Open reduction for hip dislocation in children with arthrogryposis multiplex congenital: Outcomes of a systematic review.

Introduction: The incidence of hip dislocation (HD) in arthrogryposis multiplex congenital ranges from 15 to 30 %. Besides a stable hip, the ambulation potential of an AMC child is also dependent on severity of associated knee and foot deformations. The primary objective of this review is to determine the proportion of ambulators in AMC children treated by open reduction for HD. Methods: We searched major electronic bibliographic databases for reports on the treatment of HD among AMC children. Based on the surgical approach for open reduction of HD in AMC children, we divided the included studies into groups 1 (Anterior approach open reduction) and 2 (Medial approach open reduction). Results: We pooled 59 children/94 hips in this review from 7 studies. We identified 45 children/71 hips and 14 children/23 hips with a mean age of 20 (4-64) and 4.5 (0.5-11) months in groups 1 and 2, respectively. There were 97 % (44) and 92 %(Obeidat et al., 2011) 13 ambulators in groups 1 and 2, respectively. 47 % and 36 % of hips in groups 1 and 2 required additional procedures besides open reduction for redislocation and maintenance of hip reduction. 31 %22 and 13 %(Fisher et al., 1970 Feb) 3 of the hips sustained avascular necrosis in group 1 and 2. Conclusion: Children with AMC associated HD can be expected to ambulate with and without assistance in 90 % of the cases however, the foot and knee problems also need concomitant management. In children less than 6 months of age the medial approach based open reduction may be more efficacious and less complicating than anterior approach based open reduction however, at a later age anterior approach based open reduction is more effective due to need for pelvic and femur sided additional procedures.

Latarjet operation carries three times the risk of failure in seizure versus non-seizure recurrent anterior dislocation of the shoulder joint: outcome of a systematic review with meta-analysis.

BACKGROUND: Recurrent anterior shoulder dislocation (RASD) in cases of seizure disorders (SDs) total 50%-80% of all SD-associated shoulder instabilities. Based on the extent of bone loss, treatment options include bony and soft-tissue reconstructions, arthroplasty, and arthrodesis. The primary objective of this paper was to review the treatment options for RASD in SDs. METHODS: Several bibliographic databases were searched for RASD treatment options in SD patients. The demographic outcome measures, the failure rate (defined as the relative risk of recurrence of dislocation postoperation), and the postoperative seizure recurrence rate were recorded. RESULTS: We pooled 171 cases (187 shoulders) from 11 studies. Of these, one, five, two, two, and one reports studied Bankart's operation with remplissage (27 cases/29 shoulders), the Latarjet procedure (106/118), bone block operation (21/23), arthroplasty (11/11), and arthrodesis (6/6), respectively, in treating SD-associated RASD. The relative risk of failure between SD and non-SD patients was 3.76 (1.3610.38) after the Latarjet operation. The failure rates were 17% and 13% for Bankart's operation with remplissage and the Latarjet procedure in SD patients, respectively, but 0% each for bone block operation, arthroplasty, and arthrodesis. The total rate of seizure recurrence after operation was 33% of the pooled cases. CONCLUSIONS: SD recurrence in the postoperative period, the size of the bone block, and the muscular attachments to a small coracoid autograft are the determinants of failure among various reconstructive operations in SD-associated RASD. Level of evidence: III.

Vigilance Needed in Treating a Child with Disseminated TB: A Case Report.

BACKGROUND: Tuberculosis is still one of the biggest causes of infection-related death around the world. Disseminated tuberculosis is a potentially fatal disease caused by the haematogenous spread of Mycobacterium tuberculosis. First-line anti-tuberculosis drugs in-clude isoniazid, rifampicin, pyrazinamide, and ethambutol. The first three drugs are known to cause hepatotoxicity. CASE PRESENTATION: We have, herein, reported a case of Drug-induced Liver Injury (DILI) due to anti-tuberculosis therapy in a one-year-old male child with disseminated tuberculosis. He was started on a fixed-dose combination of Anti-tuberculosis Therapy (ATT; isoniazid 50 mg, rifampicin 75 mg, and pyrazinamide 150 mg) and pyridoxine 10 mg orally. Initially, liver pa-rameters were normal, but later on with the course of the treatment, there was a rapid rise in liver enzymes, suggesting liver injury. DISCUSSION: The association between liver injury and anti-tuberculosis therapy has been con-firmed by applying various causality association scales. It is obvious that proper treatment of disseminated tuberculosis can avoid the development of drug-resistant strains that can be harm-ful, worsening the prognosis as there are fewer therapeutic alternatives available. At the same time, there is a need to monitor the patient with ATT-induced DILI. CONCLUSION: The diagnosis of tuberculosis in children is difficult because of the mild, nonspe-cific clinical presentation, which usually reflects the implicated underlying organ. In addition to prompt diagnosis and treatment of disseminated TB, careful monitoring is equally important.

