaneous reduction or small incisions with indirect fragment manipulation. Main Outcome Measurement AOFAS hindfoot score, pre-operative and postoperative radiology. Results There were 9 fractures in the Extensile group and 12 in the MIS group, with both groups having comparable demography, fracture classification, surgery delay & initial radiology. Bohler′s angle improved after surgery by an average of 18.44 with ORIF and 14.67 with MIS (p=0.28). Mean AOFAS in the MIS group was 82.58 (66.67% good and 33.33% fair) and was 89.56 (44.44% excellent, 55.56% good, 0 fair/poor) with ORIF (p=0.034). Two patients who underwent ORIF had a major complication (one deep infection and Sural nerve injury each) while none in the MIS group. Conclusions MIS methods minimized soft tissue complications and achieved comparable radiological reductions but clinical outcomes were poorer, with percutaneous methods having the worst outcomes.

Purpose Cadaveric studies have shown that deficiency of the posterior horn of the medial meniscus (PHMM) increases strain on the anterior cruciate ligament (ACL) graft. However, its influence on the clinical and radiological outcome after ACL reconstruction is less discussed and hence evaluated in this study. Materials and methods This study included 77 cases of ACL reconstruction with a minimum 18-month follow-up. Of the 77 cases, 41 patients with intact menisci were compared clinically and radiologically with 36 patients with an injury to the PHMM that required various grades of meniscectomy. The knees were evaluated using subjective International Knee Documentation Committee (IKDC) score and Orthopadische Arbeitsgruppe Knie (OAK) score. Results Cases with intact menisci showed better stability (p=0.004) at an average of 44.51 months after surgery. No significant differences were noted in the overall OAK score, subjective IKDC score, and functional OAK score (p=0.082, p=0.526, and p=0.363, respectively). The incidence of radiological osteoarthrosis was significantly higher in the posterior horn deficient knees (p=0.022). Conclusions The tendency toward relatively higher objective instability and increased incidence of osteoarthrosis in the group with absent posterior horn reinforces its importance as a secondary stabiliser of the knee.

Background: Vascular trauma associated with bony injuries is an orthopaedic emergency. Lack of timely intervention can lead to loss of limb or even life. Inspite of the rising incidence of high speed road traffic accidents in India, there is paucity of literature regarding the demographic pattern, clinical morbidity, management strategies and outcome of arterial injuries associated with lower limb trauma. The aim of this study is to describe the epidemiology and outcome of lower extremity musculoskeletal trauma with associated vascular injuries in a tertiary care institute in India. Materials and Methods: All individuals who presented to our tertiary care trauma center from July 2013 to December 2014 with lower extremity vascular injury associated with lower limb fractures were identified from a retrospective trauma database for this descriptive study. For the 17 months, there were 82 lower extremity vascular trauma cases admitted in our trauma center, of which 50 cases were included in the study. 32 patients with crush injuries, traumatic amputations, and those with head injury and blunt trauma to chest or abdomen were excluded from the study. Results: Out of the 50 cases of lower extremity vascular injury with associated lower limb fractures, 19 limbs were salvaged, 28 amputated, and three patients expired. Young males in the age group of 20–39 years were frequently injured. Motor vehicle accident (MVA) (82%) was found to be the most common cause followed by pedestrian injury. Popliteal artery (62%) was the most common vessel injured, followed by femoral artery (28%). The salvageability percentage was much higher (64%) in the femoral artery injury group when compared to popliteal artery injury group (25%). There were 32 open fractures, with amputation rates (60%) being higher and all three cases of death falling in this group. In addition, the limb salvageability percentage was 43.2% when the patient presented within 12 h of injury and this decreased to a mere 16.7% when the patient had presented more than 24 h after injury. Conclusion: MVAs are the leading cause of vascular injuries in India. Road safety measures and prevention programs are the need of the hour to prevent these kinds of injuries in the future.

Objective To evaluate magnetic resonance imaging (MRI) features of tubercular involvement of elbow joint. Methods Fourteen patients with tubercular arthritis of elbow were evaluated. The following findings were recorded on MRI ( n =12): bones involved; erosions, intraosseous abscesses, synovial thickening, and effusion; hypointensity within the thickened synovium on T2-weighted images; and periarticular soft tissue changes. Results The common abnormalities on MRI were synovial thickening and bone erosions ( n =12), soft tissue ( n =9)/intraosseous ( n =5) abscesses, and T2 hypointensity within the thickened synovium ( n =5). Conclusions A diagnosis of elbow tuberculosis should be considered if there is a combination of findings involving bone and soft tissue.

