Characterization of the enzymatic and multifunctional properties of Acinetobacter baumannii erythrose-4-phosphate dehydrogenase (E4PDH).

Infections due to Acinetobacter baumannii (A. baumannii) are rapidly increasing worldwide and consequently therapeutic options for treatment are limited. The emergence of multi drug resistant (MDR) strains has rendered available antibiotics ineffective, necessitating the urgent discovery of new drugs and drug targets. The vitamin B6 biosynthetic pathway has been considered as a potential antibacterial drug target but it is as yet uncharacterized for A. baumannii. In the current work, we have carried out in silico and biochemical characterization of Erythrose-4-phosphate dehydrogenase (E4PDH) (EC 1.2.1.72). This enzyme catalyzes the first step in the deoxyxylulose-5-phosphate (DXP) dependent Vitamin B6 biosynthetic pathway i.e. the conversion of d-erythrose-4-phosphate (E4P) to 4-Phosphoerythronate. E4PDH also possesses an additional activity whereby it can catalyze the conversion of Glyceraldehyde-3-phosphate (G3P) to 1,3 bisphosphoglycerate (1,3BPG). Our studies have revealed that this enzyme exhibits an alternate moonlighting function as a cell surface receptor for the human iron transport proteins transferrin (Tf) and lactoferrin (Lf). The present work reports the internalization of Tf and consequent iron acquisition as an alternate strategy for iron acquisition. Given its essential role in two crucial pathways i.e. metabolism and iron acquisition, A. baumannii E4PDH may play a vital role in bacterial pathogenesis.

Locking plate fixation in distal metaphyseal tibial fractures: series of 79 patients.

Open reduction and internal fixation in distal tibial fractures jeopardises fracture fragment vascularity and often results in soft tissue complications. Minimally invasive osteosynthesis, if possible, offers the best possible option as it permits adequate fixation in a biological manner. Seventy-nine consecutive adult patients with distal tibial fractures, including one patient with a bilateral fracture of the distal tibia, treated with locking plates, were retrospectively reviewed. The 4.5-mm limited-contact locking compression plate (LC-LCP) was used in 33 fractures, the metaphyseal LCP in 27 fractures and the distal medial tibial LCP in the remaining 20 fractures. Fibula fixation was performed in the majority of comminuted fractures (n = 41) to maintain the second column of the ankle so as to achieve indirect reduction and to prevent collapse of the fracture. There were two cases of delayed wound breakdown in fractures fixed with the 4.5-mm LC-LCP. Five patients required primary bone grafting and three patients required secondary bone grafting. All cases of delayed union (n = 7) and nonunion (n = 3) were observed in cases where plates were used in bridge mode. Minimally invasive plate osteosynthesis (MIPO) with LCP was observed to be a reliable method of stabilisation for these fractures. Peri-operative docking of fracture ends may be a good option in severely impacted fractures with gap. The precontoured distal medial tibial LCP was observed to be a better tolerated implant in comparison to the 4.5-mm LC-LCP or metaphyseal LCP with respect to complications of soft tissues, bone healing and functional outcome, though its contour needs to be modified.

Soft-tissue osteochondroma of the heel pad: a case report and review of literature.

Extraskeletal osteochondroma of the foot are rare benign cartilaginous tumours. We present a case of soft-tissue osteochondroma in the heel pad superficial to the postero-inferior aspect of the calcaneus. We propose the pathogenesis of this lesion might be related to metaplasia in the plantar aponeurosis as described in literature, or it may be a fracture of the calcaneal osteochondroma, growing and presenting as soft-tissue lesion in the heel pad.

Correlation of Clinical Findings in Acute Spinal Injury Patients with Magnetic Resonance Including Diffusion Tensor Imaging and Fiber Tractography.

