The management of comminuted metaphyseal fractures is a technical challenge and satisfactory outcomes of such fixations often remain elusive. The small articular fragments and bone loss often make it difficult for standard fixation implants for proper fixation. We developed a novel technique to achieve anatomical reduction in multiple cases of comminuted metaphyseal fractures at different sites by employing the cantilever mechanism with the help of multiple thin Kirschner wires augmented by standard fixation implants.

We performed a retrospective study of 10 patients with different metaphyseal fractures complicated by comminution and loss of bone stock. All patients were treated with the help of cantilever mechanism using multiple Kirschner wires augmented by compression plates. All the patients were operated by the same surgeon between November 2020 to March 2021 and followed up till March 2023. Surgical outcomes were evaluated according to the clinical and radiological criteria.

A total of 10 patients were included in the study. Since we only included patients with highly unstable and comminuted fractures which were difficult to fix with traditional methods, the number of patients in the study were less. All 10 patients showed satisfactory clinical and radiological union at the end of the study with good range of motion. One of the patient in the study had post-operative wound complication which was managed conservatively with regular dressings and oral antibiotics.

Comminuted metaphyseal fractures might differ in pattern and presentation with every patient and there can be no standard treatment for all. The cantilever technique of fracture fixation is based on the principle of cantilever mechanism used in bridges and helps achieve good anatomical reduction and fixation. It provides a decent alternative when standard modes of fixation don't give desired result owing to comminuted nature of fractures and deficiency of bone stock.

Introduction

External fixation (EF) devices are commonly used in the management of complex skeletal trauma, as well as in elective limb reconstruction surgery for the management of congenital and acquired pathology. The subsequent removal of an EF is commonly performed under a general anaesthetic in an operating theatre. This practice is resource intensive and limits the amount of operating theatre time available for other surgical cases. We aimed to assess the use of regional anaesthesia as an alternative method of analgesia to facilitate EF removal in an outpatient setting.

This study was proposed to evaluate the efficacy of fibrin clot augmentation in meniscal tear using inside-out meniscal repair.

A total of 35 patients with meniscus tears were operated on with inside-out meniscus repair and fibrin clot augmentation. Patients were evaluated preoperatively and postoperatively with clinical criteria, Lysholm knee scoring system, and MRI.

Out of the total 35 cases, 5 cases were lost to follow up. Clinical improvement was observed in 29 out of 30 patients (96.6%). The mean Lysholm score improved significantly from 67.63 ± 6.55 points preoperatively to 92.0 ± 2.9 points postoperatively (P < 0.05) in 2 years follow-up. Follow-up MRI in all patients revealed complete healing except in 1 case where the patient presented with recurrence of symptoms such as pain and locking which resolved with partial meniscectomy. Paraesthesia in the anterior part of the knee was observed in 2 cases. (6.6%).

We conclude that fibrin clot augmentation is a good cost-effective modality of treatment for repairable meniscus tears to preserve the meniscus and decrease the point contact pressure on the condyles which may prevent the early occurrence of osteoarthritis.

To evaluate the functional outcome of open humerus diaphyseal fractures treated with the Three-stitch technique of antegrade humerus nailing.

This is a retrospective study conducted at the Department of Orthopaedics in D. Y. Patil University, School of Medicine, Navi Mumbai, India. The study included 25 patients who were operated on from January 2019 to April 2021 and follow-ups done till May 2022. Inclusion criteria were adult patients with open humerus diaphyseal fractures (Gustilo-Anderson Classification). All patients with closed fractures, skeletally immature patients, and patients with associated head injury were excluded from the study. All patients were operated on with a minimally invasive Three-stitch technique for antegrade humerus nailing. All patients were evaluated based on DASH score.

Out of the 25 patients included in the study, all patients showed complete union. The mean age of the patients was 40.4 years (range 23–66 years). The average period for consolidation of fracture was 10.56 weeks (range 8–14 weeks). The DASH score ranged from 0 to 15.8 with an average score of 2.96. Five patients reported complications with three patients of post-operative infection and delayed wound healing and two patients with screw loosening. All complications were resolved with proper wound care and the complete union was noted. None of the patients had an iatrogenic neurovascular injury.

