Search

Background: Distal forearm fracture is the most common fracture encountered in daily life. Patients with this type of injury suffer from meaningful pain after Emergency Department discharge. Various studies reported that short-arm, below-the-elbow casts perform as well as long-arm, above-the-elbow casts for maintaining a reduction of distal forearm fractures demonstrated with a comparable risk of complication. Consequently, short casts are the commonly used method of immobilization however, short casts carry a potential disadvantage. Objective: To evaluate the safety and efficacy of the next-generation FlexiOH® (Short Arm Immobilizer). Settings and Design: This is a prospective, multicentre, and open-label clinical trial conducted in 5 different sites in India by recruiting a total of 137 subjects who were presented with distal forearm fractures. Materials and M ethods: Vital signs, concomitant medication taken by subjects during the study, X-ray results, and adverse events caused during all three visits were evaluated. Results: Overall patients showed normal vital signs, minimal adverse events, and relatively less concomitant medication consumption during the study period and at the end of the study, 100% healing was noted among all the study participants in the X-ray investigation. This clearly demonstrates the benefits over the conventional methods. Conclusion: For uncomplicated care of fractures and sports injuries of the limbs, FlexiOH® (Short Arm Immobilizer) technology offers more than just reliable immobilization and has advantages over contemporary plaster and cast bandages. This product is the most advanced orthopaedic immobilization technology and has the potential to be used and adopted worldwide. Keywords: FlexiOH®, Distal radius fractures, Short arm immobilizer, Adverse events

Abstract Background Adolescent idiopathic scoliosis (AIS) is a common structural deformity of the spine affecting adolescent individuals globally. The disorder is polygenic and is accompanied by the association of various genetic loci. Genetic studies in Chinese and Japanese populations have shown the association of genetic variants of SOX9 with AIS curve severity. However, no genetic study evaluating the association of SRY-Box Transcription Factor 9 (SOX9) variants with AIS predisposition has been conducted in any Indian population. Thus, we aimed to investigate the association of the genetic variants of the SOX9 along with 0.88 Mb upstream region with AIS susceptibility in the population of Northwest India. Methods In total, 113 AIS cases and 500 non-AIS controls were recruited from the population of Northwest India in the study and screened for 155 genetic variants across the SOX9 gene and 0.88 Mb upstream region of the gene using Global Screening Array-24 v3.0 chip (Illumina). The statistical significance of the Bonferroni threshold was set at 0.000322. Result The results showed the association of 11 newly identified variants; rs9302936, rs7210997, rs77736349, rs12940821, rs9302937, rs77447012, rs8071904, rs74898711, rs9900249, rs2430514, and rs1042667 with the AIS susceptibility in the studied population. Only one variant, rs2430514, was inversely associated with AIS in the population, while the ten variants were associated with the AIS risk. Moreover, 47 variants clustered in the gene desert region of the SOX9 gene were associated at a p-value ≤ 0.05. Conclusion The present study is the first to demonstrate the association of SOX9 enhancer locus variants with AIS in any South Asian Indian population. The results are interesting as rs1042667, a 3' untranslated region (UTR) variant in the exon 3 and upstream variants of the SOX9 gene, were associated with AIS susceptibility in the Northwest Indian population. This provides evidence that the variants in the enhancer region of SOX9 might regulate its gene expression, thus leading to AIS pathology and might act as an important gene for AIS susceptibility.

Spine surgery has advanced tremendously over the last decade. The number of spine surgeries performed each year has also been increasing constantly. Unfortunately, the reporting of position-related complications in spine surgery has also been steadily increasing. These complications not only result in significant morbidity for the patient but also raises the risk of litigation for the surgical and anesthetic teams. Fortunately, most position-related complications are avoidable with basic positioning knowledge. Hence, it is critical to be cautious and take all necessary precautions to avoid position-related complications. We discuss the various position-related complications associated with the prone position, which is the most commonly used position in spine surgery, in this narrative review. We also discuss the various methods for avoiding complications. Furthermore, we briefly discuss less commonly used positions in spine surgery, like the lateral and sitting positions.

