Cadaveric Study of Variations in the Course of Lateral Femoral Cutaneous Nerve: Insight to Prevent Injury.

Objective: A recent spurt in incidence of meralgia paresthetica to 0.1-81% due to minimally invasive anterior approach to hip joint has resulted in reinterest in anatomy of lateral femoral cutaneous nerve (LFCN). Familiarity with variations in the course of LFCN will reduce the morbidity associated with orthopedic procedures around the anterior superior iliac spine (ASIS) and inguinal ligament (IL). Methods: Twenty five adult human formalin embalmed cadavers were dissected. Course and relations of nerve to ASIS, IL and sartorius muscle was noted, distance of nerve from ASIS at IL was measured and statistically analyzed. Results: Mean distance of LFCN from ASIS at IL was 1.73±1.15 cm. Differences between two sides and sexes was statistically not significant (p=0.51 and p=0.96 respectively). Inferomedial to ASIS, 94% of LFCNs crossed IL with 92% of them present within 4 cm medial to ASIS. Majority of LFCNs (90%) exited pelvis and entered thigh posterior to IL. Out of these nerves 48% were single trunks on entry into thigh, then bifurcated into anterior and posterior branches. Remaining LFCNs bifurcated proximal to IL or at level of IL. Trifurcations were seen in 6% while a rare case of pentafication was observed. In 66% main trunk/branches were present in intermuscular cleft between sartorius muscle and tensor fascia lata. Conclusions: Care should be exercised by surgeons while dissecting around IL as more than half of nerves are liable to be injured during operative procedures. This would help in better anticipation of problem, acceptance and reducing litigation.

Evaluation of vertebral shortening and interbody fusion with short segment pedicle screw fixation for unstable thoracolumbar fractures.

Background: Various operative procedures have been described for the treatment of traumatic paraplegia caused by unstable thoracolumbar fractures. We prospectively evaluated interbody fusion (IBF) with SS-PSF in these cases with regard to clinico-radiological outcome with the objectives: (1) Does IBF and short segment pedicle screw fixation (SS-PSF) prevent progression of kyphotic angle after surgery? (2) Can this procedure be safely performed in the setting of acute trauma?. Methods: Sixteen patients suffering from traumatic paraplegia caused by acute unstable thoracolumbar fractures were enrolled prospectively and underwent IBF with SS-PSF. They were evaluated for magnitude of shortening in spine, progression of kyphotic angle, and neurological improvement by American spinal injury association scale (ASIA). Results: Out of total sixteen, 14 patients were ASIA grade A and 2 were grade C, at the time of presentation. Thirteen out of these 14 remained grade A and one improved to B. Both the patients who had grade C involvement at the time of presentation improved to grade D at one-year follow-up. The mean blood loss was 750 ml (range; 650 ml-1150 ml). Mean kyphotic angle decreased from 20.6° (range; 13° to 37°) preoperatively to 6.2° (range; 3° to 10°) at postoperative day 2 (p = 0.002). Its mean value after 6 months was 6.5° (range; 3° to 11°). The procedure resulted in mean spinal column shortening of 18 mm (range; 16 mm-22 mm) in the spinal column. All the patients achieved bony union by a mean duration of 3.9 months (range; 3 months-6 months). Conclusions: IBF with SS-PSF has the shortest possible instrumented construct for thoracolumbar junction fusion done by posterior approach. The interbody fusion for unstable thoracolumbar junction fractures prevents the progression of kyphotic angle post-operatively. Level of evidence: Level 4.

Correlation between clinical scoring systems and quantitative MRI parameters in degenerative lumbar spinal stenosis.

