Prevalence and factors associated with psychological morbidity, phantom limb Pain in lower limb amputees.

BACKGROUND: Lower limb amputation can lead to psychological problems.There is a lack of data to evaluate the psychological problems and associated factors in lower limb amputees. AIM: Prevalence and factors associated with psychological disorder and phantom limb pain in lower limb amputees METHODS: It was a cross-sectional study with a consecutive sampling technique. Patients were assessed on the Hospital Anxiety and Depression Scale (HADS) for the presence of depression and anxiety disorder. DSM-5 diagnostic criteria for substance use disorder were used, andphantom limb pain was diagnosed as defined by Pare. RESULTS: 103 patients were included in the present study with a mean age of37.7 ± 14.5 yrs. The majorityof patients were males (87.4 %), married (69.9 %), on paid employment (95.1 %), and were of middle socioeconomic status (83.5 %). Most of the patients presented with roadside accident injuries (83.5 %)and had below-knee amputation (58.3 %). As per DSM-5, 38.8 % had a substance use disorder, out of which 35.9 % and 24.3 % had alcohol and tobacco use disorders, respectively. On HADS, 48.5 % had a presence of depressive disorder, and 30.1 % had anxiety disorder. The majority of patients (97.1 %) had phantom limb pain. Those from rural areas reported significantly more frequency of anxiety (x2-5.501; p-0.019) and depressive disorder (x2-7.009; p-0.008). Lower incomehad a significant positive association with depression (r-0.228; p-0.021) and phantom limb pain (U-22.500; p-0.008). CONCLUSION: The prevalence of psychiatric morbidity in lower-limb amputeeswas very high. The most common psychological morbidity was depression,followed by anxiety disorder and substance use disorders.Our findings reflect that we would benefit by including mental health professionals asintegral members of the multidisciplinary team to do an early psychological assessment and intervention, which would help prevent psychological illnesses and improve quality of life.

Non-vascularised fibula as an adjuvant in the management of diaphyseal humerus non-union- A meta-analysis and systematic review.

Introduction: There is no standard protocol for managing non-union of diaphyseal humerus bone, with several authors reporting their results using various techniques and methods for its management. No meta-analysis has reported the results of managing these cases with non-vascularized fibula grafting as an adjuvant for osteosynthesis. Materials and methods: This meta-analysis was performed to estimate the pooled data for calculating the union rates in diaphyseal humerus fractures managed with non-vascularized fibula grafting. Risk of Bias was computed using the Joanna Briggs Institute appraisal tool. Results: A total of 5 studies, comprising 102 patients, were included. The pooled estimate demonstrated that 94 patients achieved bone union with intramedullary fibular strut grafting. The pooled union rate (per 100 events) was 90.59 (95 % CI, 82.86-95.04, I2 = 0). The present meta-analysis also showed a significant improvement in DASH scores following the use of a non-vascularized fibula graft with a common effects model (SMD = 4.08; 95%CI: 3.44; 4.72; p < 0.01 I2 = 19 %, p-value for Q test = 0.29). Conclusion: Non-vascularized fibula grafting is an excellent adjuvant for the internal fixation of non-union diaphyseal humerus fractures. Although there is limited literature, further studies should highlight and assess the treatment of these uncommon but disabling conditions.

Outcome of Complex Coronal Shear Fractures of the Distal Humerus (Dubberley Type 3) Managed by the Transolecranon Approach.

Introduction: Complex distal humerus coronal shear fractures are rare injuries. These fractures involve small articular fragments and are challenging to fix. Design: Aprospective case series of 10 patients was done at a level 1 trauma centre between February 2017 and July 2021. Dubberley type 3 fractures were included in the study. Intervention: All patients underwent ORIF using posterior approach with olecranon osteotomy by a single surgeon. Patients were followed up for a minimum of 12 months postoperatively. Outcome Measures: The primary outcome measures were radiographic union and functional status of the limb (DASH score and MEPI score). Results: All patients achieved radiographic union of fracture as well as the osteotomy. The mean DASH score as measured on the final follow-up was 12.6 ± 10.2 and the mean MEPI score was 90 ± 8.2. None of the cases needed reoperation. Conclusion: Consistently good functional outcomes can be obtained in complex coronal shear fractures by posterior approach with olecranon osteotomy. Dubberley type 3b patients should undergo additional plate fixation.