Three-stitch antegrade nailing technique is a novel method to treat diaphyseal humerus fractures and provides excellent results. It has various advantages such as minimal invasiveness, minimal injury to the rotator cuff, fewer infection rates, minimal iatrogenic injuries, and good functional outcomes. Therefore, this treatment modality can be effectively used for open humerus diaphyseal fractures.

Osteomyelitis is an inflammatory condition accompanied by the destruction of bone and caused by an infecting microorganism. Open contaminated fractures can lead to the development of osteomyelitis of the fractured bone in 3-25% of cases, depending on fracture type, degree of soft-tissue injury, degree of microbial contamination, and whether systemic and/or local antimicrobial therapies have been administered. Untreated, infection will ultimately lead to non-union, chronic osteomyelitis, or amputation.

We report a case series of 10 patients that presented with post-operative infected non-union of the distal femur with or without prior surgery. The cases were performed at Padmashree Dr. D. Y. Patil Hospital, Nerul, Navi Mumbai, India. All the patients’ consents were taken for the study which was carried out in accordance with the Helsinki Declaration. The methodology involved patients undergoing a two-stage procedure in case of no prior implant or a three-stage procedure in case of a previous implant. Firstly, debridement and implant removal were done. The second was a definitive procedure in form of knee arthrodesis with ring fixator and finally followed by limb lengthening surgery.

Arthrodesis was planned in view of infection, non-union, severe arthritic, subluxated knee, stiff knee, non-salvage knee joint, and financial constraints. After all the patients demonstrated wound healing in 3 months along with good radiographic osteogenesis at the knee arthrodesis site, limb lengthening surgeries by tibial osteotomy were done to overcome the limb length discrepancy. Distraction was started and followed up for 5 months. All 10 patients showed results with sound knee arthrodesis and good osteogenesis at the osteotomy site followed by achieving the limb length just 1-inch short from the normal side to achieve ground clearance while walking. Our case series is unique and distinctive as it shows that when patients with infected nonunion of distal femur come with the stiff and non-salvage knee with severe arthritic changes and financial constraints, we should consider knee arthrodesis with Ilizarov ring fixator followed by limb lengthening surgery.

Higher uric acid levels or hyperuricemia is a product of more uric acid production, dysfunctional renal excretion, or a combination of both leading to deposition of urate crystals in the joints and kidneys and has been strongly linked with the development of gout, that is, acute inflammatory arthritis. Uric acid levels have been suggested to depend on multiple factors including lifestyle, diet, alcohol consumption, etc. As these are risk parameters for hyperuricemia and since lifestyle choices vary amongst different Indian communities, we sought to study the prevalence of hyperuricemia in these communities. Also, large-scale data (in terms of gender, age, lifestyle, community) on the prevalence of hyperuricemia in subjects amongst different community populations, Hindu, Muslim, Sikh, and Christian was generated.

In a retrospective study conducted at Dr. D. Y. Patil School of Medicine & Research Centre, Navi Mumbai from April 2018 to May 2021, information was gathered from four major communities on a range of indicators including serum uric acid levels followed by a thorough multilevel logistic analysis. We evaluated uric acid levels in 10,378 patients of four different communities. Outcomes were assessed biochemically as well as clinically based on the levels of serum uric acid.

The mean serum uric acid levels were highest in Sikhs (7.6 mg%, n=732) followed by Christians (7.3 mg%, n=892) and then by Hindus (5.9 mg%, n=6846) and Muslims (5.6 mg%, n=1908). About 83.7% of Christians consumed meat in a non-vegetarian diet followed by 45.7% Muslims. Percentage of Christians who binge drink were highest whereas percentage of Sikh people in the heavy drinkers’ category were 5.2%. Further, 9.5% Hindus were current smokers followed by 7.8% Sikhs who smoked at present.

Overall, our study of 10,378 patients demonstrated that the serum uric acid levels varied from one Indian community to another due to varying external factors like diet, age, lifestyle, and addictions. Thus, lifestyle modification in communities with higher serum uric acid levels is highly advocated and this may reduce the healthcare burden of gouty arthritis in these communities.

