Management of post-traumatic ankle deformities in children.

The objective of this clinical appraisal was to assess the clinical-radiological results of ankle deformity correction secondary to physeal injury, utilizing the methods based on the age of the child, site & severity of the deformity, remaining growth potential, condition of the soft tissue envelop and integrity of neurovascular status. Fifteen subjects ≤ 16 years of age, with angular deformities of the ankle secondary to physeal injury, were included. Deformities secondary to infection and pathological fractures were excluded. Demographic data, type of injury, treatment method, and follow-up were recorded from the case files. Treatment categories included osteotomies for acute correction (> 10 years) and growth modulation (≤ 10 years). Male to female ratio was 7:8, with an average age of 11.8 ± 2.31 years (range 9-16 years). The right and left ratio was 7:8. Mean duration of follow-up was 1 year and 4 months. Gradual deformity correction was done in 2 cases utilizing the principle of growth modulation, while acute correction by osteotomy was done in 13 cases. The average pre-operative ankle deformity was 20.8 ± 3.11 degrees (Range -25 to 24 degrees). Radiological union was attained at a mean of 11 weeks (8-24). Nine patients achieved neutral ankle alignment. The mean residual varus was 2.3°, and the valgus was 4°. There was a statistically significant improvement of the AOFAS score by 17 points from a mean pre-operative score of 57 (44-84) to 74 (56-100) points at the final follow-up (p-value < 0.001). The average pre-operative shortening was 2.36 ± 0.21 cm, which was completely corrected in 9 individuals. Management of angular deformities around the ankle calls attention to correcting the resultant angular deformity and/or limb length disparity, utilizing acute or gradual correction. A successful outcome depends on early recognition and patient-specific treatment of paediatric ankle fracture patterns. Correlating the results of our study with the available literature, we feel that both acute or gradual correction for angular deformities around the ankle is a feasible solution as long as principles of deformity correction are adhered to. Techniques for salvaging and restoring the viability of injured physeal plate warrant additional research.

Embracing the Timeless Value of Vintage Instrumentation in Orthopedics for Broken Femoral Nail Extraction with Novel Technique.

Introduction: Intramedullary nail placement is a preferred method for femoral shaft fractures due to biomechanical advantages. Despite its simplicity and efficacy, complications, such as pseudoarthrosis and nail fracture, pose challenges. Removing the distal fragment presents a vexing issue, often requiring specialized instruments. Current retrograde techniques may not be universally accessible, potentially leading to non-union site opening and tissue damage. While intramedullary nailing benefits fracture treatment, addressing its removal complications is crucial for further advancements. In this case, universal zig and K-nail reamers are used to extract the broken nail. Case Report: A 42-year-old male suffered an injury to his left thigh in a bike collision. Radiological examination revealed an oblique fracture in the proximal 1/3rd and distal 2/3rd junction of the left femur shaft. Closed reduction and internal fixation were initially performed, but delayed union occurred. Nine months post-surgery, a broken femoral nail and non-united fracture were observed. The patient underwent successful removal and replacement of the broken nail with a wider intramedullary nail. The procedure involved using a universal zig for removal of the proximal fragment and K-nail reamers to remove the distal fragment of the broken nail, and inserting a wider proximal femoral nail. The patient was discharged in satisfactory condition with tolerable weight-bearing. Conclusion: Broken femoral nail presents a unique challenge to the operating surgeon. It requires diligent planning with appropriate instruments and techniques. There have been many techniques devised to tackle this problem and the use of K-nail reamers as described in this case is another innovative method in this regard.

Shining a Spotlight on Stigma: Exploring Its Impact on Oral Health-Seeking Behaviours Through the Lenses of Patients and Caregivers.

