Prevalence and Associations of Depression in Parents of Children With Congenital Talipes Equinovarus: A Single-Centre Study.

INTRODUCTION: Congenital talipes equinovarus (CTEV) is a congenital deformity that requires weekly visits to the hospital for manipulation and corrective cast application, followed by an intensive bracing regimen requiring multiple visits to the hospital spread over the years. Parents of children with clubfoot are known to undergo a range of negative emotions. The objective of this study was to identify the prevalence of depression and the factors associated with depression in parents of children with idiopathic CTEV. METHODS: This cross-sectional study consecutively enrolled 190 parents of children with idiopathic CTEV undergoing treatment at King George Medical University. Parents with conditions that preclude the assessment of mental status were not included. These conditions include a history of head injury or psychiatric illness, parents with ongoing treatment of psychiatric illness, ongoing chronic illness, chronic neurological disease, and parents with clinically established intellectual disability. Information was recorded on certain parent-related characteristics and certain child-related characteristics. Parent-related information included age and sex of the parent, religion, area of residence, number of children in the family, degree of perceived social support (using the Multidimensional Scale of Perceived Social Support, MSPSS), level of education, socio-economic status, depression subscale score of DASS 21 (Depression, Depression Anxiety, and Stress Scale -21), chronic pain (visual analogue scale, VAS), family history of clubfoot or depression, and level of stress caused by a major life event during the past year using the Presumptive Stressful Life Event Scale (PSLES). Child-related information included the sex of the child, phase of treatment (casting or bracing), limb involvement (unilateral or bilateral), relapse of the deformity, and Pirani score of the deformity. Bivariate analysis and logistic regression were used to identify factors associated with a score ≥10 on the depression subscale of DASS 21. RESULTS: One hundred forty-five subjects were males (76.3%). The mean age of the enrolled parents was 28.47±4.89 years. The mean score on the depression subscale of DASS-21 was 4.87±6.3. Thirty-two parents (16.8%) had a score of ≥10 on the depression subscale of the DASS-21. On bivariate analysis, female sex, being Hindu, having studied up to class 12th, relapse, MSPSS score, and PSLES score were found to be associated with a score ≥10 on the depression subscale of the DASS-21. On logistic regression, female sex, lack of graduate education and above, and MSPSS scores were found to be significantly associated with a score of ≥10 on the depression subscale of the DASS 21 score. CONCLUSION: The prevalence of depression in parents of children with idiopathic clubfoot was 16.8%. Female gender, lack of college education, and the level of perceived social support (MSPSS) are independently associated with a score ≥10 on the depression subscale of DASS 21. We recommend screening parents of children with clubfoot and referring those with abnormal scores to a psychiatrist for a confirmed diagnosis.

Assessing the Radiological and Functional Outcomes of Colles' Cast Versus Functional Position Cast Immobilization in the Conservative Treatment of Distal End of Radius Fractures.

INTRODUCTION: The distal end radius fracture represents a prevalent orthopedic condition that affects individuals across various age groups, commonly resulting from falls onto outstretched hands. Ongoing research endeavors have delved into diverse methodologies for addressing this condition, encompassing conservative and operative modalities, yielding variable outcomes. While the literature extensively delineates numerous mobilization approaches, such as the functional position cast and Colle's cast, scant comparative studies evaluate these immobilization forms. Consequently, our study sought to holistically appraise and compare the radiological and functional outcomes associated with Colles' cast and functional position cast immobilization in managing distal end radius fractures. METHOD: This retrospective study was conducted at a tertiary trauma center over two years, from October 2018 to September 2020. Data was collected from medical records with prior approval from the institutional ethics committee. The study included 64 patients, all above the age of 40, who suffered from distal end radius fractures and received conservative management. Patients with bilateral distal end radius fractures, associated ipsilateral limb injury, open or comminuted fractures, or inadequate medical records were excluded. The patients were divided into two groups based on the type of cast immobilization: group I comprised 30 patients managed with Colles' cast immobilization (volar-flexion and ulnar deviation position). In contrast, group II consisted of 34 patients with functional position cast immobilization (immobilization with dorsiflexion). The clinical (including pain, thumb swelling, finger swelling, finger stiffness, shoulder stiffness, and tenderness), radiological (including radial deviation, radial height, and volar tilt), and functional (range of motion (ROM), and disability of arm, shoulder, and hand (DASH)) outcomes were evaluated at 6, 12, and 24 weeks. The data analysis was conducted using the IBM SPSS Statistics for Windows, Version 25 (Released 2017; IBM Corp., Armonk, New York, United States). The chi-square test, independent samples t-test, and paired t-test were employed to analyze and compare radiological and functional outcomes between the two groups. A p-value of less than 0.05 indicated a statistically significant association. RESULTS: The radiological parameters, including volar tilt, radial inclination, and radial shortening, were derived from the medical records at various points: pre-reduction, post-reduction, 6-week follow-up, 12-week follow-up, and 24-week follow-up. Upon assessing these parameters, no statistically significant variance was observed between the two groups at specified time points. Comparison of the ROM between the two groups unveiled noteworthy results, indicating superior outcomes in the functional cast group at 6 and 12 weeks as opposed to the Colles' cast group. Grip strength assessment at the 24-week follow-up demonstrated statistically significant differences, with the functional cast group displaying enhanced grip strength. CONCLUSION:  Our study revealed comparable radiological parameters between the two cohorts, yet it demonstrated a notable enhancement in both the ROM and functional outcomes in those subjected to functional cast positioning. These findings underscore the potential advantages of functional immobilization in bolstering patient rehabilitation.

