Is Ultrasound (US)-Guided Platelet-Rich Plasma Injection More Efficacious as a Treatment Modality for Lateral Elbow Tendinopathy Than US-Guided Steroid Injection?: A Prospective Triple-Blinded Study with Midterm Follow-up.

Background: Lateral elbow tendinopathy (LET) has an array of modalities described for its management. The present study analyzed two modalities used for managing the condition. Methods: The present study included 64 non-athletes with LET who failed conservative treatment that included avoiding strenuous activities, ice-fomentation, non-steroidal anti-inflammatory drugs, bracing, and physiotherapy for 6 months. A random allocation of the participants was done, with one group injected with platelet-rich plasma (PRP) and the other group with corticosteroids. The procedure was performed by the same blinded orthopedic surgeon after localizing the pathology using ultrasound. Visual analog scale (VAS) scores, disabilities of the arm, shoulder and hand (DASH) scores, Patient-Rated Tennis Elbow Evaluation (PRTEE) scores, and handgrip strengths were recorded by blinded observers other than the surgeon administering the injection. Results: The average age of the patients was 40 years. The mean VAS score at the latest follow-up of 2 years in the PRP group was 1.25 and it was significantly better than the score of 3.68 in the steroid group (p < 0.001). The mean DASH score at the latest follow-up of 2 years in the PRP group was 4.00 and it was significantly better than the score of 7.43 in the steroid group (p < 0.001). The mean PRTEE score at the latest follow-up of 2 years in the PRP group was 3.96 and it was significantly better than the score of 7.53 in the steroid group (p < 0.001). The scores were better in the steroid group at a short-term follow-up of 3 months (p < 0.05), while they were better in the PRP group at a long-term follow-up of 2 years (p < 0.05). Hand-grip strength was comparable in the PRP group (84.43 kg force) and steroid group (76.71 kg force) at the end of the 2-year follow-up with no statistically significant difference (p = 0.149). Conclusions: Corticosteroid injections alleviated symptoms of LET over short-term follow-up providing quicker symptomatic relief; however, the effect faded off over the long term. PRP injections provided a more gradual but sustained improvement over the long-term follow-up, indicating the biological healing potential of PRP.

Efficacy of Periarticular Local Infiltrative Analgesic Injection on Postoperative Pain Control and Functional Outcome in Sequential Bilateral Total Knee Replacement: A Prospective Controlled Trial in 120 Consecutive Patients.

Background: One of the drawbacks of total knee replacements (TKR) is the early postoperative pain, which affects patient satisfaction and increases the duration of rehabilitation. The present study analyzes the potency of local infiltrative analgesia and its effect on rehabilitation in bilateral sequential TKRs. Materials and Methods: The present prospective observational study was conducted on 120 patients undergoing bilateral sequential TKR performed by a single surgeon using an anterior midline incision with a standard medial parapatellar approach. At the end of the surgery, a periarticular cocktail injection was administered to one knee, whereas the other knee served as the control. Postoperatively, patients were assessed for the pain level in each knee based on the visual analog scale (VAS) score and improvement in the range of motion (ROM). Intergroup and intragroup analyses were performed using the unpaired t test and analysis of variance, respectively. A p value of < 0.05 was considered significant. Results: Of the 120 patients, 58% were women and 42% were men with a mean age of 62.14 ± 8.58 years. The postoperative mean VAS score was significantly lower in the test knee group than in the control knee group (p < 0.05). The postoperative mean ROM was more in the test group as compared to the control group on days 3 and 7 (p < 0.05), whereas it was comparable on day 14 (p > 0.05). Conclusion: Periarticular injection of a drug combination in patients managed with bilateral TKRs that are done simultaneously reduces the early postoperative pain and improves rehabilitation during the first week after surgery.

The Glomus Tumor of Finger - A Case Series.

