Choice of Entry Point Does Not Affect Clinical and Radiological Outcomes in Antegrade Intra-medullary Nailing in Patients with Shaft of Femur Fracture: A Prospective Randomized Controlled Trial.

Purpose: The choice of entry point, Greater trochanter (GT), or Piriformis entry (PE) for antegrade intramedullary nailing (IMN) of the femur is crucial. This study was performed to compare these two entry points in the patients with shaft of femur fractures regarding intra-operative parameters, radiological and functional outcomes. Materials and Methods: Twenty-four patients underwent GT entry nailing, while 25 patients underwent PE nailing. Surgical time, Intra-operative blood units transfused, Intra-operative fluoroscopy exposure by number of C-arm shots taken, mean drop in hemoglobin, and incidence of iatrogenic fracture were recorded. Patients were followed up at 4 weeks, 6 weeks, and 6 months to look for radiological healing and improvements in functional outcome using Modified Harris Hip Score (MHHS). MRI of bilateral hips with pelvis was done in 25 patients at 6 months of follow-up to detect any preliminary signs of AVN. Results: The mean drop in hemoglobin in the GT group was significantly lesser than the PE group (p = 0.02). Mean MHHS at 4 weeks post-op was also significantly higher in the GT group (p = 0.01). There was no significant difference between both the groups regarding surgical duration, fluoroscopy exposure, radiological and functional outcomes in the long term. None of the patients who underwent MRI displayed any preliminary sign of AVN. Conclusion: GT entry nails lead to lesser surgical time, fluoroscopy exposure, and intra-operative blood loss. Both the nailing systems achieve excellent fracture unions and comparable functional outcomes in the long term, and there is a minuscule risk of AVN in adult patients undergoing IMN.

Medial versus anterior approach for open reduction of hip in children with DDH under two years - A meta-analysis of comparative studies.

Purpose: Open reduction (OR) is usually required in developmental dysplasia of hip (DDH) for children below 24 months of age, those who failed to achieve a satisfactory reduction by the closed method. OR in this age group can be performed either through a medial or anterior approach. However, there is a paucity of literature and a lack of more substantial evidence regarding which approach (medial versus anterior) is superior for performing OR in this age group with minimal complications. Methods: Four databases (PubMed, Embase, Scopus, and Cochrane Library) were searched for relevant articles reporting outcomes and complication rates of DDH children less than 24 months undergone OR either through medial or anterior approach using pre-defined keywords. Data on avascular necrosis (AVN) rates, further corrective surgery (FCS) rates, and clinical and radiological grading using McKay clinical criteria and Severin radiological criteria were assessed. Meta-analysis was carried out using RevMan (Review Manager 5.4) software. Results: Five comparative studies, having a minimum of two-year follow-up, were included for final analysis. According to the MINORS tool assessment, all five studies were of good to high quality. Of 257 hips, 151 and 106 underwent OR through medial and anterior approaches, respectively. Our meta-analysis showed a statistically significant (p = 0.01) number of AVN cases with the anterior approach compared to the medial approach. The overall random effect showed the odds of having AVN with an anterior approach to be 2.27 (95% CI: 1.18,4.38) times more than the same with a medial approach. Regarding FCS rates, the meta-analysis depicted no significant difference between the two groups (p = 0.63). The two groups had no statistically significant difference regarding clinical and radiological outcomes using McKay and Severin criteria, respectively. Following surgery, improvement in the acetabular index from pre-operative value showed no statistically significant difference between the two groups (p = 0.48). Conclusions: Medial approach is safe and effective for OR of the hip in DDH up to 24 months of age. Our analysis showed that AVN rates are lower with a medial approach than the anterior approach, with similar clinical and radiological outcomes and rates of FCS. However, one should consider the surgeon's expertise while choosing between these approaches.

Forgotten Foreign Bodies Mimicking Osteomyelitis, a Diagnostic Dilemma - A Report of Two Cases.