Corrective Osteotomy and Ligamentous Reconstruction in a Neglected Elbow Dislocation with Radial Neck Malunion: A Case Report.

CASE: Neglected elbow dislocation and radial neck malunion frequently result in chronic pain, instability, and early arthrosis. These complications are best prevented by early treatment with open reduction, corrective osteotomy, and ligament reconstruction, followed by early supervised physiotherapy. We present a peculiar case with neglected complex elbow dislocation and radial head malunion. In this case, we performed an open reduction of the elbow joint and radial neck corrective osteotomy, medial collateral ligament, annular ligament reconstruction, and lateral collateral ligament repair. CONCLUSION: Neglected complex elbow dislocations require reconstruction of both ligamentous and osseous structures to achieve a good functional outcome.

Osteonecrosis in patients with inflammatory bowel disease: a systematic review and meta-analysis.

BACKGROUND: The relationship of inflammatory bowel disease (IBD) with osteonecrosis or avascular necrosis (AVN) is uncertain. METHODS: Systematic review to estimate the frequency of osteonecrosis in IBD was performed. Electronic databases were searched on 12 December 2022 to identify relevant studies. We planned to estimate the pooled prevalence of AVN in IBD, the risk in IBD when compared to the healthy population (without any chronic disease), and the impact of steroid use on osteonecrosis (IBD with and without steroid use). The risk of Bias was assessed with the Joanna Briggs Institute appraisal tool. RESULTS: Fifteen studies including 105 154 individuals were included. The pooled rate AVN was 10.39 per 1000 patients (95% confidence interval, 4.44-24.11, I 2  = 97%). Subgroup analysis suggested that the prevalence was lower in larger studies (>1000 participants) at 3.10, 1.07; 8.98, I 2  = 98% versus 21.03, 8.69; 50.01, I 2  = 83%. The use of steroids did not seem to increase the risk of osteonecrosis in the included studies (pooled odds ratio: 1.88, 0.55-6.41, I 2  = 39%). The systematic review was limited by the absence of comparison with the control population free of chronic disease. CONCLUSION: IBD may be associated with a risk of osteonecrosis. Future studies should assess the risk in comparison to the healthy population and the impact of disease activity and IBD therapies on the risk.

Longitudinal Experience and Determinants for Common Mental Health Problems, Phantom Limb and Functional Outcome in Lower Limb Amputees.

Background: Amputation of a limb is equivalent to loss of a person's life. Psychological aspects are essential factors in dealing with the disability and functional outcome is a significant concern. Longitudinal studies have not examined the experience and determinants of common mental health problems and functional outcome in lower limb amputees. Materials and Methodology: A total of 103 lower limb amputees were recruited and followed up for 6  months. Patients were assessed on Hospital Anxiety and Depression Scale (HADS) and Social Functioning (SF-36) Quality of life, semi-structured clinical interview for psychiatric disorders and phantom limb at baseline (in hospital), at 2 weeks, 3 months and 6 months, respectively after discharge. Holistic care was provided through psychological counselling, supportive sessions, medications if required, rehabilitation counselling, prosthesis implantation, and treatment as usual. Results: Holistic care resulted in a statistically significant reduction in anxiety, depression and overall psychiatric morbidity as measured on HADS (p < 0.001). There was a significant improvement in all the domains of SF-36 (p -< 0.001) except the role of limitation due to physical activity. The intervention also resulted in a statistically significant reduction in the presence of phantom limbs. Conclusion: Amputees should be provided holistic care under one roof, which was found to be very useful in treating psychiatric morbidity, social functioning and quality of life.

Outcomes of plate osteosynthesis for displaced 3-part and 4-part proximal humerus fractures with deltopectoral vs. deltoid split approach.

