Time from injury to hip-fracture surgery in low-income and middle-income regions: a secondary analysis of data from the International Orthopaedic Multicentre Study in Fracture Care (INORMUS).

BACKGROUND: Globally, fall-related injuries are a substantial problem, and 80% of fatal falls occur in low-income and middle-income countries. We aimed to measure time from injury to hip-fracture surgery in people aged 50 years or older living in low-income and middle-income regions, as well as to measure the proportion of patients with surgical stabilisation of their hip fracture within 72 h of admission to hospital and to identify risk factors associated with surgical delay. METHODS: For this secondary analysis, we analysed data collected from Africa, Latin America, China, India, and Asia (excluding China and India) for the International Orthopaedic Multicentre Study in Fracture Care (INORMUS) between March 29, 2014, and June 15, 2022. Patients from INORMUS were included in this analysis if they were aged 50 years or older and had an isolated, primary hip fracture sustained from a ground-level fall. Staff at participating hospitals identified patients with musculoskeletal injury and referred them for assessment of eligibility. We report time from injury to surgery as three distinct time periods: time from injury to hospital admission, time from admission to surgery, and a total time from injury to surgery. Date and time of injury were self-reported by patients at the time of study recruitment. If time to hospital admission after injury exceeded 24 h, patients reported the primary reason for delayed admission. Reasons for surgery, no surgery, and surgical delay were reported by the treating team. For patients undergoing surgery, multivariable regression analyses were used to identify risk factors for surgical delay. FINDINGS: 4486 adults aged 50 years or older with an isolated, primary hip fracture were enrolled in INORMUS from 55 hospitals in 24 countries. Countries were grouped into five regions: Africa (418 [9·3%] of 4486), Latin America (558 [12·4%]), China (1680 [37·4%]), India (1059 [23·6%]) and Asia (excluding China and India; 771 [17·2%]). Of 4486 patients, 3805 (84·8%) received surgery. The rate of surgery was similar in all regions except in Africa, where only 193 (46·3%) of 418 patients had surgery. Overall, 2791 (62·2%) of 4486 patients were admitted to hospital within 24 h of injury. However, 1019 (22·7%) of 4486 patients had delayed hospital admission of 72 h or more from injury. The two most common reasons for delayed admission of more than 24 h were transfer from another hospital (522 [36·2%] of 1441) and delayed care-seeking because patients thought the injury would heal on its own (480 [33·3%]). Once admitted to hospital, 1451 (38·1%) of 3805 patients who received surgery did so within 72 h (median 4·0 days [IQR 1·7-6·0]). Regional variation was seen in the proportion of patients receiving surgery within 72 h of hospital admission (92 [17·9%] of 514 in Latin America, 53 [27·5%] of 193 in Africa, 454 [30·9%] of 1471 in China, 318 [44·4%] of 716 in Asia [excluding China and India], and 534 [58·6%] of 911 in India). Of all 3805 patients who received operative treatment, 2353 (61·8%) waited 72 h or more from hospital admission. From time of injury, the proportion of patients who were surgically stabilised within 72 h was 889 (23·4%) of 3805 (50 [9·7%] of 517 in Latin America, 31 [16·1%] of 193 in Africa, 277 [18·8%] of 1471 in China, 189 [26·4%] of 716 in Asia [excluding China and India], and 342 [37·5%] of 911 in India). INTERPRETATION: Access to surgery within 72 h of hospital admission was poor, with factors that affected time to surgery varying by region. Data are necessary to understand existing pathways of hip-fracture care to inform the local development of quality-improvement initiatives. FUNDING: The National Health and Medical Research Council of Australia, the Canadian Institutes of Health Research, McMaster Surgical Associates, Hamilton Health Sciences, and the US National Institutes of Health.

Chronic Recurrent Osteomyelitis of Ribs Due to Bamboo Stick Injury in an Adult Man: A Case Report.

