Ultrasound-guided interventions in primary carpal tunnel syndrome: perineural injection to thread carpal tunnel release.

Carpal tunnel syndrome (CTS), the most common entrapment neuropathy, is compression of the median nerve deep to transverse carpal ligament at wrist. Ultrasonography and electrophysiological study are complementary in the diagnosis and grading of CTS in appropriate clinical settings. The initial management of patients with CTS is conservative with medical therapy and splinting. However, surgical interventions are indicated in patients in whom medical management has failed. With evolution of the concept of safe zone on ultrasonography and identification of the sonoanatomical landmarks of carpal tunnel in greater detail, Ultrasonography-guided interventions are safer and preferred over surgical management in CTS. The primary ultrasonography-guided interventions include perineural injection, perineural hydrodissection and ultrasonography-guided release of transverse carpal ligament. This review article presents the principles of ultrasonography-guided perineural injection, perineural hydrodissection in CTS, the merits and demerits of injectant used in perineural injection/ hydrodissection, and percutaneous ultrasonography-guided thread release of transverse carpal ligament utilizing the concept of safe zone of the ultrasonography-guided interventions for CTS.

Association between lateral femoral wall thickness and BMD with the occurrence of lateral wall fracture in DHS fixation.

BACKGROUND: Nearly 50% of all hip fractures are intertrochanteric fractures (ITF) and are linked to osteopenia and advancing age. For secure ITF repair, the dynamic hip screw (DHS) fixation is regarded gold standard surgery. However, controversy exists regarding the use of DHS in the treatment of unstable ITF especially in patients with pre-operative lateral femoral wall fracture (LWF). The purpose of this study is to find if there's a link between lateral femoral wall thickness, bone mineral density and the risk of LWF in DHS fixation. PATIENT AND METHODS: A prospective, observational cohort analysis of 70 consecutive patients with ITF was undertaken in a tertiary care government hospital. All patients were treated with a 135° DHS fixation under regional anaesthesia and fluoroscopic guidance. Lateral femoral wall thickness was assessed pre-operatively on radiographs and during surgery. Mean T score as a measure of bone mineral density was recorded in all patients. RESULT: Postoperative LWFs occurred in 11 individuals. In 11 patients who had a postoperative LWF, the mean lateral femoral wall thickness was 19.545 mm, while the remaining 54 patients had a mean lateral femoral wall thickness of 29.285 mm (P < 0.001) With 81.5% sensitivity, the lateral femoral wall thickness threshold that could predict LWF was determined to be less than 25 mm. The mean T score of the contralateral hip in LWF patients was -2.255 standard deviation, whereas it was -2.428 standard deviation in patients without LWF, the difference of which was statistically not significant. CONCLUSION: DHS fixation alone should be avoided in ITF patients with lateral femoral wall thickness <25 mm and other implant choices should be explored for management of these patients.

Is Revision Bankart Repair with Remplissage a Viable Option for Failed Bankart Repair in Non-contact Sports Person Aiming to Return to Sports?

PURPOSE: Failure of a well-executed Bankart repair in non-contact athletes is difficult to predict and its management is a lesser investigated area with uncertain outcome in terms of return to sports (RTS). This study analyses effectiveness of revision Bankart repair with remplissage for failed Bankart repair in non-contact athletes, focusing on time and level of RTS. MATERIALS AND METHODS: Fifty-five consecutive non-contact athletes with evidence of instability after primary arthroscopic Bankart repair having glenoid loss < 25% and off-track Hill-Sachs lesion were included in the study according to algorithm mentioned. All cases underwent revision arthroscopic Bankart repair with remplissage and followed-up for 24 months. Rowe, UCLA, WOSI and Quick-DASH scores were recorded preoperative and at 24 months. RTS was allowed after unilateral seated shot-put test. RESULTS: Out of 55 cases, 6 were excluded because of poor tissue quality, 7 were lost to follow-up. Forty-two cases with a mean age of 28.2 ± 5.2 years were included. Mean duration between primary surgery and failure was 7.3 ± 1.4 months with a mean 1.9 redislocations. The mean Rowe, WOSI, UCLA, Quick-DASH scores improved from 37 to 89, 39.3 to 83.7%, 18.4 to 30.5, 45.3 to 18.7 at 24 months. Thirty-five cases could RTS in a mean time 15.4 ± 1.4 months. Out of seven cases who could not RTS, four had instability, one had pain and two voluntarily quit sports. CONCLUSION: Revision Bankart repair with remplissage is a feasible option for failed primary Bankart repair in non-contact athletes who have glenoid bone loss < 25% with off-track Hill-Sachs. LEVEL OF EVIDENCE: Level IV.