Introduction: Glomus tumor is a rare hamartoma, common in young female which is excruciatingly painful and affects daily activities. It is usually present in distal phalanx (subungual) but may occur in different locations. A clinician needs high-level suspicion to diagnose this condition. Case Report: We hereby reviewed five cases (four females and one male) of this rare entity selected from patients attending our outpatient department since 2016 and were operated on. Out of these five cases, four were primary cases and one reoccurrence. Each of these was managed with en bloc excision of tumor and confirming it with biopsy after diagnosing it clinically and radiologically. Conclusion: Glomus tumors are rare, benign, and slow-growing tumors that arise from neuromuscular-arterial structures called glomus bodies. Radiologically, magnetic resonance imaging classically shows T1 weight isointense and T2 mild hyperintense. Approaching a subungual glomus tumor through transungual approach with complete excision of the nail plate has reduced the risk of reoccurrence due to complete view/access of the tumor and placing intact the nail plate after excision reduces the incidence of post-operative nail deformity.

Hemi-hamate arthroplasty for the management of chronic proximal interphalangeal joint fracture dislocations: Analysis of 21 cases in Indian population and review of the literature.

Background: Chronic fracture-dislocations involving the proximal interphalangeal (PIP) joint are challenging cases. We conducted this study to analyze the outcomes following hemi-hamate autograft reconstruction of such injuries and to compare our results with the existing literature. Methods: A retrospective analysis of 21 patients with chronic dorsal PIP fracture-dislocations that were managed with hemi-hamate autograft reconstruction was done. The average articular surface involvement was 64%. The average duration between injury and surgery was 9.4 weeks (range, 6-16). Quick DASH (Disabilities of Shoulder and Hand) scores, VAS (Visual Analog Scale) scores, range of motion of the PIP joints, DIP (distal interphalangeal) joints, and MCP (metacarpophalangeal) joints were measured during serial follow-up visits. Results: Union and graft incorporation was seen in all cases. The average Quick DASH score at four weeks post-surgery was 66 and it improved to eight at one year (p-value<0.05). The average VAS score at four weeks post-surgery was 7.66 and it improved to 2.09 at one year (p-value<0.05). The mean flexion of the MCP joint improved from 52.85° at the end of four weeks to 72.38° at one year (p-value<0.05). The average flexion at the PIP joint improved from 10.47° at the end of four weeks to 70.47° at one year (p-value<0.05). The average DIP flexion improved from 38.33° at the end of four weeks to 62.38° at one year (p-value<0.05). The average hand grip strength was 85% of the normal side. Conclusion: Hemihamate autograft reconstruction is a suitable procedure for the management of chronic PIP joint fracture-dislocations, especially in cases with extensive involvement of the articular surface. Level of evidence: III.

Degenerative Cervical Spondylosis: A Cause of Vertigo?

STUDY DESIGN: Prospective observational study. OBJECTIVES: Studying the effect of degenerative cervical spondylosis(CS) on blood flow velocity of vertebral artery (VA) during cervical spine rotation in different head positions and its association with vertigo. INTRODUCTION: Vertigo is one of the most common complaints seen in an out-patient clinic. Its association with CS remains an enigma for a treating physician. This study planned to systematically analyze the association between vertigo and CS by evaluating VA blood flow dynamics in different head positions. METHODS: 100 patients with ages ranging from 20-80 years were recruited. First group of 50 patients with CS with vertigo were compared with second study group of 50 patients having CS without vertigo. Cervical radiographs were used to evaluate CS using cervical degenerative index (CDI). Color doppler was used to measure VA blood flow with head in neutral position and 60° lateral rotation with 30° extension. Same procedure was repeated on opposite side. Measurements performed included peak systolic blood flow velocity(PSV) and end diastolic blood flow velocity (EDV). RESULTS: Among patients with CS, patients having vertigo showed significantly more evident degenerative changes (CDI ≥25) (P=<0.001). High grade CS patients (CDI ≥25) with vertigo had statistically significant lower blood flow parameters with head rotation in the left and right VAs as compared to CS patients without vertigo. CONCLUSION: This study highlights important pathophysiological mechanism of vertigo observed in patients of CS. The magnitude of reduction in VA blood flow was significantly higher in patients with advanced CS presenting as vertigo.

