A Comparison of the Clinicoradiological Outcomes of Intertrochanteric Fractures Treated Using Proximal Femoral Nail and Proximal Femoral Nail Anti-rotation.

Background Managing intertrochanteric fractures presents challenges for orthopedic surgeons, not only in fixing the fracture but also in preventing and managing associated complications, especially in the vulnerable geriatric population. Cephalomedullary nails are commonly used for surgical fixation due to their favorable functional profile, which preserves the hip's abductor lever arm and proximal femur anatomy. However, there's a lack of data comparing two major options: proximal femoral nail (PFN) and proximal femoral nail anti-rotation (PFNA). This study aimed to compare the radiological fracture reduction and fixation as well as functional outcomes of these two implants in treating intertrochanteric fractures. Methods The study, spanning 24 months, involved a prospective comparative design. Participants included patients diagnosed with intertrochanteric femur fractures classified as AO Type 31 A1, AO Type 31 A2, and AO Type 31 A3. Fifty patients were evenly distributed into PFN and PFNA groups. Preoperatively, clinical and radiological assessments were conducted, along with serum vitamin D level measurements. Surgeries, performed under anesthesia with image intensifier guidance, followed defined reduction and implant insertion protocols for each group. Postoperatively, evaluations were conducted up to six months, examining parameters such as tip-apex distance (TAD), Cleveland index, and modified Harris hip score, while documenting intraoperative duration and blood loss. Data analysis utilized the statistical software Statistical Package for Social Sciences (SPSS), version 22.0 (IBM Corp., Armonk, NY), employing descriptive statistics, chi-square tests, independent t-tests, and paired t-tests, with significance set at p < 0.05. Results In our study, 50 patients were enrolled, with equal gender distribution (64.0% male, 36.0% female, p=1.000). The mean ages in the PFN and PFNA groups were 66.2 ± 9.8 years and 66.4 ± 11.3 years, respectively (p=0.936). All fractures united by six months, with no implant-related complications reported. PFNA showed significantly lower blood loss and shorter surgery durations (p<0.001). TAD and neck shaft angle were similar between groups (p=0.826, p=0.555). Cleveland index placement and modified Harris hip score improvement were comparable (p=0.836, p<0.001). Predominant vitamin D deficiency was observed in both groups. Conclusion PFNA offers measurable intraoperative benefits over conventional PFN in terms of operative time, blood loss, and need for fluoroscopic imaging. However, no statistically observable benefits were noted in postoperative functional outcomes or complications between the two implants.

Serum Osteopontin as a Potential Marker for Metastasis and Prognosis in Primary Osteogenic Sarcoma: A Systematic Review.

Osteosarcoma (OS), a primary malignant bone tumor, poses significant challenges in diagnosis and prognosis. It is a painful medical burden, and treating it is still a difficult issue. Osteopontin (OPN), a multifunctional extracellular matrix protein, has emerged as a promising biomarker in this context. This systematic review explores the role of OPN as a diagnostic and prognostic marker in OS, highlighting its potential in enhancing early detection, monitoring disease progression, and predicting patient outcomes. Various studies have demonstrated elevated levels of OPN in OS patients, correlating with tumor aggressiveness, metastatic potential, and poor prognosis. In addition, OPN's involvement in tumor microenvironment regulation and metastatic processes underscores its clinical relevance as a biomarker. For this systematic review, comprehensive literature searches were conducted in the PubMed databases for research published between the database's establishment and November 11, 2022. Out of the nine studies that were available for analysis, a higher level of OPN in primary osteogenic sarcoma patients indicates a poorer prognosis and higher incidence of metastasis. OS has not shown commensurable progress with concerns to treatment approches and survical outcomes. However, the discovery of a biological marker that can predict metastasis and severity will be a groundbreaking development for advancements in OS diagnosis and treatment. Therefore, understanding the intricate interplay between OPN and OS pathogenesis holds promise for improving patient management and developing targeted therapeutic strategies.

Total Hip Arthroplasty in Neglected Acetabular Fracture with Pipkin Type 4 Femoral Head Fracture. A Case Report.

Introduction: Pipkin type 4 fracture is defined as hip dislocation with femoral head fracture and concomitant acetabular rim fracture. These fractures are rare. Neglected fractures develop adaptive changes in the acetabulum, femoral head, and soft tissues around the hip joint, leading to hip arthritis. Total hip arthroplasty is preferred in such cases. After an extensive literature review, we did not find any guidelines for managing neglected Pipkin type 4 fractures. Case Report: A 47-year-old male presented with pain in his left hip and an inability to bear weight on his left lower limb. He had a road traffic accident 1 year ago. On clinical examination, there was a shortening of 3 cm and reduced hip range of motion on 3D computed tomography posterosuperior defect of the acetabular wall along with Pipkin type 4 femoral head fracture was detected. Total hip arthroplasty with acetabular reconstruction using a femoral head autograft was done. At 1 year of follow-up, the patient was pain-free and could walk without any assistance with a normal gait. Conclusion: Uncemented total hip arthroplasty with an autologous structural femoral head graft is a suitable method of treatment for neglected Pipkin type 4 fractures. It preserves bone stock and does not add any financial burden.