Introduction: Chronic osteomyelitis of the ribs in adolescents and adults is a rare condition. Current understanding of its diagnosis and management is primarily derived from case reports and small series studies. Here, we present a case of chronic rib osteomyelitis initially managed conservatively with antibiotics, followed by debridement, sequestrectomy, and continued antibiotic therapy. However, due to recurrence, rib excision was ultimately chosen as the definitive management approach. Case Report: A 18-year-old male presents with a discharging sinus from the chest persisting for 6 months, with no history of fever, shivering, or weight loss. He sustained a blunt injury to the chest with a bamboo stick 9 months ago. Initially, the patient was treated with antibiotics, but there was no relief. He was later operated on with debridement, sequestrectomy, and antibiotics. Six weeks later, he again presented to us with a discharging sinus. Due to recurrence, he underwent re-operation with partial resection of the 6th rib. At the 1-year follow-up after rib excision, the patient is doing well, with all blood parameters within the normal range and without any systemic or local complications. Conclusion: Rib osteomyelitis is a rare complication of blunt chest trauma. Surgical management is indicated in cases of persistent infection. Sequestrectomy and antibiotics, though standard procedures in chronic osteomyelitis, may encounter failure due to various factors. Moreover, due to limited literature on chronic osteomyelitis of ribs, the standard approach to its management is not available. Partial excision of the rib with appropriate antibiotics in our case provided complete cure for the patient.

Myocardial Injury in Patients with Hip Fracture: A HIP ATTACK Randomized Trial Substudy.

BACKGROUND: Myocardial injury after a hip fracture is common and has a poor prognosis. Patients with a hip fracture and myocardial injury may benefit from accelerated surgery to remove the physiological stress associated with the hip fracture. This study aimed to determine if accelerated surgery is superior to standard care in terms of the 90-day risk of death in patients with a hip fracture who presented with an elevated cardiac biomarker/enzyme measurement at hospital arrival. METHODS: The HIP fracture Accelerated surgical TreaTment And Care tracK (HIP ATTACK) trial was a randomized controlled trial designed to determine whether accelerated surgery for hip fracture was superior to standard care in reducing death or major complications. This substudy is a post-hoc analysis of 1392 patients (from the original study of 2970 patients) who had a cardiac biomarker/enzyme measurement (>99.9% had a troponin measurement and thus "troponin" is the term used throughout the paper) at hospital arrival. The primary outcome was all-cause mortality. The secondary composite outcome included all-cause mortality and non-fatal myocardial infarction, stroke, and congestive heart failure 90 days after randomization. RESULTS: Three hundred and twenty-two (23%) of the 1392 patients had troponin elevation at hospital arrival. Among the patients with troponin elevation, the median time from hip fracture diagnosis to surgery was 6 hours (interquartile range [IQR] = 5 to 13) in the accelerated surgery group and 29 hours (IQR = 19 to 52) in the standard care group. Patients with troponin elevation had a lower risk of mortality with accelerated surgery compared with standard care (17 [10%] of 163 versus 36 [23%] of 159; hazard ratio [HR] = 0.43 [95% confidence interval (CI) = 0.24 to 0.77]) and a lower risk of the secondary composite outcome (23 [14%] of 163 versus 47 [30%] of 159; HR = 0.43 [95% CI = 0.26 to 0.72]). CONCLUSIONS: One in 5 patients with a hip fracture presented with myocardial injury. Accelerated surgery resulted in a lower mortality risk than standard care for these patients; however, these findings need to be confirmed. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Outcomes following gel-based autologous chondrocyte implantation for articular cartilage defects of the knee.

