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STUDY DESIGN: Retrospective cohort study. OBJECTIVES: To study the incidence of concomitant calcaneum fractures in participants with traumatic spine fractures and to study the association of calcaneum injury with the mode of trauma, morphology and level of vertebral fracture and neurological status in participants with concomitant spine and calcaneum fracture. SETTING: Central Institute of Orthopaedics, Safdarjung Hospital, New Delhi, India. METHODS: Records of participants with traumatic spine fractures were analyzed. Participants who had calcaneum fracture confirmed on radiographs were considered to have concomitant spine and calcaneum fracture. In these participants, variables noted were age, gender, mode of trauma, level and morphology of vertebral fracture and neurological status. RESULTS: Concomitant calcaneum fracture was present in 43 participants out of a total of 358. The lumbar spine was involved in 72.09% of participants. 46.51% of participants had complete burst type of vertebral fractures. Neurology was found to be intact in 58.13% of participants. The association of concomitant calcaneum injury with the level of spine fracture and type of fracture were found to be statistically significant (p

Cervical split cord malformations are extremely rare with less than 75 cases reported in the literature worldwide. The widely different terminologies used to describe the same pathoanatomy make the documentation of all reported cases a difficult task. We conducted a systematic review of 71 cases documented over 38 reports from 1889 to 2016. The controversy regarding prophylactic surgery in asymptomatic individuals remains. We advocate prophylactic surgery in all asymptomatic individuals to preclude severe neurological deficit following trivial trauma in future. The results of surgery in asymptomatic individuals are excellent while those in symptomatic individuals are good as well.

Background: Pediatric forearm fractures are still considered an enigma in view of their propensity to redisplace in cast. The redisplacement may be a potential cause for malalignment. We prospectively analyzed the role of risk factors and above casting indices in predicting significant redisplacement of pediatric forearm fractures treated by closed reduction and cast. Materials and Methods: 113 patients of age range 2–13 years with displaced forearm fractures, treated by closed reduction and cast were included in this prospective study. Prereduction and postreduction angulation, translation, and shortening were noted. In addition, for distal metaphyseal fractures, obliquity angle was noted. In postreduction X-ray, apart from fracture variables, casting indices were also noted (cast index [CI] for all patients with three-point index [TPI] and second metacarpal radius angle in addition for distal metaphyseal fractures). In 2nd week, X-rays were again obtained to check for significant redisplacement. These patients were managed with remanipulation and casting or were operated if remanipulation failed. Comparison of various risk factors was made between patients with significant redisplacement and those which were acceptably reduced. A subgroup analysis of patients with distal metaphyseal fractures was done. Results: Thirteen (11.5%) patients had significant redisplacement; all of them required remanipulation. No association with respect to age, sex, level of fracture, side of injury, surgeon's experience, number of bones fractured, and injury to definitive cast interval was seen. The presence of complete displacement in any of the plane in either of the bones was seen to be highly significant predictor of redisplacement (P < 0.001). Postreduction angulation more than 10° in any plane in either of the bone and fracture obliquity angle in distal metaphyseal fracture also had a highly significant association with redisplacement. There was a significant difference in the mean values of all three casting indices assessed. TPI was the most sensitive casting index (87.5%). Conclusions: Conservative management with aim of anatomical reduction, especially in patients with complete displacement, should be the approach of choice in closed pediatric forearm fractures. Casting indices are good markers of quality of cast.

A 30-year-old woman presented to our outpatient department with complaints of pain and swelling in bilateral infrapatellar regions and a discharging sinus in the right knee over the duration of one year. Radiographs showed lytic regions in bilateral patellae. Samples sent from material curetted from sinus yielded no organism but histopathology reported granulomatous inflammation. Following a fresh magnetic resonance imaging (MRI) scan that revealed the infrapatellar pad of fat communicating with the patellar lesions, an exploration and evacuation was done. Material sent revealed epithelioid cell granulomas with caseous necrosis consistent with tuberculosis (TB). The patient was put on first line anti-tubercular treatment (ATT) and has responded favourably with healing of sinus and patellar lesions. Bilateral infrapatellar bursitis is not rare. However patellar TB as a cause for OMIT is not a common diagnosis. A bilateral patellar involvement has not been reported in literature to the best of our knowledge.