Osteochondromas are benign chondrogenic lesions arising on the external surface of the bone with aberrant cartilage (exostosis) from the perichondral ring that may contain a marrow cavity also. In a few cases, depending on the anatomical site affected, different degrees of edema, redness, paresthesia, or paresis can take place due to simple contact or friction. Also, depending on their closeness to neurovascular structures, the procedure of excision becomes crucial to avoid recurrence. We report a unique case of recurrent osteochondroma of the proximal humerus enclosing the brachial artery which makes for an important case and procedure to ensure that no relapse occurs.

We report a unique case of a 13-year-old female who had presented with a history of pain and recurrent swelling for 5 years. The swelling size was 4.4 cm x 3.7 cm x 4 cm with a previous history of swelling at the same site operated in 2018. CT reports were suggestive of a large well defined broad-based exophytic diaphyseal lesion in the medial side of the proximal humerus extending posteriorly. Another similar morphological lesion measuring approximately 9 mm x 7 mm was noted involving the posterior humeral shaft. The minimal distance between the lesion and the brachial artery was 2 mm just anterior to the posterio-medial growth. Two intervals were made, first between the tumor and the neurovascular bundle and the other between the anterior tumor and brachial artery followed by exostosis and cauterization of the base.

Proper curettage and excision of the tumor was done after dissecting and removing the soft tissue, blood vessels, and nerves so that there were very less chances of relapse. Post-operative X-ray was done and post 6 months of follow-up, there were no changes, and no relapse was observed. Thus, when presented with a case of recurrent osteochondroma of the proximal humerus, osteochondroma could also be in proximity to important vasculature as in this case enclosing the brachial artery. Thus, proper curettage and excision should be done in such cases to avoid recurrence.

Total Knee Arthroplasty (TKA) improves the quality of life of osteoarthritic and rheumatoid arthritis patients, however, is associated with moderate to severe postoperative pain. There are multiple methods of managing postoperative pain that include epidural anesthesia but it prevents early mobilization and results in postoperative hypotension and spinal infection. Controlling local pain pathways through intra-articular administration of analgesics is a novel method and is inexpensive and simple. Hence, we assess the effects of postoperative epidural bupivacaine injection along with intra-articular injection in total knee replacement patients.

The methodology included 100 patients undergoing TKA randomly divided into two groups, one administered with only epidural bupivacaine injection and the other with intra-articular cocktail injection. The results were measured based on a 10-point pain assessment scale, knee's range of motion (ROM), and Lysholm knee score.

The VAS score was lower in the intra-articular cocktail group compared to the bupivacaine injection group until the end of 1-week post-administration (p<0.01). Among inter-group comparisons, we observed that the range of motion was significantly more in cocktail injection as compared to the bupivacaine group till the end of one week (p<0.05). Lysholm's score was significantly more in cocktail injection as compared to the bupivacaine group till the end of one week (p<0.05).

Our study showed that both epidural bupivacaine injection and intra-articular injection were effective in reducing pain after TKA and have a comparable functional outcome at the end of 4 weeks follow up. However, the pain relief was faster in cases with intra-articular injection, providing the opportunity for early rehabilitation. Thus, we recommend the use of intra-articular cocktail injection for postoperative management of pain after total knee arthroplasty, which enables early rehabilitation and faster functional recovery of these patients.

Aims

To compare the efficacy of decompression alone (DA) with i) decompression and fusion (DF) and ii) interspinous process device (IPD) in the treatment of lumbar stenosis with degenerative spondylolisthesis. Outcomes of interest were both patient-reported measures of postoperative pain and function, as well as the perioperative measures of blood loss, operation duration, hospital stay, and reoperation.

En bloc resection for primary bone tumours and isolated metastasis are complex surgeries associated with a high rate of adverse events (AEs). The primary objective of this study was to explore the relationship between frailty/sarcopenia and major perioperative AEs following en bloc resection for primary bone tumours or isolated metastases of the spine. Secondary objectives were to report the prevalence and distribution of frailty and sarcopenia, and determine the relationship between these factors and length of stay (LOS), unplanned reoperation, and 1-year postoperative mortality in this population.