Comparative Analysis of Arthroscopic Tight Rope ACL Reconstruction Using four Strand Isolated Semitendinosus Graft and Quadrupled Combined Hamstring Graft.

Background: Arthroscopic ACL reconstruction using hamstring autograft is a quite a popular surgical procedure. But there is a conflict regarding the use of isolated semitendinosus graft or a combined hamstring graft. We did a comparative analysis of the functional outcome after ACL reconstruction performed with four strand semitendinosus graft and a combined hamstring graft over tightrope. Methods: Two groups of 30 patients each with similar demographic profiles, presenting with symptoms of instability after chronic ACL tear were included. A standard single bundle arthroscopic ACL reconstruction was performed by using four-strand semitendinosus graft in Group A and combined hamstring graft in Group B patients. Clinical and functional outcome analysis was done using quantitative anterior tibial translation measurement and Lysholm score. Results: The mean age of subjects in group A was 29 years and in Group B was 28 years. The semitendinosus graft length was insufficient in 13.33% cases in group A. The improvement in Lysholm score and the decrease in the tibial translation were comparable in both the groups at one year of follow-up. No added comorbidities were noted in additional removal of gracilis tendon in group B patients. Conclusion: Isolated semitendinosus four-strand autograft can be used for arthroscopic single bundle ACL reconstruction when adequate graft length is obtained. However, one should not be hesitant in additional removal of gracilis tendon when needed. In terms of functional outcome and patient satisfaction, both the graft configurations stand the same.

Calcaneal lengthening osteotomy in spastic planovalgus feet.

PURPOSE OF STUDY: Planovalgus deformity in cerebral palsy is disabling for the child in terms of increased energy expenditure during the gait cycle. The lever arm function of the foot is lost due to midfoot break and the achilles tendon is at a disadvantage being unable to lift the body weight during push-off. We evaluated the results of calcaneal lengthening osteotomy in such patients with clinical, radiological and gait parameters. METHODS: 17 spastic feet in a sample of 10 children were included in our study. The children were classified according to the GMFCS classification system and clinical parameters such as heel valgus and heel rise tests, radiological angles such as Talo-calcaneal angle and Talo-navicular coverage angle on AP view and Calcaneal pitch angle, calcaneus-5th metatarsal angle and talus-1st metatarsal angle on lateral view were measured. Video gait analysis was performed to observe knee progression angle in mid stance and peak knee flexion angle in mid and terminal stance. RESULTS: Improvement was noted clinically in the heel valgus angle (preop-12.06°, postop-5.12°) and radiological parameters showed an improved coverage of the talus by navicular with simultaneous lifting of the medial longitudinal arch. Gait analysis showed decreased knee flexion trend in mid and terminal stance phase with better restoration of the knee axis. CONCLUSION: Calcaneal lengthening osteotomy with peroneus brevis lengthening corrects almost all aspects of planovalgus deformity with an improved gait pattern without disturbing joint range of motion. It is a safe procedure for GMFCS grade 1 and 2 patients without much complications.

CT Based Characterization of Volar Surface of Distal Radius: Can an Ideal Volar Plate for Fixation of Distal Radial Fractures be Designed?

Background: Literature has limited evidence concerning the morphology of volar surface of distal radius. A mismatch between the plate-contour and contour of the actual volar bony surface can result in malreduction. The purpose of this study is to analyze the normal curvature morphology of volar surface of distal radius and related parameters that can help in designing of the volar plates for fixation of distal radial fractures. Methods: We retrospectively analyzed CT scans of uninjured healthy distal radii performed during a one year period (2018-2019). The mediolateral extent of the pronator quadratus line, the mediolateral curve of the pronator quadratus line, the mediolateral surface angle between intermediate column and radial column of distal radius, the curvatures and locations of their vertices for radial and intermediate columns were measured. Results: A total of 84 CT-based studies were analyzed. The mediolateral extent of the pronator quadratus line, the mediolateral curve of the pronator quadratus line, and the mediolateral surface angle between intermediate column and radial column of the distal radius were 24.27 mm, 144.8 degrees and 163.1 degrees, respectively. The mean volar curvatures of the radial and intermediate columns were 156.5 and 151.4 degrees, respectively and distances of their vertices from the pronator-quadratus line were 10.96 mm and 14.13 mm, respectively. Conclusions: Considerable variations occur in curvature morphology of distal radial volar surface. A best fit rather than an anatomical fit can be considered during implant selection owing to these variations. Besides volar curvature of radial and ulnar columns, location of their vertices, mediolateral angulation and surface curvature between these columns at the level of watershed line should also be considered in plate selection. A combination of a few serial increments of the described parameters in the designs of volar fixation plates would be helpful for surgeons in the best implant selection.