BACKGROUND: Gel-based autologous chondrocyte implantation (GACI) enables a simpler and more effective delivery of chondrocytes with reproducible three-dimensional structural restoration of the articular cartilage surface. There is limited documentation of medium-term outcomes. This study assessed safety and effectiveness of GACI for treatment of cartilage defects of the knee. METHODS: This multicentric retrospective study was conducted across eight hospitals in India. Patients who had undergone GACI (CARTIGROW®) between 2008 and 2014 for the treatment of focal articular cartilage defects of the knee (mean defect size 4.5 ± 5.8 cm2) in limbs with normal alignment were analyzed. Primary outcomes were changes in Lysholm Knee Scoring Scale score, and Knee Outcome Sports Activity Scale (SAS). RESULTS: A total of 107 patients (110 knee joints) with mean age 31.0 ± 10.5 years were included. The mean follow-up was 9.8 ± 1.5 years (range 7.85-13.43). Majority had osteochondritis dissecans (n = 51; 46.4%). The mean Lysholm Knee Scoring Scale score (81.23 ± 13.21 vs. 51.32 ± 17.89; p < 0.0001) and SAS score (80.93 ± 8.26 vs. 28.11 ± 12.28; p < 0.0001) improved significantly at follow-up as compared to pre-operative. Magnetic Resonance Observation of Cartilage Repair Tissue score in 39 patients at minimum 2 years follow-up was 84.5 ± 4.3. Among 30 patients who were playing sports before treatment, 17 patients (56.7%) could return to the same or higher level of sports post-transplantation. No major intra-operative or post-operative complications were noted. Four patients warranted revision surgery. CONCLUSION: GACI is an effective treatment option for large focal articular cartilage defects of the knee with a low complication rate and revision rate and significant improvement in functional scores.

Ultrasound-guided Parasagittal Infraclavicular Block for Patients without Neurostimulation Endpoints: A Case Report in Crush Injuries of the Upper Limb.

Evoked motor responses (distal muscle responses) to a specific nerve stimulation are considered an endpoint. Often in crush injuries of the upper limb below the level of the elbow, the distal muscle responses are irrelevant. We report 14 cases of crush injuries of the upper limb that underwent an amputation below the level of the elbow. A parasagittal ultrasound-guided infraclavicular block without neurostimulation was administered in all patients. A reliable local anesthetic (LA) spread either in the perineural or perivascular area is considered adequate. Adequate intraoperative anesthesia and postoperative analgesia were achieved with the deposition of LA beneath the axillary artery.

Analysis of the Characteristics and Intricacies of Arrangement of Neural Elements in the Costoclavicular Block Using Ultrasound: A Retrospective Qualitative Study.

Background: Ultrasound (US)-guided costoclavicular block (CCB) is a promising new approach to brachial plexus (BP) block which is increasingly being utilized. Conventionally, the costoclavicular space (CCS) has been described to contain three cords. However, there may be variations in the neural pattern of the BP which is important to know to prevent inadvertent injury. We intend to describe the variations in neural patterns from retrospective scans of patients receiving costoclavicular BP block. Methods: The stored US images of patients who had received BP block using the CCB for surgery at the level of the elbow or below in the last year (from March 2021 to March 2022) were analyzed by two investigators independently. The clinical data were retrieved from the records of the same patients for the study outcomes. We collated the variations of the neural pattern, the number of neural structures seen, and the echogenicity of the structures in the costoclavicular BP space. Results: In the CCS, the median number of neural structures was 4.5 (minimum of 3 to maximum of 8). With the BP lateral to the axillary artery and sandwiched between the subclavius-pectoralis minor superiorly and the serratus anteriorly inferiorly, numerous variations in the neural structures were noted. The most common arrangement was caterpillar-like (28.6%) and pecker-like (20.3%). The neural structures were found to be hypoechoic in the majority (66%). Conclusion: The CCS hosts several mostly hypoechoic neural structures which may be the variations of the cords or the extension of BP divisions. These new findings have been unreported in the recent past.

Utility of Asymmetric Multilevel Pontes Osteotomy in Ankylosing Spondylitis with Scoliosis using Ultrasonic Bone Scalpel: Case Report.