Twenty-five displaced intra-articular calcaneal fractures in 21 patients, aged 15–55 years were included in this study. Sanders' type I fractures, severe crushing or partial amputation, were excluded from the study. Patients were divided into group 1 (open fractures treated by MIS), and group 2 (closed fractures treated by ORIF). Group 1 had 16 and group 2 had 9 cases. Seven of 25 fractures (28%) developed wound related issues postoperatively. One patient (11.1%) in group 2 had wound margin necrosis, while 6 patients (37.5%) in group 1 developed pin tract and/or wound infection. At 1-year follow-up, the mean MFS for group 1 was 79 and mean MFS for group 2 was 84.4 (66.67% were good). The AOFAS score for group 1 was 77.37 and for group 2 was 86.1. The Bohlers' angle was restored in 81.16% cases in group 1 and 88.8% in group 2, while Gissane angle was restored in 68.75% of group 1 cases and 77.79% of group 2 cases. This study shows that acceptable fracture reduction can be obtained and maintained by MIS technique and it can be used as the primary definitive treatment option in open calcaneal fractures.

Background Fall is an important cause of injury morbidity in older adults. However, epidemiological information on fall is limited in low- and middle-income countries. We investigated the extent, pattern, characteristics, and context of falls in Chandigarh. Methods A cross sectional survey was carried out among 300 persons (≥60 years), sampled from urban, rural and slums areas of Chandigarh, India from March 2011 to October 2012 using multistage cluster sampling. A pre-tested interview schedule was used and relevant medical examinations were conducted. Multivariable logistic regression was carried out to estimate Odds Ratio (OR) and 95% confidence interval (CI). Results In the past one year, 31% (92/300) respondents reported one or more falls. On an average 0.67 fall episodes occurred/person/year (202/300). Most (68%; 63/92) falls occurred at home; 75% (47/63) occurred while carrying out activities such as toileting, bathing, sleeping and eating etc. Injuries due to falls were reported by 67% (62/92). In these cases, lower extremities, 37% (23/62) were the most common site of injury. Eight percent (5/62) reported fractures. A general physician was consulted by 44% (27/62), and 11% (7/62) utilized emergency services whilst another 11% (7/62) of fall injuries required hospital admission. Risk of fall was higher among females (OR 1.6, 95%CI 1.0–2.8, p 0.068), those taking four or more medicines (OR 2.1, 95%CI 1.2–3.5, p 0.009) and having poor body balance (OR 1.9, 95%CI 1.0–3.4, p 0.037). Conclusion Fall injuries were common in older adults of Chandigarh. Large cohort studies are needed to identify risk factors particularly those related to home environment.

Purpose. To compare a single leukocyte-poor (type-4B) platelet-rich plasma (PRP) injection versus bupivacaine injection for recalcitrant lateral epicondylar tendinopathy (LET). Methods. 25 patients aged 27 to 50 years with painful and recalcitrant LET of the humerus were randomised to receive leukocyte-poor (type-4B) PRP (n=15) or bupivacaine (n=10) injection. Outcome measures included visual analogue scale (VAS) for pain, modified Mayo clinic performance index for elbow (MMCPIE) for elbow function, and Nirschl score for activity-related pain at 1, 3, 6, and 12 months by a single assessor. Results. At baseline, the PRP and bupivacaine groups were comparable in terms of age, sex, duration of symptoms, VAS for pain, MMCPIE score, and Nirschl score. After one month, the percentage of improvement was less in the PRP than bupivacaine group in terms of the VAS for pain (17.7% vs. 26.5%), MMCPIE score (24.0% vs. 27.6%), and Nirschl score (20.7% vs. 31.1%). Nonetheless, improvement in the respective scores was greater in the PRP than bupivacaine group after 3 months (42.5% vs. 30.9%, 34.1% vs. 27.2%, and 50.7% vs. 39.6%), 6 months (67.3% vs. 20.1%, 40.6% vs. 16.3%, and 71.4% vs. 31.1%), and one year (83.2% vs. 45.6%, 47.0% vs. 21.7%, and 76.6% vs. 56.3%). The differences in scores between groups were significant at 6 months and one year only (pConclusion. Leukocyte-poor (type-4) PRP injection for recalcitrant LET enabled good improvement in pain and function.

Purpose.To evaluate outcomes of 36 patients who underwent curettage, use of phenol, and reconstruction using the sandwich technique for giant cell tumour (GCT) of bone around the knee.Methods.22 women and 14 men aged 19 to 46 (mean, 29.6) years underwent intralesional curettage, use of phenol, and reconstruction using the sandwich technique for GCT of the proximal tibia (n=23) or distal femur (n=13). Two of the cases were recurrences. Two, 18, and 16 tumours were classified as grade I, grade II, and grade III, respectively. Five of the grade III tumours were associated with an extra-articular pathological fracture. Patients underwent intralesional curettage, use of phenol, and reconstruction with allograft, gel foam, and cement (the sandwich technique). Pathological fractures were fixed with plates. Functional outcome was evaluated using the Musculoskeletal Tumor Society (MSTS) score.Results.The mean follow-up period was 5 (2.5–11) years. The mean MSTS score was 27.7 out of 30 (standard deviation, 3; range, 16–30). One patient with a grade III tumour in the proximal tibia had a recurrence detected elsewhere after 3 years. Her MSTS score at 2 years was 26. No patient had malignant transformation.Conclusion.Intralesional curettage, use of phenol, and reconstruction with allograft, gel foam, and cement (the sandwich technique) for GCT of bone achieved good functional outcome and a low recurrence rate.