INTRODUCTION: Many types of research are being carried out in the fields of understanding of the pathogenesis, early recognition, and improving the outcomes after spinal cord injury (SCI). Diffusion tensor imaging (DTI) is one of the modalities used in vivo microstructural assessment of SCI. The aim of the present study is to evaluate the role of DTI imaging and fiber tractography in acute spinal injury with clinical profile and neurological outcome. METHODS: The study was carried out on twenty-five patients of acute spinal cord injury who presented within 48 hours of injury and completed minimum of six months follow-up. RESULTS: The mean age of patients was 37.32±13.31 years and male & female ratio of 18:7. Total MIS score was 91.64±6.0 initially which improved to 96.92±3.68 after 3 months and 99.4±1.35 after 6 months. Total SIS score was similar at all the time intervals i.e. 224±0. Maximum subjects 14(56%) were classified into AIS C and 5(20%) into AIS D whereas only 6(24%) subjects were having no deficit (AIS E). At the end of 6 months, 13(52%) subjects had no deficit (AIS E). Mean fractional anisotropy (FA) initially was 0.451 (± 0.120) but after 6 months, it increased to 0.482 (± 0.097) (p<0.001). The mean apparent diffusion coefficient (ADC) initially was 3.13 (± 2.68) but after 6 months, it decreased to 3.06 (± 2.68) and this change was found to be statistically highly significant (p<0.001). Mean anisotropy index (AI) initially was 0.420 (± 0.245) but after 6 months, it increased to 0.430 (± 3.41) and this change was found to be statistically significant (p<0.01). CONCLUSIONS: DTI is a sensitive tool to detect neurological damage in SCI and subsequent neurological recovery. FA correlated with ASIA impairment scale. It can be useful as an adjunct to conventional MRI for better evaluation and predicting prognosis in SCI patients.

Magnetic Resonance Imaging of Trunk Musculature and Intervertebral Discs in Patients with Spinal Cord Injury with Thoracolumbar Vertebral Fractures: A Prospective Study.

STUDY DESIGN: This study is a prospective clinical study. PURPOSE: This study aims to evaluate the characteristics of trunk musculature and intervertebral discs by using magnetic resonance imaging in patients with spinal cord injuries (SCIs) with thoracic and lumbar fractures. OVERVIEW OF LITERATURE: Muscle atrophy is an immediate consequence of SCI and is associated with secondary complications. At present, there are limited clinical data on muscle and disc responses to fractures of the thoracic and lumbar spine. METHODS: A total of 51 patients with a mean age of 31.75±10.42 years who suffered traumatic SCI were included in this study. Complete neurological examinations (American Spinal Injury Association grading) and magnetic resonance imaging (MRI) were performed at the time of admission and at 3-6 months after injury to study the neurological status and disc and trunk parameters. The type of management (operative or conservative) was decided on the basis of clinical, radiological, and MRI evaluations, and a robust rehabilitation program was initiated. RESULTS: Disc parameters including disc angle, skin angle, cross-sectional area (CSA), and disc height and trunk parameters (mean trunk width, mean trunk depth, and CSA of the lumbar muscles) decreased significantly (p <0.001) during the first 3 months after SCI. However, improvements were observed in disc and muscle parameters at the 6-month follow-up, but these parameters did not return to normal levels. Neither initial neurological status (complete vs. incomplete) nor type of management (operative vs. conservative) had a significant effect on these parameters. CONCLUSIONS: Spinal trauma leads to alterations in the morphology of the vertebral column, spinal cord, intervertebral discs, and paraspinal muscles in the initial phase of injury. The extent of these changes may determine the initial neurological deficit and subsequent recovery. Although this study did not identify any statistically significant effect of neurological status or management strategy on these parameters, rehabilitation was found to result in the improvement of these parameters in the later phase of recovery. Future studies are required to evaluate the exact causes of these alterations and the potential benefits of rehabilitation strategies and to minimize these changes.

A Prospective Study of Clinicoradiologic-Urodynamic Correlation in Patients with Tuberculosis of the Spine.

INTRODUCTION: Involvement of spinal cord in spinal tuberculosis (TB) has been associated with bladder disturbances on which literature is scarce. The present study aimed at evaluating the urodynamic profile, its correlation with clinical and radiological features, and the prognosis with treatment in these patients. MATERIALS AND METHODS: Thirty patients of spinal TB were prospectively evaluated clinically, radiologically, and urodynamically in this single center prospective study. All patients underwent urodynamic assessment at presentation; and those with bladder dysfunction on initial urodynamics were followed with sequential testing at 3, 6, and 12 months. RESULTS: Patients were divided into two groups on the basis of the absence (Group 1, n = 14) or presence (Group 2, n = 16) of bladder dysfunction. The magnitude of deformity (P = 0.011), sensory deficit (P = 0.025), and tenderness (P = 0.030) at presentation was found to be significantly more in Group 2 and involvement of posterior elements, reduction in disc height, endplate erosion, and nerve root were significantly higher. The initial urodynamic assessment showed delayed sensations in 23.3% and early sensations in 13.3%, respectively; decreased bladder compliance in 3.33%; underactive detrusor in 16.6%, and overactive in 13.3% of cases. The sphincter was dyssynergic in 13.3% of cases. Statistically significant (P < 0.001) improvement in sensory parameters of bladder, detrusor contractility, and compliance with treatment was observed. Thirteen (81.3%) patients of Group 2 showed overall improvement on serial urodynamics after chemotherapy. Patients with bladder disturbances had poorer functional recovery at 6 and 12 months. CONCLUSION: Significant bladder comorbidity is associated with spinal TB and its presence can be recognized as a poor prognostic factor. Urological morbidity is strongly linked to the nerve root and posterior element involvement; reduction in disc height; and end plate erosion. Clinical/neurological improvement correlates with marked radiological and urological improvement.