ABSTRACT: Background: The diagnosis of spinal tuberculosis often relies on clinical, radiological, and laboratory findings, particularly in resource-constrained settings. However, numerous noninfectious conditions exhibit similar clinical and radiological features to spinal tuberculosis, leading to potential misdiagnosis in the absence of microbiological or histopathological confirmation. This study aims to present a case series from a developing country, highlighting noninfectious conditions that mimic spinal tuberculosis. Methods: A retrospective analysis was conducted on hospital records and imaging of patients diagnosed with spinal tuberculosis, lacking microbiological or histopathological evidence, and unresponsive to empirical antitubercular treatment. Patients displaying noninfectious conditions resembling spinal tuberculosis upon further investigation were included. Clinical and radiological findings of these patients were thoroughly analyzed. Results: Among a total of 23 patients observed over a 6-year period (2015–2020), various noninfectious conditions were identified as mimickers of spinal tuberculosis. These conditions included vertebral body haemangioma, ankylosing spondylitis (with or without Andersson lesion), rheumatoid pannus, osteoid osteoma, cystic hygroma, multiple myeloma, vertebral metastasis, malignant small round-cell tumor, pancreatic pseudocyst, esophageal duplication cyst, Modic changes in degenerative disc disease, Paget's disease, and psoas hematoma. Conclusion: Noninfectious spinal conditions can masquerade as spinal tuberculosis, underscoring the importance of obtaining a definitive tissue diagnosis before initiating antitubercular treatment. Particular attention should be given to features such as central lesions and the absence of soft tissue involvement in suspected cases of spinal tuberculosis, warranting a careful reconsideration of the diagnosis.

Over recent decades, the surgeries for spinal disorders have grown exponentially. Overall reported occurrence of complications in spine surgery is 16.4%. With the increased incidence of complications in spine surgeries, clinicians focused on the prevention of risk factors related to the onset of complications. Here we discuss four case scenarios with varied complications occurring in each case, namely (1) a case of proximal junctional failure, (2) placement of pin or guide wire first in minimally invasive transforaminal lumbar interbody fusion surgery, (3) a case of complication with endoscopic posterior cervical discectomy, and (4) few cases of complications with vertebroplasty.

Historically, osteoarticular tuberculosis (TB), including spinal TB, was treated with prolonged course of antitubercular therapy (ATT). Due to various challenges, there has been reluctance to explore the use of short-course ATT in spinal TB. However, with the success of short-course ATT being demonstrated in other forms of extrapulmonary TB, the subject is open for debate again. Therefore, we systematically reviewed various published literature to determine whether short-course treatment regimen (6 months) of ATT provides equivalent results in terms of disease healing as long-course treatment regimen (≥9 months) in the management of spinal TB. Five electronic databases (PubMed, MEDLINE, EMBASE, CENTRAL, and Web of Science) and their reference lists were searched to identify relevant randomized controlled trials with at least 1 year of follow-up that compared short-course with standard-course ATT for treatment of spinal TB. The methodological quality of included studies was assessed, and their data were extracted. A meta-analysis was used to calculate pooled effect sizes and 95% confidence interval (CI). The outcome measure was healed status of the disease at the final follow-up. Of 331 publications identified through literature search, eight publications describing six randomized studies were included. Moreover, 375 of 414 patients (90.58%) who received 6 months of ATT had healed status at their final follow-up compared to 404 of 463 patients (87.26%) who received ≥9 months of ATT. Overall, the healed status of spinal TB was equivalent in patients in both groups (pooled relative risk, 0.98; 95% CI, 0.92–1.04; p=0.439). However, there was considerable heterogeneity among the trials (I2=40.8%, p=0.149). The results suggest that the use of short-course (6 months) chemotherapy may be considered for the treatment of spinal TB in view of the similarity in the healing response achieved compared to treatment regimens of longer duration.

Study Design Retrospective cohort. Purpose To report the demographic characteristics, clinico-radiological presentation, laboratory findings, and outcomes of “middle-path” treatment in patients with spinal tuberculosis from a single public healthcare facility in a developing country. Overview of Literature Tuberculosis is a global health problem that is endemic in developing countries and undergoing resurgence in developed ones. Spinal tuberculosis can cause disabling back pain, progressive deformity, and neurological involvement. However, there is a lack of large-scale epidemiological studies quantifying the size and severity of the problem of spinal tuberculosis. Methods Hospital records of spinal tuberculosis patients treated at a single center over a period of 5 years were retrospectively reviewed. A diagnosis of spinal tuberculosis was based on standard clinical, radiological, microbiological, and histopathological evidence. Patients were treated in accordance with the “middle-path” regimen; surgery was reserved for selective indications. Results A total of 1,652 patients were included. Their median age was 32.4 years, with 53% being male. Axial pain (98%) was the most common presenting symptom; 19% of patients had neurological deficit. Lumbar spine (37%) was the most common site of involvement, with a paradiscal pattern (82%) of involvement predominating. Multi-level involvement was seen in 19% of patients; skip lesions were noted in 2.8%. Transpedicular biopsy was performed in 667 patients; at least one tissue test was diagnostic of tuberculosis in 65% of patients. Forty-four patients had drug resistance to rifampicin. Surgery was required in 10.5% of patients. The “middle-path” regimen was associated with high compliance and significant improvements in pain (Visual Analog Scale score) and function (36-Item Short Form Health Survey). Conclusions Our findings confirm the widespread prevalence of spinal tuberculosis and describe various epidemiological characteristics of a large sample of spinal tuberculosis patients. Adoption of the “middle-path” regimen is associated with high compliance and favorable outcomes in spinal tuberculosis.