Background: Many quantitative MRI parameters and clinical scores have been used patients with lumbar spinal stenosis (LSS). However, the correlation between clinical scores and MRI parameters is not very clear. The objective of the study was to find out the correlation between commonly used clinical scoring systems and quantitative MRI parameters. Methods: Eighty two patients (more than 40 years) with clinical and radiological characteristics of degenerative LSS completed 10 clinical questionnaires which included Oswestry disability index (ODI), Swiss spinal stenosis (SSS) questionnaire, Quebec pain disability scale (QPD), Visual analogue scale (VAS), modified Japanese orthopaedic association scale (mJOA), Pain disability index (PDI), Short form health survey (SF-36), Self-paced walking test (SPWT), Euro quality of life-5D (EQ-5D) and Neurogenic claudication outcome score (NCOS). Lumbosacral MRIs were performed and 8 quantitative parameters namely transverse & AP diameter of dural sac (TDD, APDD), anteroposterior diameter of spinal canal (APDS), ligamentous interfacet distance (LID), mid-sagittal diameter of thecal sac (MSDT), cross-sectional area dural sac (CSAD), lateral recess depth and angle (LRD, LRA) were measured at the maximum stenotic level at the level of the disc. The clinical and radiological parameters were then statistically analysed. Results: There were 51 females and 31 males in the study with a mean age of 53.0253.02 ± 9.18 years. NCOS score had a moderate correlation with CSAD, LID and TDS (p<0.05,0.7>r ≥ 0.3). MSDT showed a moderate negative correlation with SSS, VAS, ODI and QPD (p<0.05,0.7>r ≥ 0.3). LRD had a moderate negative correlation with ODI and VAS score (p<0.05,0.7>r ≥ 0.3). LRA had a moderate correlation with the EQ-5D and ODI (p<0.05,0.7>r ≥ 0.3). The CSAD had a moderate negative correlation with PDI (r = -0.383, p = 0.000). For all other comparisons, there was poor or no correlation. MRI parameters showed poor or no correlation with most of components of SF-36 score. Conclusions: A poor correlation or no correlation was noted for most of the MRI parameters when compared to commonly used clinical scores. Hence, poor MRI's don't necessarily mean poor clinical scores in LSS. The role of MRI parameters should be supplementary and overreliance on them in LSS management should be avoided.

The Effect of Customized and Silicon Insoles on Mid- and Hindfoot in Adult Flexible Pes Planovalgus.

Background: Flexible flat foot or pes planovalgus is a common foot deformity, and silicone and customized insole are commonly used as a non-operative treatment modality of flexible planovalgus. However, there are inadequate data and limited evidence available regarding the immediate effects of their use in midfoot and hindfoot of adults. The aim of this study is to quantify and compare the radiological parameters immediately on weightbearing with silicon and customized insoles and without them to assess the effect on midfoot and hindfoot of the flexible planovalgus in adults. Methods: A total number of 11 (8 females and 3 males) subjects with flexible pes planovalgus deformity without any other foot deformity were included in the study. Each patient was assessed three times in a random sequence without and with use of either silicon insoles or customized insole. The radiographic parameters without insole, with silicon insole, and with customized insole conditions were calculated using online available computer software Kinovea. Results: One-way ANOVA analysis was performed between groups (without insole, with silicone insole and with customized insole). The hindfoot parameters depicted that calcaneal inclination angle (CIA) was significant increased (P = 0.000) and talar declination angle (TDA) was significantly decreased (P = 0.003) only with the use of customized insole compared to without insole. The midfoot parameters depicted that the first metatarsal angle (FMA) and talonavicular coverage angle (TCA) were significantly lower with customized insole (P = 0.00) as compared to other two groups and significantly lower with silicone insole (P = 0.00) as compared to without insole group. Conclusion: The results imply that the compressibility of the insole material affects the forefoot and hindfoot biomechanics differently. This study concludes that silicone insole affects only the midfoot which bears 45% of bodyweight and customized insole affects both midfoot and more importantly the hindfoot which bears 55% of bodyweight.

Perceived usefulness of trauma audit filters in urban India: a mixed-methods multicentre Delphi study comparing filters from the WHO and low and middle-income countries.