Introduction: The first differential diagnosis for a chronic discharging sinus on an extremity is usually chronic osteomyelitis. These patients are usually treated with surgical debridement and intravenous antibiotics. However, all discharging sinuses are not osteomyelitis. Case Report: We encountered two such cases, initially treated as osteomyelitis, which did not respond to initial surgical debridement and, on further workup, were found to have foreign bodies in situ that mimicked osteomyelitis. The first case is a 1 ½-year-old child with an intact rubber band inside the wrist, presenting with sinuses on the wrist, and the second one is a 12-year-old with an old penetrating injury to the foot through the sole of a rubber slipper. Both patients recovered completely once the foreign bodies were removed. Conclusion: We stress the importance of keeping the possibility of a foreign body in mind in patients with discharging sinuses not responding adequately to debridement and antibiotics.

Techniques, anaesthesia preferences, and outcomes of Achilles tenotomy during Ponseti method of idiopathic clubfoot correction: A systematic review.

BACKGROUND: Achilles tenotomy (AT) forms an important aspect of Ponseti's casting method and is performed in 80-90% of idiopathic clubfoot cases to correct residual hindfoot equinus. Different techniques are described in the literature with no clarity on which method is superior. This review aims to analyse the various techniques described, anaesthesia preferences, and outcomes of AT. METHODS: We searched PubMed, Embase, Scopus, and Ovid MEDLINE for articles describing idiopathic clubfoot cases undergoing primary AT during Ponseti's casting method. Data were extracted from eligible studies for qualitative and quantitative synthesis. The repeat tenotomy and complication rates were taken as outcome parameters. RESULTS: Nineteen studies were included for systematic review. A percutaneous AT using a scalpel or needle is adequate in most cases and shows promising results. The out-patient department (OPD) tenotomies under local anaesthesia (LA) and operation room (OR) tenotomies under general anaesthesia (GA) were associated with a repeat tenotomy (RT) rate of 2.5% (95%CI, 0.4-5.4%) and 0.8% (95%CI, 0-1.6%), respectively. The difference between OPD and OR groups was not statistically significant (p = 0.875). The pooled analysis shows a failure/relapse rate of 4.2% (1.9-6.4%, p < 0.001) after AT. OPD and OR tenotomies were associated with a complication rate of 1.6% (95%CI, 0.2-3.0%) and 0.5% (95%CI, 0.1-0.8%), respectively, and the difference was not statistically significant (p = 0.807). Bleeding is the most common complication and is controlled in most cases by applying local pressure. CONCLUSION: Performing Achilles tenotomy in OPD under LA is safe and cost-effective with similar success rates to those done under GA. With the lack of many comparative and higher-level evidence studies at present, we can't conclude if one technique is better than another.

A Novel, Low-Cost Telescopic Nail Design for Prevention and Treatment of Osteogenesis Imperfecta Associated Long-Bone Pathological Fractures in Children.

Telescopic nailing and intermittent doses of bisphosphonates are now considered the standard treatment for preventing long bone pathological fractures in osteogenesis imperfecta (OI) children. Even though the telescopic nail designs have evolved over time, we are yet to get an affordable, worldwide uniformly and easily available, surgeon-friendly telescopic nail with good rotational stability. We designed a telescopic nail with modifications in Küntscher nail (outer, hollow component) and square nail (inner, solid component). The distal end of the square nail has a slot to allow locking in the distal epiphysis using a threaded K wire. The interlocking geometry between the two nails allows reasonable rotational control while allowing only longitudinal movements. This novel, low-cost, rotationally stable telescopic nail design is a good alternative to existing telescopic nails in the market, especially for children from low and middle-income countries (LMIC) where affordability and uniform availability are a concern.

Correction results of atypical clubfeet managed with modified Ponseti technique: A meta-analysis of 354 feet.