Background: Depression in pregnancy affects nearly one in five women in low- and middle-income countries and is associated with adverse obstetric and neonatal outcome. Burden of morbidity is high, but specialized mental health resources are meager. Effective low intensity psychosocial interventions hold promise to fill the treatment gap for maternal depression. In this paper, we aim to describe the process of development of a stepped care model incorporating screening, providing brief intervention, and referral pathways developed for managing depression in pregnancy in antenatal care health facilities in India. Methodology: Using complex intervention development and evaluation method of Medical Research Council, United Kingdom, we searched evidence-based strategies from preexisting manuals, conducted formative research for need assessment and stakeholder engagement, and developed the intervention following an expert review panel. We conducted pilot testing to assess the feasibility and acceptability of intervention supplemented by three focused group discussions. Results: Manual review identified psychoeducation, empathetic listening, behavior activation, and supportive counseling as important elements. Need assessment revealed huge gap in perinatal mental health knowledge. Nearly 92% of total 272 perinatal women had poor awareness and 35%–70% of total 62 health-care providers had poor knowledge. In qualitative interview, women reported depressive symptoms as a normal part of pregnancy and had poor help seeking, behavior symptoms of depression were more prominent. A stepped care algorithm was developed for screening all expectant mothers in each trimester for depression using Patient Health Questionnaire-9 (PHQ-9). Women with PHQ-9 score >19 or reporting self-harm ideation were urgently referred to psychiatrist. Women with PHQ-9 score 5–19 were given brief intervention for depression in pregnancy intervention by antenatal nurse. The intervention developed consists of three sessions of psychoeducation, relaxation exercise, and mental health promotion, each lasting 20 min and at gap of 2 weeks each. Service providers and mothers reported good acceptability of psychosocial intervention and reported satisfaction with content and delivery of intervention. Conclusion: Low intensity brief psychosocial interventions can be adapted for implementation if relevant stakeholders are engaged at each step right from development of such as screening, intervention pathway to delivery, and effectiveness study.

Introduction: The purpose is to report on the fourth set of recommendations developed by SPINE20 to advocate for evidence-based spine care globally under the theme of “One Earth, One Family, One Future WITHOUT Spine DISABILITY”. Research question: Not applicable. Material and methods: Recommendations were developed and refined through two modified Delphi processes with international, multi-professional panels. Results: Seven recommendations were delivered to the G20 countries calling them to: - establish, prioritize and implement accessible National Spine Care Programs to improve spine care and health outcomes. - eliminate structural barriers to accessing timely rehabilitation for spinal disorders to reduce poverty. - implement cost-effective, evidence-based practice for digital transformation in spine care, to deliver self-management and prevention, evaluate practice and measure outcomes. - monitor and reduce safety lapses in primary care including missed diagnoses of serious spine pathologies and risk factors for spinal disability and chronicity. - develop, implement and evaluate standardization processes for spine care delivery systems tailored to individual and population health needs. - ensure accessible and affordable quality care to persons with spine disorders, injuries and related disabilities throughout the lifespan. - promote and facilitate healthy lifestyle choices (including physical activity, nutrition, smoking cessation) to improve spine wellness and health. Discussion and conclusion: SPINE20 proposes that focusing on the recommendations would facilitate equitable access to health systems, affordable spine care delivered by a competent healthcare workforce, and education of persons with spine disorders, which will contribute to reducing spine disability, associated poverty, and increase productivity of the G20 nations.

