The interplay of rheumatoid arthritis and osteoporosis: exploring the pathogenesis and pharmacological approaches.

Rheumatoid arthritis (RA) and osteoporosis are two chronic disorders that are often seen together. RA is an autoimmune disorder that causes pain and inflammation in the joints, while osteoporosis is a disorder in which the bones become weak and fragile. Risk factors for bone loss in RA include disease activity, longer disease duration, erosive disease, autoantibody positivity, and joint damage leading to impaired physical activity. Recent research has shown that there is a complex interplay between immune cells, cytokines, and bone remodeling processes in both RA and osteoporosis. The bone remodeling process is regulated by cytokines and immune system signaling pathways, with osteoclasts activated through the RANK/RANKL/OPG pathway and the Wnt/DKK1/sclerostin pathway. Understanding these mechanisms can aid in developing targeted therapies for treatment of osteoporosis in RA patients. Current pharmacological approaches include anti-osteoporotic drugs such as bisphosphonates, denosumab, teriparatide, abaloparatide, raloxifene, and romosozumab. Conventional disease-modifying antirheumatic drugs such as methotrexate and biologicals including TNF inhibitors, IL-6 inhibitors, rituximab, and abatacept lower disease activity in RA and can improve bone metabolism by reducing inflammation but have limited impact on bone mineral density. This review will shed light on the relationship between osteoporosis and rheumatoid arthritis as well as the various factors that influence the onset of osteoporosis in RA patients. We also explore several treatment approaches to effectively managing osteoporosis in RA patients.

Role of calcium &/or vitamin D supplementation in preventing osteoporotic fracture in the elderly: A systematic review & meta-analysis.

Background & objectives: Calcium and vitamin D, separately or in combination are usually prescribed to prevent fragility fractures in elderly population. However, there are conflicting results regarding the ideal dosage and overall efficacy obtained from randomized controlled trials (RCTs) conducted in the past. The objective of this study was to assess the fracture risk with the administration of calcium or vitamin D alone or in combination in elderly population (>60 yr). Methods: PubMed, Cochrane and Embase databases were searched to identify the studies from inception to February 2021 with keywords, 'vitamin D', 'calcium' and 'fracture' to identify RCTs. The trials with comparing vitamin D, calcium or combination with either no medication or placebo were included for final analyses. The data were extracted and the study quality was assessed by two reviewers. The principal outcome measure was fractures around hip joint and secondary outcomes assessed were vertebral and any other fracture. Results: Eighteen RCTs were considered for the final analysis. Neither calcium nor vitamin D supplementation was associated with risk of fractures around hip joint [risk ratio (RR) 1.56; 95% confidence interval (CI), 0.91 to 2.69, I[2]=28%; P=0.11]. In addition, the combined administration of calcium and vitamin D was also not associated with fractures around the hip joint in comparison to either no treatment or placebo. The incidence of vertebral (RR 0.95; 95% CI, 0.82 to 1.10, I[2]=0%; P=0.49) or any other fracture (RR 0.83; 95% CI 0.65 to 1.06, I[2]=0%; P=0.14) was not significantly associated with the administration of calcium and vitamin D either individually or in combination. Further subgroup analysis of the results did not vary with the dosage of calcium or vitamin D, dietary calcium intake sex, or serum 25-hydroxyvitamin D levels. Interpretation & conclusions: The present meta-analysis of RCTs on calcium, vitamin D or a combination of the two in comparison to no treatment or placebo did not support the routine administration protocol of calcium and vitamin D either alone or in combination to lower the risk of fractures in elderly population.

EFFICACY AND SAFETY OF KNOTLESS BARBED SUTURES IN CAPSULAR CLOSURE FOLLOWING DISTAL FEMUR FRACTURE FIXATION.