Outcome of Joint Aspiration in Acute Knee Haemarthrosis in a Haemophilic Joint: A Prospective Randomised Controlled Trial in 120 Patients in a Tertiary Haemophilia Care Centre.

Background: Bleeding into the joints cause major morbidity in haemophilia patients. The clinical hallmark of haemophilia is haemarthrosis especially in knee, ankle and elbow joint. Current literature suggests that aspiration of an acute haemarthrosis in haemophilia may lead to further bleeding and prevent tamponade effect. But the rehabilitation gets delayed, leading to joint stiffness and the function gets deteriorated. This study was done to evaluate the efficacy of joint aspiration in the management of acute knee haemarthrosis, with regard to pain relief and functional outcome. Materials and Methods: This is a prospective, randomised controlled trial in a tertiary care haemophilia treatment centre comprising 120 haemophilic patients with unilateral acute knee haemarthrosis. Factor level was checked and appropriate factor replacement [40%] was done. The patients were randomly allocated in two groups: Group A and Group B, each consisting of 60 patients. All patients received ice application, limb immobilisation, analgesics, physiotherapy and compression bandage as the routine primary management. In addition, study Group A also received therapeutic aspiration of the knee joint at initial presentation, after the first factor infusion. All patients were clinically evaluated for pain in terms of Visual Analogue Scale (VAS score) and function in terms of Haemophilic Joint Health Score [HJHS], before and at 4 h, 48 h and 7 days after initial factor administration. Results: All patients showed therapeutic improvement in terms of a declining trend in VAS and HJHS scores. Pain relief (VAS Score) in Group A, was found to be significantly better compared to Group B at the end of 4 h [4.80 ± 0.49 vs 6.54 ± 1.05; p < 0.001], 48 h [2.48 ± 0.50 vs 3.30 ± 0.46; p < 0.001] and 7 days [1.16 ± 0.37 vs 1.70 ± 0.46; p < 0.001]. Functional improvement (HJHS Score) in Group A, was found to be significantly better compared to Group B as well at the end of 4 h [11.24 ± 0.77 vs 14.52 ± 0.61; p < 0.001], 48 h [7.24 ± 0.65 vs 11.28 ± 0.64; p < 0.001] and 7 days [2.36 ± 0.48 vs 5.52 ± 0.67; p < 0.001]. Conclusion: Our study recommends the use of joint aspiration as a therapeutic tool in the holistic management of acute knee haemarthrosis in addition to usual treatment of ice application, immobilization and oral tranexamic acid. Early factor replacement along with therapeutic joint aspiration is a key for better pain relief and a better functional outcome.

Morphometric Analysis of Ulnar Variance and Its Demographic Dynamics Using High Resolution MRI: A Retrospective Study in Indian Population and Review of Literature.

Background: Ulnar variance (UV) is the variation of the level of the distal articulating surface of the radius with respect to the distal articulating surface of the ulna. These variations either positive or negative can predispose to pathologies involving the wrist joint. The aim of this study was to measure the ulnar variance in a subset of Indian population using high-resolution MRI and compare our results with the existing literature. Materials and Methods: Retrospective analysis of 100 normal wrist MRIs were done performed during November 2020 to November 2021 and the ulnar variance was calculated using the Method of Perpendiculars. All the MRI sequences were performed by an experienced radiologist with prior fixed protocol for the study. The measurements were done on the mid-coronal section based on the Method of Perpendiculars using Meddiff Rispacs software. Results: The average age of the participants was 42 years, with Male to female ratio of 0.9:1. 47 MRIs were of the left wrist, while 53 MRIs were of the right wrist. The mean UV was - 0.7 mm (SD-0.175), ranging from - 4.5 mm to 3.5 mm. There was a significant relationship between ulnar-variance and age, as ulnar-variance increases with the age (p value = 0.039). There was no statistically significant correlation of ulnar-variance with gender distribution and handedness. Conclusions: This study utilized high-resolution MRI for measuring ulnar-variance in a subset of Indian population and disclosed that the ulnar-variance affirms a positive correlation with age, while no specific pattern between the ulnar-variance and gender or handedness could be established.