Reliability of relation between greater trochanter and center of rotation of femoral head in Indian population.

PURPOSE: Accurate limb length restoration forms an important aspect of reconstructive surgeries around the hip joint. Among the various intraoperative methods for accurate limb length restoration, the relation between the greater trochanter and the center of the femoral head has been conventionally used owing to its simplicity and replicability. The current study aims to study the normal relation between the greater trochanter and the center of rotation of the femoral head, its population-based variation and its gender-based and contralateral differences in the Indian population. METHODS: Standard anteroposterior radiographs of normal hip joints with the proximal femur, performed over a one year period were studied. A software-based analysis was conducted to measure the difference between the levels of the greater trochanteric tip and the center of the femoral head along the longitudinal axis of the femur. The measurements among the male and female cases and the contralateral sides were compared. RESULTS: The greater trochanteric tip lies at a higher level than the center of rotation of the femoral head by a mean difference of 9.20 ± 5.30 mm. No significant differences were observed among male and female groups and between the contralateral hip joints. Intraobserver and Interobserver reliability were high. CONCLUSIONS: The tip of the greater trochanter and the center of the femoral head do not lie at the same level. This differential relation should be considered during the reconstructive surgeries around the hip joint to prevent an inadvertent limb length discrepancy. Considering the wide interindividual variations, this difference cannot be generalized for all the patients and restoring it to the contralateral normal hip would be more appropriate.

Risk of bony violation with standard triple screw configurations for fixation of femoral neck fractures: A preliminary computed tomography based analysis.

PURPOSE: The reduction and fixation of femoral neck fractures is mainly an indirect one with intraoperative fluoroscopy being trusted for the safe containment of screws within the bony limits of the femoral neck. Radiologically undetected bony perforations may have an impact on the fracture stability and radiological outcomes that have not been studied previously. The purpose of this computed tomography (CT) based study is to analyze the safety of containment of triple screw configurations using standard 6.5 mm diameter screws for fixation of femoral neck fractures in the Indian population using a software-based analysis. METHODS: Data from consecutive CT scans with intact proximal femur performed over a six month period were retrospectively analyzed using iPlan® BrainLab AG, Feldkirchen, Germany. The safe containment of virtual screw trajectories placed in inverted triangular and non-inverted triangular configurations for a 6.5 mm diameter screw was analyzed in intact femoral necks. RESULTS: A total of 72 cases were considered for the final assessment. For 6.5 mm screws, the proportion for safe containment (without bony violation) of triple screw inverted triangular configuration was 75% with additional safety corridor to 1 mm around the screw trajectories and 31.94% for non-inverted triangular configuration. All male cases and 28% of female cases allowed safe placement of three 6.5 mm screw trajectories in an inverted triangular pattern with a safety margin of 1 mm around the screw. Replacement of one of the two superior 6.5 mm diameter screw trajectories with a 4.5 mm diameter trajectory resulted in 100% safe containment in female cases. CONCLUSION: Inverted triangular configuration is a relatively safer configuration compared to the non-inverted triangular configuration. Standard triple 6.5 mm screws for fixation of femoral neck fractures carry a risk of bony violation, especially in females. A preoperative radiographic assessment to screen the cases with narrow vertical and anteroposterior extents of the femoral neck can help in reducing the risk of fluoroscopically undetected violation of the bony margins. Replacement of one of the two superior screws with a 4.5 mm diameter screw can be helpful in such cases.

"Clamp and plate" - A simple technique for prevention of varus malreduction in reverse oblique peritrochanteric fractures.

Reverse oblique peritrochanteric fractures are unstable injuries. They have an inherent tendency of lateral wall opening and varus displacement. Cephalomedullary nails are the preferred implants for fixation of these fractures. Standard techniques and a medial entry point may not always be helpful in correcting alignment, resulting in persisting varus malreduction. A simple technique using a Lowman clamp and a conventional 3.5 mm plate has been described to prevent lateral wall opening and indirectly, the varus malreduction.

Fracture of first metacarpal head: A rare case presentation and review of literature.