Study design Prospective case series. Purpose To study the safety and feasibility of cotransplantation of bone marrow stem cells and autologous olfactory mucosa in chronic spinal cord injury. Overview of literature Stem cell therapies are a novel method in the attempt to restitute heavily damaged tissues. We discuss our experience with this modality in postspinal cord injury paraplegics. Methods The study includes 9 dorsal spine injury patients with American Spinal Injury Association (ASIA) Impairment Scale (AIS) A neurological impairment who underwent de-tethering of the spinal cord followed by cotransplantation with bone marrow stem cells and an olfactory mucosal graft. Participants were evaluated at the baseline and at 6 monthly intervals. Safety and tolerability were evaluated through the monitoring for adverse events and magnetic resonance imaging evaluation. Efficacy assessment was done through neurological and functional outcome measures. Results Surgery was tolerated well by all participants. No significant difference in the ASIA score was observed, although differences in the Functional Independence Measure and Modified Ashworth Scale were statistically significant. No significant complication was observed in any of our patients, except for neurogenic pain in one participant. The follow-up magnetic resonance imaging evaluation revealed an increase in the length of myelomalacia in seven participants. Conclusions The cotransplantation of bone marrow stem cells and olfactory mucosa is a safe, feasible and viable procedure in AIS A participants with thoracic level injuries, as assessed at the 24-month follow-up. No efficacy could be demonstrated. For application, further large-scale multicenter studies are needed.

Background Plantar fasciitis is one of the commonest, and most frustrating, foot ailments seen in a regular orthopaedic clinic. There are a number of modalities available to treat this condition, of which corticosteroid injection is, perhaps, the most popular. However, recent years have seen an increased interest in the use of platelet-rich plasma (PRP) injections in various clinical situations such as plantar fasciitis. Methods We undertook a prospective non-randomized study to compare the efficacy of traditional corticosteroid injection (Steroid group) to PRP injection (PRP group), in a cohort of patients. Results We studied both groups of patients before and after the injections using Visual Analogue Score (VAS), the Foot & Ankle Disability Index (FADI) and American Foot and Ankle Score (AFAS). Our study confirms that there is significant clinical improvement in PRP group at three months after the injection. Conclusion The use of PRP injection can be an attractive alternative in the treatment of disabling, recalcitrant plantar fasciitis. Study design Cohort study. Level of clinical evidence Level 3.

Introduction: The 3 bony point relationship of the elbow is an important surface evaluation done in all cases of elbow pathology; its importance is highlighted by the fact that significant emphasis is also laid on this during the specialty board examinations. Confusion about the exact inter relationship exists even in the standard orthopaedic books, with various authors labeling it as isosceles, equilateral or a different triangle, without any citation to back this statement. Materials and Methods: The knowledge of the three bony points relationship in elbow was verified after a survey of orthopaedic surgeons undertaken by the senior author, produced disparate answers. Most (63%) classified this as an isosceles triangle. To clarify this further, 200 elbows were prospectively evaluated to measure the distances between these points and the angles were calculated. Conclusion: Our observations indicate that this triangle is neither isosceles, nor equilateral, but a scalene triangle of unequal sides. There may even be a minimal difference in the 2 sides of the same individual, which has the potential to complicate routine comparison of the two elbows during examination. Results: The analysis of data revealed that all surgeons were aware of the three bony points relationship; however 21 of the 179 (mostly senior surgeons) did not give too much importance to this evaluation in daily clinical practice. Nine surgeons were not sure what type of triangle was formed, 17 thought it was an equilateral triangle, 40 thought it was some other type of triangle while 113 (63%) thought these points formed an isosceles triangle. This is a reflection of the disparity in the perception about this triangle in the orthopaedic community in general.

Orthobiologics have evolved to the extent that they significantly influence modern orthopedic surgical practice. A better understanding of the role of various growth factors and cells in the process of tendon healing, ligament repair, cartilage regeneration and bone formation has stimulated focused research in many chronic musculoskeletal ailments. Investigators have published results of laboratory as well as clinical studies, using orthobiologics like platelet rich plasma, stem cells, autologous conditioned serum etc., with variable results. However, a clear consensus over the best orthobiologic substance and the method of preparation and usage of these substances is lacking. Much of the confusion is due to the fact that studies ranging from RCTs to case reports present variable results, and the interpretations are wide-ranging. We have reviewed the available orthobiologics related data with a focus on platelet rich plasma in orthopedic conditions.