An Analysis of the Structures at Risk from Percutaneous Pinning of Distal Radius Fractures and a Comparison of Two Pinning Techniques: A Cadaveric Study.

Background: A stab incision and blunt dissection prior to wire placement are believed to decrease the risk of injury to underlying structures during percutaneous pinning of distal radius fractures (DRF). However, only a few studies have compared stab incision and blunt dissection to direct wire placement. The aim of this cadaveric study is to analyse the structures at risk during percutaneous pinning of DRF and compare the two methods of wire placement. Methods: A total of 10 cadavers (20 upper limbs) were divided into two groups of five each. Five 2.0 mm Kirschner (K)-wires were inserted into the distal radius under fluoroscopic control in a standard fashion to simulate percutaneous pinning of DRF. In group 1, the K-wires were inserted directly, whereas in group 2, the wires were inserted after making a stab incision and blunt dissection to reach the bone. Each cadaveric limb was then dissected carefully to measure the distance of the K-wires from the branches of the superficial radial nerve (SRN), the cephalic vein and the first dorsal compartment and to determine the structures injured (pierced or in close contact) by the K-wires. Results: Out of the 100 K-wires placed, 18 wires were in close contact or pierced an underlying structure. These included 11 wires injuring tendons, six wires injuring branches of the SRN and one wire injuring the cephalic vein. Direct wire placement (group 1) resulted in injury to eight structures (44.4%) while stab incision and blunt dissection prior to wire placement (group 2) resulted in injury to 10 structures (55.5%). This difference was not statistically significant. Conclusions: Percutaneous pinning of DRF is associated with a high risk of injury to the extensor tendons and branches of the SRN. This risk is not reduced by making a stab incision and blunt dissection prior to K-wire placement.

The influence of joint line restoration on functional outcome after primary total knee arthroplasty: A prospective study.

Objective: Restoration of proper joint line position after primary total knee arthroplasty (TKA) is important for improved knee function and kinematics. We reviewed the magnitude of joint line alteration and the resulting effect on post-operative knee outcomes scores at one year follow-up. Materials and methods: 120 patients who underwent TKA for primary osteoarthritis knee were included. Assessment of joint line position before and after surgery was performed with the help of bony landmarks (excluding osteophytes): Medial Epicondyle Joint Line distance (MEJL), Lateral Epicondyle Joint Line distance (LEJL) and Fibula Head Joint Line distance (FHJL) were calculated. Post-operative knee function was assessed using 'The Western Ontario and McMaster Universities Arthritis Index' (WOMAC) and 'Knee Society Score' (KSS) at one year follow-up. Results: Joint line elevation was observed in 104/120 (86.7%) patients and 16/120 (13.3%) patients had no joint line elevation. The mean joint line elevation was 3.00 (±2.13) mm. The patients were sub-classified into two study groups: Group A- Joint line elevation <5 mm and Group B- Joint line elevation ≥ 5 mm. The mean post-op one-year KSS score was significantly higher in patients in Group A compared to Group B (52.82 ± 7.564 vs. 40.73 ± 7.146; p < 0.001). The mean post-op one-year WOMAC score was lower in patients in Group A compared to Group B (65.51 ± 14.762 vs.75.64 ± 8.203) and the difference was statistically significant (p = 0.002). Conclusion: Elevation of joint line ≥5 mm from the pre-operative value has a negative impact on post-operative functional outcome in primary TKA.

Short-Term Analysis of the Changes in the Bone Mineral Density of the Proximal Femur After Uncemented Total Hip Arthroplasty: A Prospective Study of 110 Patients.