Introduction: Good wound closure is an important step in management of distal femur fracture to prevent infection and faster rehabilitation. Knotless barbed sutures can save time and distribute wound tension evenly. However, its role in terms of functional outcome, closure time, and postoperative complications has not been studied in a distal femur fracture. Material and methods: A total of 47 patients aged more than 18 years of distal femur fracture treated with distal femur locking plate were randomized either into either barbed or traditional suture groups. in the barbed group, capsular wound closure was carried out with 2-0 bidirectional barbed knotless sutures (Quill SRS® PDO, Angiotech, Vancouver, BC, Canada). In patients assigned to group B, capsular closure was done with 1-0 Vicryl® (Ethicon inc. Somerville, NJ) and 5-0 Ethibond® alternatively. Results: The mean flexion at the knee joint was 105.7±15.6 degrees in the study group while it was 110.4±13.7 in the control group (p= 0.2133). Mean estimated closure time was significantly shorter in the study group as compared to the control group (p<0.05). Cases of needle prick injury were higher in traditional suture group. Patients developed stitch abscess and superficial infection in both groups. However, the difference in incidence between the two was not statistically significant. Conclusion: Barbed suture is an efficient method of wound closure. It reduces wound closure time with similar complication rate as with use of conventional sutures. Evidence Level II; Randomized Clinical Trial.

Introdução: O fechamento adequado da ferida é um passo importante no manejo da fratura distal do fêmur a fim de evitar infecção e permitir uma rápida reabilitação. Suturas farpadas sem nós podem poupar tempo e distribuir uniformemente a tensão da ferida. Entretanto, seu papel em termos de resultado funcional, tempo de fechamento e complicações pós-operatórias não tem sido analisado em casos de fratura distal do fêmur. Material e métodos: Um total de 47 pacientes com mais de 18 anos de idade com fratura distal do fêmur tratados com placa de fixação distal do fêmur foram aleatorizados em grupos de sutura farpada ou tradicional. No grupo de farpados, o fechamento da ferida capsular foi feito com suturas sem nós farpados bidirecionais 2-0 (Quill SRS® PDO, Angiotech, Vancouver, BC, Canadá). Em pacientes designados para o grupo B, o fechamento capsular foi feito com Vicryl®1-0 (Ethicon inc. Somerville, NJ) e Ethibond® 5-0 respectivamente. Resultados: A flexão média na articulação do joelho foi de 105,7±15,6 graus no grupo de estudo e 110,4±13,7 no grupo controle (p= 0,2133). O tempo médio estimado de fechamento foi significativamente menor no grupo de estudo em comparação com o grupo controle (p<0,05). Os casos de ferimento por perfuração da agulha foram maiores no grupo de sutura tradicional. Os pacientes desenvolveram abscesso de pontos e infecção superficial em ambos os grupos. Entretanto, a diferença na incidência entre os dois não foi estatisticamente significative. Conclusão: A sutura farpada é um método eficiente para o fechamento de feridas. Ele reduz o tempo de fechamento das feridas com uma taxa de complicação semelhante à utilização de suturas convencionais. Evidência Nível II; Ensaio Clínico Randomizado.

Efficacy and safety of knotless barbed sutures in capsular closure following distal femur fracture fixation / Eficácia e segurança das suturas farpadas sem nós no fechamento capsular após fixação de fratura distal do fêmur

ABSTRACT Introduction: Good wound closure is an important step in management of distal femur fracture to prevent infection and faster rehabilitation. Knotless barbed sutures can save time and distribute wound tension evenly. However, its role in terms of functional outcome, closure time, and postoperative complications has not been studied in a distal femur fracture. Material and methods: A total of 47 patients aged more than 18 years of distal femur fracture treated with distal femur locking plate were randomized either into either barbed or traditional suture groups. in the barbed group, capsular wound closure was carried out with 2-0 bidirectional barbed knotless sutures (Quill SRS® PDO, Angiotech, Vancouver, BC, Canada). In patients assigned to group B, capsular closure was done with 1-0 Vicryl® (Ethicon inc. Somerville, NJ) and 5-0 Ethibond® alternatively. Results: The mean flexion at the knee joint was 105.7±15.6 degrees in the study group while it was 110.4±13.7 in the control group (p= 0.2133). Mean estimated closure time was significantly shorter in the study group as compared to the control group (p<0.05). Cases of needle prick injury were higher in traditional suture group. Patients developed stitch abscess and superficial infection in both groups. However, the difference in incidence between the two was not statistically significant Conclusion: Barbed suture is an efficient method of wound closure. It reduces wound closure time with similar complication rate as with use of conventional sutures. Evidence Level II; Randomized Clinical Trial.