Background/purpose: Atypical clubfeet are distinct from idiopathic clubfeet. It is resistant to correction by conventional casting methods and often requires a modification of Ponseti's casting technique. Although the initial correction rates are reasonable, relapse and complications are frequent. There is limited literature on the results of modified Ponseti casting of these feet. We conducted this meta-analysis to study a few important aspects of atypical/complex clubfeet treatment by the modified Ponseti technique. Research question: What are the results of atypical or complex clubfeet after treatment by the modified Ponseti technique? Methodology: Five electronic databases (PubMed, Embase, Scopus, Ovid, and Cochrane Library) were searched for articles reporting on the results of atypical/complex clubfeet treated by the modified Ponseti technique. Details of the number of casts required for correction, rate of percutaneous Achilles tenotomy (PAT), other soft tissue procedures required, complications, and relapse rates were extracted into spreadsheets, and meta-analysis was carried out using OpenMeta Analyst software. Results: Ten studies were included for analysis with a total of 240 patients with 354 clubfeet. The initial correction was achieved in all feet. A pooled analysis of the data showed that a mean of six casts was required for the initial correction. The rate of PAT was 98.3%. The overall complication rate was 16.8%. 7.2% required an additional soft tissue procedure apart from the PAT, and relapse of the deformity was observed in a mean of 19.8% cases. Conclusion: Modified Ponseti technique is effective in the initial management of atypical/complex clubfeet. Although the PAT rate is slightly higher in the Modified Ponseti technique, the remaining result parameters are comparable with the results of idiopathic clubfoot managed with the Ponseti method of casting. However, these children should be kept under follow-up for a longer duration to find the exact relapse rates.

Is modified reverse step-cut osteotomy better than Yun's reverse V osteotomy in paediatric cubitus varus deformity correction? A prospective, double-blinded, randomized controlled trial.

BACKGROUND: Various corrective osteotomy techniques have been described in the literature for correcting paediatric cubitus varus. But we are still in search of the perfect technique that gives maximum possible deformity correction and cosmetic appearance that satisfies parents with minimal complications. We compared the outcomes of two technically sound osteotomy techniques having minimal postoperative lateral condyle prominence described in the literature. RESEARCH QUESTION: Is modified reverse step-cut osteotomy (MRSO) better in terms of clinical, radiological, and cosmetic outcomes than Yun's reverse V osteotomy (RVO) in pediatric cubitus varus deformity correction? METHODS: In total, 20 children with unilateral cubitus varus resulting from malunited supracondylar humerus fractures were included. Randomization was done by computer-generated random slips. A total of ten cases each were operated by MRSO and RVO techniques, respectively. Clinical, radiological, and cosmetic appearance assessments were done at the final two year follow-up and compared between the two groups. RESULTS: The mean age of children in the MRSO and RVO groups is 9.9 years (3-16) and 8.6 years (3-16), respectively. The mean pre-operative carrying angle in the deformed elbow of MRSO and RVO group was - 20.5° and - 19.5°, respectively, and the mean pos-toperative carrying angle in the corrected elbow of MRSO and RVO group was + 6.8° and + 6.5°, respectively. Regarding the lateral prominence index (LPI), a positive correlation was noted between pre-operative and post-operative periods with a value of 0.855 and 0.844 (p value: 0.001 and 0.03, respectively) in both MRSO and RVO groups, respectively. However, the change was statistically not significant when compared between the two groups (p = 0.63). There was no statistically significant difference (p > 0.05) when the clinical, radiological, and cosmetic outcomes were compared between the groups at final follow-up. CONCLUSION: The surgeon can choose either one of these techniques based on their expertise since the results of both the techniques are comparable in terms of clinical, radiological, and cosmetic outcomes.

Does the use of ultrasound guidance during percutaneous Achilles tendon tenotomy improve outcomes of clubfoot management? A randomized controlled trial.

Achilles tenotomy is a crucial aspect in the non-operative management of clubfoot as per Ponseti's casting protocol. Achilles tenotomy is routinely carried out percutaneously in a blind manner without any image guidance. This study aimed to determine the role of ultrasound-guided percutaneous Achilles tenotomy (PAT) in improving outcomes in clubfoot management. There are no previous studies that have explored the role of image guidance in PAT. This prospective, single-center randomized control trial included 50 clubfoot cases (74 feet) planned for PAT at a mean age of 30.2 months. A single experienced senior surgeon performed tenotomies. Patients were randomized to two groups, with the tenotomies performed under ultrasound guidance in one group (test group) and PAT carried out without image guidance in the other (control) group. Outcome measures assessed included rate of complications, immediate postoperative FLACC score for pain severity and Pirani score at a minimum follow-up of 12 months. There were no significant differences in the complication rates between the test and control groups regarding bleeding, nerve injury and incomplete tenotomies. The mean pain FLACC score was significantly higher in the control group (PAT without image guidance) (P = 0.03), suggesting that the child would better tolerate the ultrasound-guided procedure. All patients in both groups had a Pirani score of zero and plantigrade feet at final follow up, with no relapses. Ultrasound-guided PAT does not have any added advantage over PAT with clinical examination without image guidance in terms of long-term outcomes. Level of evidence: Therapeutic level II.

