Neutrophil Extracellular Traps and NLRP3 Inflammasome: A Disturbing Duo in Atherosclerosis, Inflammation and Atherothrombosis.

Atherosclerosis is the formation of plaque within arteries due to overt assemblage of fats, cholesterol and fibrous material causing a blockage of the free flow of blood leading to ischemia. It is harshly impinging on health statistics worldwide because of being principal cause of high morbidity and mortality for several diseases including rheumatological, heart and brain disorders. Atherosclerosis is perpetuated by pro-inflammatory and exacerbated by pro-coagulatory mediators. Besides several other pathways, the formation of neutrophil extracellular traps (NETs) and the activation of the NOD-like receptor family pyrin domain containing 3 (NLRP3) inflammasome contribute significantly to the initiation and propagation of atherosclerotic plaque for its worst outcomes. The present review highlights the contribution of these two disturbing processes in atherosclerosis, inflammation and atherothrombosis in their individual as well as collaborative manner.

Treatment of Cleft Foot Deformity using Fish Mouth Incision and Suture-Button in Paediatric Foot: A case report.

Cleft foot is a congenital anomaly characterised by absence of the metatarsal bones and phalanges. It is commonly seen in children with ectrodactyly-ectodermal dysplasia-clefting syndrome ranging from a median cleft up to the mid metatarsals to a deep cleft up to the tarsal bones. Surgical treatment in the form of cleft closure, excision of the rudimentary metatarsal bone and cross K-wire fixation of metatarsal bones have been tried for the management of such cases. We report a one-year-old child who presented to the paediatric orthopaedic clinic at a medical college in New Delhi, India, in 2018 with type III cleft foot with four metatarsals. The patient was treated with a suture-button system using three transverse tunnels in the second and third metatarsal bones in order to bring them closer together. A satisfactory outcome was achieved with normal fitting footwear.

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.

Nasoethmoidal Schwannoma as a Mimicar of Esthesioneuroblastoma: A Case Report and Literature Review.

Nasoethmoidal schwannomas are rare lesions and their presentation with intracranial extension is even rarer. Here, a patient presenting with rhinorrhea, epistaxis, and proptosis of left eye was diagnosed with giant nasoethmoidal schwannoma extending to frontal lobe and orbit, which was managed with bifrontal craniotomy with endoscopic transnasal gross total excision. This being predominantly a benign lesion has good prognosis if total excision is achieved.

Bilateral Neck of Femur Fracture in a Child With Underlying Vitamin D Deficiency: A Case Report on Management and 10-Year Follow-Up.

Bilateral femoral neck fracture is a rare entity in the pediatric age group. These types of fractures occur mostly due to high-velocity trauma. We report the surgical outcome with approximately 10 years of follow-up in a 10-year-old child presenting with bilateral femoral neck fracture after trivial trauma and underlying nutritional vitamin D deficiency. A 10-year-old female child with bilateral neglected fracture neck of femur was managed with a primary valgus osteotomy done on the left side and closed reduction and screw fixation with fibular grafting done on the right side. Later on, as the right side fracture progressed to non-union, it was converted to valgus osteotomy fixed with an external fixator. The patient had a good functional outcome at 10 years of follow-up with no difficulty in her day-to-day activities. Pathological bilateral fracture neck of femur is rare in children and it is often mismanaged due to a delayed diagnosis. It can have potentially dangerous complications with a grave outcome affecting the rest of the life of the child. Hence it is important to know about such rare presentations so that they can be adequately addressed early on, thereby minimizing the risk of complications like non-union and avascular necrosis.

Surgical Nuances of Intramedullary White Epidermoid Cyst in the Conus Medullaris: A Rare Entity.

Spinal epidermoid cysts (ECs) are benign slow-growing spinal tumors. The account for <1% of spinal tumors and are usually found intradural extramedullary. This report is regarding two rare cases of intramedullary white ECs present at the conus medullaris. In the first case, a 32-year-old male presented with a complaint of lower backache for 5 years, which progressively increased in intensity, radiating to the left leg. The patient had left lower limb weakness in the form of difficulty in walking. On examination, power of left knee and ankle was 4/5. Left extensor hallucis longus power was 3/5. Left Babinski sign was extensor. In the second case, a 42-year-old male, presented with a complaint of numbness over the left foot for 5-6 months. On examination, the power of the left ankle was 3/5, left extensor hallucis longus was 3/5. Both patients had EC in conus medullaris, which was hyperintense on T1-weighted magnetic resonance imaging and underwent laminectomy with the evacuation of the cyst with electrocoagulation of cyst epithelial lining. White ECs are extremely rare in the conus medullaris. Electrocoagulation of the cyst wall is like walking on a tight rope. Liberal electrocoagulation can lead to the neurological deficit but decreases the chances of recurrence. On the other hand, conservative electrocoagulation can lead to recurrence but decreases the chance of a new deficit. Recurrence should also lead to suspicion of atypical changes in the cyst wall, which may require adjuvant treatment such as radiotherapy and chemotherapy.

Evaluation of Arm Length as a New Upper Limb Anthropometric Method for Preoperative Estimation of Tibial Intramedullary Nail Length.