Introduction Mechanical loading continuously exposes the bone to remodeling processes. Increased load leads to a gain in bone mass, and reduced load results in a loss. After inserting a prosthesis, the proximal femur is bypassed in loading as the bodyweight shifts distally. This lack of load induces bone resorption according to Wolff's law. To avoid this bone resorption, the implant's bending stiffness should be less than the femoral bone. Dual-energy X-ray absorptiometry (DEXA) is a well-accepted method to measure periprosthetic bone mineral density (BMD) after total hip arthroplasty (THA). Since the strength and durability of the fixation of a femoral prosthesis in cementless hip arthroplasty depend largely on the quantity and quality of the surrounding bone, preoperative and postoperative evaluation of the quantity and quality of the femoral bone is very important in the long-term prognosis of hip arthroplasty. Materials and methods A prospective study of 110 patients in the age group of 25-60 years who underwent uncemented total hip arthroplasty in our tertiary healthcare institution was performed. An uncemented, fully hydroxyapatite-coated implant from a single manufacturer was used in all the patients. All the patients were mobilized on the first post-operative day. The BMD was measured at the proximal femur and the distal tip using a DEXA scan. Gruen zones were used for calculating BMD at different anatomical locations in the femur, with particular importance to zones 1, 4, and 7. Results The pre-operative BMD in all zones measured, viz. zones 1, 4, and zone 7 of the affected side, was found to be significantly lower as compared to the BMD values on the control side (P< 0.05). The mean change in the mean BMD was calculated for all the zones and compared with each other using an unpaired t-test. The mean BMD changes were found to be significantly higher in zone 7 in comparison to both zones 1 and 4 (p<0.05). Conclusion Significant periprosthetic bone loss after uncemented THA in the femur was noted in Gruen zones 1, 4, and 7 during the first six months after THA, with the greatest bone loss in the femoral calcar area (zone 7). The lower the preoperative BMD of the patient, the greater the postoperative bone loss.

Prospective Randomized Control Pilot Study to Compare the Role of Injection Cerebrolysin in Operated cases of Degenerative Cervical Myelopathy.

STUDY DESIGN: Prospective randomized control trial. OBJECTIVE: The aim of this study was to analyze role of cerebrolysin in patients of degenerative cervical myelopathy (DCM) managed by surgical modalities. SUMMARY OF BACKGROUND DATA: Cerebrolysin has been extensively researched with variable success in neurodegenerative pathologies. There has been only one study in published literature till date that has studied role of cerebrolysin in DCM in conservatively managed patients but none in the patients treated surgically. We present our pilot study which analyzes the role of cerebrolysin in patients of DCM managed by surgical modalities. METHODS: This prospective randomized control trial was conducted at a tertiary care institute in Mumbai. Sixty operated cases of DCM were randomly divided into 2 groups. The first group was given Injection Cerebrolysin 5 mL diluted in 100 mL Normal Saline over 30 minutes once a day for 21 days postoperatively. The second group was given placebo. Modified Japanese Orthopedic Association scores (mJOA) and visual analog scale (VAS) were used to document functional outcomes at 3 weeks, 3 months, 6 months, and 1 year. Recovery of hand function was separately accessed by improvement in hand power and sensations. RESULTS: Preoperative mJOA and VAS scores were comparable between 2 groups. Both groups showed significant improvement in both mJOA and VAS scores at 3weeks, 3 months, 6 months and 1-year follow-up (P < 0.01). In comparing the two groups, there was no difference in improvement of mJOA and VAS scores. However, cerebrolysin group showed significant improvement in hand function at 1 year compared to the placebo. Postoperative neurological recovery was better in the cerebrolysin group with 66.7% patients showing complete neurological recovery compared to 56.7% for placebo, but this was statistically insignificant. Two patients developed headache and one patient complained of dizziness in the cerebrolysin group, but these resolved without any intervention. CONCLUSION: Use of cerebrolysin in postoperative cases of DCM is safe and results in improved hand function.Level of Evidence: 1.

Analysis of Functional Outcomes Following Surgical Management of Neglected Multiple Carpometacarpal Dislocations: A Series of four Cases and Review of Literature.