Introduction: Ankylosing spondylitis is a spondyloarthropathy that commonly involves the axial skeleton with predilection to the sacro-iliac joints and spine. The disease frequently results in a smooth globular kyphotic deformity of the spine; however, a coronal plane scoliotic deformity is extremely rare. We present a unique case of scoliotic deformity in a patient diagnosed with ankylosing spondylitis. To the best of our knowledge, following a review of the literature, this appears to be the first report of this kind. Case Report: A 23-year-old male patient presented with chronic back pain, stiffness, and a truncal shift of the body. He had a rigid left-sided thoracolumbar curve measuring 41° with a coronal imbalance of 3.6 cm. We present a case report on scoliosis deformity correction performed with a four-level asymmetric pontes osteotomy using a bone scalpel with excellent correction of the scoliotic deformity that was well maintained at 2-year follow-up. Conclusion: Scoliosis in ankylosing spondylitis has not been documented in literature. We report the complete correction of the deformity, which is well maintained at the 2-year follow-up.

Radiofrequency Treatment of Genicular Nerves Using a Hybrid Technique.

BACKGROUND: Radiofrequency ablation of genicular nerves is recommended to ameliorate the pain of osteoarthritis of the knee. However, long-term efficacy in patients with persistent pain following total knee arthroplasty remains elusive. The current study aimed to evaluate radiofrequency ablation of genicular nerves using a hybrid technique to manage severe incapacitating pain and quality of life following surgery. METHODS: This prospective, observational study included patients suffering from intractable knee pain with scores > 4 on the Numeric rating scale after 6 months of total knee arthroplasty. Therapy included radiofrequency ablation of the superior medial, lateral, and inferior medial genicular nerves using a hybrid technique. The Numeric rating scale and Oxford Knee Score for quality of life were assessed before therapy and at 1-, 3- and 6 months following treatment. RESULTS: Average pain scores reduced from 8.4 ± 1.3 (admission) to 3.3 ± 1.4 (1 month; p= <0.001) but subsequently started to increase to 4 ± 1.2 (3 months; p = 0.58), and 5.6 ± 0.9 (6 months; p= <0.001). Average Oxford Knee Score significantly improved from 14.2 ± 5.9 (admission) to 38 ± 8.6(1 month); p= <0.001, but these too subsequently reduced to 36.4 ± 7.9 (3 months); p= 1, and 22.5 ± 12.5(6 months); p= <0.001. CONCLUSIONS: Ultrasound-guided radiofrequency ablation of genicular nerves diminishes intractable pain and disability in patients with chronic knee pain following total knee arthroplasty. Treatment is safe and effective, however, the benefit declined by 6 months. A repeat block would be necessary if the pain score worsens.

Comparison between effects of instrument-assisted soft tissue mobilization and manual myofascial release on pain, range of motion and function in myofascial pain syndrome of upper trapezius - A randomized controlled trial.

Background: Myofascial pain syndrome (MPS) is a muscle pain disorder characterized by the presence of Myofascial Trigger Point (MTrP) within a taut band, local tenderness, referral of pain to a distant site, restricted range of motion, and autonomic phenomena. The upper trapezius is the muscle most often affected by MTrPs. Manual myofascial release (MFR) and Instrument-Assisted Soft Tissue Mobilization (IASTM) are techniques of soft tissue release that are used to resolve MPS. Fifty six percent of physiotherapists complain of pain in multiple areas due to the massage and manual therapy that they have to perform. Objective: The objective of this study is to find whether IASTM is better than manual MFR in treating patients with MPS in upper trapezius. Methods: This study was a single-blinded randomized controlled trial that included 31 participants, both males and females between the age groups of 18-50 years. Participants were randomly divided into two groups. Three sessions were given over a period of one week for both groups. Group A received IASTM along with conventional treatment and Group B received Manual MFR along with the conventional treatment. The outcome measures evaluated were pain, cervical range of motion, pain pressure threshold (PPT) of trigger points, and the neck disability index. Pre- and post-measurements were taken and the analysis was done. Results: Both the treatment methods significantly reduced pain, improved PPT, range of motion, and function. The effects between the groups showed that IASTM was significantly better than manual MFR to reduce pain. The improvement in PPT, range of motion and function were equal in both the groups. Conclusion: IASTM and manual MFR both are effective individually as treatment procedures for pain, PPT, range of motion, and function. Neither of the treatment options can be considered better that the other. The clinician can decide based on the availability of the instrument, training, patient's preference, and his/her comfort whether which of the two treatment methods should be used.