Introduction The unique nature of a lack of good oral health, coupled with the lack of discussion and recognition surrounding the associated stigma, highlights it as a distinct issue. This stigma causes discomfort, devalues individuals, and necessitates urgent care and intervention. In Pakistan, a variety of reasons, including cultural beliefs, socioeconomic gaps, and poor access to dental care services, tend to exacerbate the stigma that is associated with dental care. This study aimed to determine the impact of stigma on oral health-seeking behaviours amongst the population of South Punjab in Pakistan. Methodology The study employed a qualitative design with a phenomenological approach, and the data collection was preceded by the administration of semi-structured interview guides and discussion guides to the patients and the consultant group, respectively. The targeted population was composed of patients who had reported stigmatization and a focus group of 10 dental consultants from various specialisations in dentistry. Data was collected until saturation from 16 patients who were recruited through the purposive convenience sampling technique. Results The study identified three themes, including perceived stigma impact on health-seeking behaviours and coping mechanisms; 10 subthemes emerged. Results showed social attitudes and unhealthy perceptions of oral conditions that lead to shame, loss of self-esteem, and lack of confidence among affected individuals. Behavioural reactions like mockery and discrimination further made it difficult for the participants who sought dental care and treatment. The study highlighted that stigma resulted in the avoidance of dental care, deterioration of oral health, and a tendency towards self-medication. People also used coping strategies such as hiding dental issues by avoiding social gatherings and seeking help from close friends to manage oral health stigma. Dental consultants had the strong opinion that care quality could be enhanced by utilising compassionate communication and patient education campaigns. Conclusions The experiences of patients and consultants related to dental stigma highlighted the complex interplay of sociocultural norms and healthcare practices. The study demonstrated that perceived stigma impacted the health-seeking behaviours of patients. Social support and education about oral health helped patients overcome this stigma. The study revealed that patients avoided dental treatments due to stigmatised behaviour from health professionals, a lack of affordability, and a feeling of shame to show and discuss the condition of their teeth, which got even worse due to self-remedy. The experiences of patients and consultants highlighted the need for increased advocacy, educational campaigns, and policies that can reduce inequalities in oral health and improve health equity. The study recommends specific intervention strategies and policy formulation to address oral health inequalities and contribute to advancing oral health equity in Pakistan.

Does early stable fixation reduce complications in paediatric femoral neck fractures?

The primary objective of this study was to juxtapose the union rate and incidence of complications in paediatric patients presenting early (≤ 7 days) following injury with children presenting later (> 7 days) with femoral neck fractures. This critical appraisal evaluated 15 patients according to their timing of presentation and surgery from the initial day of injury (Group A: operated ≤ 7 days or Group B: > 7 days of injury). Patients with traumatic femoral neck fractures with Delbet 1 to 4 subtypes who were skeletally immature (age ≤ 16 years) were included in the study. Pathological fractures and post-infective fractures were not included. Each patient's secondary loss of reduction was calculated by measuring the Neck shaft angle (NSA) on the immediate post-operative radiograph and at the union. A change in NSA of ≥ 5 degrees was considered a significant loss of reduction. Ratliff's Criteria was used to analyze the final result, and a thorough record of complications was kept. There were no significant variations in the two groups' with respect to distributions of age, sex, injury mechanism, or fracture pattern. The most frequent injury culprit in both groups was falling from a height. Type II fracture pattern (54.54%) was more common in group A, while Type III and Type II fracture pattern was equally distributed in group B. In group A, the mean operation time was 55 ± 8.25 minutes, whereas in group B, it was 65 ± 15 minutes (p-value > 0.05). In group A, 90.9% of patients underwent CCS fixation, and in group B, 75% underwent fixation by CCS. The quality of reduction in post-operative radiographs was anatomical in 10 (90.9%) patients and unacceptable in 1 (9.1%) patient. In group B, 2 (50%) patients had an anatomical reduction, while 2 (50%) patients had an unacceptable reduction. Timing of reduction and its association with complications showed that early stable reduction and fixation decrease the occurrence of complications in femoral neck fractures (p-value = 0.033). Fracture union was seen in all our patients in both groups and none of our patients underwent non-union. The mean union time was 11.11 ± 7.06 weeks in group A and 16.5 ± 2.59 weeks in group B (p-value = 0.0189). In group A, only 1 (9.1%) patient developed coxa vara. In group B, out of 4 patients, the femoral head of one patient underwent avascular necrosis, one patient exhibited coxa vara, and 1 patient developed premature physeal closure with limb length inequality. Management of femoral neck fractures in children is challenging because of the paediatric bone's peculiar anatomic and physiological considerations. In our study, patients operated within 7 days developed fewer complications as compared to patients who were operated after 7 days, which was statistically significant. Although AVN is a frequent adverse consequence of pediatric femoral neck fractures, early reduction and stable fixation lowers AVN rates, as observed in our study. Our short-term functional and radiological results using the Ratliff scoring system were comparable to previous studies owing to stable anatomic reduction. Based on our findings and the existing literature, we emphasize long-term follow-up and recommend an early stable anatomic reduction in the treatment of paediatric femoral neck fractures.