Assessment of Functional Outcome and Postoperative Complications in Proximal Humerus Fracture Patients Managed With Proximal Humerus Internal Locking System (PHILOS) Plating.

BACKGROUND: Proximal humerus fractures are primarily common in the old age group. The appropriate approach to managing such displaced and comminuted fracture patterns is often questionable. Hence, this study was conducted to assess the functional outcome of proximal humerus fractures following treatment with a proximal humerus locking plate and to assess the frequency of complications in such patients. METHODOLOGY: In this robust study, 33 cases of proximal humerus fractures underwent surgical management at a prestigious teaching hospital from February 2021 to August 2022 utilizing a proximal humerus internal locking system (PHILOS) plate. The NEER classification was employed to categorize the fractures, and the NEER score was used for functional assessment. It's crucial to note that individuals with pathological fractures, associated injuries in the ipsilateral limb, nerve injuries, and cases of open fracture were rigorously excluded from the study. RESULTS: The mean age was 47 ± 5.2 years. Based on NEER's classification, the distribution of fractures was as follows: two-part fractures accounted for 18.18% (n = 6) of cases, three-part fractures for 54.54% (n = 18) of cases, and four-part fractures for 27.27% (n = 9) of cases. A history of road traffic accidents and falls was reported in 54.54% (n = 18) and 45.45% (n = 15) of cases, respectively. Functional outcome assessment utilizing NEER's score revealed a minimum score of 48 and a maximum of 96, with an average score of 82.96 ± 12.73. Notably, 39% of patients demonstrated excellent results, 27% exhibited satisfactorily, 21% manifested unsatisfactorily, and 12.12% presented failure outcomes. Of the 33 operated cases, 81.8% (n = 27) exhibited no complications during follow-up. The predominant complication observed was shoulder stiffness (9.09%, n = 3), followed by Varus mal-union (6.06%, n = 2), and superficial surgical site infection (3.03%, n = 1), managed with debridement and antibiotics leading to subsequent resolution. CONCLUSIONS: Managing proximal humerus fractures has consistently posed a formidable challenge. Our study indicates that using the PHILOS plate represents a reliable option for addressing such fractures. This plate provides sturdy fixation, facilitates early mobilization, and culminates in exceptional functional outcomes. The insights gained from this study can inform clinical decision-making and guide orthopedic surgeons in selecting the appropriate treatment strategy for proximal humerus fracture patients.

Bilateral Van Neck-Odelberg Disease: A Case Report.