PURPOSE: Three part and four-part fractures of the proximal humerus offer challenges in reduction and plate fixation, with considerable debate about use of Deltoid splitting (DS) and Delto-pectoral (DP) approaches, especially when they involving the greater tuberosity. We prospectively compared the results using DS approach and DP approach in these cases, with special focus on functional outcomes, complications, and ease of tuberosity reduction. MATERIALS AND METHODS: 84 patients with three- and four-part proximal humerus fracture were alternately allocated the DP approach or DS approach for proximal humerus locking plate fixation. The outcome analysis was done by evaluating relative Constant score and ease of surgical reduction of greater tuberosity; radiological malunion was evaluated using Beredjiklian classification and complications were noted. RESULTS: At mean follow-up of 23 months (19-48 months), the mean 'relative Constant score was 74.27 ± 8.19 in the DP group and 73.26 ± 8.02 in the DS group and the difference was statistically insignificant (p = 0.988). There was no significant difference with respect to shoulder ROM, abductor strength, radiological malunion or complications. However, the mean surgical time was significantly less (p value = 0.042) in DS group (65 ± 5 min) in comparison to DP group (92 ± 4.3 min); significantly less difficulties were documented by the surgeon in reducing the greater tuberosity in DS group(p value = 0.02). CONCLUSION: Although surgical time was reduced and greater tuberosity reduction was easier in DS group, the other outcomes were similar; either surgical approach can be used based, and can be based on the experience and comfort level of the surgeon.

An unusual mechanism of sideswipe injury in passengers traveling in a train and review of literature.

INTRODUCTION: Sideswipe injuries are most commonly described in passengers traveling in a car or bus, but here we report an unusual mode of sideswipe injuries, in passengers traveling in a train sitting on window seats with elbow protruding outside the window. CASE SERIES: Four patients reported to our Orthopaedic emergency 2 hours after a railway track accident with more or less similar pattern of injury, an open proximal forearm monteggia fracture-dislocation with bone and soft tissue loss along with closed fracture humerus, and with or without radial nerve palsy and intact distal pulses. We followed a multidisciplinary approach with initial wound lavage followed by wound debridement, stabilization of monteggia and humerus fractures with different justifiable modalities of treatment with an exploration of the radial nerve. DISCUSSION AND CONCLUSION: Sideswipe injury is a well-known case entity in literature, classically described mode of trauma is when an elbow protruding out of the window of a vehicle struck by a moving or fixed object. However, in our series patients sitting in a train on window seat with elbow protruding outside sustained sideswipe injury which has not been reported in literature. We also explained the mechanism of impact forces caused bony and soft tissue injury in our series presented in diagrammatic representation. Hence, the purpose of this case series is to spread the awareness regarding such kind of preventable injury which can be easily prevented with awareness, and an appropriate preventive measure can be taken by the local administration.

Coexistence of Osteomalacia in Osteoporotic Hip Fractures in More Than 50 Years Age Group.

INTRODUCTION: Osteomalacia is a hitherto common orthopaedic condition and is commonly coexists with osteoporosis. However, the identification of osteomalacia always slips under the radar and more emphasis is given to diagnosis and management of osteoporosis. Identification of osteomalacia is equally relevant as management of the osteoporotic fractures is different with or without osteomalacia. METHODS: This was a prospective study design that included patients 50 years or above of either sex presented with proximal femur fractures. Osteoporosis was identified by DEXA scan of hip and lumbar spine. Metabolic tests including serum calcium, phosphorus, ALP and vitamin D levels were done. Histopathological diagnosis of osteomalacia was performed on bony tissues that were taken during surgery from a site adjacent to the fracture and histological examination was performed on non-decalcified paraffin sections using special stains. RESULTS: A total of 45 patients was included in study. Mean age was 68.7 years (53-85 years). Abnormal values of serum calcium, phosphorus, ALP, vitamin D were noted in 44.4%, 22.2%, 53.3% and 48.9% patients, respectively. On histopathology, 73.17% patients showed osteomalacia. No significant correlation was found between serum biochemical markers and histopathology except with serum Vitamin D (p value - 0.004). CONCLUSION: The majority of patients with osteoporotic hip fractures had coexisting osteomalacia. Abnormal biochemical values were not significantly associated with osteomalacia. Hence, histopathology remains the gold standard for the diagnosis of osteomalacia. Further research is needed to identify a biomarker that may enable the clinician to diagnosis and treat osteomalacia well in time.