Characteristics of Musculoskeletal Involvement in Pediatric Patients with Disseminated Sepsis in a Tertiary Care Center.

BACKGROUND: Pediatric bone and joint infections account for one of the major causes of childhood morbidity. Disseminated sepsis being a systemic disorder with multisystem involvement, overshadows the timely recognition of bone and joint infections. Hence, we did this cross sectional study to evaluate the prevalence of septic arthritis and osteomyelitis in disseminated sepsis in children, the organisms implicated, and their antibiotic sensitivities. METHODS: We prospectively collected data from 1st July 2016 to 31st September 2017 of children aged less than 12 years with disseminated sepsis, i.e., patients with fever and two or more sites of focal infection of anatomically non-contiguous tissues. RESULTS: Fifty-four patients of disseminated disease were included, of which 25 patients (46.3%) had osteoarticular infections. Septic arthritis was seen in 17 patients, and osteomyelitis was seen in 12 patients. The most common joint was hip (41.6%), and the most common bone involved was femur (53.8%). Blood culture showed MRSA in 28% and MSSA in 20%. Joint and bone aspirates showed S. aureus in 56% with 28% of MRSA and MSSA each. All Staphylococcus aureus organisms were found sensitive to vancomycin and teicoplanin. The mean values of CRP, duration of stay and duration of intravenous antibiotic was higher in MRSA infected patients compared to MSSA patients. CONCLUSIONS: Staphylococcus aureus is the most prevalent organism in musculoskeletal infection in disseminated sepsis children, with vancomycin sensitivity of 100% and methicillin sensitivity of 46.2% only. Cases of osteoarticular involvement with MRSA were higher compared to MSSA among the cases of disseminated disease. The prevalence of osteoarticular involvement is high in disseminated sepsis in children and increased clinical suspicion for such must be maintained.

Ilizarov Frame Application Based on Ponseti Principles for Clubfoot Correction: A Case Report and Description of Surgical Technique.

Ilizarov external fixator has proved to be a successful method in the management of neglected and relapsed clubfoot cases as it has lesser surgical morbidity, better functional outcome and does not cause shortening of foot as compared to other surgical methods. Though Ilizarov has been routinely used in the management of neglected/relapsed CTEV, residual varus and equinus deformities are still present/recur in some cases. Here we demonstrated a surgical technique in a case of 8-year-old child with residual club foot who achieved good functional outcome after being treated using Ilizarov frame application in lieu with Ponseti's principles.

Results of the modified reverse step-cut osteotomy in paediatric cubitus varus.

PURPOSE: Cubitus varus deformity occurs in children as a late consequence of supracondylar fracture of the distal humerus. Different types of corrective osteotomies have been described, but a gold standard has not yet been established. The aim of this study is to report the clinical, radiological, and cosmetic outcome of the modified reverse step-cut osteotomy technique. METHODS: This study was conducted on 15 cases, which were operated during the period between July 2015 and June 2016. We used the technique modified reverse step-cut osteotomy with the calculated medial translation of the distal fragment to correct varus and sagittal plane deformity and to achieve anatomical alignment of the forearm axis with the axis of the humerus. Follow-up was done for two years. Pre-operative and post-operative clinical and radiological parameters were compared, and patient satisfaction was assessed. RESULTS: The mean pre-operative humerus-elbow-wrist (HEW) angle was - 22.4°; it improved to + 9.4° post-operatively. The pre-operative mean range of motion was 131.6°, and the post-operative mean was 132°. The clinico-radiological outcome was assessed according to Oppenheim criteria. There was an excellent result in nine patients (60%), a good result in five patients (33.3%), and poor results in one patient (6.6%). Cosmetic outcome was assessed as per Barrett's criteria, excellent result in thirteen patients (86.6%) and poor results in two patients (13.3%). Post-operative lateral condylar prominence index (LCPI) was compared with the normal side, and there was no significant difference. CONCLUSION: We have achieved satisfactory results with acceptable cosmetic appearance and functional outcomes with minimal complications. We recommend this technique as a safe, reliable, reproducible, technically easy procedure for correction of cubitus varus deformity.