Management Guidelines for Infection After ACL Reconstruction: Expert Opinion Statement Based on the Modified Delphi Survey of Indian Arthroscopy Surgeons.

AIM: Infection after anterior cruciate ligament (ACL) reconstruction, though rare, is a potentially devastating complication and the evidence-based recommendation on the various topics in its management is limited. The purpose of this study was to develop recommendations for the prevention and management of infections in ACL reconstruction surgery by performing a structured expert consensus survey using Delphi methodology. MATERIALS AND METHODS: 22 topics of relevance in the prevention and management of infection following ACL reconstruction were chosen from an extensive literature review. 30 panelists were requested to respond to a three-round survey, with feedback, to develop a consensus statement on the topics. RESULTS: Consensus statements could be prepared in eleven out of twenty-two topics including: the graft is retained at the first arthroscopic debridement, the graft is removed when repeated debridement are needed, and revision ACL reconstruction is needed only if the patient develops instability. Concurrence could be obtained in the topics including: longer duration of antibiotics is needed in immunocompromised patients, soaking graft in antibiotic solution reduces infection risk, and knee swelling without warmth does not suggest infection. CONCLUSIONS: A proper skin preparation, a longer course of antibiotics in immunocompromised patients, and soaking the graft in antibiotics reduces the risk of infection. In case of infection, a healthy-looking graft must be retained at the first debridement and if the graft must be removed, revision ACL reconstruction is advised only if the patient develops instability. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s43465-021-00363-z.

Postoperative clinical outcome between lateral retraction and eversion of patella following simultaneous bilateral total knee arthroplasty.

AIMS AND OBJECTIVE: Among the various exposure technique used in total knee arthroplasty (TKA); the midline medial parapatellar knee approach is most commonly performed; which require mobilisation of patella for adequate surgical exposure. In this study, we compare the effect of patellar eversion with lateral retraction in simultaneous bilateral TKA to find out difference in postoperative clinical outcome between the two patellar mobilisation techniques. METHODS: We enrolled 41 patients who underwent bilateral simultaneous TKR (82 knees) from Nov 2016 to Dec 2018. During surgery patellar eversion was done in one knee and lateral retraction was done in other knee selecting them randomly to reduce the bias. During the follow up period achieving unassisted active straight leg raise (SLR), 90 flexion and complications were recorded. Measurement of Oxford knee society score (OKSS), American knee society score (AKSS), Visual Analogue Scale (VAS) score, and quadriceps strength (measured by handheld dynamometer) was done daily up to one week, 1 month, 3 months, 6 months, and 1 year postoperatively. RESULTS: The time of achieving active SLR and 90∗ flexion postoperatively was quicker in the lateral retraction group with a statistically significant difference. VAS pain score at 1 week and 1 month along with quadriceps strength in 1-month had statistically significant favourable outcomes in the lateral retraction group. Throughout the follow up lateral retraction group had better Oxford and American knee score but the difference being statistically insignificant. No significant difference was found on the complication rate. CONCLUSION: In comparison to lateral retraction, patellar eversion has an adverse effect in early knee functional recovery after TKA; it delays achieving active SLR, 90∗ flexion and has unfavourable outcome in functional scores, quadriceps strength, and postoperative pain relief. However it has minimal effects on long term functional outcomes.

Decreased motion with normal strength after Latarjet procedure has minimal impact on return to activity.