OBJECTIVE: To compare experts' perceived usefulness of audit filters from Ghana, Cameroon, WHO and those locally developed; generate context-appropriate audit filters for trauma care in selected hospitals in urban India; and explore characteristics of audit filters that correlate to perceived usefulness. DESIGN: A mixed-methods approach using a multicentre online Delphi technique. SETTING: Two large tertiary hospitals in urban India. METHODS: Filters were rated on a scale from 1 to 10 in terms of perceived usefulness, with the option to add new filters and comments. The filters were categorised into three groups depending on their origin: low and middle-income countries (LMIC), WHO and New (locally developed), and their scores compared. Significance was determined using Kruskal-Wallis test followed by Wilcoxon rank-sum test. We performed a content analysis of the comments. RESULTS: 26 predefined and 15 new filter suggestions were evaluated. The filters had high usefulness scores (mean overall score 9.01 of 10), with the LMIC filters having significantly higher scores compared with those from WHO and those newly added. Three themes were identified in the content analysis relating to medical relevance, feasibility and specificity. CONCLUSIONS: Audit filters from other LMICs were deemed highly useful in the urban India context. This may indicate that the transferability of defined trauma audit filters between similar contexts is high and that these can provide a starting point when implemented as part of trauma quality improvement programmes in low-resource settings.

Positive QuantiFERON test and the severity of COVID-19 disease: A prospective study.

BACKGROUND: A strong negative correlation is reported between the Bacille Calmette Guerin (BCG) index and COVID-19 mortality. The present study explored if frequent exposure to strong Th1 antigens like Mycobacteria or Salmonella have any effect on the progression of the disease in COVID-19 patients. METHODS: This prospective comparative study comprised of 3 groups of 20 each of mild or asymptomatic COVID-19 patients (A), severely ill patients (S) and healthy volunteers with a COVID Negative report (H). RESULTS: QuantiFERON TB Gold (QFT) which is interferon gamma release assay (IGRA) against Mtb antigen was used to quantify immunity status of patients against the tuberculosis. Group S showed positive QFT in only 15% patients as against 50% QFT positive patients in group A and H. All fourteen patients in group S with QFT negative report died while 5 of six survived patients showed positive QFT report either on initial or repeat testing done at 6 weeks. The sixth survived patient was QFT negative but showed high antibody titre against H antigen (TH) on Widal test. All severely ill group S patients showed huge reduction of IGRA even to the mitogen stimulus thus suggesting gross general unresponsiveness of T cells. Presence of BCG scar showed no correlation with prevalence or progression of the disease. CONCLUSION: Population in an endemic area of tuberculosis and typhoid with good community exposure to these antigen is likely to withstand COVID -19 better and show reduced mortality following it.

Spectrum of Drug Resistance in Musculoskeletal Tuberculosis.

BACKGROUND: Very few studies report resistance pattern exclusively in musculoskeletal tuberculosis (MSK-TB). METHODS: This study of 100 pus samples from patients of MSK-TB with active disease in whom Mycobacterium tuberculosis (MTB) was detected by cartridge-based nucleic acid amplification test (CBNAAT), revealed the pattern of resistance among newly diagnosed and previously treated cases. Liquid culture and drug susceptibility testing (DST) using MGIT 960 was done for 11 anti-tubercular drugs. RESULTS: Among these 100 cases; 22% were AFB positive; MGIT 960 detected MTB in 58.33% (35/60) new cases and 30.0% (12/40) previously treated cases. Five new and 10 previously treated cases had drug resistance and 12 were detected rifampicin resistance (Rif-R) by CBNAAT. Among new cases MGIT-DST detected mono-INH resistant in 2.86% (1/35), mono-STR resistant in 2.86% (1/35), MDR-TB in 5.7% (2/35) and pre-XDR in 2.9%(1/35).Among previously treated cases Rif-R was found in 10% (4/40) where MTB was not detected by MGIT and MGIT-DST detected mono-INH resistant in 8.33% (1/12); MDR-TB in 8.33% (1/12) and pre-XDR in 33.3%. There were no cases of XDR-TB. CONCLUSION: High disease burden of various type drug resistance were seen more commonly in previously treated cases and was not uncommon in new cases of MSK-TB. Both CBNAAT and DST are essential for detecting resistance pattern in MSK-TB.

Trapezius sparing minimally aggressive surgical technique for sprengel deformity: A case report.