Bilateral simultaneous quadriceps rupture is a rare entity. Its occurrence without associated aetiology is even rarer. It has a bimodal age distribution, with majority of cases occurring in population older than 50 years. Its occurrence in younger population is unusual. Aetiology is trauma, long term steroid usage, fluoroquinolone injections at local site or associated co-morbidities such as chronic renal failure, diabetes, obesity, hyperparathyroidism, endocrine disorders and gout, which via different mechanism lead to weakening of tendon thereby predisposing it to rupture. Surgical repair is the treatment of choice; it ranges from direct repair using Bunnel or Krackow sutures in acute cases to repair via lengthening procedures in chronic cases as described by Scuderi and Codivilla. Distal fixation to patella is a matter of debate in today's time as suture anchors have emerged as an alternative to trans-osseous repair. Although various studies have demonstrated good outcomes with suture anchors, biomechanical studies comparing the two techniques have shown conflicting results. We present a case of spontaneous bilateral quadriceps rupture in a young female without associated identifiable pathology. Also, we attempt to describe the Codivilla repair technique and discuss recent trends in quadriceps repair.

Background: Hinge-Door Cervical laminoplasty is commonly performed procedure in patients with cervical spondylotic myelopathy. Most available studies have established restriction of flexion and extension motion post laminoplasty but the literature on post-laminoplasty axial rotation is sparse. Objective: To study the axial neck rotation on either side following hinge door cervical laminoplasty. Materials and Methods: Twenty consecutive patients of cervical spondylotic myelopathy planned for cervical laminoplasty were included in the study. Preoperative and postoperative radiological data was recorded for each patient and analysed by an experienced neuroradiologist. The clinical and radiological follow-up was recorded at 6 months post surgery. All patients underwent standard hinge door C3-C6 laminoplasty preserving the muscle attachments to C2 and C7 vertebra. Results: There were 13 men and 7 women with a mean age of 60.5 years, age range 58-70 years. The mean preop C1 C2 rotation was 46.5 degrees and mean post-operative C1-C2 rotation was 44.3 degrees. The average subaxial cervical spine rotation was 11.66 degrees preoperatively and 12.47 degrees postoperatively. The global cervical spine rotation was 80.95 degrees preoperatively and 76.82 degrees postoperatively. There is no significant change in segmental, subaxial and global cervical spine rotation following hinge door C3-C6 laminoplasty preserving the muscle attachments to C2 and C7 vertebra. Conclusion: Cervical laminoplasty preserves cervical ROM and is a motion-preserving surgery as far as axial rotation is concerned.

Recurrent anterior shoulder instability following shoulder dislocation has an incidence as high as 68% among the younger population, however its association with coracoid fracture is extremely rare. Majority of coracoid fractures reported earlier have been shown to be associated with seizure disorder. We report a case of displaced coracoid fracture associated with recurrent anterior instability in a patient with no history of seizure disorder and its implications in causation as well as management are discussed. A 28 year old male, paramedic by profession, presented with complaints of multiple episodes of shoulder dislocation of right dominant extremity for last ten months. Pre-operative CT scan showed Hill-Sach's lesion associated with coracoid process fracture. In view of significant engaging Hill-Sach's lesion, bony reconstruction of glenoid to increase the articular arc was planned. However in view of the small coracoid fragment occurred due to fracture, Latarjet's procedure could not be planned and iliac crest bone graft (ICBG) was planned instead. Till date only 10 cases of coracoid fracture with anterior shoulder instability have been reported in English literature. Of the ten cases, six cases had history of seizure disorder while four cases had only traumatic association. In our case as coracoid fragment was small, it could not be used for Latarjet's procedure and instead was fixed to its proximal stump with suture anchors. This case highlight's rare injury pattern and emphasises on good clinico-radiological examination supplemented by high index of suspicion needed to diagnose this unusual presentation.

Baker's cyst is usually degenerative in origin, infective etiology is rare, and tubercular origin is exceptional; only 5 such cases have been reported in English literature till date. We present a case of a young female who presented with clinico-radiological features suggestive of Baker's cyst with associated posterior horn medial meniscal tear. Arthroscopic evaluation revealed suspicious synovial hypertrophy along with meniscal tear and Baker's cyst. Arthroscopic management of Baker's cyst and meniscal pathology was done along with radical synovectomy. Histopathological examination revealed epitheloid granulomas and Langhans giant cells pointing toward a tubercular etiology. Standard ATT protocol with rehabilitation was followed. The patient was asymptomatic at 1 year with complete resolution of symptoms and full range of motion. This case highlights the need to maintain high index of suspicion in cases hailing from endemic region with unusual intra-operative findings; also, it underlines the importance of routine histo-pathological examination.