PURPOSE: The Latarjet procedure can affect the range of motion (ROM) and strength of the shoulder, which determine the time to return to the preinjury level of activity. This study prospectively assessed whether the Latarjet procedure leads to a decrease in range of motion and muscle strength, affecting the time to return to the previous level of activity. METHODS: Fifty-one consecutive patients who underwent the Latarjet procedure for recurrent dislocation of the shoulder were included prospectively. The ROM, strength, Walch-Duplay score, and Rowe score were measured every 3 months for 1 year and then every 6 months for 2 years. Radiological assessments were performed to confirm the graft location, union, and the humeral head position in abduction and external rotation (ER). RESULTS: Out of 51 patients, 49 completed all follow-ups. The median age was 27 years (17-45 years), and the dominant side was involved in 36 patients. The median number of dislocations was 11 (5-50). Twelve patients were sleep dislocators. There was a significant loss (p < 0.0001) of abduction, forward flexion (FF), ER, and internal rotation (IR) in the affected shoulder compared to the contralateral shoulder. Recovery plateaued at 12 months. There was near complete recovery of muscle strength after the Latarjet procedure, and the difference between the affected and contralateral shoulders was not significant (n.s.). The modified Rowe score was excellent in 44 (90%) patients, and the Walch-Duplay score was excellent in 43 patients (88%) at 24 months. Suboptimal results were associated with non-compliance with rehabilitation in two (4%) patients and neglected unreduced dislocation in one (2%) patient. The coracoid graft position was below the equator in 44 patients (90%). Forty-six patients (94%) could return to the previous level of activity. CONCLUSION: The Latarjet procedure results in a restricted ROM of the shoulder, but there is no loss of muscle strength. LEVEL OF EVIDENCE: III.

Is in-vivo 80 N tensioned quadrupled hamstring graft better than conventional unmeasured pull for arthroscopic ACL reconstruction.

PURPOSE: To find clinical outcome of in-vivo standard 80 N tensioning of quadrupled hamstring graft during arthroscopic single bundle ACL reconstruction in comparison to traditional graft tensioning. METHODS: Sixty cases of isolated ACL tears were included in this study. All cases underwent Arthroscopic ACL reconstruction with Tibial attachment sparing quadrupled hamstring graft. Cases were divided into group I and group II (30 cases each). Graft Tensioning in group 1 was conventional one-handed unmeasured pull and in group II it was measured tension of 80 N with tensionometer during graft fixation. Pre-operative and post-operative (12 months) Anterior tibial translation (ATT) was measured with KT-1000 arthrometer. Clinical outcome was measured using Lysholm knee scoring system at 6weeks, 3months, 6months, 12 months and compared statistically among both groups. RESULTS: The mean pre-op ATT of 10.6 ± 2.04 mm (group I) & 10.83 ± 2 mm (group II) improved to 3.63 ± 1.16 mm (group I) & 3.63 ± 0.92 (group II) respectively at one year without significant difference (p value 1). The mean pre-op Lysholm score was 46.73 ± 6.77 (group I) and 45.97 ± 8.68 (group II). The mean Lysholm score at 6 weeks was 91.5 ± 2.78 (group I) and 93.43 ± 3.02 (group II) with significant difference (p value 0.014). At 3 months it was 95.4 ± 2.99 (group I) and 97.07 ± 2.07 (group II) with significant difference (p value 0.025). At 6 months it was 95.53 ± 2.46 (group I) and 97.5 ± 1.2 (group II) with significant difference (p value 0.0002). At 1 year it was 95.73 ± 2.22 (group I) and 97.8 ± 0.979 (group II) with significance (p value 0.0001). CONCLUSION: The clinical score of ACL reconstruction is better when in-vivo 80 N tension is applied using tensionometer during graft fixation in comparison to conventional manual tensioning but there is no difference in ATT.

Long term outcome of early single stage surgery in multi-ligamentous injuries of knee.

BACKGROUD: Multi-ligamentous knee injuries have been a grey area due to unavailability of large scale control trials with a long term follow up. Several studies have documented good results with different protocols of management regarding time of treatment, repair versus reconstruction, choice of graft and sequence of repair. The author wishes to put forward long-term results of early (<6 weeks) single-stage surgery in multi ligamentous injuries. METHODS: The prospective trial included 29 patients diagnosed with three or more ligaments involved. Patients having fractures involving proximal tibia, distal femur, patella, patients with history of compound trauma to knee, osteochondral lesions, associated neuro-vascular injury & poly-trauma patients were excluded from the study. The patients also underwent AP, lateral & stress skiagrams in addition to a standard 3T MR scan for pre-operative planning and confirmation of diagnosis. The pre & post-operative outcomes were assessed using KSS & Lysholm score. The patients were followed up for two years with clinical examination and stress skiagrams. RESULTS: The mean increase in knee scores was statistically significant at both 12 months and 24 months (p < 0.05) with mean ROM of 132.8° at final follow-up. Three patients required manipulation under anaesthesia. All patients could carry out their activities of daily living at mean period of 8.2 months. Osteoarthritis was most common complication at 2 years follow-up. CONCLUSION: The most important aspect of a single stage reconstruction lies in earlier restoration of function with a tremendous decrease in loss of medical expenses, improvement of quality of life and early & improved function in terms of both physical and psychological factors. Better restoration of kinematics from early rehabilitation is probably the factor responsible for the results. Osteoarthritis remains an important follow-up finding.