Comprehensive treatment algorithm for atlanto-axial rotatory fixation (AARF) in children.

BACKGROUND: Atlanto-axial rotatory fixation (AARF) is an uncommon condition in children presenting with torticollis. Many studies have elaborated on the diagnostic sequence of AARF. However, there is no consensus for the algorithm of management of AARF. METHODS: This study proposes to provide a comprehensive step-by-step guideline which aims to achieve and retain anatomic reduction of the atlanto-axial joint (AAJ). We recommend a 'therapeutic crescendo': closed reduction and immobilization in a rigid cervical collar (step I). In cases of re-dislocation, a second attempt of closed reduction and immobilization in a Halo-jacket (step II). Cases of recurrent dislocations due to persistent instability require open reduction and internal fixation. We present a new surgical technique of transverse suture transfixation (TSF) of C1/C2 (step III). Alternatively, a dorsal stabilization of C1/C2 is indicated after open reduction (step IV). 13 patients with radiologically confirmed AARF were included in this study. These patients were treated as per the above mentioned algorithm. All these patients were serially evaluated with a minimum follow-up of 1 year. RESULTS: Clinical data of 10/13 patients were available for follow-up evaluation at mean 4.6 years after the onset of symptoms. Two patients were managed surgically. We recorded good clinical results in all patients treated according to the algorithm. CONCLUSIONS: AARF is a subacute pediatric emergency. Reduction and maintenance of joint congruency of the AAJ are the treatment goals. The comprehensive therapeutic algorithm presented in this study is applicable in patients with AARF to achieve excellent long-term results. LEVEL OF EVIDENCE: IV, Retrospective cohort study. TRIAL REGISTRATION NUMBER: Clinical Trial Registry University of RegensburgZ-2014-0453-4. Registered 01 December 2014.

Changing Pattern of Orthopaedic Trauma Admissions During COVID-19 Pandemic: Experience at a Tertiary Trauma Centre in India.

INTRODUCTION: COVID-19 has emerged as a medical threat to mankind, with a serious disruption of lifestyle in 2020. This has not only changed the way we live and work but has also changed the pattern of hospital admissions and medical care. To see if there was significant change in the pattern and management of trauma in our region, we evaluated data from our centre for the lockdown period and compared it with data from the previous year, and also with some available international data. METHODS: We collated data from our Tertiary care hospital for two periods, i.e. from 25th March 2020 to 3rd May 2020 signifying strict lockdown and then from 4th May to 31st May during which some conditional relaxations were given. This was compared to data from similar periods in 2019. We looked at patient demographics, fracture types, injury mechanisms, and even changes in treatment protocols. RESULTS: Significant reductions in caseloads were noted; open injuries were less, road accidents were infrequent, but cases due to falls, especially children and the elderly were still seen, although slightly reduced. The plan to minimize operative interventions could not be fully implemented due to complex nature of trauma seen by us. Only one case of bilateral amputation turned out to be positive, with no infectious consequences to the treating staff. CONCLUSIONS: COVID-19 pandemic led to significant reductions in trauma caseload and change in injury patterns. Doctor responses and patient management needs significant alteration to prevent spread of disease.

Risk factor analysis for delayed union after subtrochanteric femur fracture: quality of reduction and valgization are the key to success.

