Association between lateral femoral wall thickness and BMD with the occurrence of lateral wall fracture in DHS fixation.

BACKGROUND: Nearly 50% of all hip fractures are intertrochanteric fractures (ITF) and are linked to osteopenia and advancing age. For secure ITF repair, the dynamic hip screw (DHS) fixation is regarded gold standard surgery. However, controversy exists regarding the use of DHS in the treatment of unstable ITF especially in patients with pre-operative lateral femoral wall fracture (LWF). The purpose of this study is to find if there's a link between lateral femoral wall thickness, bone mineral density and the risk of LWF in DHS fixation. PATIENT AND METHODS: A prospective, observational cohort analysis of 70 consecutive patients with ITF was undertaken in a tertiary care government hospital. All patients were treated with a 135° DHS fixation under regional anaesthesia and fluoroscopic guidance. Lateral femoral wall thickness was assessed pre-operatively on radiographs and during surgery. Mean T score as a measure of bone mineral density was recorded in all patients. RESULT: Postoperative LWFs occurred in 11 individuals. In 11 patients who had a postoperative LWF, the mean lateral femoral wall thickness was 19.545 mm, while the remaining 54 patients had a mean lateral femoral wall thickness of 29.285 mm (P < 0.001) With 81.5% sensitivity, the lateral femoral wall thickness threshold that could predict LWF was determined to be less than 25 mm. The mean T score of the contralateral hip in LWF patients was -2.255 standard deviation, whereas it was -2.428 standard deviation in patients without LWF, the difference of which was statistically not significant. CONCLUSION: DHS fixation alone should be avoided in ITF patients with lateral femoral wall thickness <25 mm and other implant choices should be explored for management of these patients.

Postoperative clinical outcome between lateral retraction and eversion of patella following simultaneous bilateral total knee arthroplasty.

AIMS AND OBJECTIVE: Among the various exposure technique used in total knee arthroplasty (TKA); the midline medial parapatellar knee approach is most commonly performed; which require mobilisation of patella for adequate surgical exposure. In this study, we compare the effect of patellar eversion with lateral retraction in simultaneous bilateral TKA to find out difference in postoperative clinical outcome between the two patellar mobilisation techniques. METHODS: We enrolled 41 patients who underwent bilateral simultaneous TKR (82 knees) from Nov 2016 to Dec 2018. During surgery patellar eversion was done in one knee and lateral retraction was done in other knee selecting them randomly to reduce the bias. During the follow up period achieving unassisted active straight leg raise (SLR), 90 flexion and complications were recorded. Measurement of Oxford knee society score (OKSS), American knee society score (AKSS), Visual Analogue Scale (VAS) score, and quadriceps strength (measured by handheld dynamometer) was done daily up to one week, 1 month, 3 months, 6 months, and 1 year postoperatively. RESULTS: The time of achieving active SLR and 90∗ flexion postoperatively was quicker in the lateral retraction group with a statistically significant difference. VAS pain score at 1 week and 1 month along with quadriceps strength in 1-month had statistically significant favourable outcomes in the lateral retraction group. Throughout the follow up lateral retraction group had better Oxford and American knee score but the difference being statistically insignificant. No significant difference was found on the complication rate. CONCLUSION: In comparison to lateral retraction, patellar eversion has an adverse effect in early knee functional recovery after TKA; it delays achieving active SLR, 90∗ flexion and has unfavourable outcome in functional scores, quadriceps strength, and postoperative pain relief. However it has minimal effects on long term functional outcomes.

Effect of posterior condylar offset in post operative range of motion in cruciate retaining and sacrificing TKR: A comparative analysis.

BACKGROUND: Restoration of posterior condylar offset (PCO) during TKA is believed to be an important to improve knee kinematics, maximizing range of motion (ROM) and minimizing flexion instability. The aim of prospective study was to find out the role of PCO in post-operative ROM after cruciate retaining (CR) and cruciate sacrificing (CS) TKA. METHODS AND MATERIALS: A total of 90 patients were divided into the CR knee group (49) and CS knee Group (41) intra-operatively by the surgeon based on the status of Posterior Cruciate Ligament. Preoperative and postoperative PCO was evaluated on true lateral knee radiographs. The ROM was measured pre operatively and post operatively at 4 weeks, 8 weeks, 3 months, 1 year and 2 years. Appropriate statistical tests were used and results were interpreted. RESULTS: The mean flexion angle was 113.86° in CR knees and 118.29° in CS knees with a significantly greater improvement observed for the latter group. Preoperative mean PCO was 35.08 mm in CR knees and 36.37 mm in CS knees, while the corresponding values post operatively were 32.74 mm and 34.88 mm respectively, at follow-up. In order to evaluate the relationship between change of PCO and postoperative improvement in range of flexion, we divided the patients into three sub groups according to the difference in pre and post-operative PCO. The first sub group had a difference in PCO ≤ 1 mm after surgery (CR: 5 and CS: 8), second sub group with a difference in PCO 1-3 mm after surgery (CR: 28 and CS: 26) and the third subgroup with a difference in PCO >3 mm after surgery (CR: 16 and CS: 7). Then a comparison of difference in PCO and post-operative range of motion was done in both CR knees and CS knees separately. The final post-operative range of motion (flexion) in CR knees was 117.6°, 115.93° and 109.06° for the three subgroups respectively. Similarly, the final post-operative range of motion (flexion) in CS knees was 116.12°, 118.81° and 118.86° for the three subgroups respectively. Thus a significant difference between three sub groups was observed in CR knees (P < 0.0001), while no difference was observed in the PS knees. CONCLUSION: The postoperative decrease in posterior condylar offset by more than 3 mm decreases the post-operative ROM in CR TKA but not in CS TKA. So it is critical to preserve PCO in CR but perhaps not CS knees to ensure optimal ROM postoperatively.