Outcome Analysis of Lateral Pinning for Displaced Supracondylar Fractures in Children Using Three Kirschner Wires in Parallel and Divergent Configuration.

BACKGROUND: Supracondylar humerus fracture is the most common fracture around elbow in children. Closed reduction and percutaneous Kirschner wire (pin) fixation is the standard method of managing displaced extension type (Gartland Type II and Type III) supracondylar humerus fractures. The configuration of wires is debatable. Although two crossed K-wires are mechanically stable, there is an inherent risk of ulnar nerve injury. Lateral K-wires - parallel or divergent - are good alternative. This study was aimed at identifying the best configuration for the lateral wires. MATERIALS AND METHODS: Patients with Gartland type 3 supracondylar humerus fractures were randomized by envelope method to receive closed reduction and K-wire fixation in either a parallel or divergent fashion. The patients were followed up at 3 weeks for wire removal and at 6 weeks and 3 months after surgery. Baumann's angle, functional outcome as per Flynn's criteria, and range of motion were recorded in each visit. Effect of delay in surgery was also evaluated as a secondary outcome. RESULTS: Nineteen patients received fixation with parallel wires and 11 patients had divergent fixation. No loss of reduction was seen in any patient at 3 months. No statistically significant difference was seen in the Baumann's angles and outcome according to Flynn's criteria irrespective of the wire configuration (divergent or parallel). Furthermore, the delay in surgery was also found not to have a significant effect on the functional outcome. CONCLUSIONS: Both parallel and divergent K-wire configurations provide satisfactory stability when accurate reduction and adequate fixation of the fracture has been done. Based on the limited number of patients in this study, one configuration cannot be judged to be superior to the other.

Surgical Retrieval of an Impaled Tapestry Needle from the True Pelvic Cavity of a Child-An Unusual Case Report.

INTRODUCTION: Impalement injuries of pelvis have been reported in children but are uncommon. Impalement could be associated with injuries to deep organs, wound contamination, crush injuries, and in certain instances, can even be fatal. CASE REPORT: We present a bizarre case of a 2-year-old female child who presented to us with a tapestry needle embedded in the true pelvic cavity after a history of fall on the buttock while playing at home. The impaled needle was eventually successfully extracted surgically using the modified Stoppa's approach and the post-operative period was uneventful. We also briefly review the literature surrounding such unusual injuries and discuss tips and tricks regarding the surgical technique in such cases. CONCLUSIONS: In impalement injuries, adequate analgesia, tetanus prophylaxis, antibiotics, and immobilization must be given initially followed by meticulous pre-operative planning in the form of radiographs and computed tomography(CT) scans. Minimally invasive CT-guided extraction of needle can be attempted by an experienced interventional radiologist when there is no significant risk of damaging neighboring vital organs or neurovascular structures. The surgical approach if an open approachis decided must be chosen wisely; backup may be needed from an abdominal surgeon, urologist, or gynecologist in certain cases.

Distal femoral physeal crush injury with metaphyseal comminution - A report of two cases and a new perspective to physeal injury.

The physis of a long bone may get 'sandwiched' and crushed between the metaphysis and the epiphysis if it is traumatically loaded along its long axis. Such a physeal injury may lead to complications like angular deformities and growth restrictions and hence, management of such injuries requires adequate planning and attentive execution. Two patients with distal femoral physeal crush injury were treated using a ring fixator such that one ring had the wires passing through the epiphysis and the other through the femoral shaft. On table image intensifier controlled distraction of the crushed physis was done to bring the height of the physis similar to that of the opposite limb. Patients were followed up for more than two years clinically and radiologically. There was no clinical or radiological angular deformity of the operated limbs. MRI scans showed intact physes with no physeal bar formation in either of the two patients. The distraction obtained by the ring fixator appears to have provided ample 'breathing space' to the compressed physis and that the growth potential may have been re-gained by the procedure. However, two years is a relatively short duration of follow-up and further follow-up of longer duration and in greater number of patients is needed to gauge the actual effectiveness of the technique used by us.

Topical vs Intravenous Tranexamic Acid in Reducing Blood Loss After Bilateral Total Knee Arthroplasty: A Prospective Study.