RESUMO Introdução: O fechamento adequado da ferida é um passo importante no manejo da fratura distal do fêmur a fim de evitar infecção e permitir uma rápida reabilitação. Suturas farpadas sem nós podem poupar tempo e distribuir uniformemente a tensão da ferida. Entretanto, seu papel em termos de resultado funcional, tempo de fechamento e complicações pós-operatórias não tem sido analisado em casos de fratura distal do fêmur. Material e métodos: Um total de 47 pacientes com mais de 18 anos de idade com fratura distal do fêmur tratados com placa de fixação distal do fêmur foram aleatorizados em grupos de sutura farpada ou tradicional. No grupo de farpados, o fechamento da ferida capsular foi feito com suturas sem nós farpados bidirecionais 2-0 (Quill SRS® PDO, Angiotech, Vancouver, BC, Canadá). Em pacientes designados para o grupo B, o fechamento capsular foi feito com Vicryl®1-0 (Ethicon inc. Somerville, NJ) e Ethibond® 5-0 respectivamente. Resultados: A flexão média na articulação do joelho foi de 105,7±15,6 graus no grupo de estudo e 110,4±13,7 no grupo controle (p= 0,2133). O tempo médio estimado de fechamento foi significativamente menor no grupo de estudo em comparação com o grupo controle (p<0,05). Os casos de ferimento por perfuração da agulha foram maiores no grupo de sutura tradicional. Os pacientes desenvolveram abscesso de pontos e infecção superficial em ambos os grupos. Entretanto, a diferença na incidência entre os dois não foi estatisticamente significative Conclusão: A sutura farpada é um método eficiente para o fechamento de feridas. Ele reduz o tempo de fechamento das feridas com uma taxa de complicação semelhante à utilização de suturas convencionais. Evidência Nível II; Ensaio Clínico Randomizado.

Comparison of Three Suture Materials in Capsular Closure Closure Time and Wound Complications Following Knee Arthroplasty.

BACKGROUND: Watertight capsular closure in knee arthro- plasty is desirable in order to achieve a good functional outcome. Barbed knotless sutures are being increasingly used in wound closure following knee arthroplasty. The prior studies have compared barbed sutures with either VICRYL® or Ethibond for closure, while none had compared all the three in a single setting in terms of closure time, needle stick injuries, postoperative complications, and functional outcome. PATIENTS AND METHODS: One hundred and forty-three subjects of unilateral knee arthroplasty were screened for eligibility in the prospective randomized controlled trial. One hundred and twenty patients fulfilled the inclusion criteria and were randomized into three groups to undergo capsular closure with barbed sutures, VICRYL, or Ethibond. RESULTS: The wound closure was fastest with barbed su- tures followed by VICRYL and Ethibond (10.4 ± 4.1; 15.4 ± 4.7; 17.2 ± 3.8 minutes; p < 0.001). There were seven needle stick injuries in the Ethibond group followed by three in the VICRYL group and none in the barbed suture group. The Knee Society Scores and wound related complications were comparable in all the three groups. CONCLUSION: Barbed suture, VICRYL, and Ethibond are equally good in the capsular closure following knee arthro- plasty. The faster wound closure time achieved may not be clinically relevant in the short term.

Cemented Calcar Replacement versus Long Stem Cemented Hemiarthroplasty in Unstable Intertrochanteric Fractures in Octogenarians.