AIM AND OBJECTIVE: To assess the use of arm length (AL) for the estimation of tibial nail length preoperatively and compare its accuracy to various established upper and lower limb anthropometric parameters. MATERIAL AND METHODS: This prospective study of 54 patients assessed upper limb parameters as a possible alternative for intraoperatively measured tibial nail length. The anthropometric parameters measured independently by two observers were AL, olecranon to fifth metacarpal head (OMD), tibial tuberosity to medial malleolus (TT-MM), tibial tuberosity to medial malleolus minus 20 mm (TT-MM-20 mm) and knee joint line to medial malleolus minus 40 mm (KJL-MM-40) and compared to final nail size used intraoperatively. Two observers were used. Bland-Altman plots were constructed to assess the limits of agreement to intraoperative estimates of optimum nail length. A repeatability assessment was also assessed by both observers. RESULTS: None of the anthropometric parameters showed limits of agreement within ±10 mm of nail length. AL showed the least average difference and best limits of agreement among all the anthropometric parameters. Among the lower limb parameters, the KJL-MM showed the least average difference but poorer limits of agreement to nail length. The OMD measurement showed a greater average difference than the AL indicating it is a poorer upper limb parameter for predicting nail length. CONCLUSION: AL as measured between the angle of the acromion to the lateral epicondyle can be used as a preoperative upper limb anthropometric estimate of nail length to one nail size of the optimum length. Further studies with a larger sample size may reduce the confidence intervals and help justify its wider use. HOW TO CITE THIS ARTICLE: Sharma A, Sinha S, Gupta S, et al. Evaluation of Arm Length as a New Upper Limb Anthropometric Method for Preoperative Estimation of Tibial Intramedullary Nail Length. Strategies Trauma Limb Reconstr 2021;16(1):20-26.

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.

"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.

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.

Gorlin-Goltz Syndrome with Intracranial Meningioma: Case Report and Review of Literature.

BACKGROUND: Gorlin-Goltz syndrome is a rare hereditary disease affecting multiple organ systems. Medulloblastoma is the most common intracranial malignancy in these patients, radiotherapy makes them more susceptible to intracranial meningioma. Here we report an intracranial meningioma without radiation exposure. CASE DESCRIPTION: We present a case of intracranial meningioma in a young woman who was postoperatively diagnosed to have Gorlin-Goltz syndrome based on presence of calcification of bilateral tent and falx. Further clinical and radiological assessment helped us identify many other syndromic features and patient was promptly advised multispecialty consultations to screen for other malignancies and counselled regarding risk factors. CONCLUSIONS: Early identification of the syndrome is important for prevention of secondary radiation-induced malignancies, both intracranial and extracranial. Patients need multidisciplinary approach for management.

An unusual Pattern of Flexor Digitorum Profundus Avulsion Injury with a Large Extra-articular Bony Fragment.

INTRODUCTION: Avulsion injury of the flexor digitorum profundus (FDP) tendon, commonly known as jersey finger, is seen in contact sports players such as rugby and football. There are mainly three patterns of this type of injury as mentioned in the Leddy and Packer classification on the basis of the level of retraction of the tendon. Subsequently, a Type IV injury was added by Smith, where the tendon was also separated from the avulsed bony fragment. It is the level of tendon retraction and the status of the long and the short vincula post-injury that determines the outcome of repair in these types of injuries. CASE REPORT: Here, we report an unusual case of jersey finger injury in a 45-year-old male patient, where the FDP tendon was found in front of the middle phalanx with a large, fractured fragment of the middle third of the distal phalanx attached to it. This type of injury pattern has not been acknowledged in the commonly used classification systems. The patient was operated with open reduction and K-wire fixation of the bony fragment with a good functional outcome. CONCLUSION: While treating the cases of jersey finger injuries in sports players and general population, one should be aware of such rare patterns which can then be easily managed with proper pre-operative planning.

Lessons Learned from a Migratory Intradural Extramedullary Schwannoma: A Case Report with Review of the Literature.

BACKGROUND: Migratory tumors of the spinal cord are rare and can present as a missing tumor intraoperatively. This can lead to unnecessary abandonment of surgery or unnecessary laminectomies. CASE DESCRIPTION: We present a case of migratory intradural extramedullary tumor of the spine, which was missing intraoperatively. The surgery was abandoned, and on reimaging the tumor was found to have migrated. Here we summarize a review of the literature of such cases and the lessons we learned from our experience, emphasizing the measures to prevent tumor displacement and the importance of intraoperative imaging. CONCLUSIONS: Migratory schwannoma should be suspected in case of a missing lesion. Intraoperative ultrasonography and myelography use should be definitely considered where facility for intraoperative magnetic resonance imaging is not available. Preventive measures should be taken to avoid tumor migration in all routine cases of intradural extramedullary lesions.

Impact on Cognitive Improvement Following Burr Hole Evacuation of Chronic Subdural Hematoma: A Prospective Observational Study.

OBJECTIVE: Patients of Chronic subdural haematoma can present with only subtle cognitive impairment without any motor deficit. It is hence imperative for the treating clinician to be aware of this entity. The aim of the study was to identify any statistically significant improvement of cognitive functions following burr hole evacuation of Chronic SDH especially in the elderly patients. METHODS AND MATERIAL: A Prospective observational study of 30 patients of CSDH, from Jan 2015 to Dec 2016 was done at a tertiary level Armed Forces Hospital. The study had 23 male, 07 female, with age ranging from 7-85 years. The cognitive function of each patient was assessed at admission and 24 hours after surgery by MMSE. Radiological confirmation was done by CT head. Standard two burr holes were made and hematoma evacuated. The clinical, cognitive assessment and radiological data were collected and analysed. RESULTS: There was no statistical significance preoperatively between age and pre operative cognitive impairment, headache, hemiparesis, dysarthria (P>0.05). We however found a statistically significant improvement postoperatively in cognitive impairment, headache (P= 0.00), motor deficit (P=0.01) and dysarthria (P=0.046). CONCLUSION: The clinical features of dementia and other neurodegenerative disorders simulate CSDH in the geriatric population. These patients should have early neuroimaging and prompt surgical intervention to alleviate cognitive deficits.