Plasma Interleukin-33 Cannot Predict Hip Osteonecrosis in Patients With Sickle Cell Disease: A Case-Control Study.

Background Plasma interleukin-33 (IL-33), a cytokine associated with inflammatory and autoimmune disease, has been described to be significantly raised in osteonecrosis of the femoral head (ONFH) and hence was recommended for use as a marker for ONFH. The concentration of plasma interleukin-33 level has not been estimated in any studies conducted in patients with sickle cell disease (SCD); hence, we investigated the levels of plasma interleukin-33 in patients with sickle cell disease with or without ONFH to assess whether it can be used as a marker for the early detection of ONFH in this disease also. Methods Forty-four consecutive patients with sickle cell disease with osteonecrosis of the femoral head and matched controls without ONFH were evaluated for plasma interleukin-33 levels by enzyme-linked immunosorbent assay (ELISA). All patients were confirmed for sickle cell disease using high-performance liquid chromatography (HPLC). ONFH was diagnosed in patients with sickle cell disease using clinical-radiological findings. Univariate and multivariate analyses were performed using the IL-33 level as the dependent variable. Results Plasma IL-33 levels were comparable in 44 patients with sickle cell disease with osteonecrosis of the femoral head as compared with 24 patients with sickle cell disease without ONFH (2.05 ± 4.57 pg/mL versus 1.50 ± 2.89 pg/mL, p-value = 0.590). There was no significant difference in IL-33 levels in different stages of avascular necrosis (AVN). Conclusions Plasma interleukin-33 levels cannot act as a marker of ONFH as were being considered in idiopathic ONFH or ONFH caused by other causes such as trauma and chronic steroid or alcohol usage.

Usage of Accessory Anteromedial Portal for Anatomical Placement of Femoral Tunnel in Transportal Anterior Cruciate Ligament Reconstruction: A Prospective Study.

Background and objective The anterior cruciate ligament (ACL) has an essential role in preserving the function and stability of the knee joint. It acts primarily to prevent anterior tibial translation. Arthroscopic ACL reconstruction using quadrupled hamstring graft is the widely practiced modality for treating ACL injuries nowadays. The objective of this study was to assess the functional outcomes of ACL reconstruction using the transportal approach for a femoral tunnel through an accessory anteromedial portal (AAM). Materials and methods This prospective study included 35 patients who met the inclusion criteria. All patients underwent arthroscopic reconstruction of ACL using quadrupled hamstring tendon graft via transportal technique for femoral canal reaming through AAM. Patients were assessed for the functional outcome for a year using the Tegner-Lysholm knee scoring system. Results The analysis of the studied cases revealed that the mean age of the patients was around 27 years. Males were affected more than females. The left side (77.14%) was affected more than the right side (22.86%); 54.28% of patients had a history of road traffic accidents (RTAs). Preoperatively, 19 (54.28%) patients had poor and 16 (45.72%) patients had fair Tegner-Lysholm scores. After one year of follow-up, 29 (82.85%) of the patients had an excellent score as per the Tegner-Lysholm scoring system. Three patients had knee pain and thigh muscle wasting (2-3 cm), and two of them also had a sense of giving away during follow-up. Conclusion Anatomical reattachment of tendon graft for ACL reconstruction at femoral and tibial footprints is indispensable for good functional outcome and knee kinematics, and the usage of the AAM provides good visualization of femoral footprint and ease to surgeons during ACL reconstruction for making a near-accurate femoral tunnel and thereby achieving better outcomes.

Mammoth Giant Cell Tumor of the First Metacarpal: A Case Report and Management Trends.

Giant cell tumor (GCT) is classically described as a locally aggressive, epiphyseo-metaphyseal osteolytic tumor occurring in young adults. They are mostly seen in long bones while some are also found in the iliac bone and spine and a very small proportion occurs in hand bones. Due to the rarity of GCT in metacarpal, there is a paucity of treatment options available. In an extensive literature search on PubMed, Embase, Medline, and Ovid from 2004 till date, very few cases were reported. The various treatment options available are intralesional curettage with or without adjuvant therapy, wide resection, free osteoarticular metatarsal transfer, and, occasionally, ray amputation may also be done. After simple curettage, a reasonably high recurrence rate also imposes comprehensive en-bloc excision, but still, there are many case reports of recurrence. Experience with a case of GCT of the whole first metacarpal extending from the carpometacarpal to the metacarpophalangeal joint is not thoroughly described in the literature. We hereby report a mammoth GCT of the first metacarpal treated by excision and reconstruction by free fibular graft and adjacent joint fusion with an excellent functional outcome at one-year follow-up.

Giant Cell Tumor of the Distal Radius: Wide Resection, Ulna Translocation With Wrist Arthrodesis.