Percutaneous pulsed radiofrequency ablation of articular nerves of the hip joint in patients with chronic hip pain refractory to conventional analgesics.

OBJECTIVES: Total Hip Arthroplasty (THA) may be a risky proposition in patients with comorbidities, and they may require systemic analgesics for chronic hip pain (CHP). Since traditional pain medications may not provide complete pain relief or carry prohibitive adverse effects, pulsed radiofrequency (PRF) treatment of the hip articular nerves (HAN) has been proposed for effective clinical outcomes. We determined the efficacy of PRF-HAN in improvement in CHP compared to baseline pain on conventional systemic analgesics. METHODS: Between August 2015 and December 2021, 31 adult patients with severe comorbid conditions and excruciating chronic hip pain were subjected to a PRF-HAN procedure following a diagnostic block. All 31 patients received PRF of the articular branches of the femoral and obturator nerves. Demographic parameters, numerical rating scale (NRS), Harris Hip Score (HHS), WOMAC scores, the change of these scores from baseline, and any adverse effects were recorded before treatment and on day 1, 1st week, 6 weeks, and 6 months after treatment. RESULTS: All the patients who underwent the PRF-HAN reported a significant improvement in NRS, HHS, and WOMAC scores compared to the baseline values on day 1, at the end of the 1st week, and the 6th week (p<0.001). No adverse events were documented in the study post-procedure until the end of 6 months. CONCLUSION: PRF-HAN is a strong alternative for chronic pain management and augments physical functioning and a return to daily activity in patients who would be deprived of arthroplasty considering associated comorbid conditions.

Minimally invasive treatment for idiopathic chondrolysis of the hip: analysis of forty-one cases.

PURPOSE: Idiopathic chondrolysis of the hip is characterized by the loss of the articular cartilage of the hip joint with spectrum ranging from full recovery to fibrous ankylosis. Study assessed outcomes following intra-articular steroid injections, joint manipulation and traction immobilization. METHODS: Retrospective (2012-2021) review of 41 cases treated for idiopathic chondrolysis of hip, assessed pre-operatively and post-operatively (minimum 2-year follow-up) using Children's Hospital Oakland Hip Evaluation Score (CHOHES), visual analogue scale (VAS) and range of motion measurements. RESULTS: Twenty-five patients (62%) achieved painless mobility, 6 (14%) had hip stiffness without pain and 10 (24%) had painful and stiff hips at final follow-up. They had a mean age of 12.49 ± 2.4 years and a mean follow-up duration of 33.15 ± 13.1 months. Range of motion improved significantly (p < 0.05). VAS improved to 3.93 ± 1.3 from 7.8 ± 0.7. CHOHES improved from 29.12 ± 9.9 to 56.37 ± 17.6. CONCLUSION: Intra-articular steroid injection, manipulation and traction immobilization may effectively treat idiopathic chondrolysis of the hip by enhancing patient function and reducing the need for further surgical intervention.

Functional Outcome of Mechanical Alignment in Total Knee Arthroplasty Surgery: A Short-Term Cohort Study at an Indian Tertiary Care Hospital.

Background: In severe arthritis cases, goal of total knee arthroplasty (TKA) management is to attain pain-free joint and restore the overall limb alignment. There are limited short-term studies published from Indian hospitals that investigated the importance of neutral mechanical component alignment in TKA patients. Methods: Retrospective and prospective study was conducted at the Department of orthopaedics, Sancheti Institute for Orthopaedics and Rehabilitation, Pune from June 2020 to September 2022. Enrolled patients were assessed preoperatively and postoperatively using clinical examination, radiological assessment and functional outcomes through the Oxford knee score, Knee society score and VAS score. Results: 204 patients enrolled, and 267 knees were evaluated for the study. Osteoarthritis was the commonest diagnosis (254 knees, 95.13%). Pre-operatively, 92.13% knees were varus, 4.87% valgus and 3% neutral while post-operatively, 51.69% were varus, 16.1% were valgus, and 32.32% were with neutral axis. Majority of patients with a pre-operative neutral axis converted to varus axis (62.5%), while most valgus axis cases preoperatively converted to a neutral axis (53.84%). For pre-operative varus subgroup, the majority patients with < 10° pre-operative axis converted to neutral (41.28%). Majority patients with 10°-20° pre-operative axis remained varus (60.53%) and with > 20° pre-operative axis remained varus (78.26%). Functional outcome parameters were significantly improved at follow-up (P < 0.05). Conclusion: Short-term postoperative functional scores were significantly improved in postoperative cases, with the postoperative alignment of 0° ± 3° relative to the mechanical axis was achieved. Thus, postoperative neutral mechanical alignment of 0° ± 3° can be the standard of care for patients undergoing TKA.