Introduction: Dislocation of the carpometacarpal (CMC) joint is a rare injury that results following high-velocity trauma. Although there are a few anecdotal reports of isolated CMC joint dislocations, there is scarce literature concerning dislocations involving multiple joints, especially those that are neglected and present late after injury. The injury is often missed when the patient presents to the surgeon since the swelling obscures the characteristic deformity, and the fracture may not be apparent on radiographs. When missed at the initial presentation, they can frequently result in pain, swelling, reduced grip strength, and arthritis. Such injuries require surgical management, along with prompt post-operative physiotherapy to enable the patient to regain satisfactory grip strength and range of motion. Case Report: We retrospectively analyzed four cases of multiple CMC joint dislocations that were managed surgically at our tertiary apex center. The average duration between injury and presentation to our center was five weeks. We used the quick disabilities of the arm, shoulder, and hand (DASH) scores and the maximum handgrip strength to assess the functional outcomes and the visual analog scale (VAS) to assess the pain at regular intervals. All patients showed an improvement in the Quick DASH scores, VAS scores, and the handgrip strength at the latest follow-up. All patients were able to return to their occupation. Conclusion: Early diagnosis and stabilization followed by early mobilization is the key to managing multiple CMC dislocations. The cases that present late are generally associated with contracted soft-tissue structures that prevent the relocation of the injury. Such cases require open reduction, along with a release of the contracted structures and internal fixation. Supervised physiotherapy in the post-operative period is essential to regain a satisfactory range of motion and grip strength.

Is Bilateral Sequential Total Hip Replacement as Safe an Option as Staged Replacement? A Matched Pair Analysis of 108 Cases at a Tertiary Care Centre.

BACKGROUND: Rationale for symptomatic severe bilateral arthritis of the hip is sequential bilateral THR completed under the same anaesthesia. The rarity of procedures and apprehension of complications preclude the widespread use. MATERIALS AND METHODS: Retrospective analysis of prospectively collected data from 108 patients (216 hips) with bilateral arthritis who underwent total hip arthroplasties was done: out of which 54 patients (108 hips) underwent a single-stage sequential procedure (sequential group) and a matched group of 54 patients (108 hips) underwent a two-stage procedure at different admissions (staged group). Patients were matched according to age (± 2 years), gender, American Society of Anaesthesiologists classification, perioperative management protocol and diagnosis. The mean duration of follow-up for sequential group was 5.1 years while that of staged group was 5.3 years. RESULTS: Most patients (88.88%) were operated with uncemented implants having ceramic on ceramic bearing surfaces under spinal or general anaesthesia. The operating time, post-op limb length and functional outcomes of both groups were comparable. Although the total estimated blood loss was significantly less in the sequential group (502 ml) as compared to the staged group (570 ml), the mean blood transfusion requirement was significantly higher (1.6 units) in the sequential group as compared to that in the staged group (0.9 units). The mean cumulative length of hospital stay was significantly longer in the staged group (23 days) compared with the sequential group (16 days). CONCLUSION: Single-stage bilateral total hip arthroplasty is a safe and viable option when performed with expertise in appropriately selected patients without any surge in complications.

Heterotopic Ossification of annular ligament: A case report and review of literature.

Heterotopic Osification (HO) commonly occurs in the hip and elbow joint post, trauma, surgery or dislocation. HO can occur anywhere in the body, and the term Heterotopic Ossification of Ligaments and Tendon (HOTL) is specifically used to denote HO occurring in ligaments and tendons. HOTL of an annular ligament is reported rarely in the literature. Here we describe a case of calcified annular ligament in a neglected monteggia fracture (Bado Type - 1), which was managed by excision and reconstruction of the same using triceps fascia. Post-op review after 2.5 years showed a stable elbow, with some restriction in pronation.

Decontamination of Escherichia coli on dried onion flakes and black pepper using Infra-red, ultraviolet and ozone hurdle technologies.