Caries risk assessment by Caries Management by Risk Assessment (CAMBRA) Protocol among the general population of Pakistan-a multicenter analytical study.

Background: Caries risk (CR) assessment tools are used to properly identify individuals with caries risk and to improve preventive procedures and programs. A tool such as CAMBRA determines the precise protective factors of caries and identifies an individual's specific therapeutic intervention. The purpose of this study was to assess the caries risk using the CAMBRA protocol among the general population of Pakistan. Methods: This multicentre analytical study was conducted in ten dental hospitals in different provinces of Pakistan and the caries risk assessment was carried out using a questionnaire that was designed using the Caries Management by Risk Assessment (CAMBRA) protocol. All 521 participants were intra-orally examined to assess oral hygiene status and the presence of disease. Multiple logistic regression test was performed for analysis. Results: A higher number of participants (61.2%) were found to be in the moderate risk category of caries risk assessment. The males are 51% less likely to have caries compared to the females (AOR = 0.49, P = 0.081). The majority of participants (71.3%) had one or more disease indicators, with white spots and visible cavities. Those with visible, heavy plaque were 13.9 times more likely to have caries compared to those without (AOR = 13.92, P < 0.001). Those using calcium and phosphate during the last 6 months were 90% less likely to have caries compared to those not using them (AOR = 0.10, P < 0.001). There was no significant interaction between all eight risk factors retained in the final model (P > 0.05), the Hosmer and Lemeshow Test P < 0.001, classification accuracy = 87.1%, and AUC = 91.2%. Conclusion: The caries risk among the general population of Pakistan is moderate, with significant variation among age groups, education levels, and socioeconomic status.

Tibial Tuberosity Avulsion Fracture with Epiphyseal Injury in a Soccer Player: Treatment Options and Challenges.

Introduction: Acute avulsion of the tibial tubercle is an uncommon fracture, with reported incidence rates of 0.4-2.7% of all epiphyseal injuries and <1% of all physeal injuries. Typically, these fractures present with marked displacement of the entire proximal apophysis, with or without intra-articular extension, and variable associated soft-tissue injury. The Ogden classification has historically directed both non-operative and operative treatment of this injury. The overarching objective of several fracture fixation techniques has been outlined as being to restore the joint surface and the extensor mechanism. Case Report: This case report describes the management of a 14-year-old male who sustained a rare avulsion fracture of the left tibial tuberosity with epiphyseal injury during a soccer game. The fracture was classified as Ogden Type III-B, indicating an intra-articular extension. The patient underwent open reduction and internal fixation with three cannulated screws and tension band wiring. Conclusion: The fracture united with no residual deformity and return of full range of motion. Tension band wiring provides stable reduction; hence, prompt diagnosis and appropriate surgical intervention in similar cases is important to optimize outcomes.

Bilateral Distal Humeral Physeal Separation-From Birth Trauma to Family Trauma.

Introduction: Chondro-epiphyseal separation of the distal humerus is a rare injury, which can occur as a consequence of excessive traction on the upper extremity accompanying a dystocic birth or one complicated by cephalopelvic disproportion. Such fracture patterns can also result from a combination of rotatory and shear forces, also typically seen following child abuse. It can be easily mistaken for a posterior elbow dislocation, creating a delay in diagnosis. Since unossified cartilage cannot be seen radiographically, these injuries are better appreciated by ultrasound or magnetic resonance imaging. Case Report: We present a case of an 8-day-old neonate who presented with pseudoparesis of the left arm following birth. Posterior displacement of the elbow joint was identified on the radiograph. On ultrasound, a trans-physical supracondylar distal humerus fracture was identified. This was presumed as trauma secondary to a difficult delivery. At the 11th week of follow-up, the patient presented with a fracture of the right proximal tibia, followed by a fracture shaft left femur at 5 months of follow-up. Chest X-ray at this time revealed uniting rib fractures with callus formation. After ruling out any congenital collagen disorder (osteogenesis imperfecta), the patient was diagnosed with a case of battered baby syndrome. The case was reported to child protection services and parents were questioned and counseled for the same. Conclusion: This case report highlights the importance of a high degree of suspicion of child abuse in any child with a rare fracture pattern, uncommon serial fracture occurrence, and unconventional clinic-radiological presentation.