Labral Support Shelf Acetabuloplasty for Late Presenting Perthes Disease: Outcomes in Indian Patients.

Introduction: The treatment of late-presenting Perthes disease with extrusion is controversial and debatable. One of the options available is the labral shelf acetabuloplasty (LSA). Aim: The aim of the study was to evaluate the results of LSA in late-presenting Perthes disease in terms of clinic-radiological outcome measures. Materials and Methods: A retrospective analysis of prospectively collected data of patients with late presenting Perthes disease (Elizabethtown stage 2B onwards) treated by LSA by 2 experienced paediatric orthopaedic surgeons was performed. Data was collected of clinical parameters such as hip range of motion(ROM) and Harris Hip score and radiological parameters such as acetabular height, width and volume, shelf width, Centre Edge angle(CEA) and the lateral extrusion. Results: Thirty-five patients (28 males and 7 females) treated between 2012 to 2019 were analyzed. Majority were in Elizabethtown stage 3A (23) followed by 2B and 3B (12 each). At a mean follow up of 36 months, the hip ROM and the Harris Hip Score (from 65 ± 3.5 to 81.33 ± 7.12) improved significantly and there was a statistically significant improvement in terms of all radiological parameters. Majority of the hips were in Stulberg grade 3 (20) followed by grade 1 and 2 (7 each) and Stulberg 4 (1). There were no major complications in any of the patients of the series. Conclusion: Labral support shelf acetabuloplasty is a valuable surgery for late presenting Perthes disease and helps in maintenance of good coverage and allows restoration of range of motion over time.

Cervical Schwannoma camouflaged by cervical intervertebral disc prolapse-A case report.

INTRODUCTION: Cervical prolapsed intervertebral disc is one of the common conditions causing cervical myeloradiculopathy. Anterior Cervical Discectomy and Fusion (ACDF) is the standard line of management for the same. Intradural neurogenic origin tumors are relatively rare and can present with features of myeloradiculopathy. Radiological imaging plays important role in diagnosis of such pathologies. CASE REPORT: We report a patient with C5-6 cervical disc prolapse that presented with radiculopathy symptoms in the right upper limb, which was refractory to conservative care. He underwent a C5-6 ACDF and reported complete relief from symptoms at 4 weeks. He developed deteriorating symptoms over the next 10 weeks and presented at 14 weeks follow-up with severe myeloradiculopathy symptoms on the left upper limb with upper limb weakness. A fresh MRI identified an intradural extramedullary tumor with cystic changes at the index surgery level. This was treated with tumor excision and histopathology confirmed a diagnosis of schwannoma. Simultaneous presence of cord signal changes with disc herniation obscured the cystic schwannoma which became apparent later on contrast enhanced MRI imaging. CONCLUSION: Careful review of preoperative imaging and contrast MRI study may help in diagnosing cystic schwannomas with concomitant cervical disc herniations that have cord signal changes.

"Critical pedicle wall" breaches analysis in complex spinal deformity using O-arm navigation.