BACKGROUND: Subtrochanteric femur fractures (SFF) are uncommon, but have a high complication rate concerning non-union and mechanical complications. There is ongoing discussion about risk factors for delayed fracture healing after SFF. The purpose of this study was to evaluate potential risk factors for delayed fracture healing after SFF. METHODS: This retrospective radio-morphometric case control study compares 61 patients after SFF in two groups (uncomplicated healing within 6 months postoperatively vs. delayed union) concerning radiographical properties. The patients were analyzed concerning the following parameter: Quality of the reduction according to Baumgaertner, CCD-angle, Tip-Apex Distance, leg-length shortening and fracture healing according to the RUSH Score. RESULTS: The mean RUSH-Score at 6 months postoperatively was 21.32(±4.57). At that point of time, only 29/61 fractures were radiographically fully consolidated (timely fracture healing) and 32 patients were rated as delayed union. The total revision rate was 9/61 (14.7%), whereof four patients required revision for symptomatic non-union of the SFF. The results of the radio-morphometric measurement showed a significant difference between both groups concerning the degree of reduction measured according to Baumgaertner (p = 0.022). The postoperative ipsilateral CCD-angle was different between the two groups (p = 0.019). After 12 months postoperatively, 48/61 (78.6%) of fractures were rated healed without any further intervention. CONCLUSIONS: Delayed union after SFF occurs frequently. In our patient population, the quality of reduction and the postoperative CCD-angle were the key factors to avoid delayed union. LEVEL OF EVIDENCE: Level III, Therapeutic study. TRIAL REGISTRATION: Clinical Trial Registry University of Regensburg Z-2018-1074-1. Registered 04. Aug 2018. https://studienanmeldung.zks-regensburg.de.

Outcomes of Core Decompression with or without Nonvascularized Fibular Grafting in Avascular Necrosis of Femoral Head: Short Term Followup study.

BACKGROUND: Avascular necrosis (AVN) of the femoral head usually occurs in the third to fifth decade. The treatment options depend on the stage of disease varying from nonoperative treatment to surgical procedure including core decompression (CD) with or without nonvascularized or vascularized fibular graft, muscle pedicle bone grafting, osteotomies, and arthroplasty. Finite life of the total hip arthroplasty (THA) prosthesis limits its use in young adults or in middle aged. In this study, we envisage to evaluate the clinicoradiological outcomes of CD and nonvascularized fibular grafting in early stages of AVN femoral head. MATERIALS AND METHODS: Our study is longitudinal observational study including 76 hips (46 patients) in the age group of 18-48 years (mean 30.07 years). Ficat and Arlet staging system was used and only early stages, that is, Stage 1 (n = 36 hips) and Stage 2 (n = 40 hips) were included in the study. The cases with traumatic AVN were excluded. All patients in Stage 1 underwent CD (Group 1) and those in Stage 2 underwent CD and fibular grafting (Group 2). Preoperative Harris Hip Score (HHS), visual analog score (VAS), plain radiographs, and magnetic resonance imaging (MRI) were compared with serial postoperative HHS, VAS, plain radiographs, and MRI taken at different intervals. RESULTS: Average period of followup was 53.5 months (44-63 months). Radiological progression was not seen in 55 hips out of 76 hips (72.3%), whereas 21 hips (27.6%) demonstrated signs of progression and collapse. Failure of surgery was defined as progression of the disease, which was 25% (n = 9) in Group 1and 30% (n = 12) Group 2. Median values of HHS at the end of the followup in Group 1 was 77 and in Group 2 was 71.5 compared to the preoperative HHS of 48 and 62 in Group 1 and 2, respectively. Median values of VAS at the end of the followup in Stage 1 was 0 and in Stage 2 was 2 compared to the preoperative VAS of 6 and 8 in Group 1 and Group 2, respectively. CONCLUSION: CD with or without fibular grafting is effective in preserving the sphericity of the femoral head and to delay the progression of the AVN of femoral head in the early stages, that is, Stage 1 and Stage 2 and aids in the early revascularization of ischemic femoral head and is a useful modality to negate or delay the requirement of THA.

Four Screws Diamond Configuration Fixation for Displaced, Comminuted Intracapsular Fracture Neck Femur in Young Adults.