Sprengel deformity is a rare congenital anomaly of the pectoral girdle of unknown incidence. Surgical intervention is indicated in moderate to severe cases having functional and cosmetic impairment. Various surgical corrective procedures have evolved over the past decades, however the extensive magnitude of some of the surgical techniques have sometimes resulted in an unwarranted worse outcome due to associated complications like brachial plexus palsy, scapular winging, sternoclavicular joint prominence, improper scar healing and keloid formation which restrict such procedures to experienced hands at few centres. We report a case of Cavendish grade 3 Sprengel deformity in a five-year-old boy managed with a minimally aggressive modified technique of preserving the trapezius and restricting the surgery to excision of omovertebral bar and supraspinatous part of scapula by a transverse incision overlying the spine of scapula. In Sprengel deformity, the trapezius attached to the elevated scapula is underdeveloped and the technique of retraction instead of detachment of this muscle during surgery, can prevent scar adhesions and improve wound healing. In our patient, satisfactory cosmetic correction and good functional shoulder movements were achieved with minimal intervention.

Freeman-Sheldon Syndrome with Stiff Knee Gait - A Case Report.

Introduction: Freeman-Sheldon syndrome (FSS), also known as the distal arthrogryposis (DA) type 2A, is a rare congenital anomaly. We report a unique case of the DA type 2A with mixed clinical features and the unusual presentation of bilateral congenital dislocation of the knee but had unassisted stiff knee gait. Case Report: A 5-year-old female child presented to the clinic with the complaint of inability to bend both knees since birth. She had an unassisted bipedal gait, but could not squat, cross-leg sit, run, and climb stairs without assistance. Her youngest brother had a similar presentation but succumbed to death at the age of 5 months due to respiratory distress. Clinical features were in the favor of FSS. Her serum creatinine kinase level was normal and the electromyography of bilateral tibialis anterior and abductor pollicis brevis was not suggestive of the myotonia. Radiograph of the skull showed cooper beaten skull appearance whereas bilateral pelvis with the hip showed following changes in the right hip; decrease femoral epiphysis height, horizontal proximal femoral physis, and the coxa brevia. She was initially managed conservatively by weekly stretching, manipulation, and casting. As a result, she could flex her knee up to 20°. Although the quadricepsplasty might be helpful for the persistent extension deformity, there was marked quadriceps weakness which could make it harder for the child to stand and walk. In addition, the abnormal muscle physiology in FSS may result in unfavorable outcomes after the surgery. Moreover, a consideration of the surgical aspect is not free of risks which include difficult endotracheal intubation, vein access, and malignant hyperthermia. Conclusion: FSS is a rare congenital anomaly that should be differentiated from another syndrome of the close resemblance, Sheldon Hall syndrome and Schwartz Jampel syndrome which are other rare autosomal recessive disorders characterized by myotonia and the chondrodysplasia. Conservative management has still a role in bilateral knee involvement especially if the patient is an independent walker.

Primary Aneurysmal Bone Cyst of the Distal Tibia Crossing the Open Physis.

Crossing the barrier of an open physis by primary aneurysmal bone cyst is an exceptional phenomenon. We present a rare case of primary active aneurysmal bone cyst of the distal tibia in a 15-year-old boy in whom the lesion had crossed the open lateral distal tibia physis. The diagnosis was confirmed by radiographs, computed tomography, magnetic resonance imaging, and histopathologic findings. The lesion was successfully treated by extended curettage and allograft impaction. The patient was asymptomatic when last seen at 30 months.

Electrocuted Hip: Late Consequences of Electrical Shock Injuries of Orthopaedic Relevance: A Case Report and Review of Literature.

CASE: A 43-year-old man suffered household electric shock from 220 V alternating current when he accidently touched a live wire with his left hand. Subsequently, he was diagnosed to have osteonecrosis of the left femoral head and underwent total hip arthroplasty. CONCLUSION: We suggest that the electric current could have thrombosed the terminal subsynovial vessels of the femoral head, leading to osteonecrosis. To the best of authors' knowledge, only 2 cases of osteonecrosis of the hip after electric shock have been reported in the literature. A literature review of the delayed consequences of electric shock injuries pertaining to orthopaedics is also presented.