Among spices, onion flakes (OF) and black pepper (BP) are commonly used ingredients in domestic cooking; however, spices have been shown to be highly contaminated with pathogenic bacteria and bacterial spores. A novel method applying a treatments of Ozone Ultraviolet (UV, 255nm) and Infra-red (IR) light in different combinations was assessed for its efficiency in decontaminating OF and BP. In this study, untreated samples, as purchased, were inoculated with 9.5 × 105 cfu/mL Escherichia coli (MG1655) and exposed to each treatment alone and in combination of ozone sequentially followed by UV/IR, and UV/IR combined followed sequentially by ozone. A difference in response towards the treatment was shown among the types of spices, with a high efficacy for BP. Typically 3 log reductions were observed for ozone, UV and IR. The sequential treatments of ozone with UV and IR combined gave improved results than individual ones, with 99.99% of E. coli inactivation, and a shorter exposure duration with ozone (2.5 and 5 min) and UV and IR (2.5 and 5 min). The combined effect (ozone 2.5 min, UV and IR 10 min) yielded a log reduction of 2.69 and 4.20 for OF and BP respectively, greater than the additive effect of the individual treatments alone. The IR lamp was modulated to reduce excessive temperature rise. This novel prototype was shown to be very effective in decontaminating spices. Further studies should be conducted to validate the effectiveness of this method on decontamination of various bacterial strains.

A Rare Case of Vanishing Bone Disease of Metacarpals.

INTRODUCTION: Vanishing bone disease is rare phenomenon of idiopathic origin that leads to extensive osteolysis of bone. Prognosis of disease is unpredictable and definitive guidelines for management are still unknown. The vanishing bone disease has been reported for multiple other bones, however, this probably is the 1st time that vanishing bone disease of the metacarpals is being reported. CASE REPORT: A 22-year-old male presented with shortening middle finger and poor grip strength of the left hand. Serial radiographs revealed progressive concentric reduction of third and then fourth metacarpal shaft, with a sucked candy appearance. All the blood parameters were normal including calcium and parathormone levels. There was no evidence of any tumor elsewhere in the body. Biopsy showed myxoid areas, proliferating vessels interposed with skeletal muscles. Thus, based on clinical, radiological, and histopathological findings, we made the diagnosis of vanishing bone disease. The patient was treated with autologous non-vascularized fibula graft and was fixed with transverse k-wires to adjacent metacarpals. At 2-year follow-up, graft was completely incorporated and the patient gained full functional recovery. CONCLUSION: Vanishing bone disease affecting the metacarpals is very rarely reported in the literature. The diagnosis should be made by excluding all the other conditions such as primary bone tumors or secondary from other sites. There are no fixed treatment guidelines. However, we could treat this condition successfully with autologous non-vascularized fibular graft.

Better late than never: Clinical outcomes of delayed fixation in thoracolumbar spinal trauma.

PURPOSE: To analyse factors influencing functional outcome and neurological recovery in patients undergoing delayed surgery for traumatic spinal cord injury (SCI) involving thoracolumbar spine. METHODS: Retrospective analysis of 33 patients with thoracolumbar SCI who underwent delayed surgery (≥ 72hrs post-trauma) with a minimum follow-up of 1 year (average:32.55 months) was done. The parameters studied included age, sex, co-morbidities, mode of trauma, associated trauma, level and number of vertebrae involved, fracture morphology, thoracolumbar injury classification and severity score (TLICS), maximal spinal cord compression (MSCC), signal changes in the cord, neurological deficit as per the American Spinal Injury Association (ASIA) scale, lower extremity motor score (LEMS), bowel bladder involvement, time interval between trauma and surgery. RESULTS: Mean time interval from injury to spine surgery was 24.45 days. At the end of 1-year follow-up, 17(51.5%), 12(36.36%), and 3(9.1%) patients had ≥ 1, ≥ 2, and ≥ 3-grade ASIA improvement, respectively. The mean LEMS rose to 33.86 from 17.09 (P < 0.001). 8 out of 20 patients with bladder involvement showed improvement. 4 patients succumbed, 22 were ambulatory, and 7 remained non-ambulatory. On comparing various parameters, pre-operative LEMS score (P-value: < 0.001), cord signal changes (P-value:0.002), and presence of cord transection (P-value:0.007) differed significantly in the above-mentioned three groups, while age (P-value:0.442), average TLICS (P-value:0.872), time from injury to surgery (P-value:0.386) did not differ significantly. CONCLUSION: This study highlights that there is still a significant scope for neurological improvement even after delayed surgery in patients with thoracolumbar SCI. The lower the LEMS score at the time of presentation, signal changes in the cord and presence of cord transection have a significant influence on unfavourable clinical outcomes at the end of 1-year post-surgery.