Cellular therapy has shown promise as a strategy for the functional restoration of ischemic tissues through promoting vasculogenesis. Therapy with endothelial progenitor cells (EPCs) has shown encouraging results in preclinical studies, but the limited engraftment, inefficient migration, and poor survival of patrolling endothelial progenitor cells at the injured site hinder its clinical utilization. These limitations can, to some extent, be overcome by co-culturing EPCs with mesenchymal stem cells (MSCs). Studies on the improvement in functional capacity of late EPCs, also referred to as endothelial colony-forming cells (ECFCs), when cultured with MSCs have mostly focused on the angiogenic potential, although migration, adhesion, and proliferation potential also determine effective physiological vasculogenesis. Alteration in angiogenic proteins with co-culturing has also not been studied. We co-cultured ECFCs with MSCs via both direct and indirect means, and studied the impact of the resultant contact-mediated and paracrine-mediated impact of MSCs over ECFCs, respectively, on the functional aspects and the angiogenic protein signature of ECFCs. Both directly and indirectly primed ECFCs significantly restored the adhesion and vasculogenic potential of impaired ECFCs, whereas indirectly primed ECFCs showed better proliferation and migratory potential than directly primed ECFCs. Additionally, indirectly primed ECFCs, in their angiogenesis proteomic signature, showed alleviated inflammation, along with the balanced expression of various growth factors and regulators of angiogenesis.

This section of the symposium draws the reader’s attention to various types of spondylolisthesis that are commonly encountered in daily routine practice on the basis of the Spinal Deformity Study Group (SDSG) classification. Each clinical scenario underlines the workup required for such cases along with various technical tips.

The restoration of global sagittal balance has become the keystone over the past decade. Various classification systems have been proposed for lumbosacral spondylolisthesis. This article describes the evolution, validation, and usage of these classification systems in the clinical setting in the current scenario.

Background: Facet joint (FJ)-mediated pain is one of the frequent causes of low back pain. Fluoroscopy and computed tomography guided medial branch blocks (MBBs) are accepted as standard techniques to diagnose FJ arthropathy. Ultrasound-guided (USG) MBB can be an alternative approach for the diagnostic MBB in FJ arthropathy. This study evaluates the feasibility of USG MBB in FJ arthropathy and validates by fluoroscopy. Materials and Methods: Diagnostic USG MBBs were performed in sixty patients. Two medial branches were targeted for each FJ. The needle was inserted in an in-plane technique after identifying the desired site. The needle position was confirmed by fluoroscopy. Pain scores were assessed before and after the nerve block. Results: Out of 161 needle insertions, 139 needles (86.3%) were at the radiologically defined target point as confirmed by fluoroscopy and were labeled as successful. Mean baseline, immediately before, immediately after, and at 24 h, Numeric Rating Scale (NRS) scores were 7.53 (0.93), 7.02 (0.93), 3.03 (1.75), and 2.80 (1.99), respectively (P < 0.05). The mean Modified Oswestry Disability Questionnaire scores before and 24 h after block were 48.77 (8.94) and 32.55 (11.32), respectively. Fifty-three patients had ≥60 points on the 100-point scale given by Helbig, and out of these patients, 44 patients had a ≥50% reduction in the NRS score. Conclusion: Diagnostic USG lumbar MBBs, a minimally invasive procedure without radiation exposure, can be performed with a high success rate in FJ arthropathy.

Study Design Prospective, comparative. Purpose To compare the histopathological and electron microscopic changes in the ligamentum flavum (LF) between degenerative lumbar canal stenosis (LCS) and lumbar disk herniation (LDH). Overview of Literature The LF has been implicated as a key structure in the pathogenesis of LCS. With aging, the LF undergoes morphological changes–a decrease in the elastic component and an increase in the collagen component, in addition to other focal changes. By comparing the histopathological and electron microscopic picture of the LF in elderly patients with LCS with that in young patients with LDH, the role of this ligament in the pathogenesis of LCS may be clarified. Methods Forty patients were prospectively recruited and divided into two groups: group 1 included 20 patients with degenerative LCS aged >55 years and group 2 included patients with LDH aged

Study Design Multicenter validation study. Purpose To evaluate the inter-rater reliability of Rajasekaran’s kyphosis classification through a multicenter validation study. Overview of Literature The classification of kyphosis, developed by Rajasekaran, incorporates factors related to curve characteristics, including column deficiency, disc mobility, curve magnitude, and osteotomy requirements. Although the classification offers significant benefits in determining prognosis and management decisions, it has not been subjected to multicenter validation. Methods A total of 30 sets of images, including plain radiographs, computed tomography scans, and magnetic resonance imaging scans, were randomly selected from our hospital patient database. All patients had undergone deformity correction surgery for kyphosis. Twelve spine surgeons from the Asia-Pacific region (six different countries) independently evaluated and classified the deformity types and proposed their surgical recommendations. This information was then compared with standard deformity classification and surgical recommendations. Results The kappa coefficients for the classification were as follows: 0.88 for type 1A, 0.78 for type 1B, 0.50 for type 2B, 0.40 for type 3A, 0.63 for type 3B, and 0.86 for type 3C deformities. The overall kappa coefficient for the classification was 0.68. Regarding the repeatability of osteotomy recommendations, kappa values were the highest for Ponte’s (Schwab type 2) osteotomy (kappa 0.8). Kappa values for other osteotomy recommendations were 0.52 for pedicle subtraction/disc-bone osteotomy (Schwab type 3/4), 0.42 for vertebral column resection (VCR, type 5), and 0.30 for multilevel VCRs (type 6). Conclusions Excellent accuracy was found for types 1A, 1B, and 3C deformities (ends of spectrum). There was more variation among surgeons in differentiating between one-column (types 2A and 2B) and two-column (types 3A and 3B) deficiencies, as surgeons often failed to recognize the radiological signs of posterior column failure. This failure to identify column deficiencies can potentially alter kyphosis management. There was excellent consensus among surgeons in the recommendation of type 2 osteotomy; however, some variation was observed in their choice for other osteotomies.