Comprehensive review of challenges associated with management of lower limb fractures in poliomyelitis patients.

Poliomyelitis is on the verge of eradication. But the survivors of polio are still living with its consequences in different parts of the world and so will continue to be seen for almost a century. Fractures in the polio-affected limb are a common entity in these patients and are difficult to manage using the common fracture management protocols. This article gives a comprehensive review of the challenges faced in fixation of fractures in polio affected limbs and possible solutions to overcome them. Knowledge of treating these fractures is important to a trauma surgeon as such scenarios are not uncommon in daily practice.

Tubercular osteomyelitis of the first metatarsal bone as a cause of forefoot pain.

The reporting of isolated metatarsal tuberculosis in the available literature is sparse, herein we report a case of 26-year-old female who presented with insidious onset pain and swelling in her forefoot. Radiograph showed osteolysis of the first metatarsal. Magnetic resonance imaging showed osseous erosion with marrow oedema. Diagnosis was ascertained by fine needle aspiration cytology of the lesion. The patient received anti-tubercular therapy and showed good clinical outcome. This case is reported because of its rarity of involving isolated metatarsal bone as a cause of forefoot pain.

Isolated intramuscular cysticercosis: Clinicopathological features, diagnosis and management - A review.

Cysticercosis is an emerging parasitic disease affecting worldwide population. There is large volume of data present in the literature for neurocysticercosis. The isolated intramuscular involvement of cysticercosis is uncommon and there are only sporadic case reports available. There is no review available in the literature which gives in detail clinicoradiological features and management of isolated intramuscular cysticercosis. Knowledge about such a presentation is important especially in developing countries and to differentiate the condition from a variety of other similar conditions.

Ollier Disease: Pathogenesis, Diagnosis, and Management.

Ollier disease (Spranger type I) is a rare bone disease that is characterized by multiple enchondromatosis with a typical asymmetrical distribution and confined to the appendicular skeleton. The pathogenesis of enchondromatosis is not clearly understood. Recently, heterozygous mutations of PTHR1, IDH1 (most common), and/or IDH2 genes have been suggested by various authors as genetic aberrations. Genomic copy number alterations and mutations controlling many vital pathways are responsible for the pathogenesis of Ollier disease. A comprehensive description of all genetic events in Ollier disease is presented in this article. Clinically, Ollier disease has a wide variety of presentations. This article describes the plethora of clinical features, both common and rare, associated with Ollier disease. Multiple enchondromas are most commonly seen in phalanges and metacarpals. Radiologically, Ollier disease presents with asymmetrical osteolytic lesions with well-defined, sclerotic margins. In this article, various radiological features of Ollier disease, including radiographs, computed tomography, and magnetic resonance imaging, are also discussed. Gross pathology, cytological, and histological features of both Ollier disease and its malignant transformation are outlined. Although treatment is conservative in most cases, different possible treatment options for difficult cases are discussed. In the literature, there is a paucity of data about the disease, including diagnosis, management, prognostication, and rehabilitation, necessitating a comprehensive review to further define all of the possible domains related to this disease.

Osteochondroma of Upper Dorsal Spine Causing Spastic Paraparesis in Hereditary Multiple Exostosis: A Case Report.

Osteochondroma of the spine is rare. It may present in solitary or multiple form (hereditary multiple exostoses). Herein, we report a case of an 18-year-old male who was diagnosed with thoracic osteochondroma, originating from the D4 vertebra with intraspinal extension and spinal cord compression in hereditary multiple exostosis. The patient was managed with surgery. Complete tumour excision was done to relieve cord compression and recurrence. Postoperatively the patient's symptoms were improved. At 2.5 year follow-up patient is doing well without any recurrence.

Melorheostosis: clinicopathological features, diagnosis, and management.

Melorheostosis is a rare sclerosing bone disease. This article describes the histological patterns and radiographic characteristics commonly associated with melorheostosis. A paucity of compiled data about the disease in the literature necessitated a comprehensive review to further define its management.

Melioidosis: a review of orthopedic manifestations, clinical features, diagnosis and management.

Melioidosis is an infectious disease caused by gram-negative soil-dwelling bacillus Burkholderia pseudomallei. Musculoskeletal melioidosis mimics other infections both clinically and radiologically. An extensive literature review has been performed over musculoskeletal melioidosis through various search engines such as Pubmed, Embase, Medscape, Altavista and Google. Diagnosis requires a high index of clinical suspicion and is dependent on microbiological confirmation. Prompt treatment with long-term combination antibiotics in high dosages and surgical drainage of abscesses improves survival.