Effect of posterior condylar offset in post operative range of motion in cruciate retaining and sacrificing TKR: A comparative analysis.

BACKGROUND: Restoration of posterior condylar offset (PCO) during TKA is believed to be an important to improve knee kinematics, maximizing range of motion (ROM) and minimizing flexion instability. The aim of prospective study was to find out the role of PCO in post-operative ROM after cruciate retaining (CR) and cruciate sacrificing (CS) TKA. METHODS AND MATERIALS: A total of 90 patients were divided into the CR knee group (49) and CS knee Group (41) intra-operatively by the surgeon based on the status of Posterior Cruciate Ligament. Preoperative and postoperative PCO was evaluated on true lateral knee radiographs. The ROM was measured pre operatively and post operatively at 4 weeks, 8 weeks, 3 months, 1 year and 2 years. Appropriate statistical tests were used and results were interpreted. RESULTS: The mean flexion angle was 113.86° in CR knees and 118.29° in CS knees with a significantly greater improvement observed for the latter group. Preoperative mean PCO was 35.08 mm in CR knees and 36.37 mm in CS knees, while the corresponding values post operatively were 32.74 mm and 34.88 mm respectively, at follow-up. In order to evaluate the relationship between change of PCO and postoperative improvement in range of flexion, we divided the patients into three sub groups according to the difference in pre and post-operative PCO. The first sub group had a difference in PCO ≤ 1 mm after surgery (CR: 5 and CS: 8), second sub group with a difference in PCO 1-3 mm after surgery (CR: 28 and CS: 26) and the third subgroup with a difference in PCO >3 mm after surgery (CR: 16 and CS: 7). Then a comparison of difference in PCO and post-operative range of motion was done in both CR knees and CS knees separately. The final post-operative range of motion (flexion) in CR knees was 117.6°, 115.93° and 109.06° for the three subgroups respectively. Similarly, the final post-operative range of motion (flexion) in CS knees was 116.12°, 118.81° and 118.86° for the three subgroups respectively. Thus a significant difference between three sub groups was observed in CR knees (P < 0.0001), while no difference was observed in the PS knees. CONCLUSION: The postoperative decrease in posterior condylar offset by more than 3 mm decreases the post-operative ROM in CR TKA but not in CS TKA. So it is critical to preserve PCO in CR but perhaps not CS knees to ensure optimal ROM postoperatively.

Analysis of modified double-bundle anterior cruciate ligament reconstruction with implantless fixation on tibial side.

PURPOSE: To avoid potential problems of double-bundle anterior cruciate ligament reconstruction (ACLR), various modifications have been reported. This study analyzed a novel technique of modified double-bundle (MDB) ACLR without implant on tibial side in comparison to single-bundle (SB) ACLR. METHODS: Eighty cases of isolated anterior cruciate ligament tear (40 each in SB group or MDB group) were included. SB ACLR was performed by outside in technique with quadrupled hamstring graft fixed with interference screws. In MDB group, ACLR harvested tendons were looped over each other at the center and free ends whipstitched. Femoral tunnel was created by outside in technique. Anteromedial tibial tunnel was created with tibial guide at 55°. The anatomic posterolateral aiming guide (Smith-Nephew) was used to create posterolateral tunnel. With the help of shuttle sutures, the free end of gracillis was passed through posterolateral tunnel to femoral tunnel followed by semitendinosus graft through anteromedial tunnel to femoral tunnel. On tibial side the graft was looped over bone-bridge between external apertures of anteromedial and posterolateral tunnel. Graft was fixed with interference screw on femoral side in 10° knee flexion. International Knee Documentation Committee (IKDC), Tegner score, Pivot shift and knee laxity test (KLT, Karl-Storz) were recorded pre- and post-surgery. At one year magnetic resonance imaging (MRI) was done. Statistical analysis was done by SPSS software. RESULTS: Mean preoperative KLT reading of (10.00 ± 1.17) mm in MDB group improved to (4.10 ± 0.56) mm and in SB group it improved from (10.00 ± 0.91) mm to (4.80 ± 0.46) mm. The mean preoperative IKDC score in MDB group improved from (49.49 ± 8.00) to (92.5 ± 1.5) at one year and that in SB group improved from (52.5 ± 6.9) to (88.4 ± 2.6). At one-year 92.5% cases in MDB group achieved their preinjury Tegner activity level as compared to 60% in SB group. The improvement in IKDC, KLT and Tegner scale of MDB group was superior to SB group. MRI confirmed graft integrity at one year and clinically at 2 years. CONCLUSION: MDB ACLR has shown better outcome than SB ACLR. It is a simple technique that does not require fixation on tibial side and resultant graft is close to native ACL.