Objective The aim of the present study was to compare functional results after Cemented Calcar replacement vis-a-vis Long stem Cemented hemiarthroplasty in patients aged more than 80 years with unstable intertrochanteric fractures. Methods The present prospective, randomized trial included 140 patients with AO/OTA type 31-A2, A3 intertrochanteric femur fracture, randomized into 2 treatment groups and followed-up for a minimum of 2 years. Sixty-seven patients in group A were treated with a cemented calcar replacing prosthesis, and 65 patients in group B were treated with a cemented long stem femoral stem prosthesis. The primary end points were hip functions at 2 years. The secondary end points were the complications encountered, mortality, surgical time, reoperation, blood loss, and activities of daily living. Results There were no major differences between the groups in terms of hip function, quality of life (health related), reoperation, mortality, and blood loss. However, the function in hip joint and activities of daily living deteriorated in both groups in comparison with prefracture levels. Conclusion In octogenarians with an unstable intertrochanteric fracture, cemented calcar replacing prosthesis has similar clinical results in comparison with long stem cemented hemiarthroplasty. Hemiarthroplasty with either implant is a good option in this subset of patients. Level of evidence: I.

Cemented Calcar Replacement versus Long Stem Cemented Hemiarthroplasty in Unstable Intertrochanteric Fractures in Octogenarians / Substituição do calcar cimentado versus hemiartroplastia de haste longa cimentada em fraturas intertrocantéricas instáveis em octogenários

Abstract Objective The aim of the present study was to compare functional results after Cemented Calcar replacement vis-a-vis Long stem Cemented hemiarthroplasty in patients aged more than 80 years with unstable intertrochanteric fractures. Methods The present prospective, randomized trial included 140 patients with AO/OTA type 31-A2, A3 intertrochanteric femur fracture, randomized into 2 treatment groups and followed-up for a minimum of 2 years. Sixty-seven patients in group A were treated with a cemented calcar replacing prosthesis, and 65 patients in group B were treated with a cemented long stem femoral stem prosthesis. The primary end points were hip functions at 2 years. The secondary end points were the complications encountered, mortality, surgical time, reoperation, blood loss, and activities of daily living. Results There were no major differences between the groups in terms of hip function, quality of life (health related), reoperation, mortality, and blood loss. However, the function in hip joint and activities of daily living deteriorated in both groups in comparison with prefracture levels. Conclusion In octogenarians with an unstable intertrochanteric fracture, cemented calcar replacing prosthesis has similar clinical results in comparison with long stem cemented hemiarthroplasty. Hemiarthroplasty with either implant is a good option in this subset of patients. Level of evidence: I

Resumo Objetivo O objetivo do presente estudo foi comparar os resultados funcionais após a substituição do Calcar cimentado em comparação com a hemiartroplastia cimentada de haste longa em pacientes com mais de 80 anos com fratura intertrocantérica instável. Métodos O presente estudo prospectivo e randomizado incluiu 140 pacientes com fratura de fêmur intertrocantérica, conforme classificação AO/OTA tipo 31-A2, A3, randomizados em 2 grupos de tratamento e acompanhados por um período mínimo de 2 anos. Sessenta e sete pacientes do grupo A foram tratados com uma prótese de substituição do calcar cimentada e 65 pacientes do grupo B foram tratados com uma prótese femoral de haste longa cimentada. Os desfechos primários foram as funções do quadril em 2 anos. Os eventos secundários foram as complicações encontradas, a mortalidade, o tempo cirúrgico, segunda cirurgia, perda de sangue e as atividades do cotidiano. Resultados Não houve grandes diferenças entre os grupos em termos de função do quadril, qualidade de vida (relacionada à saúde), segunda cirurgia, mortalidade e perda de sangue. No entanto, a função da articulação do quadril e as atividades da vida diária se deterioraram em ambos os grupos em comparação com os níveis pré-fratura. Conclusão Nos octogenários com fratura intertrocantérica instável, a prótese de substituição do calcar cimentada apresentou resultados clínicos semelhantes em comparação com a hemiartroplastia de haste longa cimentada. A hemiartroplastia comqualquer umdos implantes é uma boa opção nesse subgrupo de pacientes. Nível de evidência: I

Validation and Cross-Cultural Adaptation of the Hindi Version of the Oxford Knee Score in Patients With Knee Osteoarthritis.