Enhancement of combustion effect leading to improved performance and exhaust emissions of an SI engine with ferrous oxide and graphite nanoparticles.

The present study was conducted to investigate the effectiveness of new, less toxic, less harmful, and nonmetallic graphite (G) and metallic iron oxide (Fe2O3) nanofuel additives by analyzing experimentally their consequences on exhaust emissions and performance of an air cooled, single cylinder, 4-stroke gasoline engine. Fe2O3 and graphite nanoparticles at 40, 80, and 120 mg/l of gasoline concentrations were mixed with gasoline by means of a magnetic stirrer. Brake power (BP), brake-specific fuel consumption (BSFC), torque (T), brake thermal efficiency (BTE), nitrogen oxides (NOx), carbon monoxide (CO), hydrocarbons (HC), and carbon dioxide (CO2) emissions were the investigated parameters. Experimental results indicated that G-blends showed a higher rise in brake power, brake thermal efficiency and torque and a greater reduction in the brake-specific fuel consumption as compared to that of Fe2O3 fuel blends. Moreover, the G-blends produced less NOx and CO2 than Fe2O3 blends but produced more emissions of CO and HC than that of Fe2O3 blends. On average, G-blends produced 0.46%, 0.71%, and 1.71% more torque, power, and BTE and 2.43%, 1.87%, and 13.39% less brake-specific fuel consumption (BSFC), NOx, and CO2 than Fe2O3 blends, respectively. So, in terms of the eight parameters, four performance parameters (i.e., T, BP, BSFC, BTE), and four engine emission exhaust indicators (i.e., CO, NOx, HC, CO2), graphite nanoparticles showed more positive results for 6 parameters (T, BP, BSFC, BTE, NOx, CO2), while two parameters HC and CO showed negative results with graphite as compared to that of Fe2O3 nanoparticles. So, overall, we conclude that nanoparticles of graphite are more engine and environment friendly than that of iron oxide fuel additives.

Short versus long proximal femoral nail in the management of intertrochanteric fractures - a comparative study.

INTRODUCTION: Intertrochanteric fractures are those that occur in the region spanning from the extracapsular basilar neck region to the region along the lesser trochanter proximal to the development of medullary canal. Low-energy falls account for 90% of fractures in people over the age of 50, with females having a higher prevalence. Intertrochanteric fractures in children and teenagers are caused by high-energy trauma. The aim of this study was to compare the functional and radiological outcomes as well as complications of intertrochanteric fractures treated with long proximal femoral nail (PFN) versus short proximal femoral nails. METHODS: The study was a clinical randomized prospective comparative study which included 30 (2 groups of 15 patients each, being treated with short and long PFNs respectively) skeletally mature patients with fresh (less than 3 weeks old) intertrochanteric fractures of femur AO/OTA 31-A1, AO/OTA 31-A2 or AO/OTA 31-A3 as per AO/OTA classification. Harris Hip score was used to compare the functional outcomes. RESULTS: The average age of patients in short PFN group (Group A) was 62.1 ± 15.77 years and in long PFN group (Group B), it was 54.1 ± 10.8 years. Male-female ratio in the study was 1.7:1. AO31A2 of AO fracture classification was the most common type of fracture in both the groups. The mean injury to surgery interval in Group A was 9.6 ± 4.45 days and in Group B, it was 6 ± 4.12 days. The mean operative duration in Group A was 68.6 ± 6.62 minutes and in Group B, it was 78.6 ± 7.35 minutes. The average time of union in Group A was 15.69 ± 2.72 weeks while that of Group B was 15.77 ± 2.05 weeks. The average Harris Hip score at final follow up in Group A was 81.0 ± 11.62 and in Group B, it was 80.3 ± 10.83. There was 1 case of implant failure in each group, which were re-operated. One case of screw back-out in Group A led to a varus collapse and had to be reoperated. One case of non-union was reported in Group B. One case of superficial wound infection was reported in each group. CONCLUSION: The Proximal Femur Nail can be used as an efficient implant to manage per trochanteric fractures regardless of the length of the implant. However, the mean operative time was found to be lower when a short nail is used.