BACKGROUND: Four cannulated cancellous screws (CCS) in diamond configuration have been recommended by some authors for fixation of intracapsular neck of femur (ICNF) fracture with posterior comminution in adults. This is also supported by biomechanical studies. However, the clinical usefulness of this biomechanical advantage is not known. This study evaluates the outcomes of displaced, comminuted ICNF fracture in young adults managed by four CCS fixation in diamond configuration. MATERIALS AND METHODS: 25 patients who met the inclusion criteria were operated during the study period. Four patients were lost to followup in the first 6 weeks postoperatively, and one patient died in first 6 months of followup unrelated to surgery. Thus, twenty patients were followed up for a mean period of 33.3 months (range 25-38 months). In all patients, fracture fixation was done with four CCS in diamond configuration. Union at fracture site and avascular necrosis (AVN) of femoral head was assessed on serial plain radiographs. Functional outcome was evaluated by Harris hip score. RESULTS: Eighteen patients had union, two patients had nonunion, and two patients had AVN of femoral head. All the sixteen patients who had union without AVN had good or excellent functional outcome. CONCLUSIONS: The present study concludes that four CCS fixation in diamond configuration appears to be a reasonable choice of fixation for displaced fracture ICNF with comminution in young adults. However, further evaluation with better study design and larger patient population is required for definite conclusions.

Evaluation of Healed Status in Tuberculosis of Spine by Fluorodeoxyglucose-positron Emission Tomography/Computed Tomography and Contrast Magnetic Resonance Imaging.

BACKGROUND: The healed status (end-point of treatment) in tuberculosis (TB) spine is not defined; hence optimum antitubercular therapy (ATT) duration is unresolved. We, for the first time, prospectively evaluated the healed status in TB spine by fluorodeoxyglucose-positron emission tomography/computed tomography (FDG-PET/CT) and contrast magnetic resonance imaging (MRI) with the objective to define end-point of treatment in TB spine. MATERIALS AND METHODS: Thirty seven patients of TB spine diagnosed on clinicoradio imaging/cytology/histologically/molecular methods were enrolled, treated and were evaluated radiologically, by contrast MRI and FDG-PET/CT at 9 months. ATT was stopped on contrast MRI-based healing or absence of FDG uptake on PET-CT. ATT was continued in active/resolving lesion. Repeat evaluation was done at 12, 18, 24, and 30 months till healing is demonstrated. In this research work, we got contrast MRI and FDG-PET/CT done for the patients from government institution free of cost, so patients did not have to bear the burden of cost of these investigations. RESULTS: Twenty-eight patients achieved healed status out of which 11 demonstrated healed status on contrast MRI and FDG-PET/CT both, 6 were MRI active (contrast enhancement) but FDG-PET/CT healed, 2 were MRI healed but FDG-PET/CT active (soft-tissue standardized uptake value <2.0), 9 patients were MRI incompatible due to stainless steel implants (n = 6), and in 3 patients MRI could not be done due to financial constraints and were declared healed on FDG-PET/CT. FDG-PET/CT showed healed bone lesion in 28/28 (100%) and on MRI 13/19 (68.42%), respectively. We had 6 patients whose spine was stabilized with stainless steel implants where MRI could not be performed, MRI was useful in 13/25 cases (52%) to demonstrate healed lesion. 7, 6, 6, 5, 1, 2, and 1 cases achieved healed status at 9, 12, 18, 24, 30, 36, and 48 months of ATT intake, respectively. CONCLUSIONS: FDG-PET/CT is more useful to demonstrate the healed status than MRI and is the only imaging to demonstrate healed status when MRI could not be performed due to metallic implants. All patients achieved healed status at variable length of ATT intake; hence TB spine should be treated by ATT till healed status (end-point of treatment) is demonstrated by FDG-PET/CT (absence of FDG uptake) or contrast MRI.

Comparative Study for Assessment of Functional Outcome of Intraarticular AO Type C Distal Humerus Fractures Treated by Parallel Plating.