Proximal femoral resection and Tensor Fascia Lata flap for recalcitrant trochanteric pressure ulcers.

Introduction: Trochanteric pressure ulcers (PrUs) are difficult to treat and are often complicated by infection spreading to the hip joint. We review three cases from India where proximal femoral resection and pedicled Tensor Fascia Lata (TFL) flapping was used in the management of infected deep trochanteric ulcers communicating to the hip joint. Case presentation: Three patients had a total of four trochanteric PrUs communicating to the hip joint. Proximal femoral resection along with radical debridement of the pressure ulcer (PrU) was the first step in our surgical protocol. Serial debridements were performed to make the resulting cavity healthier and ready for the subsequent flap surgery. TFL flapping was done to cover the raw area of the PrU and the donor site was closed either primarily or with a split skin graft. All patients were males with AIS A spinal cord injury (SCI) and stage 4 PrUs in the trochanteric region. One patient had bilateral trochanteric ulcers. There was complete healing of all PrUs with improvement in wheelchair mobility, and general health. Discussion: PrUs are a common complication of patients with SCI and are often considered one of the most neglected issues of health care delivery in India. Proximal femoral resection with pedicled TFL muscle flap is a versatile and reliable procedure for the coverage of recalcitrant trochanteric PrU with hip joint involvement. Minimal donor site morbidity occurs.

Demographic Study of Orthopedic Trauma among Patients Attending the Accident and Emergency Department in a Tertiary Care Hospital.

BACKGROUND: Trauma causes a major burden on the health system and economy of the country. A better understanding of the epidemiology of trauma can be of great help in planning preventive and curative strategies. MATERIALS AND METHODS: A total of 4834 patients of trauma presenting during 1 year were included in this observational study. Demographic profile and other related criteria were noted, and data were statistically analyzed. RESULTS: Male to female ratio was 5:1; most affected age group was 25-44 years in males and 45-64 years in females; 23.2% were illiterate; and professionals and students were most commonly affected. Road traffic accident (RTA), fall, and assault were the three most common causes; two wheelers were the most common accident causing vehicle. Nearly 17.7% were below poverty line and 67.6% reached hospital within 12 h. Medicolegal cases were 29.7%; only 29.3% reached hospital by ambulance and 3.72% were hemodynamically unstable. Only 3.6% received prehospital care and 16.23% were under alcohol influence. About 23.18% of RTA victims were pedestrians; city roads were the most common accident site. Head injury (25.85%) was the most common associated injury. Fractures were most common in hand (9.72%). The injury severity score (ISS) and New ISS were worse in the patients who were not using seat belt/helmet or were under influence of alcohol. The rate of death and associated injuries was also higher in this group. CONCLUSION: Trauma is a major preventable cause of mortality and morbidity mainly affecting the productive age group of the society.

Computed tomographic evaluation of the proximal femur: A predictive classification in displaced femoral neck fracture management.

BACKGROUND: Femoral neck fracture is truly an enigma due to the high incidence of avascular necrosis and nonunion. Different methods have been described to determine the size of the femoral head fragment, as a small head has been said to be associated with poor outcome and nonunion due to inadequate implant purchase in the proximal fragment. These methods were two dimensional and were affected by radiography techniques, therefore did not determine true head size. Computed tomography (CT) is an important option to measure true head size as images can be obtained in three dimensions. Henceforth, we subjected patients to CT scan of hip in cases with displaced fracture neck of femur. The study aims to define the term small head or inadequate size femoral head" objectively for its prognostic significance. MATERIALS AND METHODS: 70 cases of displaced femoral neck fractures underwent CT scan preoperatively for proximal femoral geometric measurements of both hips. Dual energy X-ray absorptiometry scan was done in all cases. Patients were treated with either intertrochanteric osteotomy or lag screw osteosynthesis based on the size of the head fragment on plain radiographs. RESULTS: The average femoral head fragment volume was 57 cu cm (range 28.3-84.91 cu cm; standard deviation 14 cu cm). Proximal fragment volume of >43 cu cm was termed adequate size (type I) and of ≤43 cu cm as small femoral head (type II). Fractures which united (n = 54) had a relatively large average head size (59 cu cm) when compared to fractures that did not (n = 16), which had a small average head size (49 cu cm) and this difference was statistically significant. In type I fractures union rate was comparable in both osteotomy and lag screw groups (P > 0.05). Lag screw fixation failed invariably, while osteotomy showed good results in type II fractures (P < 0.05). CONCLUSION: Computed tomography scan of the proximal femur is advisable for measuring true size of head fragment. An objective classification based on the femoral head size (type I and type II) is proposed. Osteosynthesis should be the preferred method of treatment in type I and osteotomy or prosthetic replacement is the method of choice for type II femoral neck fractures.