INTRODUCTION: Cases of knee osteoarthritis are on the rise in India with an increasingly ageing population. A large number among them shall undergo total knee replacement, so there is a requirement for validated patient-reported outcome measures in the Hindi language. Oxford Knee Score (OKS) is one of the most commonly used patient-reported outcome measure scoring systems. The current study was designed to test and validate cross-cultural adaptation and translate the Hindi version of the Oxford Knee Score (OKS-H).  Material and Methods: The OKS-H was formulated as per recommendations for cross-cultural adaptation and translation. The OKS was tested on 162 patients with knee osteoarthritis who underwent a total knee replacement. Reliability of the OKS-H was tested using the intraclass correlation coefficient (ICC) and internal consistency was assessed using Cronbach's alpha. The construct validity was assessed using OKS-H, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and 36-Item Short Form Survey (SF-36) questionnaire.  Results: The translation was performed with no major difficulty. The OKS was completed by 158 (97.5%) and 157 (96.9%) patients at test and retest, respectively, after one week. With an ICC of 0.87, OKS had shown good reliability. The construct validity obtained against the WOMAC and SF-36 scores was strong (ICC between 0.49 to 0.86). CONCLUSION: The translated OKS-H is a reliable and valid instrument for patient-reported outcome measures in cases of knee osteoarthritis opting for total knee arthroplasty.

Comparison Between Vancomycin and Gentamicin for Intraoperative Presoaking of Hamstring Graft in Primary Anterior Cruciate Ligament Reconstruction.

Introduction Postoperative infection is an uncommon complication with grave consequences following anterior cruciate ligament reconstruction (ACLR). Presoaking of the hamstring graft with antibiotics results in a lower rate of infection. The purpose of the current study was to compare the efficacy of two commonly used antibiotics, vancomycin and gentamicin, in reducing infection rates following anterior cruciate ligament reconstruction. Methods The retrospective study included a total of 578 patients who underwent arthroscopic anterior cruciate ligament reconstruction between June 2015 and October 2021. The timeline was categorized as the period between June 2015 to October 2018 (Vancomycin presoaking of hamstring graft) and November 2018 to October 2021 (Gentamicin presoaking of hamstring graft). All patients were examined for the development of infection, causative organism, and treatment received. Patients with intravenous drug abuse, alcoholism, steroid use, revision cases, and a prior history of infection in the knee were excluded from the study. Fisher's exact test was used for comparison of categorical data, and Poisson regression analysis was carried out to calculate incidence rate ratios after adjusting for confounding variables. Results Presoaking of hamstring grafts with vancomycin was carried out in 224 patients, and gentamicin was used in 354 patients. In total, three patients in the vancomycin and four patients in the gentamicin groups developed an intraarticular infection, and the difference in infection rate between the two groups was not statistically significant (p=0.919). Coagulase-negative Staphylococcus aureus was isolated in four cases, Enterobacter cloacae in one, and no organism was seen in two cases. The groups were comparable in terms of age (p=0.563), smoking (p=0.84), sex (p=0.359), and operative time (p=0.09). Conclusion Presoaking of hamstring autografts with gentamicin intraoperatively is a good alternative to vancomycin in the prevention of infection following arthroscopic anterior cruciate ligament reconstruction.

Postoperative Epidural Fibrosis Prevention: Which Is Better-Autologous Fat versus Gelfoam.