BACKGROUND: Total knee arthroplasty (TKA) results in substantial postoperative blood loss with increased morbidity. Despite various studies proving the efficacy of tranexamic acid (TXA), no consensus exists on the routes of administration. METHODS: Seventy consecutive patients with knee arthritis undergoing simultaneous bilateral TKA, who were eligible and fulfilled the criteria, were taken up for this study. They were randomly allocated by a computer-generated random number table, either to receive intravenous TXA (IVTXA; group 1) or topical TXA (TTXA; group 2) in a prospective, double-blinded study. The primary outcome measures were total blood loss and total drain output. The secondary outcome measures were number of blood units transfused and clinical and functional outcomes as evaluated by the Knee Society Score, Western Ontario and McMaster Universities Arthritis Index score, visual analog score, and wound score. RESULTS: Both groups were similar in age, sex, and body mass index, and no statistical significance was observed. There was statistically significant difference between IVTXA and TTXA groups in mean postoperative total blood loss (P < .001), postoperative hemoglobin (P < .001) with a higher drop of hemoglobin in the former, total drain output (P < .001), and allogeneic blood transfusion (P < .001). No complication was observed in either group. Significant difference was observed in the Western Ontario and McMaster Universities Arthritis Index score at 12 weeks and 6 months (P = .015 and .007) and Knee Society Score at 6 and 12 months (P = .050 and .045, respectively). However, no significant difference was found at 6 weeks. CONCLUSION: TTXA is better than IVTXA in reducing blood loss and clinical outcome after simultaneous bilateral TKA.

Tarsal Bone Dysplasia in Clubfoot as Measured by Ultrasonography: Can It be Used as a Prognostic Indicator in Congenital Idiopathic Clubfoot? A Prospective Observational Study.

BACKGROUND: Congenital talipes equinovarus (CTEV )/clubfoot is the most common congenital orthopedic condition. The success rate of Ponseti casting in the hands of the legend himself is not 100%. The prediction of difficult to correct foot and recurrences still remains a mystery to be solved. We all know that tarsal bones are dysplastic in clubfoot and considering it; we hypothesize that the amount of tarsal dysplasia can predict management duration and outcome. In literature we were not able to find studies that satisfactorily quantify the amount of tarsal dysplasia. Hence, it was considered worthwhile to quantify the amount of dysplasia in tarsal bone and to correlate these parameters with the duration and outcome of treatment by conventional method. METHODS: A total of 25 infants with unilateral idiopathic clubfoot that have not taken any previous treatment were included in the study. An initial ultrasonography was done before start of treatment in 3 standard planes to measure the maximum length of 3 tarsal bones (talus, calcaneus, and navicular). Ponseti method of treatment was used; pirani scoring was done at each OPD (out patient department) visit. Number of casts required for complete correction and need for any surgical intervention were taken as the outcome parameters. RESULTS: We found that there is a significant correlation between number of casts required and the dysplasia of talus (α error=0.05). We also found a significant negative correlation between relative dysplasia of talus and number of casts required (r=-0.629 sig=0.001, r=-0.552 sig=0.004). CONCLUSIONS: Tarsal bone dysplasia as quantified by using ultrasonography can be used as a prognostic indicator in congenital idiopathic clubfoot. Although promising the method needs further studies and can be more useful after long-term follow-up where recurrences if any can be documented. LEVEL OF EVIDENCE: Level II.

Pediatric Subtalar Joint Synovial Chondromatosis Report of a Case and an Up-to-date Review.

Synovial chondromatosis is a rare, usually benign disorder affecting the population predominantly in the third and fourth decades of life and mainly involving the large weightbearing joints of the lower limb-the knees and the hip. In this report, we highlight an unusual pediatric clinical presentation of synovial osteochondromatosis involving the subtalar joint and discuss its surgical management; we also provide a comprehensive up-to-date literature review of the disorder. This patient was successfully treated with en masse surgical excision. He has been doing well, with complete pain relief and improved range of motion at 1-year follow-up. An exceptional involvement of the subtalar joint and an unusual presentation in the pediatric age group makes this case unique.

Primary non Hodgkin's lymphoma of talus in a child-a rare presentation.

We report a rare case of primary non-Hodgkin's lymphoma of bone which presented with an osteolytic lesion of the head of the right talus which to the best of our knowledge is the first case to be reported in the paediatric age group. Early and accurate identification is necessary as it has a good prognosis.