Anterior Cruciate Ligament Reconstruction with Tibial Attachment Preserving Hamstring Graft without Implant on Tibial Side.

BACKGROUND: Tibial attachment preserving hamstring graft could prevent potential problems of free graft in anterior cruciate ligament (ACL) reconstruction such as pull out before graft-tunnel healing or rupture before ligamentization. Different implants have been reportedly used for tibial side fixation with this technique. We investigated short-term outcome of ACL reconstruction (ACLR) with tibial attachment sparing hamstring graft without implant on the tibial side by outside in technique. MATERIALS AND METHODS: Seventy nine consecutive cases of ACL tear having age of 25.7 ± 6.8 years were included after Institutional Board Approval. All subjects were male. The mean time interval from injury to surgery was of 7.5 ± 6.4 months. Hamstring tendons were harvested with open tendon stripper leaving the tibial insertion intact. The free ends of the tendons were whip stitched, quadrupled, and whip stitched again over the insertion site of hamstring with fiber wire (Arthrex). Single bundle ACLR was done by outside in technique and the femoral tunnel was created with cannulated reamer. The graft was pulled up to the external aperture of femoral tunnel and fixed with interference screw (Arthrex). The scoring was done by Lysholm, Tegner, and KT 1000 by independent observers. All cases were followed up for 2 years. RESULTS: The mean length of quadrupled graft attached to tibia was 127.65 ± 7.5 mm, and the mean width was 7.52 ± 0.78 mm. The mean preoperative Lysholm score of 47.15 ± 9.6, improved to 96.8 ± 2.4 at 1 year. All cases except two returned to the previous level of activity after ACLR. There was no significant difference statistically between preinjury (5.89 ± 0.68) and postoperative (5.87 ± 0.67) Tegner score. The anterior tibial translation (ATT) (KT 1000) improved from 11.44 ± 1.93 mm to 3.59 ± 0.89 mm. The ATT of operated knee returned to nearly the similar value as of the opposite knee (3.47 ± 1.16 mm). The Pivot shift test was negative in all cases. None had a failure of graft till final followup. CONCLUSION: Attachment sparing hamstring graft without a tibial implant is a simple, cost-effective technique that provides a consistently satisfactory outcome.

Fate of coracoid grafts after the Latarjet procedure: will be analogous to the original glenoid by remodelling.

PURPOSE: To evaluate the location, magnitude, and change over time of osteolysis of coracoid grafts after Latarjet procedure. METHODS: This is a retrospective study of 54 patients (55 shoulders) who underwent the Latarjet procedure. Three-dimensional computed tomography (CT) scans were performed preoperatively, immediately postoperatively, and at follow-up (mean 7.7 and 31.7 months postoperative). "En face" views of the glenoid, size of glenoid defect and changes in the glenoid surface area postoperatively were measured relative to the area of an assumed outer-fitting circle. On the oblique sagittal planes, location and subsequent severity of osteolysis of the graft at follow-up were documented. RESULTS: The mean glenoid surface area increased significantly from 79.7 ± 4.8% of the original circle preoperatively to 111.3 ± 8.0% immediately postoperatively. At 7.7 and 31.7 months of follow-up, glenoid surface area decreased to 102.2 ± 6.0% and 100.3 ± 5.3%, respectively. Osteolysis occurred on the outer side of the graft in all cases, but did not occur on the inner side. Maximum osteolysis was observed in the superior third of the graft (78.5 ± 17.1%), followed by the middle third (15.8 ± 10.4%), and the inferior third (8.0 ± 5.1%). No significant difference in magnitude of osteolysis was observed between 7.7 and 31.7 months of follow-up. CONCLUSION: Osteolysis of the grafted coracoid mainly occurred on the outer side of the superior portion, resulting in reshaping of the rectangular shape of graft coracoids after Latarjet procedure. Coracoid graft remodelling was almost completed approximately 8 months postoperatively to reach the original glenoid dish with no further changes thereafter. These results may help surgeons to understand changes of grafts after the surgery. LEVEL OF EVIDENCE: IV.