We present a rare case of glomus tumor of Hoffa's fat pad in a 42-year-old woman. Magnetic resonance imaging findings along with the characteristic clinical picture led us to suspect a glomus tumor as the possible etiology. An ischemia test was found to be positive and this further substantiated our diagnosis. An arthroscopic excision was performed and the histology confirmed the diagnosis of glomus tumor of Hoffa's fat pad. The patient responded well to the excision with immediate complete resolution of pain and she remains asymptomatic at the last follow-up after 15 months. To our knowledge, this is the second reported case of glomus tumor of Hoffa's fat pad and the first ever to be managed by simple arthroscopic excision. The tumor poses a great chal - lenge to an orthopedic surgeon. However, knowledge of its characteristic clinical presentation and the recognition of such a rare entity can help achieve an early diagnosis and timely management.

Background. Septic arthritis is a true orthopaedic emergency. Important factors determining outcome are rapid diagnosis and timely intervention. Changing trends in microbiological spectrum and emerging drug resistance poses big challenge. Present study evaluates bacterial strains and their sensitivity pattern in septic arthritis of North Indian children.Methods. Fifty children with septic arthritis of any joint were evaluated. Joint was aspirated and 2 cc of aspirated fluid was sent for gram stain and culture. Blood cultures were also sent for bacteriological evaluation.Results. Fifty percent cases had definite radiological evidence of septic arthritis whereas ultrasound revealed fluid in 98% cases. Aspirated fluid showed isolates in 72% cases. The most common organism wasStaphylococcus aureus(62%) followed byStreptococcus pneumoniaeand Gr. BStreptococcus. Blood culture could grow the organism in 34% cases only. The bacterial strain showed significant resistance to common antibiotic cocktail in routine practice. Resistance to cloxacillin and ceftriaxone was 62% and 14% respectively. No organisms were resistant to vancomycin and linezolid.Conclusion.S. aureusis still the most common organism in septic arthritis. Though a significant resistance to common antibiotic cocktail is noticed, the strain is susceptible to higher antibiotics. We recommend using these antibiotics as an empirical therapy till culture and sensitivity report is available.

BACKGROUND: Epidural steroid injections are commonly used for management of low back pain with lumbosacral radicular pain and can be administered by either interlaminar or transforaminal routes. The transforaminal route is reported to be more effective than the interlaminar route due to higher delivery of drug at the ventral epidural space. However, the transforaminal route has been associated with serious complications including spinal cord injury and permanent paralysis. Hence, there is a search for a technically better route with fewer complications for drug delivery into the ventral epidural space. Recently, a parasagittal interlaminar (PIL) approach of epidural contrast injection was reported to have 100% ventral epidural spread. However, the therapeutic efficacy of this route has never been investigated. We compared the therapeutic efficacy of the PIL approach and midline interlaminar (MIL) approach. We hypothesized that the PIL approach may produce a better clinical outcome because of better ventral epidural spread of the drug compared with MIL approach. METHODS: Thirty-seven patients were randomized to receive injection of 80 mg methylprednisolone either by the PIL (PIL group, n = 19) or MIL (MIL group, n = 18) approach under fluoroscopic guidance. Patients were evaluated for effective pain relief (≥50% from baseline) by visual analog scale and improvement in disability by the modified Oswestry Disability Questionnaire at intervals of 15 days, 1, 2, 3, and 6 months. Patients having

The introduction of locking plates in the treatment of periarticular fractures was a major breakthrough in orthopaedic evolution. Removal of these implants is extremely difficult as a result of cold welding and stripping of screw heads.A 31-year-old man had a schwannoma of the left C5-C6 nerve roots and upper trunk of the brachial plexus. One year before presentation he had undergone excision of the lesion through an approach using a clavicular osteotomy. The osteotomy had been fixed with a titanium locking recon plate. While surgically removing the implant, only one screw could be removed. The remaining five screws could not be turned owing to cold welding; repeated attempts at removing the screws damaged the screw heads. A large bolt cutter was used to cut the plate between the holes, and the resulting rectangular sections with the screws then were unscrewed from the bone.Limited literature is available regarding techniques for locking screw removal. These include using a carbide drill bit or diamond-tipped burr, high-speed disc, or conical extraction screw.Not all centers have specialized instruments such as carbide drill bits to remove screw heads, but a large bolt cutter usually is available when screws cannot be unscrewed owing to cold welding. The technique of cutting is easily reproducible and does not require additional soft tissue stripping.