Van Neck-Odelberg disease, also known as ischiopubic osteochondritis, is a rare cause of buttock or groin pain in the pediatric age group. The challenge in its diagnosis is due to its radiologic similarity. Ischiopubic synchondrosis occurs in childhood and is seen before the fusion of the pubis and ischium. With the advancement of age toward skeletal maturity, ischiopubic synchondrosis reduces in size and gradually vanishes due to synostosis or bony union. Here, we report the case of a 13-year-old girl who came to our outpatient department with complaints of bilateral groin pain for one year. After a thorough evaluation, she was diagnosed with a case of bilateral Van Neck-Odelberg disease, or ischiopubic osteochondritis, and conservative management was planned. Closure of ischiopubic synchondrosis varies with age and is usually finished before puberty. In a typical scenario, such fusion of the pubis and ischium does not lead to any clinical symptoms. However, in a few instances, children may experience some pain in the groin, hip, or gluteal region, which results in restricted movements at the hip joint and can lead to limping while walking. Van Neck-Odelberg disease is rare in children, causing pain in the groin region. As it is a rare condition, diagnosis is often missed. The radiological appearance suggests many differential diagnoses, such as a stress fracture, neoplasm, or infection. Prompt diagnosis and treatment can relieve the symptoms.

The Effect of Vitamin D Deficiency as a Risk Factor of Early Fragmentation in Legg-Calve-Perthes Disease: A Prospective Study.

INTRODUCTION: Legg-Calve-Perthes disease (LCPD) is a disorder involving the hips in young children of preschool and school-going age groups, more common in 4-8 years. The insufficient blood supply to the femoral head is the main reason behind various etiologic theories. Multiple factors affect the natural progression of the disease. The natural progression of the disease involves early avascular necrosis, fragmentation, reconstitution, and healed stages. In the fragmentation stage, the bony epiphysis begins to fragment, and the subchondral radiolucent zone (crescent sign) is the result of a subchondral stress fracture, which later on determines the extent of a necrotic fragment of the femoral head. These changes later contribute to changes in the shape of the femur head and the extent of deformity. As vitamin D plays a vital role in the onset of the fragmentation stage, we conducted a study to assess the effect of vitamin D deficiency as a risk factor for early fragmentation in Legg-Calve-Perthes disease. METHODS: In our study, 50 patients aged 4-12 years were examined over three years and classified according to Catterall and Herring's lateral pillar classification; the length of the fragmentation stage and the vitamin D level were considered. A vitamin D level of less than 20 ng/mL was labeled as the deficient group, 20-30 ng/mL as the insufficient group, and more than 30 ng/mL as the sufficient (normal) group. RESULTS: The critical fragmentation stage was significantly longer (more than 12 months) in vitamin D deficiency (34%), leading to a higher risk of deformity and extrusion of the femoral head, which led to higher rates of surgical intervention and containment procedures. CONCLUSION: The fragmentation stage is critical in the course of LCPD. Vitamin D levels play a vital role in predicting the prognostic of LCPD, and it should be measured in all patients of LCPD. Patients with normal vitamin D levels have a comparatively shorter fragmentation stage duration than patients with insufficient or deficient levels, leading to a lesser duration of femoral head damage.

A Rare Case of Fungal Osteomyelitis of the Distal Tibia in a Pediatric Patient.

Staphylococcus aureus infection is the most common cause of osteomyelitis. Over 100,000 fungal species have been described; only 150 are pathogenic to humans. These opportunistic infections frequently enter the body due to a decrease in host defense or through an invasive gateway, such as a dental extraction or skin discontinuity due to trauma. Symptoms and radiological examination often mimic those of other etiologies, which can lead to substantial delays in treatment. Our case is a 13-year-old healthy boy with no history of immune incompetency who presented to us with complaints of pain and swelling over his left ankle and leg with an on-and-off history of fever for 15 days. Based on his history and examination, he is diagnosed as having sub-acute osteomyelitis of the distal tibia with septic arthritis. The bacterial culture has no growth; however, the potassium hydroxide mount came positive for fungal elements having hyphae and pseudohyphae, and the fungal culture came positive for Candida. Management of fungal infections is challenging as they have infrequent involvement in bones. Fungal osteomyelitis is considered a rare entity in the literature, and the current case is studied for the management and diagnosis of a rare variant of osteomyelitis in the pediatric population. The treatment guidelines vary based on the identified organism and the duration of treatment. Debridement of fungal osteomyelitis or septic arthritis includes removing sinus tracts, evaluation for squamous cell carcinoma, bony and soft-tissue debridement, and antibiotic or antifungal bead placement. The spectrum of osteomyelitis ranges from Staphylococcus aureus organisms to tumors; therefore, it is necessary to investigate every spectrum of the disease, and fungal infections should be considered differential even though they are a rare entity. Early diagnosis, surgical debridement, and proper antifungal treatment based on fungal species lead to better clinical outcomes and results.