Objective Higher level impairments and activity limitation among those scheduled for total knee arthroplasty (TKA) is known. Sex differences in participation restriction which is the final domain of disablement pathway is not known. No data from developing countries exist on sex differences in disability levels at the time of TKA. Methods In a cross‐sectional analysis of 240 patients (188 women; 72 men) scheduled for TKA, impairment (pain, symptoms, quadricep muscle strength, and knee range of motion [ROM]), activity limitation (self‐reported and objective performance‐based measurements), and participation restriction were compared. Multivariable regression analyses were used to adjust for key sociodemographic and clinical characteristics. Associations between impairments and participation restriction were analyzed. Results Compared with men, women were more likely to have higher levels of impairment (knee injury and osteoarthritis outcome pain score adjusted mean difference [aMD]: −6.9 [95% confidence interval {CI} −13.7 to −0.18]; flexion ROM of less than 100° adjusted odds ratio: 5.7 [95% CI 1.6‐20.3]; and 36% lower muscle strength [95% CI 24%‐49%]) and lower objectively measured functional ability (walking speed aMD: −0.12 m/s [95% CI −0.23 to −0.02]; stair climbing time aMD: 9.5 s [95% CI 1.5‐17.5]). Participation restriction was higher in women compared with men. Of the impairment measures (pain, ROM, and muscle strength), pain contributed to participation restriction in both sexes. Conclusion This study demonstrated higher levels of disability in women than in men at the time of TKA. Effect of pain on participation restriction was higher compared with muscle strength and ROM. Evidence of delay in decision‐making to undergo TKA and reasons for delay need to be studied specifically in the context of lower middle–income countries.

Pedicle screw instrumentation is currently the “gold standard” in scoliosis surgery. However, placement of pedicle screws in thoracic spine is considered challenging. Previous studies have described morphometric changes in the pedicle when a larger screw is inserted, with pedicle expansion preceding screw cutout and pedicle fracture. We report an unusual case of neurological deficit due to cord compression by an expanded pedicle following pedicle screw insertion on the concave side of the apical vertebra in a 14-year-old patient with Lenke Type 3C(-) adolescent idiopathic scoliosis. Identification of the expanded pedicle as the cause of neurological symptoms, prompt action, and deferring the corrective surgery while accepting less correction helped us in negotiating the problem without causing permanent neurological deficit. Pedicle expansion in an immature spine can cause neurological complications. The screw diameter at the apical vertebrae on the concave side should be carefully selected.

Bracing constitutes the most widely practiced treatment method for nonoperative management of adolescent idiopathic scoliosis (AIS). Brace treatment has undergone a large number of variations from the time of its inception, and it has led to a number of available options to choose from in present times. The evidence for bracing has also evolved tremendously in the last few years from single-center cohort studies to multicenter randomized controlled trials. For bracing to be successful, proper patient selection is an important prerequisite. A coordinated team effort from the patient, parents, family, the surgeon, and orthotist is also essential for ensuring compliance and treatment success. This article is a narrative review and focuses on the role of bracing in the management of AIS in terms of the brace history, types, indications, results, and drawbacks with relevant literature.