Outcome of pedicle screw fixation and monosegmental fusion in patients with fresh thoracolumbar fractures.

STUDY DESIGN: Prospective clinical study. PURPOSE: The present prospective study aims to evaluate the clinical, radiological, and functional and quality of life outcomes in patients with fresh thoracolumbar fractures managed by posterior instrumentation of the spine, using pedicle screw fixation and monosegmental fusion. OVERVIEW OF LITERATURE: The goals of treatment in thoracolumbar fractures are restoring vertebral column stability and obtaining spinal canal decompression, leading to early mobilization of the patient. METHODS: Sixty-six patients (46 males and 20 females) of thoracolumbar fractures with neurological deficit were stabilized with pedicle screw fixation and monosegmental fusion. Clinical, radiological and functional outcomes were evaluated. RESULTS: The mean preoperative values of Sagittal index, and compression percentage of the height of the fractured vertebra were 22.75° and 46.73, respectively, improved (statistically significant) to 12.39°, and 24.91, postoperatively. The loss of correction of these values at one year follow-up was not statistically significant. The mean preoperative canal compromise (%) improved from 65.22±17.61 to 10.06±5.31 at one year follow-up. There was a mean improvement in the grade of 1.03 in neurological status from the preoperative to final follow-up at one year. Average Denis work scale index was 4.1. Average Denis pain scale index was 2.5. Average WHOQOL-BREF showed reduced quality of life in these patients. Patients of early surgery group (operated within 7 days of injury) had a greater mean improvement of neurological grade, radiological and functional outcomes than those in the late surgery group, but it was not statistically significant. CONCLUSIONS: Posterior surgical instrumentation using pedicle screws with posterolateral fusion is safe, reliable and effective method in the management of fresh thoracolumbar fractures. Fusion helps to decrease the postoperative correction loss of radiological parameters. There is no correlation between radiographic corrections achieved for deformities and functional outcome and quality of life post spinal cord injury.

Morphometric measurements of cadaveric thoracic spine in Indian population and its clinical applications.

STUDY DESIGN: Analysis of morphometric data obtained from direct measurements of 100 cadaveric thoracic spines in Indian population. PURPOSE: To collect a base line morphometric data and analyze it in reference to the musculoskeletal anatomy and biomechanics of the spine; implants and instrumentations; and to suggest the requisite modification in spinal surgery instrumentations. OVERVIEW OF LITERATURE: Most of the previous studies in the world literature have focused primarily on the parameters of the pedicle and to the authors' knowledge; no study has been published from the Indian subcontinent reporting a detailed morphometry of the thoracic spine. METHODS: One thousand and two hundred thoracic vertebrae were studied by direct measurements for linear and angular dimensions of the vertebral body, spinal canal, pedicle, and spinous and transverse processes in 100 human cadavers. RESULTS: Thirty-five point five percent of all the pedicles; 71% of T5 pedicles; 54.6% of all the female pedicles; and 94.4% of the T5 pedicles in females were smaller than 5 mm in mid-pedicle width dimension. Transverse pedicle angle was more at all levels and pedicles were sagittaly angulated in cephalad direction in comparison to other studies. Minimum value of interpedicular distance was at T5 (15.48 ± 1.24). Vertebral body width showed slight decrease from T1 to T4. The transverse process length was relatively constant between T2 to T10. The spinous process angle showed increasing trend from T1 to T6 and then gradually decreased to T12. CONCLUSIONS: Most of the trends in changes of the parameters from T1 to T12 can be explained on the basis of local musculoskeletal anatomy and biomechanical stresses. The smallest diameter screw and shortest available screw for adults may not be safe in majority of the Indian population in mid-thoracic region. The results of the present study can help in designing implants and instrumentations; understanding spine pathologies; and management of spinal disorders in this part of the world.

Bladder management methods and urological complications in spinal cord injury patients.