Arthroscopic Fixation of Tibial Spine Avulsion in Skeletally Immature: The Technique.

INTRODUCTION: Tibial spine avulsion fracture is more frequent in children than adults. Various methods of fixation have been mentioned, but concern remains about crossing the tibial physis. We present a technique of arthroscopic fixation with non-absorbable suture. CASE REPORT: A total of 10 skeletally immature patients with tibial spine avulsion of Meyers and McKeever Type 2 and 3 were included in the study. The knee was arthroscopically cleared of hematoma. The avulsed tibial insertion of anterior cruciate ligament was reduced and held in place with tibial guide. By drilling guide wire through the tibia, reduced fragment, a fiber wire was passed. The avulsed fragment was tied on a suture post on tibia. Outcome was evaluated radiologically and clinically (Lysholm score, pivot shift, and KT 1000) at 12 months after surgery. All cases attained full range of motion, stable knee and could return to previous level of activity. The mean pre-operative Lysholm score of 50.8 ± 1.4 (35-59) improved to 96.3 ± 2.9 (92-100). The mean pre-operative anterior translation of tibia (measured by KT 1000) of 7.6 ± 1.26 improved significantly to mean of 3.3 ± 0.82 mm after surgery. CONCLUSION: The presented technique of arthroscopic fixation of avulsed tibial spine is a simple technique that provides reproducible results. It also offers cost-effective secure fixation.

Comparative study of multiple cancellous screws versus sliding hip screws in femoral neck fractures of young adults.

PURPOSE: Both cannulated cancellous screw (CCS) and sliding hip screw (SHS) are used in femoral neck fracture fixations, but which is superior is yet to be determined. This study was aimed to compare the clinicoradiological outcome of femoral neck fracture treated with SHS or CCS in young adults. METHODS: Adults (16e60 years) with femoral neck fracture were divided into Group 1 fixed with SHS and Group 2 fixed with three CCS after closed reduction. Pain relief, functional recovery and postoperative radiographs at 6 weeks, 3 months, 6 months and then yearly for upto 4 years were analyzed. RESULTS: Group 1 (n=40) achieved radiological union at mean of 7.6 months, with the union rate of 87.5% (n=35), avascular necrosis (AVN) rate of 7.5% (n=3) and mean Harris Hip Score (HHS) of 86.15 at the end of 4 years. In Group 2 (n=45) these parameters were union at 7.1 months, union rate of 82.22% (n=37), AVN rate of 6.67% (n=3) and HHS of 88.65. Comparative results were statistically insignificant. CONCLUSION: There is no significant difference in clinicoradiological outcome between the two implants.

Tubercular osteomyelitis of the first metatarsal bone as a cause of forefoot pain.

The reporting of isolated metatarsal tuberculosis in the available literature is sparse, herein we report a case of 26-year-old female who presented with insidious onset pain and swelling in her forefoot. Radiograph showed osteolysis of the first metatarsal. Magnetic resonance imaging showed osseous erosion with marrow oedema. Diagnosis was ascertained by fine needle aspiration cytology of the lesion. The patient received anti-tubercular therapy and showed good clinical outcome. This case is reported because of its rarity of involving isolated metatarsal bone as a cause of forefoot pain.

Contiguous multiple cervicothoracic spinous process fractures in an adult: A case report.

Fracture of isolated spinous processes at multiple levels is a rare injury. Herein, we present a 45-year-old male with cervical pain and swelling following a road traffic accident. Computerized tomography and magnetic resonance imaging revealed fractures of spinous process from C7 to D6 vertebra. The patient was managed with rest, analgesics and immobilization. At the 1-year follow-up, the patient is doing well without any neurological problem.

Trans-tibial guide wire placement for femoral tunnel in single bundle anterior cruciate ligament reconstruction.