Study Design Observational study. Purpose This study aims to assess the clinical and urodynamic parameters in patients with spinal tuberculosis (TB) exhibiting lower urinary tract symptoms (LUTS) at the time of presentation and after spinal surgical intervention. Overview of Literature Variable urodynamic findings in patients with spinal TB. Methods We prospectively evaluated 10 patients with spinal TB exhibiting LUTS. Urinary symptoms were assessed by the American Urological Association (AUA) symptom score. We performed a urodynamic study (UDS), including electromyography, in all patients before and 3 months after spinal surgery. Results The mean age of patients was 29.7 years (range, 15–52 years), and the mean AUA symptom score was 12.5 and 11.8 before and after spinal surgery, respectively. Overall, five patients exhibited improvement in the AUA symptom score, and three showed no change, while two patients’ condition worsened. We observed detrusor overactivity (DO) in two patients, and detrusor sphincter dyssynergia (DSD) in four patients. In addition, high-pressure voiding (HPV) was noted in two patients. On follow-up after spinal surgery, DO and DSD exhibited no improvement. Although HPV resolved, two patients developed new-onset poor compliance with worsening DO and DSD. Furthermore, two patients had bilateral hydronephrosis before surgery, which resolved on follow-up. Conclusions Patients with spinal TB exhibiting LUTS can display a spectrum of clinical presentations and variable UDS findings. As two patients exhibited new onset poor compliance with bilateral hydronephrosis in one of them, this study concludes that a close follow-up for upper tracts in these patients is required despite successful spinal surgery.

Insulin resistance has been associated with depressive symptoms and depressive syndrome. Studies have attempted to assess the relationship between metabolic syndrome and depression and more specifically insulin resistance and depression. Studies have also been carried out to assess the direction of this relationship. This brief review is purported to present and discuss the currently available literature evidence about relationship of insulin resistance with depression and the treatment implications of this relationship. The presence of insulin resistance in an individual is positively associated with increased depressive symptoms and the presence of depressive symptoms is found to be associated with insulin resistance. However, a causal relationship could not be established. Prospective study designs can help to enhance our knowledge in finding a causal relationship. Intervention studies that will further help in treatment decisions are required.

Increasing evidence in recent years has suggested that regulatory B cells (Bregs) are one of the crucial modulators in various inflammatory disease conditions. However, no study to date has investigated the significance of Bregs in modulating osteoclastogenesis. To the best of our knowledge, in the present study, we for the first time examined the anti-osteoclastogenic potential of Bregs under in vitro conditions and observed that Bregs suppress RANKL-induced osteoclastogenesis in a dose-dependent manner. We further elucidated the mechanism behind the observed suppression of osteoclasts differentiation via Bregs. Our results clearly suggested that the observed anti-osteoclastogenic property of Bregs is mediated via the production of IL-10 cytokine. Next, we explored whether Bregs have any role in mediating inflammatory bone loss under post-menopausal osteoporotic conditions in ovx mice. Remarkably, our in vivo data clearly suggest that the frequencies of both CD19+IL-10+ Bregs and CD19+CD1dhiCD5+IL-10+ “B10” Bregs were significantly reduced in case of osteoporotic mice model. Moreover, we also found a significant reduction in serum IL-10 cytokine levels in osteoporotic mice, thereby further supporting our observations. Taken together, the present study for the first time establishes the direct role of regulatory B cells in modulating osteoclastogenesis in vitro. Further, our in vivo data suggest that modulations in the percentage of Bregs population along with its reduced potential to produce IL-10 might further exacerbate the observed bone loss in ovx mice.

Study Design Single-center, observational, case–control study. Purpose Comparison and analysis of the metabolic and coagulative profiles in patients with idiopathic scoliosis, patients with congenital scoliosis, and healthy controls. Overview of Literature Serum melatonin deficiency has been a controversial topic in the etiopathogenesis of scoliosis. Low bone mineral density, low vitamin D3 levels, and high parathyroid hormone levels are common metabolic abnormalities associated with scoliosis that may be responsible for its pathogenesis. In addition to metabolic defects, several studies have shown coagulation defects that either persist from the preoperative period or occur during surgery and usually lead to more than the expected amount of blood loss in patients undergoing deformity correction for scoliosis. Methods The study population (n=73) was classified into those having congenital scoliosis (n=31), those with idiopathic scoliosis (n=30), and healthy controls (n=12). After detailed clinicoradiological evaluation of all the subjects, 10-mL blood samples were collected, measured, and analyzed for various metabolic and coagulation parameters. Results The mean serum melatonin levels in patients with idiopathic scoliosis were significantly lower than those in the healthy controls. Although the mean serum melatonin level in the congenital group was also low, the difference was not statistically significant. Serum alkaline phosphatase and parathyroid hormone levels were higher in the scoliosis groups, whereas the vitamin D level was lower. No differences were observed in the coagulation profiles of the different groups. Conclusions Low serum melatonin levels associated with scoliosis can be a cause or an effect of scoliosis. Moreover, low bone mineral density, high bone turn over, and negative calcium balance appear to play an important role in the progression, if not the onset, of the deformity.