Effect of Coronavirus Disease 2019 Pandemic on Spinal Surgery Patients: Our Experience at a Tertiary Care Center.

Introduction: In December 2019, a cluster of atypical cases of pneumonia was reported in Wuhan, China, which was later designated as Coronavirus disease 2019 (COVID-19) by the World Health Organization (WHO) on Feb 11, 2020. We all are facing a global pandemic, and it is very important to be clear that there is no correct roadmap to navigate this difficult situation. It is imperative to state that this global pandemic impacted the spine care services of our institute. In the present study, we have assessed the spine surgeries performed by orthopedic surgeons in terms of volume and etiologies during the COVID-19 pandemic and compared the data with a pre-COVID period. Materials and Methods: We retrospectively collected data from all patients who underwent spinal surgeries at our institute under the department of orthopedics from August 20, 2019 to August 20, 2020 (a total of 12 months duration). The data was then divided into two groups-pre-COVID period (August 20, 2019-February 19, 2020-6 months) and during the COVID pandemic (February 20, 2020-August 20, 2021-6 months). Results: A total of 140 patients underwent surgery at our institute from August 20, 2019 to August 20, 2020. Of these, 91 patients underwent surgery during the pre-COVID period, and 49 patients underwent surgery during the COVID pandemic. In this devastating phase of the pandemic, our department's total number of surgeries significantly declined to 46.15%. The routine surgeries performed during the pandemic phase show a steep fall from 59.34% in the pre-COVID period to 10.20%. Conclusion: This paper is meant to focus attention on the exorbitant reduction in the operative workflow of the spine patients during the COVID-19 pandemic at a tertiary healthcare institute. It is the need of the hour that orthopedic surgeons maintain equilibrium while providing the best possible treatment to their patients and limiting the spread of the COVID-19 pandemic.

A Rare Case of Large Osteochondral Fracture of Patella.

Osteochondral fractures of the patella are relatively common pediatric knee injuries, often missed during the initial evaluation, and almost always associated with acute patella dislocations. We report the case of an adolescent patient with a very large osteochondral fracture of the patella involving almost the whole of the medial patellar facet and without concomitant dislocation of the patella. A 16-year-old adolescent presented to the emergency with pain and swelling in the left knee after sustaining a road traffic accident. On evaluation with an X-ray and a CT scan, a large osteochondral fracture of the patella was diagnosed. The fracture was treated with open reduction and internal fixation with headless compression screws after performing medial parapatellar arthrotomy. After two years, the patient recovered with a full and painless range of movement of the knee, with the complete radiological union of the fracture. This case report discusses a rare case of an adolescent with a large osteochondral fracture of the patella without concomitant patella dislocation.

Lumbar Pedicle Morphometry of Dry Vertebral Columns in Relation to Transpedicular Fixation: A Cross-Sectional Study From Central India.

INTRODUCTION:  The lumbar vertebrae are the largest vertebrae of the vertebral column, which support the maximum body weight. There has been an increased focus on transpedicular spinal fixation for addressing various lumbar spine pathology. However, its safety and efficacy require precise knowledge of the lumbar pedicle anatomy. Mismatched size of screw and pedicle may lead to failure of instrumentation. It may result in cortex perforation or pedicle fracture and loosening of the pedicle screw. The oversizing of the pedicle screw can result in dural tears, leakage of the cerebrospinal fluid, and injuries to the nerve root. As the racial variations in the anatomy of a pedicle are well known, this study was performed to assess the morphological parameters of the lumbar vertebrae pedicles in the Central Indian population so that the appropriate sizes of pedicular implants can be selected. MATERIAL AND METHODS: The present study was conducted at a tertiary-level hospital and medical college on dry lumbar vertebrae specimens available in the department of anatomy. The measurement of morphometric parameters of the lumbar vertebrae pedicles was performed in 20 dry lumbar specimens using vernier calipers and a standard goniometer. The morphometric parameters included in the study are pedicle transverse external diameter (pedicle width), pedicle sagittal external diameter (pedicle height), transverse angle of the pedicle, and sagittal angle of the pedicle. Statistical analysis was performed using Statistical Package for the Social Sciences (SPSS) system version 25 (Chicago, IL: SPSS Inc.). RESULTS:  The broadest external transverse diameter was at the L5 level, with a mean of (17.54±1.6 mm) in the lumbar vertebrae. The broadest external sagittal pedicle diameter was at the L1 level (13.7±0.88 mm). The maximum transverse angle of the pedicle was at L5 with a mean of 25.39±3.10°. The maximum sagittal angle was at L1 with a mean of 5.44±0.71°. CONCLUSION:  The increased concern regarding the internal fixation of the spine with pedicle screw systems created the need to have almost accurate anatomical knowledge of lumbar pedicles. Due to the dynamic nature of the lumbar spine and the body's load, maximum degeneration occurs at this spine segment, making it the most commonly operated region of the vertebral column. In our study, pedicle dimensions are comparable to populations of other Asian countries. However, the pedicle dimension of our population is lower than the White American population. This morphological variation of pedicle anatomy will help surgeons choose appropriate size screws and optimum angulations to insert the implant, decreasing complications.