Fractures around the head and neck region of first metacarpal are unusual and have not been reported in literature. We report a case of fracture of head of first metacarpal with intact articular surface, treated with open reduction and internal fixation, with a follow up period of six months. Surgical procedure, intraoperative difficulties in obtaining reduction and steps to overcome them have been described. Satisfactory functional outcomes can be achieved using stable internal fixation with minimal hardware and early mobilization in first metacarpal head fractures.

Malleolar tips as reference points for positioning of syndesmotic screw: A preliminary CT based analysis.

PURPOSE: The risk of malpositioning of the syndesmotic screws is very high. A lack of standard radiological or physical references for accurate syndesmotic screw placement is a potential contributing factor in syndesmotic screw malpositioning. Malleolar tips are clinically as well as radiologically appreciable bony references. The purpose of this preliminary CT based study was to investigate the axial relations of the central syndesmotic axis with the malleolar tips. METHODS: CT based studies of uninjured adult ankle joints with intact syndesmosis, conducted over a six months period were analysed. The axial differences between the coronal plane along the malleolar tips and that along the central syndesmotic axis in the axial plane were measured. Gender-based variations were also analyzed. RESULTS: A total of 70 CT studies were analyzed, and the axial difference between the malleolar tips based coronal plane and that along the central syndesmotic axis was observed to be 3.70 ±â€¯5.61°. The male and female measurements were comparable. CONCLUSION: Being in a static relation to the syndesmosis independent of the foot position and the limb rotation, the malleolar tips can be reliably used as references for directing syndesmotic screw in the axial plane. A knowledge of this axial difference between malleolar tips and central syndesmotic axis can help surgeons in an accurate syndesmotic screw placement.

Distal Locked versus Unlocked Intramedullary Nailing in Intertrochanteric Fracture; A Systematic Review and Meta-Analysis of Randomized and Non-Randomized Trials.

OBJECTIVE: To compare the outcome of distal locked and unlocked intramedullary nailing in patients with intertrochanteric fractures through systematic review and meta-analysis of randomized and non-randomized clinical trials. METHODS: Randomized or non-randomized controlled studies comparing the effects of unlocked and locked nails for treatment of intertrochanteric fractures were searched using the search strategy of Cochrane collaboration up to April 2019. Four eligible studies involving 691 patients were included. Their methodological quality was assessed, and data were extracted independently for meta-analysis. RESULTS: The results showed that the unlocked group has significantly less operative time (MD: -8.08; 95%CI -11.36 to -4.79; P< 0.00001), fluoroscopy time (MD: -7.09, 95%CI -7.09 to -4.79; p<0.00001), length of incision (MD: -2.50, 95%CI 2.85 to -2.14; p< 0.00001) than the locked group. The complication rate was significantly higher in the locking group (OR: 0.55, 95%CI 0.26 to 1.15; p=0.03). No significant differences were found in the Harris hip score between the two groups (MD: 0.68, 95% CI -0.83 to 2.19, p<0.08). CONCLUSION: The present meta-analysis suggests that intramedullary nailing without distal locking is reliable and acceptable option for treating intertrochanteric fracture. The advantages are reduced operative time, decreased fluoroscopy time, smaller size of incision and decreased complication rate. However, owing to the low-quality evidence currently available, additional high quality Randomized controlled trials are needed to confirm these findings.

Waddling Gait: A complication of valproate therapy and a thought beyond vitamin D deficiency.

Proximal muscle weakness is a common presentation in paediatric-orthopaedic clinics and is frequently paired with a vitamin D deficiency diagnosis. Recently, side effects of the extensive use of antiepileptic and antipsychotic drugs such as sodium valproate in childhood disorders are being documented. Sodium valproate causes a time-dependent, drug-induced proximal myopathy. We report a 13-year-old female patient who presented at the Orthopaedic Outpatient Department at Lady Hardinge Medical College, New Delhi, India, in 2019 with an abnormal gait. The patient was taking a combination therapy of sodium valproate, risperidone and trihexyphenidyl for absence seizures and a mood disorder. Following clinical investigations, the patient was diagnosed with proximal myopathy. As a result of elevated serum alkaline phosphatase and creatine kinase myocardial band levels, sodium valproate was replaced with ethosuximide and a carnitine supplementation was prescribed. The patient fully recovered and regained full mobility. Proximal myopathy had been incorrectly managed and assumed to be caused by a vitamin D deficiency.

Lateral Approach Versus Combined Lateral and Anteromedial Approach for Surgical Treatment of Terrible Triad of Elbow: A Meta-Analysis.