This is a retrospective study of prospectively collected data from a single quaternary care referral center consisting of patients undergoing an elective en bloc resection for a primary bone tumour or an isolated spinal metastasis between January 1st, 2009 and February 28th, 2020. Frailty was calculated with the modified frailty index (mFI) and spine tumour frailty index (STFI). Sarcopenia, determined by the total psoas area (TPA) vertebral body (VB) ratio (TPA/VB), was measured at L3 and L4. Regression analysis produced ORs, IRRs, and HRs that quantified the association between frailty/sarcopenia and major perioperative AEs, LOS, unplanned reoperation and 1-year postoperative mortality.

One hundred twelve patients met the inclusion criteria. Using the mFI, five patients (5%) were frail (mFI ³ 0.21), while the STFI identified 21 patients (19%) as frail (STFI ³ 2). The mean CT ratios were 1.45 (SD 0.05) and 1.81 (SD 0.06) at L3 and L4 respectively. Unadjusted analysis demonstrated that sarcopenia and frailty were not significant predictors of major perioperative AEs, LOS or unplanned reoperation. Sarcopenia defined by the CT L3 TPA/VB and CT L4 TPA/VB ratios significantly predicted 1-year mortality (HR of 0.32 per one unit increase, 95% CI 0.11-0.93, p=0.04 vs. HR of 0.28 per one unit increase, 95% CI 0.11-0.69, p=0.01) following unadjusted analysis. Frailty defined by an STFI score ≥ 2 predicted 1-year postoperative mortality (OR of 2.10, 95% CI 1.02-4.30, p=0.04).

The mFI was not predictive of any clinical outcome in patients undergoing en bloc resection for primary bone tumours or isolated metastases of the spine. Sarcopenia defined by the CT L3 TPA/VB and L4 TPA/VB and frailty assessed with the STFI predicted 1-year postoperative mortality on univariate analysis but not major perioperative AEs, LOS or reoperation. Further investigation with a larger cohort is needed to identify the optimal measure for assessing frailty and sarcopenia in this spine population.

The routine use of intraoperative vancomycin powder to prevent postoperative wound infections has not been borne out in the literature in the pediatric spine population. The goal of this study is to determine the impact of vancomycin powder on postoperative wound infection rates and determine its potential impact on microbiology.

A retrospective analysis of the Harms Study Group database of 1269 adolescent idiopathic scoliosis patients was performed. Patients that underwent a posterior fusion from 2004-2018 were analyzed. A comparative analysis of postoperative infection rates was done between patients that received vancomycin powder to those who did not. Statistical significance was determined using Chi-squared test. Additionally, the microbiology of infected patients was examined.

In total, 765 patients in the vancomycin group (VG) were compared to 504 patients in the non-vancomycin group (NVG). NVG had a significantly higher rate of deep wound infection (p<0.0001) and associated reoperation rate compared to VG (p<0.0001). Both groups were compared for age, gender, race, weight, surgical time, blood loss, number of levels instrumented, and preop curve magnitude. There were significant differences between the groups for race (p<0.0001); surgical time (p=0.0033), and blood loss (p=0.0021). In terms of microbiology, VG grew p.acnes (n=2), and serratia (n=1), whereas NVG grew p.acnes (n=1) and gram positive bacilli (n=1). The remaining cultures were negative.

The use of intraoperative vancomycin powder in adolescent idiopathic scoliosis appears to contribute significantly to deep wound infection prevention and reduction of associated reoperations. Based on this study's limited culture data, Vancomycin does not seem to alter the microbiology of deep wound infections.

Abstract

Abstract

Abstract

Abstract

Introduction and Objective

Management of gap non-union of the tibia, the major weight bearing bone of the leg remains controversial. The different internal fixation techniques are often weighed down by relatively high complication rates that include fractures which fail to heal (non-union). Minimally invasive techniques with ring fixators and bone transport (distraction osteogenesis) have come into picture as an alternative allowing alignment and stabilization, avoiding a graduated approach. This study was focused on fractures that result in a gap non-union of > 6 cm. Ilizarov technique was employed for management of such non-unions in this case series. The Ilizarov apparatus consists of rings, rods and kirschner wires that encloses the limb as a cylinder and uses kirschner wires to create tension allowing early weight bearing and stimulating bone growth. Ilizarov technique works on the principle of distraction osteogenesis, that is, pulling apart of bone to stimulate new bone growth. Usually, 4–5 rings are used in the setup depending on fracture site and pattern for stable fixation. In this study, we demonstrate effective bone transport and formation of gap non-union more than 6 cm in 10 patients using only 3 rings construct Ilizarov apparatus.