Substance P aggravates ligature-induced periodontitis in mice.

Periodontitis is one of the most common oral diseases in humans, affecting over 40% of adult Americans. Pain-sensing nerves, or nociceptors, sense local environmental changes and often contain neuropeptides. Recent studies have suggested that nociceptors magnify host response and regulate bone loss in the periodontium. A subset of nociceptors projected to periodontium contains neuropeptides, such as calcitonin gene-related peptide (CGRP) or substance P (SP). However, the specific roles of neuropeptides from nociceptive neural terminals in periodontitis remain to be determined. In this study, we investigated the roles of neuropeptides on host responses and bone loss in ligature-induced periodontitis. Deletion of tachykinin precursor 1 (Tac1), a gene that encodes SP, or treatment of gingiva with SP antagonist significantly reduced bone loss in ligature-induced periodontitis, whereas deletion of calcitonin related polypeptide alpha (Calca), a gene that encodes CGRP, showed a marginal role on bone loss. Ligature-induced recruitment of leukocytes, including neutrophils, and increase in cytokines leading to bone loss in periodontium was significantly less in Tac1 knockout mice. Furthermore, intra-gingival injection of SP, but not neurokinin A, induced a vigorous inflammatory response and osteoclast activation in alveolar bone and facilitated bone loss in ligature-induced periodontitis. Altogether, our data suggest that SP plays significant roles in regulating host responses and bone resorption in ligature-induced periodontitis.

Chondrosarcoma of Great Toe: A Case Report.

Introduction: Chondrosarcoma (CHS) of the toes is very rare and the involvement of phalanges is extremely rare. The osteolytic destruction of this tumor severely affects limb function and carries the risk of distant metastasis. These tumors are removed surgically to minimize local recurrence and distant metastases, maximize limb function with better prognosis. The main objective of this report is to present the case of a CHS that invaded the phalanx of the left great toe and formed a large phalangeal mass with osteolytic destruction of the distal bone. Case Report: This case report includes a 60-year-old man suffering from swelling of his left great toe for 2 years, with pain and swelling for 6 months. Serial hematological, radiological and tumor investigations were done. Magnetic resonance imaging revealed a well-defined peripherally enhancing multilobulated soft-tissue mass with central necrotic component involving the entire proximal phalanx of left great toe extending to distal phalanx and head of first metatarsal. The patient was planned for operative intervention due to the possibility of invasion into the adjacent bones. The tumor was excised and sent for histopathological examination, which was reported as Grade 2 CHS (PT, Nx, and Mx) and was S100 positive. The patient has been followed-up for 5 months. Results: There were no signs of local recurrence or distant metastasis on radiological investigations or clinical assessment during follow-ups. Conclusion: CHS occurring in toes is extremely rare. In this case, extensive surgical resection of the large low-grade CHS was safe and effective.

Haemophilic arthropathy of the knee: a surgeon's nightmare.

Surgical management of knee synovitis secondary to mild haemophilia, without any significant previous medical history and an adverse family history of haematological disorders, is arduous. Due to its rare occurrence, the diagnosis is often delayed or sometimes missed, leading to the grave and often lethal consequences in intraoperative and postoperative periods. Hardly isolated knee arthropathy due to mild haemophilia has been reported in the available literature. In this report, we present the management of a case of a 16-year-old male with isolated knee synovitis with undiagnosed mild haemophilia, who came to us with the first episode of knee bleeding. We elucidate the signs and symptoms, investigations, surgical management, and difficulties faced, especially during the postoperative period. This case report is presented to enhance awareness of the existence of this disorder and its management to prevent postoperative complications.

Effectiveness of Ponseti technique in management of arthrogrypotic clubfeet - a prospective study.