OBJECTIVE: To find out which surgical approach, optimize the functional outcomes and reduce the risk of complications in terrible triad of elbow". METHODS: Medline, EMBASE, Cochrane Library, and Google Scholar were searched to identify relevant studies, which were included if they were retrospective or prospective in design, involved participants who had terrible triad of elbow (TTIE) that compared lateral approach (LA) with combined lateral and anteromedial approach (CML), and were published in English. Outcomes of interest were functional outcomes, complications, and operative time. RESULTS: Four studies, involving 470 patients were included in the systematic review. Mean follow up after surgery was typically 24 to 30 months. We found significant more range of motion (ROM) of elbow in CML as compared to LA group (MD: -14.21, 95% CI: -21.13 to-7.29, p<0.00001). There was significant more forearm rotation in CML as compared to LA group (MD: -18.88, 95% CI: -32.35 to -5.40, p<0.00001). Mayo elbow performance score (MEPS) was significantly more in CML (MD: -3.31, 95% CI: -7.23 to 0.62, p=0.00001). Blood loss, operative time, VAS and complications were more in CML group; however, the difference was not significant. The heterogeneity of the study and synthesizing retrospective data were the primary limitations. CONCLUSION: Our analysis demonstrated that combined lateral and medial approach had significantly more elbow ROM and forearm rotation. The combined approach also had significantly more MEPS. However, using combined approach significantly increased the operative time.

Defining the "mediolateral widening of tibial plateau" as a guide for reduction in tibial plateau fractures: An Indian perspective.

PURPOSE: The primary aim in fixation of the tibial plateau fractures is the restoration of normal anatomy. Evaluation of the widening of the tibial plateau, which has been linked with adverse long term outcomes, still needs precise markers for quantification. The purpose of this study is to analyze the normal limits of tibial plateau widening in the Indian population in relation to the distal femur in a standardized manner to provide important radiological parameters for the same. METHODS: We retrospectively analyzed electronically archived true AP radiographs of uninjured normal knee joints during one year between 2018 and 2019. We measured the mediolateral width of the articular surface and extraarticular extent of the tibial plateau and compared them with the distal femoral articular and extra-articular extents. The measurements were compared between the male and female groups. RESULTS: Tibial plateau articular width was found to be 4% wider in relation to the distal femoral articular surface. The medial articular rim of distal femur matches closely to the medial articular rim of the tibial plateau. The lateral articular rim of distal femur lies medial to the lateral articular rim of tibial plateau with a mean distance of 3.49 mm. CONCLUSIONS: Owing to individual variations in bony extents around the knee, the differential extent of tibial plateau relative to distal femur would be a more reliable parameter than absolute measurements. Medially the articular extent of distal femur matches closely with the articular extent of tibial plateau while the lateral extra-articular extent of distal femur matches closely with the lateral tibial articular extent. Gender-based differences do not significantly affect these two parameters.

New landmarks for ideal positioning of syndesmotic screw: a computerised tomography based analysis and radiographic simulation.

PURPOSE: A lack of specific intra-operative markers for accurate positioning of the syndesmotic screw can result in its malpositioning. Knowledge of the axial orientation of the syndesmosis can help in reducing this risk of malpositioning of the syndesmotic screw. In this CT-based study, we investigated the axial relationships of intact syndesmoses with various rigid bony landmarks around the ankle joint that were independent of foot and horizontal plane. METHODS: We analyzed 126 CT-based studies of uninjured normal ankle joints and defined the following bony landmarks: posteromedial and posterolateral surface of the distal tibia, bimalleolar tips, and anterior and posterior extents of both malleoli. Axial differences between coronal plane through the central axis of syndesmosis and modified coronal planes through these bony landmarks were then measured. Software-based lateral radiographs were created with the reference coronal plane for each radiograph being kept perpendicular to the plane of the viewing screen. RESULTS: The mean axial differences parting the syndesmotic axis from the modified coronal planes based on distal tibial posteromedial surface, distal tibial posterolateral surface, bimalleolar tips, anterior bimalleolar extents, and posterior bimalleolar extents were - 3.15°, 13.73°, 4.10°, 11.95°, and 12.24°, respectively. With the exception of the posterolateral surface of the distal tibia, all other bony landmarks were radiologically identifiable in the majority of cases. CONCLUSION: Our study attempts to provide a solution to the issues related to malpositioning of the syndesmotic screw by providing new bony landmarks that can be clinically and fluoroscopically used for syndesmotic-screw positioning. The relationships of bimalleolar tips, anterior and posterior bimalleolar extents, and the posteromedial surface can be reliably used as landmarks for directing syndesmotic screws.