Outcomes after primary intramedullary nail fixation of open tibial and femoral fractures in low resource settings.

INTRODUCTION: Open fractures are unique in the urgency they impart to the injury and the therapeutic challenge they pose. Non-union and infection are among the major concerns. Open tibial and femoral shaft fractures are among the commonest orthopaedic urgencies. Primary intramedullary (IM) nailing requires a skillset and knowledge of the principles of open fracture management and also a well-equipped operating room with the necessary implants and instruments. In a low resource setting, one or more of these prerequisites may not be met, and the outcome may thus be affected similarly. The objective of this study was to study these outcomes. METHODS: We prospectively studied primary IM nailing of open 1, 2 and 3A tibial and femoral fractures done in our hospital, in a simple non-modular operating room without an image intensifier. RESULTS: There were 106 fractures in 104 patients: 93 tibial and 13 femoral. The mean time from injury to surgical debridement was 19.6 h. Mean duration of antibiotics therapy was 4.3 days, and the mean duration of hospital stay was 4.1 days. All patients were followed up to union. Mean time to radiographic union was 6.1 months for the tibia and 5.7 months for the femur. Non-union was seen in 4 tibial and 1 femoral fractures. There were 3 superficial infections but no deep infection. CONCLUSION: The outcomes were comparable to, and in some cases better than, those found in existing literature. We conclude that primary IM nailing in open long bone fractures can be performed in austere environments with good success, in expert hands if the principles are adhered to.

Mistletoe Eradicator - A Novel Tool for Simultaneous Mechanical and Chemical Control of Mistletoe.

Some species of mistletoes, an aerial plant hemiparasites, play a Janus-like role in ecosystems by being rich biodiversity hotspots due to their trophic and topic associations with various organisms and at the same time acting as biological pirates, exhausting the host trees by stealing water and nutrients via the haustorium. Many crop and timber trees are attacked by mistletoes, for example, dwarf mistletoes parasitize conifers, representatives of genus Tapinanthus target guava, and Phoradendron mistletoe target pecans. Recently, an increasing infestation of the European mistletoe (Viscum album subsp. album L.) in monoculture stands of common walnuts (Juglans regia L.) was recorded for the first time during 2018 in different regions of Kashmir Valley, India. The common chemical approach based on the spraying of mistletoe exophytes with the growth regulators, ethephon and glyphosate, was not efficient since V. album resprouted in the next vegetation season. Hand pruning of mistletoe was time-consuming, and a polyethylene covering resulted in the localized rotting of host tissues. The most efficient approach to eradicate mistletoe was the use of a novel tool called Mistletoe Eradicator, which allows to use mechanical and chemical means of mistletoe control simultaneously. It consists of a manipulating pole with the terminal pruning saw having a container filled with the growth regulator, from which the liquid slowly drops onto the saw blade through the nozzle. It allows working both from the ground and in the tree canopy. After the targeted application of 5%-10% ethephon or glyphosate to the base of the just pruned V. album stems (stubs), exophyte resprouting was significantly reduced 9 months after the pruning as compared to the only pruned or sprayed exophytes. An alternative variant of Mistletoe Eradicator was constructed in Ukraine filled just with a food color additive to track the liquid dropping and was successfully tested.

Plating the radial shaft on the lateral surface: An outcome study.

PURPOSE: Plate fixation is the gold standard for the treatment of displaced forearm shaft fractures in adults. Conventionally radial shaft fractures will be plated either on the volar surface or on the dorsal surface depending on which approach has been chosen. The lateral surface of the radius provides an even and uniformly curved area for placing a plate. It has the advantage of restoring and easy assessing the radial bow after surgery. We designed a prospective study to observe the outcome of lateral plating of radius shaft fractures. METHODS: Nineteen patients were included in this study performed in Government Medical College, Jammu, India. Among them, 13 had fractures of both the forearm bones and 6 had isolated radial shaft fracture. Three patients had Galeazzi fracture dislocation. Fixation was done within 36 h of injury in all using 3.5 mm limited contact dynamic compression plate or locking compression plate applied to the lateral surface of the radius. Ulna was fixed in routine manner. RESULTS: Union was achieved in 18 out of 19 patients, after a mean time of 17.44 weeks. According to Anderson et al.'s criteria, 12 patients had excellent results, 5 had satisfactory and 1 had unsatisfactory result. There was one failure (nonunion). CONCLUSION: The outcomes including rate of union were comparable to those in the existing literature. Plating the radial shaft on the lateral surface is a viable alternative to volar or dorsal plating of the radius. Larger studies with randomized data are needed to assess whether it has any superiority over other existing techniques.