STUDY DESIGN: Prospective, randomized study of 100 patients with prolapsed intervertebral disc with an average of 12- to 18-month follow-up postoperatively. PURPOSE: To compare the role of Gelfoam and autologous fat in the prevention of postoperative epidural fibrosis (EF) after lumbar spine surgery. OVERVIEW OF LITERATURE: EF is a possible sequelae of lumbar disc surgery. Different treatments and surgical strategies have been attempted to prevent postoperative fibrosis without providing consistent long-term results. METHODS: The study was conducted on 100 adult patients. The patients were randomly allocated into two groups of 50 patients each: group A, autologous fat group, and group B, Gelfoam group. The postoperative follow-up was conducted at intervals of 6 weeks, 3 months, 6 months, and 12 months. Both groups were evaluated clinically (Oswestry Low Back Pain Disability Questionnaire [ODI], Visual Analog Scale [VAS], Straight Leg Raising Test [SLRT]) and radiologically (using Ross grading by contrast magnetic resonance imaging [MRI]) for development of radicular pain and hence EF. RESULTS: Based on the analysis, improvement in mean values of ODI score, VAS score, and SLRT were found to be statistically significant postoperatively at intervals of 6 weeks, 3 months, 6 months, and 12 months when compared individually in both groups. However, improvement was greater in the autologous fat group than in the Gelfoam group. Based on contrast-enhanced MRI, the number of patients who developed EF was smaller in the autologous fat group than in the Gelfoam group. CONCLUSIONS: In the present study, on clinical and radiological assessment, we conclude that both groups prevent radicular pain and postoperative EF individually but relatively autologous fat was found to be more effective than Gelfoam in the prevention of EF and hence radicular pain.

Known data on applied regenerative medicine in tendon healing.

Tendons and ligaments are important structures in the musculoskeletal system. Ligaments connect various bones and provide stability in complex movements of joints in the knee. Tendon is made of dense connective tissue and transmits the force of contraction from muscle to bone. They are injured due to direct trauma in sports or roadside accidents. Tendon healing after repair is often poor due to the formation of fibro vascular scar tissues with low mechanical property. Regenerative techniques such as PRP (platelet-rich plasma), stem cells, scaffolds, gene therapy, cell sheets, and scaffolds help augment repair and regenerate tissue in this context. Therefore, it is of interest to document known data (repair process, tissue regeneration, mechanical strength, and clinical outcome) on applied regenerative medicine in tendon healing.

Bilateral Monteggia Fracture: A Rare Case Presentation.

INTRODUCTION: Giovanni Monteggia was the first to describe two cases of fractures of the proximal third of ulna with dislocation of the radial head. Monteggia fractures much more commonly are seen in children than in adults, but the bilateral entity is rare in both age groups. The following case is about the course of treatment for bilateral Monteggia fractures in a young male. CASE REPORT: A 35-year-old male came to the emergency with alleged history of roadside accident. Radiography showed bilateral Monteggia fracture type III (by the Bados classification). Surgical intervention was required with locking compression plates put on the both sides. Closed reduction of the radial head was done on both sides. The patient was given pop slabs for bilateral forearms for 21 days. After removing the splints, the function of the elbow was determined by the Broberg Morrey score which was on the right side 45 and on the left side 47 and 100 on both sides after 5 months of follow-up. CONCLUSION: Surgical intervention and early rehabilitation are the most important and ideal line of treatment for the return of the good function of both elbows. Diagnosis, surgical technique, rehabilitation program, and clinical results are reported. The bilateral nature of the presentation does not affect the outcome of the fractures.

Meta-Analysis of Randomized Controlled Trials Involving Anterior Shoulder Instability.

BACKGROUND: Arthroscopic repair is gaining popularity over open repair for the treatment of bankart lesions. The study aims to evaluate the outcome of arthroscopic repair with open repair in randomised controlled trials conducted comparing the two techniques. METHODS: We searched the Cochrane library, PubMed and EMBASE up to December 2017 for clinical trials comparing the outcomes of arthroscopic bankart repair with open bankart repair. We used fixed or random effects model depending upon heterogenicity. Dichotomous variables were presented as Risk Ratios (RRs) with 95% Confidence Intervals (CIs), and continuous data were measured as measured differences with 95% CIs. RESULT: Five studies were included, with sample size ranging from 42 to 196. Fixed effect analysis showed that the shoulder was more stable in open repair (RR=0.897, 95% CI: 0.821 to 0.980, P= 0.94) but the loss of external rotation at shoulder joint was also higher in those had open repair (RR=0.325, SMD=-0.411, 95% CI: -1.229 to 0.407). The functional outcome assessed by Rowe score was better in open repair (P=0.325). The operative time was lesser in arthroscopic repair but was not statistically significant (P=0.085). CONCLUSION: Our meta-analysis showed that the use of arthroscopic repair though offers better shoulder movement but the open repair is superior in terms of shoulder stability.