Hip and knee dislocations are not uncommon but simultaneous ipsilateral dislocation of the hip and knee joint is rare; consequently, there is an inadequate amount of literature on the subject. We identified only 11 such cases reported in English literature. In the present report, we describe the case of a 23-year-old male patient who presented with ipsilateral hip and knee dislocation on the right side after being involved in a road traffic accident. The hip dislocation was associated with a posterior wall acetabular fracture. The hip as well as the knee joints was reduced in the emergency bay. The patient underwent an urgent fixation of the posterior wall acetabular fracture with delayed ligament reconstruction for the knee dislocation. At one-year follow-up, he had no pain in the hip or knee. There was grade 1 posterior sag but no symptoms of knee instability. Radiographs revealed no evidence of avascular necrosis or arthritis of the femoral head. The normal treatment protocol for individual injury is affected by the simultaneous occurrence of hip and knee dislocation.

Case Report: Cold welding of barrel plate to Richard screw: an unusual complication witnessed during sliding hip screw removal. Abstract Implant removal is one of the most common procedures performed in orthopaedics. More often than not, it is more difficult than the index operation to insert the implant. The sliding hip screw (SHS) is one of the most commonly used devices for the fixation of intertrochanteric fractures. The screw and barrel are designed to allow for smooth gliding. Titanium implants are often associated with the complication of cold welding. Stainless steel implants are less commonly associated with this phenomenon. We report an unusual case of cold welding of the barrel and Richard screw encountered during the removal of a stainless steel sliding hip screw construct in a routine case of peri-implant fracture in a 80 year old female who had sustained household trauma due to a slip. Keywords: sliding hip screw, peri-implant fracture, implant removal, cold welding, hip fractures.

Background: Duration of treatment in tuberculosis of spine has always been debatable in the absence of marker of healing. The objective of the study was to evaluate the efficacy of extended DOTS regimen (2 months of intensive phase and 6 months of continuation phase) as recommended by WHO, by using MRI observations as the healing marker. Materials and Methods: 51 (Group A -28 prospective and Group B- 23 retrospective) patients of spine TB with mean age of 26.8 years (range 15-54 years) diagnosed clinico radiologically/imaging (n=36), histopathology or by PCR (n=15) were enrolled for the study. They were treated by extended DOTS regimen (2 months of HRZE and 6 months of HR) administered alternate day. The serial blood investigations and X-rays were done every 2 months. Contrast MRI was done at the end of 8 months and healing changes were recorded. Criteria of healing on the basis of MRI being: complete resolution of pre and paravertebral collections, resolution of marrow edema of vertebral body (VB), replacement of marrow edema by fat or by calcification suggested by iso- intense T1 and T2 weighted images in contrast enhanced MRI. Patients with non healed status, but, responding lesion on MRI after 8 months of treatment were continued on INH and rifampicin alternate day and contrast MRI was done subsequently at 12 months and 18 months till the healed status was achieved . Results: 9 patients had paraplegia and required surgical intervention out of which 1 did not recover neurologically. All patients have completed 8 months of extended DOTS regimen, n=18 achieved healed status and duration of treatment was extended in rest (n=33) 5 were declared healed after 12 months, 8 after 18 months and one after 36 months of treatment, thus 32 were declared healed at varying periods. Conclusion: 35.2% patients demonstrate MRI based healed vertebral lesion at the end of 8 months of extended category 1 DOTS regimen. It is unscientific to stop the ATT by fixed time frame and MRI evaluation of the patients is required after 8 months of ATT and subsequently to decide for the continuation stoppage of treatment.

Background: India ranks second amongst the high-burden multi drug resistant tuberculosis (MDR-TB) countries, with an estimated incidence of 2.3% MDR-TB cases amongst the new cases and 17.2% amongst the previously treated cases. The diagnosis and treatment protocol for MDR-TB of the spine are not clearly established. We report outcome of a series of 15 cases of TB spine who were suspected to be therapeutically refractory cases (MDR-TB) on the basis of clinicoradiological failures of initial treatment. Materials and Methods: Fifteen cases of TB spine from C2 to L5 spine were suspected to be the cases of MDR-TB (therapeutically refractory cases) on the basis of failures of adequate clinicoradiological healing response at 5 months or more on antitubercular treatment (ATT). None of the patient was immunocompromised. Thirteen out of 15 patients had tissue samples sent for histopathology, culture and sensitivity, smear, BACTEC, and polymerase chain reaction (PCR). All patients were put on second line ATT and followed up fortnightly with regular liver and kidney function tests, erythrocyte sedimentation rate (ESR), and plain X-ray. Healing was documented as subjective improvement of symptoms, reduction in ESR, and observations on contrast enhanced magnetic resonance imaging (MRI) such as resolution of marrow edema, fatty replacement of bone marrow and resolution of abscesses. Ambiguous MRI observations in a few patients were resolved on positron emission tomography (PET) scan. Patients were monitored continuously for 2 years after stopping ATT. Results: We could demonstrate a positive culture in three cases. Two of them had multi drug resistance. We could achieve healing status in 13 out of 14 patients after starting second line drugs, one patient is still on treatment while other patient with no drug resistance is responding well on ATT. Conclusions: The suspicion of therapeutically refractory case is of paramount importance. Once suspected, surgery to procure tissue for diagnosis and culture is to be undertaken. The demonstration of drug resistance on culture may not be achieved in all TB spine cases and empiric drug regimen for MDR-TB is to be started. We have achieved the healed status with immunomodulation and second line ATT. The length of treatment needs to be monitored with MRI and PET scan.