Injuries to the hamstring muscle complex are common in athletes, accounting for between 12% and 26% of all injuries sustained during sporting activities. Acute hamstring injuries often occur during sports that involve repetitive kicking or high-speed sprinting, such as American football, soccer, rugby, and athletics. They are also common in watersports, including waterskiing and surfing. Hamstring injuries can be career-threatening in elite athletes and are associated with an estimated risk of recurrence in between 14% and 63% of patients. The variability in prognosis and treatment of the different injury patterns highlights the importance of prompt diagnosis with magnetic resonance imaging (MRI) in order to classify injuries accurately and plan the appropriate management.

Low-grade hamstring injuries may be treated with nonoperative measures including pain relief, eccentric lengthening exercises, and a graduated return to sport-specific activities. Nonoperative management is associated with highly variable times for convalescence and return to a pre-injury level of sporting function. Nonoperative management of high-grade hamstring injuries is associated with poor return to baseline function, residual muscle weakness and a high-risk of recurrence. Proximal hamstring avulsion injuries, high-grade musculotendinous tears, and chronic injuries with persistent weakness or functional compromise require surgical repair to enable return to a pre-injury level of sporting function and minimize the risk of recurrent injury.

This article reviews the optimal diagnostic imaging methods and common classification systems used to guide the treatment of hamstring injuries. In addition, the indications and outcomes for both nonoperative and operative treatment are analyzed to provide an evidence-based management framework for these patients.

Cite this article: Bone Joint J 2020;102-B(10):1281–1288.

Aims

As the peak of the COVID-19 pandemic passes, the challenge shifts to safe resumption of routine medical services, including elective orthopaedic surgery. Protocols including pre-operative self-isolation, COVID-19 testing, and surgery at a non-COVID-19 site have been developed to minimize risk of transmission. Despite this, it is likely that many patients will want to delay surgery for fear of contracting COVID-19. The aim of this study is to identify the number of patients who still want to proceed with planned elective orthopaedic surgery in this current environment.

Background

Radiotherapy has contributed with a significant and impressive stride to the survival rates of oral cancer patients. However, quality and alterations in the biochemical composition of bones used for dental implantation after radiotherapy in cancer patients is always a critical and debatable factor. The aim of this study was to determine compositional alterations in human mandible bone after irradiation using Raman microspectroscopy.

The objectives of this study are to ascertain primary caregivers' understanding of risks associated with home trampoline use; to educate caregivers in regard to documented literature based risks associated with home trampoline use; and to evaluate if this information will have any influence on their future regulation of home trampoline use for their children.

One hundred primary caregivers of patients treated in the paediatric orthopaedic surgery outpatient clinic at London Health Sciences centre were surveyed. All caregivers in clinic were invited to participate. The only exclusion criteria was the inability to provide consent. Caregivers' baseline perceptions on the risks associated with home trampoline use were assessed using a questionnaire. Caregivers then received an information pamphlet outlining documented trampoline safety data. They were then sent the same questionnaire to complete within one week of reading the pamphlet. Using our research electronic database capture (Redcap), the results of the surveys were compiled and analysed using spss 22, paired t-test and repeated measures anova. A sample size of 55 was calculated to result in a power of 80%.

Of primary caregivers surveyed, 36% owned a home trampoline, and only 5% had personal experiences with their child sustaining a trampoline injury. Pre-education, when caregivers were asked on a scale of one (not dangerous) to 10 (very dangerous) how dangerous they felt a trampoline was for their child, the average response was six. Post-education, this number changed to eight. Providing education to primary caregivers significantly changed their perceptions on all sections of the questionnaire, yet 47% of primary caregivers were willing to allow their child to use a trampoline at home despite their new understanding of trampoline injury and safety.

Providing education to primary caregivers significantly changed their perceptions on all trampoline safety questions, indicating effective comprehension. Despite caregivers' understanding of the risks associated with home trampoline use, approximately half of the study population continue to permit this activity for their children. There is potential to reduce paediatric orthopaedic injuries associated with home trampoline use if safer trampoline related practices are implemented based on information provided.