BACKGROUND: Clubfoot constitutes roughly 70 percent of all foot deformities in arthrogryposis syndrome and 98% of those in classic arthrogryposis. Treatment of arthrogrypotic clubfoot is difficult and challenging due to a combination of factors like stiffness of ankle-foot complex, severe deformities and resistance to conventional treatment, frequent relapses and the challenge is further compounded by presence of associated hip and knee contractures. METHOD: A prospective clinical study was conducted using a sample of nineteen clubfeet in twelve arthrogrypotic children. During weekly visits Pirani and Dimeglio scores were assigned to each foot followed by manipulation and serial cast application according to the classical Ponseti technique. Mean initial Pirani score and Dimeglio score were 5.23 ± 0.5 and 15.79 ± 2.4 respectively. Mean Pirani and Dimeglio score at last follow up were 2.37 ± 1.9 and 8.26 ± 4.93 respectively. An average of 11.3 casts was required to achieve correction. Tendoachilles tenotomy was required in all 19 AMC clubfeet. RESULT: The primary outcome measure was to evaluate the role of Ponseti technique in management of arthrogrypotic clubfeet. The secondary outcome measure was to study the possible causes of relapses and complications with additional procedures required to manage clubfeet in AMC an initial correction was achieved in 13 out of 19 arthrogrypotic clubfeet (68.4%). Relapse occurred in 8 out of 19 clubfeet. Five of those relapsed feet were corrected by re-casting ± tenotomy. 52.6% of arthrogrypotic clubfeet were successfully treated by the Ponseti technique in our study. Three patients failed to respond to Ponseti technique required some form of soft tissue surgery. CONCLUSION: Based on our results, we recommend the Ponseti technique as the first line initial treatment for arthrogrypotic clubfeet. Although such feet require a higher number of plaster casts with a higher rate of tendo-achilles tenotomy but the eventual outcome is satisfactory. Although, relapses are higher than classical idiopathic clubfeet, most of them respond to re-manipulation and serial casting ± re-tenotomy.

Matrix Metalloproteinases in Dental and Periodontal Tissues and Their Current Inhibitors: Developmental, Degradational and Pathological Aspects.

OBJECTIVES: This review article aims to describe some of the roles of Matrix metalloproteinases (MMPs) in enamel, dentine, dental caries, hybrid layer degradation, pulp and periodontal tissues, throwing light on their current inhibitors. The article addresses the potential of MMPs to serve as biomarkers with diagnostic and therapeutic value. DESIGN: The sections of this review discuss MMPs' involvement in developmental, remodeling, degradational and turnover aspects of dental and periodontal tissues as well as their signals in the pathogenesis, progress of different lesions and wound healing of these tissues. The literature was searched for original research articles, review articles and theses. The literature search was conducted in PubMed and MEDLINE for articles published in the last 20 years. RESULTS: 119 published papers, two textbooks and two doctoral theses were selected for preparing the current review. CONCLUSIONS: MMPs are significant proteases, of evident contribution in dental and periapical tissue development, health and disease processes, with promising potential for use as diagnostic and prognostic disease biomarkers. Continuing understanding of their role in pathogenesis and progress of different dental, periapical and periodontal lesions, as well as in dentine-pulp wound healing could be a keystone to future diagnostic and therapeutic regimens.

A comparative study of Proximal Femoral Nail (PFN) versus Dynamic Condylar Screw (DCS) in management of unstable trochanteric fractures.