Giant cell tumor (GCT) of the bone is a locally aggressive neoplasm and usually managed with extended curettage and adjuvant therapy, which is associated with reduced risk of recurrence. The juxta-articular distal radius giant cell tumor is challenging due to the destruction of subchondral bone and articular cartilage, making it difficult to salvage the wrist joint anatomy and function. Various methods described include wide resection and reconstruction of allograft or centralization of the ulna with wrist arthrodesis. We present the functional outcome of distal end radius GCT, which was successfully managed with wide local excision, ulna translocation, and wrist arthrodesis. At the two years follow-up, the patient shows excellent functional outcome with supination and pronation movements and no local recurrence.

The Successful Management of a Repetitively Infected Recurrent Proximal Humerus Giant Cell Tumour of 20 Years' Duration With Two-Staged Surgery: A Rare Case Report.

The recurrence of giant cell tumour of bone (GCTB) is quite well known. It is mainly attributed to the presence of microscopic tumour remnants left behind after tumour treatment by intralesional curettage. This condition becomes more serious and alarming when the lesion gets infected postoperatively. Several studies have indicated that the role of adjuvants in preventing the recurrence of GCTs is limited, and complete removal of malignant cells is often mandatory. We present a rare case GCT of the proximal humerus in a female patient who developed repetitive recurrences of the tumour; her salvage procedures were also complicated by the development of infection after every treatment procedure for over 20 years. The patient was finally treated successfully with a two-stage revision and reconstruction procedure.

Septic arthritis of knee due to Burkholderia pseudomallei: a case report.

Burkholderia pseudomallei is an important cause of sepsis in certain parts of Asia and northern Australia. It usually causes abscess in the lungs, liver, spleen, skeletal muscle and parotids, especially in patients who are immunocompromised. In India, musculoskeletal melioidosis has rarely been reported. We report such a case with septic arthritis of the knee, diagnosed on the basis of a positive pus culture. After being treated by arthrotomy and surgical debridement followed by a combination of intravenous ceftazidime (acute phase = three weeks) and oral doxycycline and co-trimoxazole (eradication phase = five weeks) for two months, the patient recovered completely with no recurrence.

Correlation between MRI appearances and serum alkaline phosphatase levels in Osteogenic sarcoma.

INTRODUCTION: Magnetic resonance imaging is a pictorial depiction of the patho-anatomy of a bony lesion. As different parts of the tumor in Osteogenic sarcoma concurrently undergo various biological processes i.e. osteoblastic new bone formation, cell death, necrosis, bony destruction and revascularization etc., we hypothesized that the image seen in MRI could be used to assess the tumor behavior at that time. This study was done as a preliminary study with the aim to find whether the MRI pictures can have identifiable patterns and if present whether they can be linked to biological behavior. We could identify 2 distinct patterns in T2 weighted images which correlated well with serum alkaline phosphatase a serum marker and the duration of symptoms and so we are reporting our observations. MATERIAL AND METHOD: T2 weighted MRI pictures of 15 cases of Osteogenic sarcoma were studied for identifiable patterns in matrix. These patterns if found were to be linked to biological behavior in the form of serum alkaline phosphatase levels and duration of symptoms. RESULTS: We could identify 2 unique patterns named by us as Group 1 Heterogeneous type (4 cases) which had a raised serum alkaline phosphatase level and had a history at presentation of less than 3 months duration. In Group 2 homogenous type (5 cases) the serum alkaline phosphatase levels were low and the cases presented after 6 months. As we could not identify any logical pattern in rest of the cases we labeled them as miscellaneous. DISCUSSION: MRI patterns can be used as markers of disease activity as there are 2 clear poles correlating well with serum alkaline phosphatase levels (high or low). Intermediate patterns may be the natural biological behavior and waxing and waning of the tumor disease activity.

Pathogenic bacteria in an orthopaedic hospital in India.

BACKGROUND: The problem of changes in pathogenic microbiological flora and the emergence of bacterial resistance has created major problems in the management of orthopaedic diseases and fractures. Due to the use of implants for open reduction and internal fixation, which are foreign bodies to the body, orthopaedic trauma surgery is at grave risk of microbiological contamination and infection. METHODOLOGY: With new microbiological agents in vogue, we have conducted a retrospective study to determine the pattern of bacterial infection, sensitivity to various antimicrobial agents, and their relations to various orthopaedic illnesses and procedures. RESULTS: Gram negative (E. coli and Pseudomonas spp.) infections have emerged as the major threat (74.37%) in orthopaedic cases in contrast to Staphylococcus aureus (23.31%). These bacteria infected patients with open fractures (34.3%), spinal instrumentation with bedsores (23.31%), osteomyelitis of bone (24.42%) and guillotine amputation stumps (14.43%). CONCLUSION: Cefaperazone and ceftriaxone were found to be the most effective antibiotics against gram negative bacteria while cefaperazone was equally effective against S. aureus. Emerging resistance was found against amoxicillin, ampicillin and the aminoglycoside: amikacin.

Closed posterior dislocation of the ankle without fracture.

Closed posterior dislocation of the ankle without a fracture is a rare injury. We are reporting a case in a young male on his motorbike, being hit at the right ankle from behind. The mechanisms of injury along with MRI findings are being discussed.