Information on Magnetic Resonance (MR) features of active and healed lesions in tuberculosis (TB) spine are lacking. We evaluated MRI findings in active and healed proven TB spine to establish the diagnostic features.Forty-nine consecutive spinal TB patients (20 male; 29 female) diagnosed clinicoradiologically and/or on histopathology, Fine Needle Aspiration Cytology (FNAC), bacteriology, or Polymerase Chain Reaction (PCR) were enrolled. Pretreatment MR scans were reviewed for diagnostic features, and eight-month follow-up MR scans were reviewed for healing changes.Cervical spine (n = 6), dorsal spine (n = 14), and lumbar spine (n = 29) were affected. Fourteen had paraplegia. Mean vertebrae involved were 2.61 on X-ray with a total of 128 vertebrae (VB) and 3.2 on MRI (range, 2-15) with 161 VB. The lesions were more extensive on MRI (34.7%) than appreciated on X-ray. The disc was preserved partially or fully in 88.2% of instances. End plate erosions (159/161 VB), lost VB height (94/161), exudative lesion (158/161), granular lesion (3/161), pre and paravertebral collections (49/49 cases), marrow oedema (161/161), discitis (98%), epidural involvement (107/161), epidural spread (100/161), and subligamentous spread (156/161) were observed. Canal encroachment (10-90%) was seen in 37 cases. Mean motor and sensory scores with greater than 50% canal encroachment were 87/100 and 156/168, respectively. Cord oedema was observed in 11 cases (eight with neural deficit and three cases without). Cord atrophy was seen in one case each before and after treatment. A total of 83% of patients had a combination of paravertebral collections, marrow oedema, subligamentous and epidural extension, endplate erosions and discitis. On healing (n = 20), complete resolution of marrow oedema and collections, fatty replacement of bone marrow and resolution of cord signal intensity were observed.The marrow oedema, preservation of disc space, subligamentous extension of abscess, septate paravertebral abscess, epidural extension, endplate erosions and discitis were consistently observed in 83% cases of TB spine on MRI.

In this article we study the max domains of attraction of distributions of sums of independent random variables belonging to the max domains of attraction of max stable laws under linear normalization. These results lead to the study of the max domains of attraction of distributions of products of independent random variables belonging to the max domain of attraction of max stable laws under power normalization.

Group Technology (GT) is a methodology which utilizes the similarity among parts or machine features. As such, the relevant features of the parts have to be considered in order to get the best grouping. In addition, GT methods require that the information is known in advance and remains constant. Contemporary manufacturing, on the other hand, advocates flexibility with less commitment to the features used for clustering. This paper analyzes the effect that information missing or arriving at a different order, has on the grouping of parts. In order to evaluate the variations in information availability, the paper presents a grouping methodology that allows parts to be grouped as they arrive, in a piecewise manner. The algorithm is based on negotiations among agents, who accept parts into their groups. The algorithm is implemented in C++ by creating classes and objects dynamically based on the algorithm's recommendations.

The book under review is based on the Center for Applied Statistics and Economics course at Humboldt University in Berlin and is designed for researchers who wish to develop professional skill in modern quantitative applications in finance. This is an electronic book and is designed as an interactive document with a stream of text and information with various hints and links to additional tools and features. The reader can access practical examples without purchasing additional software or material to be downloaded. Prerequisite for reading the book is a sound knowledge of probability, statistics and some software applications. The book contains four main parts, each consisting of articles by 30 contributors including the three authors. The contributors are either from universities or from financial institutions. Part I is about value at risk. The three chapters in this part deal with statistical approximations of value at risk in conditional Gaussian models, the calculation of value at risk by using copulas and the quantification of spread risk by means of simulation.