A fresh look at radial shaft fracture fixation: The lateral approach to the radius.

INTRODUCTION: Open reduction and internal fixation using plates is the gold standard for the treatment of displaced forearm bone fractures in adults. The ulna being subcutaneous throughout has a constant approach. However, the radius is approached from either the dorsal or the volar side. Both the dorsal and the volar approaches to the radial shaft involve meticulous dissection and preservation of important neurovascular structures. The posterior interosseus nerve is at risk in the dorsal approach and the radial artery and its branches in the volar approach. Dissection of these structures also adds to the operative time. The possibility of a third alternate approach was perceived, which could decrease the potential risks of the conventional approaches. PATIENTS AND METHODS: Sixteen patients with radial shaft fractures in the middle third were operated on using the lateral approach: 6 of them had isolated radius fracture and 10 had both-bone fractures. There were 13 males and three females with a mean age of 37.9 years. Limited contact dynamic compression plate or locking compression plate of 3.5 mm was used to fix all fractures. All patients were operated on within 36 h of injury and then followed up till union. Union was assessed using serial radiographs and functional outcome using Anderson et al.'s criteria. The final functional outcome was assessed at an average 6 months after surgery and the results compiled. RESULTS: The mean operative time in isolated radius fractures was 37.5 min and that for plating of both bones was 80.7 min. Primary bone grafting of the radius was done in one case and secondary bone grafting in another patient with delayed union of the radius. Union was achieved in all cases at a mean time of 17.25 weeks. The functional outcome was excellent in 10 patients, satisfactory in 5 patients, and unsatisfactory in 1 patient. CONCLUSION: The lateral approach is a simple approach with low operative complexity and complications. We found this approach to provide a reliably good exposure of the middle third of the radius, enabling lateral plating without complications.

High Prevalence of Osteoporosis and Morphometric Vertebral Fractures in Indian Males Aged 60 Years and Above: Should Age for Screening Be Lowered?

Current guidelines recommend bone mineral density (BMD) measurement in asymptomatic men above age 70 years and vertebral fracture (VF) assessment above 80 years with T-score <-1.0 with risk factors. We studied the prevalence of osteoporosis and morphometric VF in asymptomatic males aged 60 years and above in North India. Free-living community-dwelling men (n = 241, age: mean ± standard deviation 68.0 ± 6.2 years) underwent a detailed history, physical examination, biochemical evaluation, and BMD measurements at 3 sites: lumbar spine, total hip (TH), and femoral neck (FN). Morphometric VF were assessed by instant vertebral assessment using Genant et al's semiquantitative method. We observed osteoporosis, osteopenia, and normal BMD in 19%, 56%, and 25% of subjects, respectively. The decade wise prevalence of osteoporosis in the age groups 60-70 years, 71-80 years, and >80 years was 16.9%, 17%, and 50%, respectively. Mean serum 25OHD levels were 17.2 ± 10.3 ng/mL. Vitamin D deficiency (<20 ng/mL) and secondary hyperparathyroidism (plasma intact parathyroid hormone >65 ng/mL) were present in 68.8% and 45.4%, respectively. VF were present in 29.6% subjects (grade I: 58%, grade II: 32.4%, and grade III: 8.8%). Age and iPTH had significant negative correlation with BMD at FN and TH. Serum 25OHD had no correlation with BMD at any site. The prevalence of VF was positively associated with age (p = 0.018) and negatively associated with BMD at FN (p = 0.002) and TH (p = 0.013). Osteoporosis and VF are common in asymptomatic Indian males aged 60 years and above. Screening for osteoporosis and instant vertebral assessment may be recommended earlier than currently existing guidelines.

Utility of Osteoporosis Self-Assessment Tool as a Screening Tool for Predicting Osteoporosis in Indian Men.