Intraoperative Surgical Wound Contamination May Not Lead to Surgical-Site Infection in Patients Undergoing Clean Orthopaedic Procedures.

Objectives Surgical-site infections (SSIs) can complicate virtually any surgical procedure. While SSI can result from numerous causes, contamination of the surgical field can also contribute to it. Intraoperative bacterial contamination during clean orthopaedic procedures can be detected using perioperative cultures. We hypothesized that perioperative cultures could be used to predict possibility of development of SSI in patients undergoing clean orthopaedic surgeries. Materials and Methods We conducted a prospective cohort study at a tertiary care hospital over a 2-year period. Intraoperative surgical wound lavage fluid and closed suction drain tip obtained in the postoperative period were sent for aerobic culture. All patients were followed up to look for the development of SSI for a period of at least 30 days for those undergoing nonimplant surgery, and 90 days for those with implant surgery. Statistical Analysis Means with standard deviation of the continuous data were calculated. Fisher's exact test and chi-square test were used for the analysis of the categorical variables. Relative risk and odds ratio were calculated to evaluate the association of the parameters under study with SSI. Results A total of 384 patients satisfying the inclusion and exclusion criteria were included. Perioperative cultures detected surgical wound contamination in 39 patients (10.1%). Forty-five patients (11.7%) developed SSI during the follow-up period. Skin commensals constituted 59% of perioperative contaminants and accounted for 20% of the SSIs. The relative risk of developing SSI with perioperative contamination was 0.41 (95% confidence interval: 0.09-1.63). Conclusion Intraoperative surgical-site contaminants could be detected using perioperative cultures. However, these contaminants did not lead to SSI. Timely treatment of perioperative contamination with appropriate antibiotics and local wound care probably helped in the reduction of SSI.

Femoral Neck Nonunion Associated With Delayed Union of Ipsilateral Femoral Shaft Fracture.

We report the case of a 36-year-old man, who presented to us five months after the initial trauma. He had been treated elsewhere with a cephalomedullary femoral nail. He described severe pain in his right thigh and groin that confined him to a wheelchair. He had shortening of the right lower limb and painful restriction of movements of the right hip. Radiographs demonstrated hypertrophic callus with a gap at the femoral shaft while the neck fracture was in varus malalignment with bone resorption; the neck fracture been fixed using two hip screws that were missing the nail. The patient was managed with removal of the previous hardware, reamed retrograde nailing and Pauwels' intertrochanteric valgus osteotomy fixed using a 120o double-angled condylar blade plate. Both the fracture sites were not opened. Postoperatively, the femoral shaft showed radiographic evidence of union at three months, while the femoral neck and the intertrochanteric osteotomy site had united at five months. As per the Friedman and Wyman criteria, our patient has a "good" outcome at the four-year follow-up.

Diagnosis of Sanfilippo disease correlating clinical, radiological and biochemical findings-a case report.

Mucopolysaccharidoses (MPS) are a group of genetic diseases and its diagnosis is a challenging task due to multiple differential diagnosis. We had combined clinical findings, radiological and ophthalmological features. Biochemical test for urine glycosaminoglycans (GAG) was done for confirmation of diagnosis in the patient. The case of Sanfilippo disease was characterized by slowly progressive, severe CNS involvement with mild somatic disease. Radiological features were suggestive of Sanfilippo disease and urine GAG test for MPS was positive in the case. With the clinical features we had multiple differential diagnoses. The radiological investigations minimized the list and the biochemical test confirmed GAG in urine. In this case the combination of clinical, radiological and biochemical findings confirmed the diagnosis of Sanfilippo disease.