Nora's lesion of 2nd metacarpal treated by wide excision, autologous fibular grafting and metacarpophalangeal joint replacement: A rare case report.

Bizarre paroxysmal osteochondromatous proliferation (BPOP) is a rare benign neoplastic lesion predominantly affecting small bones of the hand and known for its recurrence after local excision. We describe a rare case of BPOP involving second metacarpal of the dominant hand which was treated using a novel technique. Wide excision and reconstruction with non-vascularised fibular autograft was performed along with metacarpophalangeal joint replacement. At a follow up of two years, there was no evidence of recurrence and patient had good functional outcome. Hence this modality of treatment could be considered in dealing such cases of BPOP involving the small bones of hand.

Resistant Non-union of Humerus After Intramedullary Nailing Treated with Locking Compression Plate with Bone Grafting With Nail in Situ and Shoulder Spica: A Case Report.

INTRODUCTION: Humerus non-union is a challenging situation for the surgeon and devastating and morbid situation for the patient. Surgical approach to the humerus is demanding because of the complex neurovascular anatomy and especially when previous surgeries have been attempted. CASE REPORT: We report a case of a young adult male who sustained a compound fracture of humerus shaft treated with intramedullary nailing followed by subsequent bone grafting and eventually landed up in non-union and was treated at our center by locking compression plate application with nail in situ with iliac crest autogenous bone graft followed by shoulder spica application. CONCLUSION: Although humerus nailing is a valid therapeutic option for humeral shaft fractures, compression plating is considered the gold standard and non-union secondary to failed interlocking nailing is a challenging situation.

Morphology of the posteromedial fragment in pertrochanteric fractures: A three-dimensional computed tomography analysis.

BACKGROUND: In this study we describe the morphology of the posteromedial fragment in pertrochanteric fractures using 3D CT scans and answer two questions 1) Do differences exist between the 3D CT appearances of posteromedial fragments and the depictions made in the AO classification 2) Does the posteromedial fragment affect stability in pertrochanteric fractures, in terms of fracture collapse? METHODS: Preoperative CT scans of eight 31-A1 and fifty 31-A2 fractures were analysed. The presence of PM fragment, its fragmentation, greater trochanter (GT) involvement, lesser trochanter (LT) fragment size (in terms of its posterior and medial extent as well as LT length), LT fragment displacement (in terms of medial displacement and rotation) were determined. All fractures were treated with a DHS. Fracture collapse was determined on postoperative radiographs. The relationship between fracture collapse and patient factors including age, gender, fracture type (A1 versus A2), characteristics of the posteromedial fragment, and the presence of a lateral wall fracture were determined. RESULTS: Three out of eight 31-A1 fractures demonstrated a separate GT fragment (three part fracture). Out of the 50 31-A2 fractures, 12 had a single PM fragment, which included the LT and GT in continuity. The more common four part fractures seem to form by further fragmentation of this basic form. In A2 fractures, the GT was almost always broken and the broken fragment comprised a mean 56% of normal GT. The LT fragment involved an average of 74% of the posterior wall, and an average of 36% of the medial wall of the proximal femur. Larger LT fragments were less displaced as compared to smaller fragments. Univariate regression analyses revealed that fracture collapse was significantly correlated with fracture type (A1 versus A2, p 0.036), GT size (p 0.002) and the presence of a lateral wall fracture (p<0.001). CONCLUSIONS: This study revealed some important differences between the 3D CT appearances and AO classification of pertrochanteric fractures. Further, neither fragmentation of the posteromedial fragment, nor the size of the lesser trochanter fragment was found to predict stability in pertrochanteric fractures. A perioperative lateral wall fracture is the main determinant of stability in these fractures.