BACKGROUND: The optimal bladder management method should preserve renal function and minimize the risk of urinary tract complications. The present study is conducted to assess the overall incidence of urinary tract infections (UTI) and other urological complications in spinal cord injury patients (SCI), and to compare the incidence of these complications with different bladder management subgroups. MATERIALS AND METHODS: 545 patients (386 males and 159 females) of traumatic spinal cord injury with the mean age of 35.4±16.2 years (range, 18 - 73 years) were included in the study. The data regarding demography, bladder type, method of bladder management, and urological complications, were recorded. Bladder management methods included indwelling catheterization in 224 cases, clean intermittent catheterization (CIC) in 180 cases, condom drainage in 45 cases, suprapubic cystostomy in 24 cases, reflex voiding in 32 cases, and normal voiding in 40 cases. We assessed the incidence of UTI and bacteriuria as the number of episodes per hundred person-days, and other urological complications as percentages. RESULTS: The overall incidence of bacteriuria was 1.70 / hundred person-days. The overall incidenceof urinary tract infection was 0.64 / hundered person-days. The incidence of UTI per 100 person-days was 2.68 for indwelling catheterization, 0.34 for CIC, 0.34 for condom drainage, 0.56 for suprapubic cystostomy, 0.34 for reflex voiding, and 0.32 for normal voiding. Other urological complications recorded were urethral stricture (n=66, 12.1%), urethritis (n=78, 14.3%), periurethral abscess (n=45, 8.2%), epididymorchitis (n=44, 8.07%), urethral false passage (n=22, 4.03%), urethral fistula (n=11, 2%), lithiasis (n=23, 4.2%), hematuria (n=44, 8.07%), stress incontinence (n=60, 11%), and pyelonephritis (n=6, 1.1%). Clean intermittent catheterization was associated with lower incidence of urological complications, in comparison to indwelling catheterization. CONCLUSIONS: Urinary tract complications largely appeared to be confined to the lower urinary tract. The incidence of UTI and other urological complications is lower in patients on CIC in comparison to the patients on indwelling catheterizations. Encouraging CIC; early recognition and treatment of the UTI and urological complications; and a regular follow up is necessary to reduce the medical morbidity.

Unusual presentation of bizarre parosteal osteochondromatous lesion of the second toe (Nora's lesion).

Bizarre parosteal osteochondromatous proliferation (BPOP) of bone is a rare benign neoplasm. This report presents the first case of BPOP associated with gangrenous changes and ulceration after remaining symptomless for 20 years. The authors hypothesize that the cause of gangrene may be attributed either to vascular occlusion due to pressure, trauma, or malignant transformation of the lesion. Although local excision of the tumor is the treatment of choice, the authors resorted to ray excision, as gangrenous changes and ulceration were present and there was the possibility of malignant change.

Unusual cause of haemorrhage from surgical wound in a child.

Haemorrhage from a surgical wound can be from many potential sources such as injury to vessel, muscle and bone; bleeding disorders; incomplete haemostasis; pseudoaneurysm; and neovascularisation. We report an unusual cause of haemorrhage from the surgical incision in a 9-year-old child. We emphasize that a high index of suspicion is required for early diagnosis, and pseudoaneurysm and neoangiogenesis should be considered in the differential diagnosis of soft tissue masses resulting from direct, blunt trauma even in children.

Internal fixation of proximal humeral fractures with locking proximal humeral plate (LPHP) in elderly patients with osteoporosis.

BACKGROUND: Different operative techniques used for treating displaced proximal humeral fractures could result in malunion, non-union, osteonecrosis of humeral head, loosening of screw and loss of reduction particularly in comminuted and osteoporotic fractures. Locking compression plate (LPHP) has been proposed for open reduction and internal fixation of these fractures and is associated with less complication rate. MATERIALS AND METHODS: We prospectively assessed the functional outcome and the complications after an average follow-up of 24.9 months in 25 patients of proximal humeral fractures with osteoporosis. Mean age was 62 years. Using AO classification, 48% were type A and 52% type B. RESULTS: Mean constant score was 80 points. According to constant score, 28% had excellent outcome, 64% had good functional outcome, and 8% had moderate outcome. When the results were related to grades of osteoporosis, grade IV osteoporotic fractures had highest average Constant-Murley score (83 points, range 78-88 points), followed by grade III osteoporotic fractures (80 points, range 71-92 points), followed by grade II osteoporotic fractures (78 points, range 66-88 points). Varus malalignment and subacromial impingement were observed in 8% patients. Loosening of implant and loss of reduction were observed in 4% patients. Superficial infection was observed in 4% patients. CONCLUSIONS: Locking compression plate (LPHP) is an advantageous implant in proximal humeral fractures due to angular stability, particularly in comminuted fractures and in osteoporotic bones in elderly patients, thus allowing early mobilization.