Background: Free-hand and fluoroscopic-guided pedicle screw placement has been associated with higher rates of pedicle breaches (frequency range 15-40% especially in deformed pedicles). Neurological complications are more "critical" (i.e., frequent and significant) with medial and inferior pedicle-wall breaches due to the proximity of the neural elements. Here, we analyzed the effectiveness of O-arm navigation in minimizing "critical" pedicle wall breaches and their complications in 21 complex spinal deformity cases. Methods: Twenty-one complex spinal deformity cases were prospectively managed with O-arm-navigated posterior-instrumented fusions. Preoperative assessment included; evaluation of the type of scoliosis, the magnitude of the deformity, and the anatomy of the pedicles - (i.e., classified using Watanabe et al.). The O-arm was used to confirm and grade both the intraoperative and postoperative location of screws. Other variables analyzed included; duration of surgery, estimated blood loss, complications, and radiation exposure. Results: In 21 patients, 259 (63.45%) of 384 pedicles were instrumented; we observed 22 of 259 pedicle screw breaches. Significant (>2 mm) breaches were observed in two medial and one inferior wall cases that required revision; the overall biomechanically significant screw breach rate was (3/259) 1.2% with an accuracy rate of 98.8%. Pedicle screw placement resulted in another 14 nonsignificant (<2 mm) breaches; ten were medial and four involved the inferior wall. As anterior, lateral, and "in-out-in" trajectory pedicle screws beaches were nonsignificant, they were not included in our analysis. Conclusion: O-arm navigation decreased the incidence of medial and inferior (i.e., >2 mm "critical") pedicle screw breaches applied in 21 patients with deformed pedicles due to scoliosis. Further, the O-arm minimized the operating time, decreased the estimated blood loss, and reduced the incidence of complications.

Learning curve across 2000 thoracolumbar pedicle screw placements using O-arm navigation: technical difficulties and their solutions.

INTRODUCTION: Instrumentation using the intraoperative O-arm navigation technique appears safer than its predecessor techniques. However, only a handful of surgeons often used navigation during spinal surgeries. Too many operative glitches and unreliable navigation accuracy were the important reasons cited even by experienced surgeons for not using spinal navigation. We have studied the accuracy of pedicle screw placement during the learning curve and beyond it. We have also discussed in detail the intricacies of the technique and solutions to the difficulties encountered using spinal navigation. MATERIALS AND METHODS: A total of 2000 thoracolumbar pedicle screws have been placed in the 324 spine surgeries meeting the inclusion and exclusion criteria included in this retrospective study. We have divided 2000 pedicle screw placements into consecutive groups of 200 each. We have compared these groups for the accuracy of screw placement with the surgeon's experience. RESULTS: The accuracy of pedicle screw placement using the "in-versus-out" grading system in group 1 was 85.5% which significantly increased in group 2 to 93.5% (p-value: 0.0099), and thereafter, there was a nonsignificant increase in subsequent groups with the graph achieving the shape of a plateau. CONCLUSION: Surgeons should learn the correct principles of the technique of O-arm navigation to prevent the loss of accuracy and place pedicle screws with high accuracy. There is a learning curve of around 30-35 surgeries or 200 pedicle screw placements to acclimatize with the technique of O-arm navigation and learn its principles.

O-arm Navigated en bloc Excision of a Solitary Subaxial Cervical Osteochondroma Presenting as Myelo-radiculopathy: A Case Report.

Introduction: Vertebral osteochondroma is a rare entity. It presents with varied complaints ranging from palpable mass to myeloradiculopathy. En bloc excision is the gold standard treatment option for symptomatic patients. Real-time intraoperative navigation has increased the accuracy and safety of tumor excision. We report a case of cervical subaxial osteochondroma with myelo-radiculopathy, treated with excision, and monosegmental fusion under O-arm-based real-time navigation. Case Report: A 32-year-old male presented with complaints of axial neck pain with the right upper limb radiculopathy for 18 months. On examination, signs of myelopathy were identified without sensory-motor deficit. Magnetic resonance imaging and computed tomography scans were suggestive of solitary C6 osteochondroma compressing spinalcord. O-arm navigated en-bloc tumor excision with C5 hemilaminectomy and monosegmental fusion was done. Conclusion: The use of O-arm navigation aids in accurate intraoperative en bloc excision without any residual tumor and with better safety.