Study of Anatomical Variations of 1,2 Intercompartmental Supraretinacular Artery-Based Vascularized Bone Graft in Cadavers.

BACKGROUND: The aim of this study is to describe the anatomy of the 1,2 intercompartmental supraretinacular artery (1,2 ICSRA), including the location of the perforators, number of perforators, and proximal and distal origins of the artery. MATERIALS AND METHODS: The study was done by dissecting both wrists of 11 fresh-frozen cadavers. In each specimen, skin incision and dissections were done in the forearm by the Henry approach. Radial artery was identified and cannulated and dye was injected. The dye consisted of the mixture of polyvinyl chloride and acetone in the ratio of 1:4, to which red-colored resin was added. The artery of interest 1,2 ICSRA was dissected and its anatomical characteristics such as distal origin, proximal origin, number of perforators, and largest perforator were measured. RESULTS: Of the 22 wrists dissected, only in 19 wrists we were able to recognize the perforators. Average number of perforators seen was 3.05 (range 1-5). Average distance of the largest perforator from the radial styloid was 11.79 mm (range 6-19 mm). The average distance of the distal origin of 1,2 ICSRA from the radial styloid was 6.71 mm distal to radial styloid. It ranged from 16 mm distal to styloid process to 6 mm proximal to the styloid process. The average distance of proximal origin of 1,2 ICSRA from the radial styloid was 40.52 mm proximal to the radial styloid (range 25-66 mm). The maximum density of perforators of 2.84 was noticed to be in the region of 6-18 mm from the distal articular margin. CONCLUSION: The distal origin of 1,2 ICSRA in our study was much more distal in comparison to the western population. The detailed anatomy of the 1,2 ICSRA presented in this study may guide in planning and dissection to maximize the vascularity of a pedicled bone graft based on this vessel for the management of scaphoid nonunions and other carpal pathologies.

Tingling hand: magnetic resonance imaging of median nerve pathologies within the carpal tunnel.

Compressive neuropathy of the median nerve at the level of the carpal tunnel, known as carpal tunnel syndrome, is the most common entrapment neuropathy, affecting about 0.1-1% of the general population. Magnetic resonance reliably imaged the flexor retinaculum and carpal bones and thus defined the borders of the carpal tunnel. In all cases the median nerve was seen as an ovoid structure of moderate signal intensity and was easily distinguished from the flexor tendons of the hands running in the carpal tunnel. Magnetic resonance imaging (MRI) serves as an extremely useful tool for evaluation of primary nerve pathologies and for the assessment of space-occupying lesions leading to its compression. We present a pictorial review of the MRI findings in the multitude of pathologies implicated in the causation of carpal tunnel syndrome. All the images were obtained from the Department of Radiodiagnosis in our own institution.

Functional evaluation of early tendon transfer for foot drop.

AIM: Early tendon transfer has shown good outcomes in peripheral nerve injuries of upper limb. However, there is lack of knowledge on early tendon transfer for peripheral nerve palsy in lower limb. This study has been designed to study the functional outcomes of early tendon transfer in the lower limb, particularly for foot drop. PATIENTS AND METHODS: We enrolled 30 cases of foot drop due to traumatic sciatic/common peroneal nerve (CPN) palsy between September 2012 and March 2016. We performed nerve exploration with repair and early tendon transfer in all patients. All patients were followed up for a minimum period of 24 months. Functional evaluation was carried out using Stanmore assessment questionnaire. RESULTS: At the end of 24 months postoperatively, the Stanmore assessment questionnaire score showed a significant improvement from a mean preoperative score of 17.5 to mean postoperative score of 86.2. All patients were free of ankle-foot orthosis (AFO). All patients were subjectively satisfied. Time to return to original job was 5.2 months on an average. Ankle dorsiflexion of the operated limb was comparable to the normal limb in cases where there was nerve recovery. Planovalgus foot, a known complication of this procedure, was noted in 24 patients. However, it was not disabling to any patient. CONCLUSION: Early tendon transfer in CPN palsy/sciatic nerve palsy has a definite place in the management of the injured patient. The transfer, if appropriately carried out, acts as a helper, an internal splint, a substitute, or perhaps all of the three at varying times in the rehabilitative phase of the patient. Dorsiflexor clearance in swing phase of locomotion was quickly restored in all patients, obviating the need for AFO.