Trochanteric hip fractures have become very common with 35-40% of these fractures being unstable. Trochanteric fractures, especially unstable ones are associated with high rates of mortality and morbidity and thus remain an inordinate challenge for surgeon to treat these fractures with proper choice of implant. Aim of the study was to compare the proximal femoral nail and dynamic condylar screw in the management of unstable trochanteric fractures. Our study was a prospective comparative study which included 26 patients with fresh (≤3 weeks old) unstable trochanteric fractures AO 31A2 and AO 31A3, with age ≥18 years of both sexes. Eleven patients in DCS and fifteen patients in PFN were included. Harris hip score was used to compare functional outcomes. Average age of patients in DCS group was 59.82±11.59 years and PFN was 54.2±16.22 years. AO 31A2 fracture pattern (63.64%) was more common than AO 31A3 in DCS group and AO 31A3 fracture pattern (60.00%) was more common than AO 31A2 in PFN group. Mean operative time for DCS was 96.36±15.51 minutes and for PFN it was 79.67±12.02 minutes with P-value of 0.003. Two patients in DCS group and 1 patient in PFN group were lost to follow up. Two patients in DCS group and 1 patient in PFN group died. Seven out of 11 (63.64%) patients in DCS group and 13 out of 15 (86.60%) patients in PFN group were available for final follow up. Union seen in 2 (28.57%) patients with DCS and 12 (92.31%) patients fixed with PFN with P-value of 0.007. Mean HHS of 62.29±24.26 in DCS and 86.92±11.65 in PFN with P-value of 0.037. Patients with combined excellent and good HHS in DCS group and PFN group were 2 (28.57%) and 11 (84.62%) respectively. Non-union was seen in 5 (71.43%) patients fixed with DCS and 1 (7.69%) patient fixed with PFN. Implant failure was seen in 3 (42.86%) patients in DCS group in which barrel plate was broken in 2 (28.57%) patients and lag screw cut out through femoral head in 1 (14.29%) patient and 1 (7.69%) patient in PFN group due to varus collapse and complete backout of screw. Varus collapse was seen in 3 (42.86%) patients in DCS group and 4 (30.76%) patients in PFN group. Proximal femoral nail is better implant as compared to dynamic condylar screw which was statistically significant in terms of lesser operative time, higher union rate and better functional outcome. So PFN is a better implant choice for unstable trochanteric fractures when compared with DCS.

Single-stage versus two-stage reconstruction in chronic multi ligament knee injury.

BACKGROUND: Multi ligament knee injury (MLKI) refers to the disruption of at least 2 of the 4 major knee ligaments. These injuries are managed in single and two-stage surgeries however, treatment guidelines for best practice are unsettled. There is no study in the literature that compares single and two-stage surgery for the management of chronic multiligament knee injury. Therefore, the aim of this study was to compare the functional outcome between single-stage and two-stage surgical fixation in chronic multi-ligament knee injury. METHODS: Twenty seven patients with chronic MLKI with at least 2 years of follow up were included. Fourteen patients underwent reconstruction of torn ligaments in a single-stage operation (Group I) and 13 patients underwent reconstruction of torn ligaments in two stages (Group II). Assessment of clinical outcome was done with IKDC knee score, TEGNER LYSHOLM knee score, range of movement and laxity tests (Anterior drawer test, Lachman, Posterior drawer test, pivot shift test, dial test, varus and valgus stress test). RESULTS: At final follow up, there was no significant difference in post-operative IKDC knee scores in group I and group II (84.7±7.1 and 81.4±8.4 respectively, p=0.3) and Lysholm scores (85.8±8.3 and 80.9±8.3 respectively, p=0.1), range of movement (133.2±5.7 and 131.5±6.6 respectively, p=0.5) and all the patients regained full extension. At the final follow up 12/14 patients (85.7%) in group I and 11/13 patients (84.6%) in group II had a negative/grade 1 anterior drawer test (p=0.6), 14/14 (100%) in group I and 13/13 (100%) patients had negative/grade 1 lachman test (p=0.6), 13/14 patients (92.8%) in group I and 13/13 patients (100%) patients in group II had negative/grade 1 pivot shift test (p=0.4), 9/10 patients (90%) in group I and 12/13 patients (92.3%) in group II had negative/grade 1 posterior drawer (p=0.6), 6/6 patients (100%) in group I and 6/7 patients (85.7%) in group II had negative/grade 1 dial test (p=0.3), 5/6 patients (83.3%) in group I and 5/7 patients (71.4%) in group II had negative/grade 1 varus stress test (p=0.4), 6/7 patients (85.7%) in group I and 7/7 patients (100%) in group II had negative/grade 1 valgus stress test (p=0.1). CONCLUSION: Chronic MLKI managed by single stage and two stage reconstruction provides similar functional outcomes. LEVEL OF EVIDENCE: Level III Retrospective Cohort Study.

Estimation of periodontal pocket surface area in small to medium dogs: a proof-of-concept study.