Comparative study lumbar plexus block and lumbar erector spinae plane block for postoperative pain relief after proximal femoral nail for proximal femoral fractures.

Background: The clinical outcomes (time to ambulation, length of stay, and home discharge) after proximal femoral nail (PFN) for proximal femoral fractures (PFF) is dependent on successful pain management. Currently, the lumbar erector spinae plane block (LESPB) is in vogue and is associated with favorable outcomes in the postoperative period. Our study aimed to evaluate whether a LESPB provided equivalent analgesia and clinical outcomes as compared to LPB in PFN for PFF. Material and Methods: We compared LPBs [L] with LESPBs [E], with 30 patients in each group, performed from June 2020 to June 2021 for PFN in PFF's. The primary outcome of this study was the average NRS pain scores over 24 hours postoperatively. Secondary outcomes included pain scores at different time points over 24 hours, opioid consumption between the groups at 24 hours postoperatively, time for request of first parenteral analgesia, quadriceps weakness and adverse events. Results: The average pain scores over 24 hours were better in the LESPB group as compared to the LPB group (p = 0.02). Further, only n = 5 (30%) of patients in the LESPB group required opioids, while n = 13 (43.333%) of patients in the LPB group required opioids. Moreover, the median time for request of first parenteral analgesia was 615 (480-975) minutes, weakness of quadriceps function occurred in 2 patients in the L group, which recovered at 3rd and 5th month, respectively, with no incidences of hemodynamic instability and respiratory complications. Conclusions: This trial demonstrated that single bolus LESPB is superior to LPB in terms of analgesic outcomes, has low adverse events, and is an agreeable substitute for patients with PFF undergoing a PFN.

Efficacy and Safety of Stempeucel in Osteoarthritis of the Knee: A Phase 3 Randomized, Double-Blind, Multicenter, Placebo-Controlled Study.

BACKGROUND: Osteoarthritis is a chronic, progressive, and degenerative condition with limited therapy options. Recently, biologic therapies have been an evolving option for the management of osteoarthritis. PURPOSE: To assess whether allogenic mesenchymal stromal cells (MSCs) have the potential to improve functional parameters and induce cartilage regeneration in patients with osteoarthritis. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: A total of 146 patients with grade 2 and 3 osteoarthritis were randomized to either an MSC group or placebo group with a ratio of 1:1. There were 73 patients per group who received either a single intra-articular injection of bone marrow-derived MSCs (BMMSCs; 25 million cells) or placebo, followed by 20 mg per 2 mL of hyaluronic acid under ultrasound guidance. The primary endpoint was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total score. The secondary endpoints were WOMAC subscores for pain, stiffness, and physical function; the visual analog scale score for pain; and magnetic resonance imaging findings using T2 mapping and cartilage volume. RESULTS: Overall, 65 patients from the BMMSC group and 68 patients from the placebo group completed 12-month follow-up. The BMMSC group showed significant improvements in the WOMAC total score compared with the placebo group at 6 and 12 months (percentage change: -23.64% [95% CI, -32.88 to -14.40] at 6 months and -45.60% [95% CI, -55.97 to -35.23] at 12 months P < .001; percentage change, -44.3%). BMMSCs significantly improved WOMAC pain, stiffness, and physical function subscores as well as visual analog scale scores at 6 and 12 months (P < .001). T2 mapping showed that there was no worsening of deep cartilage in the medial femorotibial compartment of the knee in the BMMSC group at 12-month follow-up, whereas in the placebo group, there was significant and gradual worsening of cartilage (P < .001). Cartilage volume did not change significantly in the BMMSC group. There were 5 adverse events that were possibly/probably related to the study drug and consisted of injection-site swelling and pain, which improved within a few days. CONCLUSION: In this small randomized trial, BMMSCs proved to be safe and effective for the treatment of grade 2 and 3 osteoarthritis. The intervention was simple and easy to administer, provided sustained relief of pain and stiffness, improved physical function, and prevented worsening of cartilage quality for ≥12 months. REGISTRATION: CTRI/2018/09/015785 (National Institutes of Health and Clinical Trials Registry-India).