Responsive immunity plays an important role fighting against infections. Worldwide, Vitamin D deficiency is a major concern not only for musculoskeletal health but also affecting the immunity status in population. Amidst COVID-19 pandemic, it is imperative to establish the role of vitamin D in destruction of pathogens. Vitamin D awareness program at school level might be an effective health governance policy to educate populations for the importance of vitamin D in overall health.

This work discusses the biomechanical testing of 3 elbow bones, namely the humerus, ulna, and radius. There is a need to identify the mechanical properties of the bones at the organ level. The following tests were performed: 3-point bending, fracture toughness, and axial compression. Six sets of whole-bone samples of human male cadaveric humerus, ulna, and radius (age of donor: 35 to 56 years) were tested. The results were analyzed for statistical significance by 2-stage, repeated-measure analysis of variance (ANOVA). The difference between the bending strength of the humerus, ulna, and radius was statistically significant ( P = .001) when compared to one another. However, the fracture toughness and compressive strength were observed to be similar for the 3 bones. The knowledge of mechanical properties of elbow bones can aid in the design of elbow implants and upper limb protection systems, and also allow us to identify criteria for injury. Further, knowledge of the mechanical properties of the elbow bones can aid in calibrating simulations through finite elements analysis.

The anterior cruciate ligament is one of the six ligaments in the human knee joint that provides stability during articulations. It is relatively prone to acute and chronic injuries as compared to other ligaments. Repair and self-healing of an injured anterior cruciate ligament are time-consuming processes. For personnel resuming an active sports life, surgical repair or replacement is essential. Untreated anterior cruciate ligament tear results frequently in osteoarthritis. Therefore, understanding of the biomechanics of injury and properties of the native ligament is crucial. An abridged summary of the prominent literature with a focus on key topics on kinematics and kinetics of the knee joint and various loads acting on the anterior cruciate ligament as a function of flexion angle is presented here with an emphasis on the gaps. Briefly, we also review mechanical characterization composition and anatomy of the anterior cruciate ligament as well as graft materials used for replacement/reconstruction surgeries. The key conclusions of this review are as follows: (a) the highest shear forces on the anterior cruciate ligament occur during hyperextension/low flexion angles of the knee joint; (b) the characterization of the anterior cruciate ligament at variable strain rates is critical to model a viscoelastic behavior; however, studies on human anterior cruciate ligament on variable strain rates are yet to be reported; (c) a significant disparity on maximum stress/strain pattern of the anterior cruciate ligament was observed in the earlier works; (d) nearly all synthetic grafts have been recalled from the market; and (e) bridge-enhanced repair developed by Murray is a promising technique for anterior cruciate ligament reconstruction, currently in clinical trials. It is important to note that full extension of the knee is not feasible in the case of most animals and hence the loading pattern of human ACL is different from animal models. Many of the published reviews on the ACL focus largely on animal ACL than human ACL. Further, this review article summarizes the issues with autografts and synthetic grafts used so far. Autografts (patellar tendon and hamstring tendon) remains the gold standard as nearly all synthetic grafts introduced for clinical use have been withdrawn from the market. The mechanical strength during the ligamentization of autografts is also highlighted in this work.

Isolated spontaneous primary tubercular erector spinae abscess in an immunocompetent patient is very rare. Here, we report such a case of 21-year-old female, which was successfully managed with timely diagnosis and intervention. Isolated primary tubercular abscess of erector spinae is a rare differential diagnosis of low back pain; however, it must be suspected in an endemic region for tuberculosis, especially when raised erythrocytic sedimentation rate and C-reactive protein are present. Excision along with anti tubercular therapy proved to be a successful strategy in our patient.

We report a case of Ewing's sarcoma of the sacroiliac joint in a 21-year-old male mimicking tubercular sacroiliitis, a rare entity not reported in literature. He presented with pain in the lower back radiating to the right lower limb along with constitutional symptoms of 3 months duration. On examination, the right sacroiliac joint was tender. The laboratory investigations showed anaemia, leukocytosis and raised erythrocyte sedimentation rate. On X-ray, features of right sacroiliitis were seen. This was further investigated with magnetic resonance imaging (MRI), which showed features consistent with tubercular sacroiliitis. Patient was then started on antitubercular treatment, but the improvement was not consistent. So, a contrast MRI was done, which indicated features of primary sarcoma. It was then further confirmed by a computed tomography-guided biopsy, which showed features consistent with Ewing's sarcoma of the sacroiliac joint.