BACKGROUND: Periodontal disease is the most common dental disease in dogs. Although the systemic effects of periodontal disease have not been clarified in veterinary science, it is necessary to evaluate the effects of periodontal disease in clinical trials in the future. There have been a few clinical attempts made, however, to assess the severity of periodontal inflammation and its impact on the systemic health of dogs. Meanwhile, in the field of dentistry for humans, the periodontal inflamed surface area (PISA) and periodontal epithelial surface area (PESA) have been used to quantitatively assess the degree of periodontal disease affecting a single tooth as well as the overall extent of periodontitis. Recent studies have also suggested the use of these assessments to examine the relationship between periodontal inflammation and systemic health. RESULTS: The estimation formula for a dog's periodontal pocket surface area (PPSA), an alternative to PISA and PESA in humans, was established using body weight and periodontal pocket depth. Actual values were measured using extracted teeth from various dog breeds and sizes (2.3-25.0 kg of body weight) to obtain universal regression equations for PPSA. Altogether, 625 teeth from 73 dogs of 16 breeds were extracted and subsequently analyzed for morphological information. PPSA was measured in 61 dogs of 10 breeds with periodontal disease using the established estimation formulas, and the correlation between PPSA and preoperative blood chemistry data was analyzed accordingly. A strong correlation was found between PPSA and serum globulin (r = 0.71) while moderate correlations were found for C-reactive protein (r = 0.54) and serum albumin (r = -0.51). CONCLUSIONS: Estimation formulas using body weight and the 6-point probing depth were established for determining PPSA. Direct correlations between PPSA and several blood test results were observed in the study sample. Taken together, these results suggest that PPSA could be useful for evaluating the effects of periodontitis on systemic conditions in dogs.

Buttress Plate Assisted Fixation for Bicondylar Hoffa Fracture: A Missed Fracture-case Report with Review of Literature.

Introduction: Bicondylar Hoffa fractures are extremely uncommon injuries and there have only been a very small number of cases documented in the literature. Case Report: A 28-year-old male presented to emergency department with injury to right knee and leg. X-ray was taken; however, they were not sufficient to determine the precise fracture pattern, so computed tomography scan was done for establishing diagnosis. Fracture managed successfully using compression screws and buttress plate with satisfactory result after a follow-up period of 1 year with ROM 20-120° with no signs of Avascular necrosis or arthritis and we also discussed the appropriate treatment options with supporting literatures. Conclusion: We conclude by describing a rare case of Bicondylar Hoffa fracture managed by open reduction and internal fixation with cancellous screws and Buttress plating. All cases of unicondylar Hoffa must be evaluated with a high index of suspicion to not miss the cases of Bicondylar Hoffa, which is extremely uncommon injury.

Prediction of peroneus longus graft diameter for anterior cruciate ligament reconstruction by inframalleolar harvest and from anthropometric data.

BACKGROUND: The literature is gradually drifting towards a graft of larger diameter for successful ACL reconstruction. There is no published literature regarding the anthropometric predictors for the diameter of the peroneus longus tendon (PLT) graft obtained in ACL reconstruction through the inframalleolar approach. METHODS: Fifty-two patients were finally evaluated for anthropometric parameters to predict quadrupled PLT graft diameter in ACL reconstruction using the inframalleolar technique. Intraoperative quadrupled PLT graft diameter was correlated to the patient's anthropometric data such as age, height, weight, duration of injury, and BMI. We used regression analysis in a stepwise manner to ascertain anthropometric indices associated with the graft diameter. RESULTS: This study included 46 males and six females. Mean age was 28.2 ± 7.4 years, mean height was 172.7 ± 2.8 cm, mean weight was 75.6 ± 3.4 kg, mean BMI was 25.3 ± 0.9 kg/m2, mean duration of injury was 9.2 ± 3.9 months, and mean graft diameter was 9.3 ± 0.4 mm. Positive correlation with graft diameter was found only with height (r = 0.6, P < 0.01) and weight (r = 0.4, P < 0.01). On analysing through linear regression, height and weight had significant association with graft diameter, and we formulated the following prediction equation: PLT graft diameter (mm) = 0.083 × height (cm) + 0.011 × weight (kg) -5.854. CONCLUSION: Patients' characteristics, including height and weight, have a significant correlation with quadrupled PLT graft diameter and the average diameter of graft is > 9 mm through this approach.