Giant cell tumour of clavicle: Occurrence of a common tumour in a rare location.

INTRODUCTION: The clavicle is rare site of bone tumours. Majority of the tumours of clavicle are malignant and are often misdiagnosed due to low index of suspicion. The oncological patterns of clavicle resemble that of flat bones. CASE PRESENTATION: A 60year old man presented to our centre with pain and swelling over lateral end of left clavicle. After thorough investigation a provisional diagnosis of giant cell tumor was made which was treated with partial claviculectomy. At one year follow up, there was no shoulder disability or any incidence of recurrence. CONCLUSION: Since majority of clavicular tumors are malignant so any selling occurring in this area should be seen with high index of suspicion and should be investigated thoroughly.

Surgical Treatment of Unstable Distal Radius Fractures With a Volar Variable-Angle Locking Plate: Clinical and Radiological Outcomes.

BACKGROUND: Unstable distal end radius fractures are difficult to manage and so various treatment modalities have been described. The use of variable-angle locking plates is promoted for the management of these fractures. OBJECTIVES: This study aimed to evaluate the functional and radiological outcomes in unstable distal end radius fractures treated with variable-angle locking plates. PATIENTS AND METHODS: We reviewed 23 unstable distal end radius fractures that were treated at our institution with volar variable-angle locking plates. The mean age of the patients was 32.82 ± 11.81 years (range 19 to 62) and the mean duration of follow-up was 11.04 ± 2.47 months (range 6 to 15). All of the patients underwent open reduction and internal fixation with a variable-angle locking plate. Radiological parameters such as radial inclination, length, tilt, and ulnar variance were measured at six weeks and at the final follow-up. The functional evaluation was conducted by measuring the range of motion at the wrist joint as well as the grip strength. Gartland and Werley's demerit scoring system was used to assess the final outcome. RESULTS: There were two cases of superficial infection that responded to oral antibiotics. One patient had developed a hypertrophic scar, while another had carpal tunnel syndrome that was conservatively managed. There was a significant improvement in the functional indices from six weeks to the final follow-up, while the radiological parameters were maintained. According to Gartland and Werley, excellent results were reported in 65.2% cases, while good results were present in 35% cases. CONCLUSIONS: The use of variable-angle locking plates in treating unstable distal end radius fractures is associated with excellent to good functional outcomes with minimal complications.

Neglected Thoraco Lumbar Traumatic Spine Injuries.

STUDY DESIGN: Retrospective study. PURPOSE: To outline the etiology, complications and management difficulties encountered in the management of neglected thoracolumbar spine injuries. OVERVIEW OF LITERATURE: The English literature describes overlooked diagnosis as the most common cause of neglected spine injuries. However, the reasons differ in developing or under-developed nations. Moreover, there is scarcity of literature about the neglected spinal injuries. METHODS: Patients presenting with thoracolumbar traumatic injuries who had not received any form of treatment for more than three weeks were included in the study. The demographic details, operative procedure performed and complications encountered, along with American Spinal Injury Association grade and spinal cord independence measure score recorded on the history sheets were noted. The data were analyzed. RESULTS: Forty patients were included in the study. Inadequate treatment at the first contact hospital (45%) followed by late presentation (38%) and missed injury (17%) were the major etiological factors for the neglected traumatic injuries in the thoracolumbar spine. The most common complications seen in the management of these cases were pressure sores (58%), back pain (57%), urinary tract infection (42%) and residual kyphotic deformity (42%). CONCLUSIONS: Management of neglected thoracolumbar injuries is challenging. The delay in presentation should not prevent spine surgeon in proceeding with operative intervention as good results can be expected.