The osteoporosis self-assessment tool (OSTA) predicts the risk of osteoporosis in an individual. It is a simple calculation-based tool [wt (kg) - age (yr)/5] and can be used for measuring bone mineral density (BMD). However, OSTA is influenced by ethnicity. We studied the performance of OSTA index as a screening tool for osteoporosis in 257 community-dwelling North Indian men above 50 yr age. Each subject underwent a detailed clinical, dietary, anthropometric, and biochemical assessment and bone density measurement using dual-energy X-ray absorptiometry. As per World Health Organization criteria, osteoporosis, osteopenia, and normal BMD were observed in 17.9%, 58.8%, and 23.3%, respectively. OSTA index ranged between -6.4 and 8.8. OST index ≤2 predicted osteoporosis with a sensitivity of 95.7% and a specificity of 33.6% and an area under the curve for a receiver operating characteristic curve of 0.702. The OSTA index is an effective screening tool for measuring BMD in elderly Indian men and can be used by primary care physicians.

Functional results after osteosynthesis of distal humeral fractures with pre-contoured LCP system.

BACKGROUND: Evaluate the functional results and determine the complications after treating distal humerus fractures with an anatomically pre-contoured double plate system. MATERIAL AND METHODS: Twenty-five patients with distal humeral fractures were treated with a pre-contoured double plate system. There were 18 males (72%), 7 females (28%), with an average age of 39.68 years (22-70years). As per the AO classification, there were 4 type A fractures (16%) and 21 type C fractures (84%). In addition to clinical examination, functional results were evaluated using the Mayo elbow performance score (MEPS). RESULTS: Using the Mayo elbow performance score, the results obtained were graded as excellent or good results in 22 patients (88%), fair in 2 (8%) and poor in 1 (4%) of cases. Average time interval between admission and surgery was 3.8 days (average 1-9 days). All the fractures as well as the olecranon osteotomies united by 10-16 weeks (12.56 weeks). No patient had deep infection, implant failure, non-union of fracture site or olecranon osteotomy site. Superficial wound infection, which occurred in 4 (16%) patients, resolved with oral antibiotics. Transient ulnar nerve palsy developed in 1(4%) case. However, the patient recovered with conservative treatment. CONCLUSIONS: 1. An anatomically pre-shaped distal humerus locking plate system is useful in providing stable fixation of distal humerus fractures, thereby facilitating early postoperative rehabilitation. 2. In contrast to conventional plating, we did not observe any case of secondary fracture displacement, non-union or implant failure even in elderly patients with potentially reduced bone mass. 3. The multiple angular stable point fixation seems to be effective in the application of this system.

Efficacy and safety of sequential therapy versus standard triple therapy in Helicobacter pylori eradication in Kashmir India: a randomized comparative trial.

BACKGROUND: Increasing resistance against Helicobacter pylori has resulted in reduced eradication rates. OBJECTIVE: This study aims to determine whether eradication rates for H. pylori infection with sequential therapy is better than standard triple therapy. PATIENTS: Patients with endoscopy documented peptic ulcer and H. pylori infection confirmed by histology and rapid urease test. INTERVENTION: Patients were randomized into two groups; 134 received standard triple therapy (pantoprazole 40 mg, clarithromycin 500 mg and amoxicillin 1 g each administered twice daily) for 10 days and 138 received sequential regimen (pantoprazole 40 mg plus amoxicillin 1 g twice daily for 5 days followed by 40 mg pantoprazole, 500 mg clarithromycin, and 500 mg tinidazole each administered twice daily for 5 days). Eradication was confirmed by histology and rapid urease test. Compliance and adverse effects were determined by the recovery of empty medicine strips and questioning. RESULTS: The eradication rates with sequential therapy were significantly greater than with standard therapy on both intention-to-treat analysis (76.0 % vs. 61.9 %, p = 0.005; difference, 14.1 % [95 % CI, 6.5-19 %] and per protocol analysis (84.6 % vs. 67.4 %, p = 0.002; difference, 17.2 % [95 % CI, 8.5-23.5 %]). The incidence of side effects did not differ between the two therapy groups. One patient in standard therapy discontinued treatment due to side effects. LIMITATION: Cultures were not performed. Loss to follow up was 5.2 % in standard therapy and 6.5 % in sequential therapy. CONCLUSION: Sequential therapy was significantly more effective than standard therapy for eradicating H. pylori infection in peptic ulcer disease in Asian patients. Side effects were similar.

Semi-synthetic analogs of pinitol as potential inhibitors of TNF-alpha cytokine expression in human neutrophils.

Semi-synthetic analogs of pinitol were subjected to screening by determining TNF-alpha expression in human neutrophils using flowcytometry. Among the tested compounds, three derivatives displayed more than 50% inhibition of TNF-alpha cytokine secretion in LPS induced stimulated neutrophils and can be considered as potent anti-inflammatory moieties.