BACKGROUND: Femoral tunnel location is of critical importance for successful outcome of ACL reconstruction. The aim was to study the femoral tunnel created by placing free hand guide wire through tibial tunnel, using the toggle of the guide wire in the tibial tunnel to improve femoral tunnel location. MATERIALS AND METHODS: 30 cases of a single bundle quadrupled hamstring graft anterior cruciate ligament reconstruction by trans-tibial free hand femoral tunnel creation is studied in this prospective study. The side to side play of the guide wire in the tibial tunnel was used to improve the tunnel location on femoral wall. The coronal angle of the femoral tunnel was measured on the anteroposterior radiograph. The femoral tunnel location on the lateral radiograph of the knee was recorded according to Amis method. Lysholm scoring was done preoperative and at each follow up. Assessment of laxity was done by Rolimeter (Aircast(™)) and pivot shift test. RESULTS: The mean coronal angle of the femoral tunnel in postoperative radiograph was 47°. In lateral radiograph, the femoral tunnel was found to be >60% posterior on Blumensaat line in 67% cases (n = 20) and in the 33% cases (n = 10) it was anterior. The mean Lysholm score improved from 74.6 preoperative to 93.17 postoperative with no objective evidence of laxity. CONCLUSION: The free hand trans-tibial creation of the femoral tunnel leads to satisfactory coronal obliquity, but it is difficult to recreate anatomic femoral tunnel by this method as the tunnel is consistently anterior in the sagittal plane.

Osteochondroma of Upper Dorsal Spine Causing Spastic Paraparesis in Hereditary Multiple Exostosis: A Case Report.

Osteochondroma of the spine is rare. It may present in solitary or multiple form (hereditary multiple exostoses). Herein, we report a case of an 18-year-old male who was diagnosed with thoracic osteochondroma, originating from the D4 vertebra with intraspinal extension and spinal cord compression in hereditary multiple exostosis. The patient was managed with surgery. Complete tumour excision was done to relieve cord compression and recurrence. Postoperatively the patient's symptoms were improved. At 2.5 year follow-up patient is doing well without any recurrence.

Triple modified French osteotomy: a possible answer to cubitus varus deformity. A technical note.

BACKGROUND: Cubitus varus is the most common delayed complication of pediatric supracondylar humerus fractures. We developed a new technique, the triple modified French osteotomy, that we believe may be the answer to this common but yet unsolved deformity. MATERIALS AND METHODS: Ten patients aged between 6 and 12 years with post-traumatic cubitus varus deformity were operated on with the triple modified French technique. A varus angle of more than 10° measured on the radiograph was an indication for surgery. RESULTS: The radiologic union at the osteotomy site took place in a mean period of 5.5 weeks (range, 4.5-7 weeks). The average correction achieved by the osteotomy was 27°. There were no cases with complications of radial or ulnar nerve palsy or joint stiffness. CONCLUSION: The triple modified lateral closing wedge French osteotomy is a simple and cosmetically effective method of treating cubitus varus deformity in children. It may obviate the need for more complex procedures; at the same time, it also addresses the potential drawbacks of a simple closing wedge osteotomy.

Creation of femoral tunnel by outside-in technique for ACL reconstruction: an analysis.

PURPOSE: To study the outcome of ACL reconstruction by retrograde outside-in (OI) creation of femoral tunnel. METHODS: ACL reconstruction was done in 41 cases by OI technique. The tip of 115° femoral guide was placed at posterior aspect of femoral foot print of ACL. Reaming was done from outside-in over guide pin. The length of femoral tunnel was obtained by measuring guide pin. The location of intra-articular femoral tunnel aperture and graft was recorded. Tibial tunnel was created with 50° guide placed at tibial foot print of ACL. Post-operative digital radiograph was taken. Antero-posterior view was used to calculate coronal inclination of femoral tunnel. On lateral view femoral tunnel location was marked in relation to the intersection of Blumensaat line and posterior femoral cortical line. Lysholm scoring and pivot shift test were performed at follow-up. Objective measurement of anterior tibial translation was done by rolimeter (aircast) at 1 year. RESULTS: The mean femoral tunnel length recorded was 39.5 mm (±3.4). There was no incidence of femoral tunnel blow out or graft impingement. All cases had femoral tunnel aperture location posterior to posterior femoral cortical line and inferior to Blumensaat line. The mean coronal angle of femoral tunnel was 30.39° (±4.6). The mean preoperative Lysholm score of 53.5 (±13) increased to 95.2 (±3.5) 1 year after surgery. All the patients had full range of motion. The pivot shift test was negative and instrumented measurement of anterior translation of tibia was near normal in all cases. CONCLUSION: OI technique of ACL reconstruction is a simple reproducible technique. The unconstrained placement and angling of femoral guide result in a femoral tunnel which is through footprint of ACL. The graft is placed very low, oblique and as posterior as possible on femoral side mimicking the native ACL. LEVEL OF EVIDENCE: III.