A Rare Case of Lateral Displacement of Median Nerve in a Dislocated Elbow and its Management.

Introduction: Elbow dislocation usually presents with a deformity and swelling, yet it can also present with neurological complication. Nerve injury with dislocation is common in the pediatric age group and is reported infrequently among adults. The most common nerve involved with dislocation is the ulnar nerve followed by the median nerve. The median nerve usually slips medially during dislocation and gets entrapped posterior to the medial epicondyle or it can get entrapped between the fractured medial epicondyle. Here, we describe a unique case of posterolateral elbow dislocation in a 30-year-old female patient with having lateral displacement of the median nerve and the mechanism probably by which the nerve got displaced laterally. Case Presentation: A 30-years-old female patient of right hand dominant came to us with a left elbow injury after a road traffic accident. Clinical and Radiological examination revealed a posterior-lateral dislocated elbow with a fracture of the radial head and lateral condyle avulsion. Clinically, there was a weakness and sensory hypoesthesia along the median nerve distribution over the left hand and forearm. Initially, closed reduction and splinting done. Later, a planned surgery with a lateral approach avulsed lateral condyle and radial head fixation done with relocation of the median nerve, which was displaced laterally. Conclusion: There are numerous cases of elbow dislocation with nerve involvement and their complications have been previously described throughout literature. Here, we present a rare case of lateral displacement of the median nerve in a dislocated elbow and the possible mechanism with its management.

Patient satisfaction related outcome after total hip arthroplasty; does bearing surface play a role?

BACKGROUND: The aim of this study was to compare the functional outcome, the patient's perception of the replaced hip joint with different bearing surfaces and to study the effect of femoral head size on joint perception as well. METHODS: One hundred and ten (110) patients, who underwent primary total hip replacement with an average follow-up of 48 months (12-156 months), were assessed for their functional outcome and joint perception. The functional outcome was calculated based on Oxford hip score (OHS) and SF-36. Joint perception was categorized as to whether the replaced joint was perceived like a natural joint or artificial joint with or without restriction of movements. RESULTS: There were 50 patients operated for ceramic on ceramic (CoC-hard-on-hard bearing), 60 patients for hard-on-soft bearing (Metal on Polyethelene-MoP 46, Ceramic on Polyethelene-CoP 14). Most of the patients with hard-on-hard bearings perceived their operated hip like a natural joint (p = 0.04) compared to hard-on-soft bearings. There was no significant difference in the functional outcome (OHS, SF-36) between the two bearing surface groups (p > 0.05). There were fifty patients with 28 mm size head while remaining 60 had larger heads (>32 mm). Patients with large heads felt like natural joint compared to small heads (p = 0.007). CONCLUSION: The hard-on-hard bearing surfaces (CoC) and large femoral heads (32 mm, 36 mm) are perceived more like a natural joint. Different bearing surfaces do not affect the functional outcome after total hip replacement in a medium term follow up.

A managed case of rare intraosseous lipoma of femoral neck.

43 year-old female presented with anterior hip pain not responding to conservative treatments. Plain radiograph showed radio-lucent area with sclerotic margin in the femoral neck region. On MRI scan the diagnosis of intraosseous lipoma was confirmed. Due to persistent pain and risk of fracture, decision of operative treatment was made. She underwent curettage of the lesion under image-intensifier and reinforcement of femoral neck with non-vascularised fibular grafting. Post-operative x-rays showed incorporation of the fibular graft with good clinical and functional outcome. Intraosseous lipoma in the femoral neck is a rare presentation and in cases with persistent symptoms or risk of impending fracture, operative treatment gives a good functional outcome.