BACKGROUND: Complex distal end of humerus fractures are one of the most challenging cases in orthopedics. There is a paucity of literature on outcomes of parallel reconstruction plates using olecranon osteotomy technique along with large sample size. This study focuses primarily on rate of various complications encountered in intraarticular AO Type C distal humerus fractures. MATERIALS AND METHODS: In this prospective study, we included 94 patients with isolated closed intraarticular AO type C distal and humerus injuries. Exclusion criteria were polytrauma, open injuries, and pathological fractures (except osteoporosis). The followup was done immediate postoperatively, 6 weeks, 6 months, 1 year and at 2 years. Range of motion (ROM), Mayo Elbow Performance Score (MEPS), and Disabilities of the Arm, Shoulder, and Hand (DASH) score was recorded at each visit. Assessment of union was done based on X-ray. Patients were classified into two groups; Group 1 - patients without complications (n = 64) and Group 2 - with one or more complications. RESULTS: The average duration of surgery was 2 h and 15 min. The complication rate was 31.9% (30/94), however, a total of 45 complications were noted. The difference between ROM in the two groups was statistically significant (P < 0.05), however, the difference between MEPS and DASH score was not statistically significant. The most common complication found was ulnar nerve neuropathy. CONCLUSION: Parallel plating using olecranon osteotomy is an acceptable approach for this fracture, but due to inherent nature of this injury, it has its own set of complications which must be counseled before surgery and active participation of patient is required to obtain realistic expectations and goals for the future.

Hypoglossal Nerve Palsy as a Rare Complication of C1-C2 Pott's Spine.

Reporting a rare scenario of hypoglossal nerve palsy in craniovertebral tuberculosis. Two patients presented in outpatient department with chief complaints of pain in neck, restricted neck movements, gait changes, difficulty in speech and weakness in all the extremities. On the basis of clinicoradiological correlation, the patients were diagnosedwithtuberculosis of C1-C2 spine. They were started on antituberculosis therapy Category 1. The patients improved clinically and there was no worsening of symptoms, but they noticed tongue deviation and hypotrophy on one side of the tongue. C1-C2 tuberculosis along with cranial nerve palsy, especially hypoglossal nerve is one of the rarest presentations. Hypoglossal nerve arises from the medulla, exits through hypoglossal canal in the base of the skull and traverses neck to supply tongue musculature. Prevertebral fascia extends from superior mediastinum to base of the skull. Abscess in this area can cause either actual compression of the hypoglossal canal or C1 and base of the skull dissociation which can lead to compression of the canal.

Ultrasound guided versus landmark guided corticosteroid injection in patients with rotator cuff syndrome: Randomised controlled trial.

OBJECTIVE: Impingement syndrome is the most common differential in a patient presenting to an orthopaedic OPD with shoulder pain. Impingement syndrome is often managed with subacromial corticosteroid injection, which can be instilled using either landmark guided (LMG) approach or with the assistance of ultrasound (US). This study was envisaged to enquire whether ultrasound assistance improves the accuracy, efficacy or safety profile of the injection. METHODS: 60 patients of rotator cuff syndrome underwent diagnostic ultrasound. They were randomly assigned to receive subacromial injection of 2 ml (40 mg/ml) methylprenisolone and 2 ml of 1% lignocaine combination either by US assistance (n = 30) or using LMG assistance (n = 30). The patients were evaluated before injection and on follow up visits at day 5, week 3, week 6 and 3rd month by a single assessor. The assessor was blinded of the treatment group to which patient belonged. Clinical assessment included demographic and clinical data, accuracy of injection, VAS (0-100) for pain, Constant score with goniometer evaluation of range of motion, patient's self assessment proforma and post injection side effects if any. RESULTS: Initial demographic, clinical and US findings in the groups exhibited no significant differences. The accuracy of US guided injections (100%) was more when compared from LMG injection (93.3%). Both VAS and Constant score showed significant improvement following steroid injection up to 3 months of follow up. However the differences in the two groups were not significant suggesting comparable efficacy of the two approaches. (Mean VAS score decrease: 27.23 for US and 25.16 for LMG, p < 0.05: Mean constant score change: 14.73 for US and 15.00 for LMG, p < 0.05). The safety profile in both groups was comparable. CONCLUSION: Although US guided injections have a higher accuracy of drug placement in the subacromial bursa, there is no difference in terms of clinical outcomes or safety profile of either of the method. Hence US guided injections seems to be unjustified, when compared to equally efficacious and cost effective LMG steroid injection.