Psoas abscess in cases of tuberculosis originates from the primary lesion in the lower dorsal or the lumbar spine. From the spinal origin of the Psoas muscle, this abscess tracks down its sheath and may be palpable in the iliac fossa, in the lumbar triangle, in the upper part of thigh below the inguinal ligament. We present a rare case, where patient presented with thigh swelling, which on first look gave an impression of a malignant origin. But subsequent investigation revealed it to be one of tuberculous origin, and that to, tracking down of a Psoas abscess. According to best of our knowledge, there has been no reported case of a Psoas abscess tracking down to the thigh and knee and mimicking a tumour.

Removal of locking plates in many ways poses novel challenges compared to conventional plates. None of the techniques described for the removal of locking plates are adequate for all situations. We report our experience of 27 patients from whom a total of 33 locking plates were removed. We also describe a novel technique for the removal of locking plates which in our experience could be used in most of these patients because it is appropriate for all situations and, from a technical point of view, is easy to use. Our new technique consists of removing the problematic locking screw by cutting the plate on both sides of the screw hole and using the screw head-plate hole unit for removal. We analyzed all these patients for the location of the plate, number of locking screws, time of implant removal since the initial surgery, reason for removal of the plate, nature of the difficulties encountered during surgery, and any perioperative complications. A total of 43 (17.34%) screws were difficult to remove. Twenty screws were found to be stripped, 15 were jammed and 8 were broken. Fourteen of the 20 stripped screws and all 15 jammed screws were removed using our technique. We found this technique of locking plate removal to be very versatile and useful in most of the cases in which removal was difficult. At the same time, it also causes less damage to the bone compared to other techniques.

Sacroiliitis caused by Salmonella typhi is rare. In India, unilateral sacroiliitis is usually caused by tuberculosis. We report a 22-year-old man who presented with a high-grade fever and positive blood culture for Salmonella typhi . The patient was treated with intravenous vancomycin and levofloxacin for 15 days and then oral levofloxacin for 6 weeks.

Purpose. To review outcomes of 106 patients after complete excision of the giant cell tumour of the tendon sheath of the hand, with or without postoperative radiotherapy. Methods. Records of 77 women and 29 men aged 11 to 61 (mean, 31) years who underwent excision of giant cell tumours of the tendon sheath of the hand were reviewed. All patients presented with gradually progressive swelling; only 3 of them also presented with pain. The lesions were located on the dorsal aspect (n=11), the palmar aspect (n=66), both aspects (n=10), or circumferentially (n=14). No patient had multiple lesions. Five patients had bony erosion and 3 had neurovascular bundle involvement. Results. The mean follow-up period was 12 (range, 4–22) years. 56 patients with well-encapsulated giant cell tumour in the palmer and/or dorsal aspects were classified as at low risk of recurrence. The remaining 50 patients were classified as at high risk of recurrence and underwent postoperative radiotherapy. None of the patients at low risk had any recurrence; 4 of those at high risk had recurrence despite radiotherapy. No complication was attributable to the irradiation, except that 3 patients had some dark pigmentation around the wound scar. Conclusion. Postoperative radiotherapy may have a role in reducing recurrence of the giant cell tumour of the tendon sheath of the hand.

Carpal tunnel syndrome, in its idiopathic form, is an extremely common entrapment neuropathy in the clinical practice however secondary compressive causes are rare. Among secondary causes, tumors are even rarer. Although lipomas are the most common soft tissue tumor in the body, less than 5% of the benign tumors of the hand are lipomas.

Purpose. To compare the outcomes of microendoscopic discectomy (MED) versus open discectomy for lumbar disc herniation. Methods. 80 men and 32 women aged 26 to 57 (mean, 37) years with a single-level disc herniation were randomised to undergo MED (n=55) or open (fenestration/laminotomy) discectomy (n=57). Patients were assessed pre- and post-operatively (at week 6, month 6, and year one). The 2 groups were compared with respect to surgical time, anaesthesia time, duration of hospital stay, intra-operative blood loss, weight of disc material removed, and self-evaluated low back pain and functional outcome (using the Oswestry low back pain disability questionnaire). Results. Surgical and anaesthesia times were significantly longer, but blood loss and hospital stay were significantly reduced in patients having MED than open discectomy. The improvement in the Oswestry score in both groups was significant at week one, but not at other follow-ups. The complication rate was similar in both groups. One patient with MED had a recurrence of disc herniation after 7 months and was treated with open discectomy. Conclusions. Both methods are equally effective in relieving radicular pain. MED entailed shorter hospital stay, less morbidity, and earlier return to work. Nonetheless, it is a demanding technique and should not be attempted without specific instruction and training.