The clinical profile of musculoskeletal injuries in children attending a major hospital in Delhi, India.

BACKGROUND: Children are vulnerable to musculoskeletal injuries both at home and on the street for various reasons. Morbidity and disabilities resulting from these, mostly preventable, injuries, make them a burden to their families and society. The role of various factors associated with injuries is often not documented. METHODS: This prospective study, done on 100 children aged up to 12 years with musculoskeletal trauma, analysed in details, the various modes of injuries. RESULTS: One in every five patient was a child below 12 years of age. Boys were injured more than girls. Injuries, especially fractures, were most common in the extremities, the upper limb more commonly injured than the lower limb. Most of the injuries occurred at home. The most common mode of injuries was falls that happened while playing both within and outside the home, followed by road traffic accidents. Most injuries occurred during daytime. CONCLUSIONS: Injuries in children were found to be preventable. Small interventions while constructing homes can contribute tremendously to injury prevention and control in children. Parental awareness about the various modes of injury, role of supervised playing and their responsibility towards injury prevention can play a key role in reducing the morbidity associated with childhood fractures.

Pseudoaneurysm of profunda femoris artery following dynamic hip screw fixation for intertrochanteric femoral fracture.

Dynamic hip screw fixation is a commonly performed procedure for internal fixation of intertrochanteric femoral fractures. Arterial injury following the operative fixation is a rare but serious event. We present a patient who developed pseudoaneurysm of profunda femoris artery after internal fixation of intertrochanteric fracture with a dynamic hip screw. The diagnosis was confirmed by angiographic study and it was successfully treated by coil embolization.

Combined intraarticular fracture of the body and the hook of hamate: an unusual injury pattern.

Isolated fractures of the carpal hamate are rare. We describe a case of 28-year-old male patient who sustained a rare pattern of wrist injury: combined intraarticular fracture of the body and the hook of hamate in the non-dominant left hand. The patient was treated with percutaneous pinning of the fracture of hamate body.

Isolated involvement of the posterior elements in spinal tuberculosis: a review of twenty-four cases.

BACKGROUND: The literature on tuberculosis of the posterior spinal elements without involvement of the vertebral body is scarce. In this study we report our experience with twenty-four cases of neural arch tuberculosis that were treated at our center. METHODS: We performed a retrospective review of the clinical and radiographic data of twenty-four consecutive patients who had tuberculosis of the posterior spinal elements with total sparing of the vertebral bodies and intervertebral disc space. We categorized the patients into two groups on the basis of the clinical and radiographic evaluation. The patients who had rapid onset weakness of the lower limbs or pyramidal signs or who showed evidence of epidural abscess underwent emergency decompressive laminectomy (Group A). Patients who had pyomyositis of the posterior spinal muscles without any neurological deficit, pyramidal signs, or epidural abscess were managed with antitubercular therapy alone (Group B). RESULTS: The common presenting features were spastic limb weakness and back pain. The majority of the patients had involvement of the thoracic spine. Epidural abscess, erosion of lamina, and pyomyositis of posterior spinal muscles were common imaging findings. Group A consisted of nineteen patients and Group B consisted of five patients. The mean period of follow-up was 16.9 months (range, nine to sixty months). Patients in Group A had a poorer outcome than those in Group B. Thirteen of the nineteen patients in Group A improved to become independent in the activities of daily living, with complete neurological recovery in eight patients and partial recovery in five patients. Six of the nineteen patients continued to have spastic paraplegia and were wheelchair-dependent. All of the patients in Group B remained neurologically intact during the follow-up period. None of the patients had recurrence of the disease or developed anterior element involvement or kyphotic deformity during the follow-up period. CONCLUSIONS: Neural arch tuberculosis is often missed at the time of initial presentation. In association with epidural abscess, it leads to rapid neurological deterioration. This atypical picture of spinal tuberculosis showed a high rate of neurological deficit at the time of initial presentation for medical care.