Surgery for pressure ulcers improves general health and quality of life in patients with spinal cord injury.

STUDY DESIGN: Prospective clinical study. BACKGROUND: Pressure ulcers interfere with the rehabilitation process in patients with spinal cord injury (SCI) and are a significant deterrent to participation in activities that contribute to independent, productive, and satisfying life. OBJECTIVE: To evaluate the effect of surgery for pressure ulcers on general health and quality of life in patients with SCI. SETTING: Tertiary care center in northern India. METHODS: Various types of flap surgery were performed on 30 patients with SCI and 32 pressure ulcers (stages III and IV). Outcome was evaluated using general improvement in health (hemoglobin, serum proteins, and general well-being), patient satisfaction, and global quality of life scores (according to the visual analog scale). RESULTS: At admission, the mean values of global quality of life, hemoglobin, serum albumin, and total serum proteins were 50.15 (range, 30-65), 8.75 g/dL (range, 6-12 g/dL), 3.12 g/dL (range, 2.9-4.3 g/dL), and 5.21 (range, 5-6.2 g/dL), respectively. At 6-month follow up, mean values of global quality of life score, hemoglobin, serum albumin, and total serum proteins were 87.36 (range, 44-96), 10.85 g/dL (range, 8.2-13.5 g/dL), 3.89 g/dL (range, 3.2-4.5 g/dL), and 6.43 g/dL (range, 5.85-6.70 g/dL), respectively. The overall rise in quality of life scores, hemoglobin, serum albumin, and total serum proteins was statistically significant. Most of the patients (76.7%) reported improvement in subjective well-being, and 83.3% were satisfied with the ultimate outcome of the surgery. CONCLUSION: Results suggest that surgery for stages III and IV pressure ulcers offers the greatest benefit to the patients in terms of improvement in general health (anemia, hypoproteinemia, and general well-being) and quality of life.

Intra-operative migration of dynamic hip screw into the pelvis.

The authors report a rare per-operative complication of intra-pelvic migration of dynamic hip screw, during osteosynthesis of an inter-trochanteric fracture. Possible reasons of migration are analyzed along with the importance of careful execution of the surgical technique to avoid such iatrogenic complications and medico-legal implications.

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.

Comparison of Clinico-radiological Outcomes of Monolateral Fixator in Infected Non-union of Tibia Based on Bone Gap Quantification.

INTRODUCTION: Monolateral rail fixators are more comfortable to the patients and have a lesser learning curve compared to ring fixators. Guidelines are still lacking for rational use of monolateral fixator for bone transport. This retrospective study aimed to analyze and compare the clinico-radiological outcomes of monolateral fixator in infected non union of tibia based on bone gap quantification. MATERIALS AND METHODS: This retrospective study included 35 patients of post traumatic infected osteocutaneous defects of tibia operated from May 2013 to May 2016. Group I having bone gap of 6 cm or less (n = 20) and group II with > 6 cm bone gap (n = 15). The mean age was 29.56 (range 18-62) years in group I and 29.67 (range 20-65) years in group II. The mean bone gap was 4.62 (2-6 cm) in group I and 7.6 cm (6.5-10 cm) in group II (P < 0.00001, Mann-Whitney test). The results were assessed by Association for the Study and Application of the Method of Ilizarov (ASAMI) criteria. RESULTS: Union was achieved primarily in 90% (n = 18) cases in group I and 73.34% (n = 11) cases in group II. The bone result was excellent, good, fair/poor in 14, 5, 1 in group I; and in 4, 6, 5 in group II, respectively (P = 0.020, Chi-square test). The functional results were excellent, good, fair/poor in 15, 4, 1 in group I; and 5, 8, 2 in group II, respectively (P = 0.0479, Chi-square test). CONCLUSION: We recommend use of monolateral fixator in patients with infected diaphyseal non union of tibia with bone gap ≤ 6 cm. Use of monolateral fixator in patients with bone gap > 6 cm is associated with higher incidence of residual problems and complications.

Nail over nail technique for distal locking of femoral intramedullary nails.

The free hand technique remains the most popular method for distal locking; however, radiation exposure is a major concern. In an endeavour to overcome this concern, distal locking with the nail over nail technique is evaluated. Seventy patients with femoral diaphyseal fractures treated by intramedullary nailing were divided in two groups for distal locking: either using the free hand technique (group I) or with the nail over nail technique (group II). The average number of images taken to achieve nail insertion without locking, for distal locking, and for the complete procedure in group I was 25.8, 24.2, and 50.08, respectively, compared with 24.8, 4.1, and 28.9, respectively, in group II (statistically extremely significant decrease in radiation). The nail over nail technique appears to be a reliable solution for decreasing radiation exposure during closed femoral intramedullary nailing. However, over-reaming of 1.5 mm is the key to the success of the technique.

Proximal Tibial Osteochondroma Leading to Chronic Compartment Syndrome.

Osteochondroma is the most common benign tumour of bone seen in 3% of the general population. Complications such as neurological compromise, skeletal defects, vascular lesions, and compartment syndrome occur in about 4% of osteochondromas. We bring forth the case of a 16-year male who presented with the complaints of swelling in calf region associated with symptoms of claudication and paraesthesias in leg after exertion and absence of any such complaints at rest. Radiographs revealed a bony pedunculated mass originating from the posterior tibial metaphyseal region causing compression of posterior soft tissue structures. Excision biopsy of the mass was done by posterior approach with an L-shaped incision. The aim of this case report was to draw attention to the early signs of vascular compromise by osteochondroma in this region in order to prevent serious complications in future by early decompression.

Effect of Intravenous Zoledronic Acid on Histopathology and Recurrence after Extended Curettage in Giant Cell Tumors of Bone: A Comparative Prospective Study.

BACKGROUND: Giant cell tumor (GCT) of the bone is known for its locally aggressive behavior and tendency to recur. It is an admixture of rounded or spindle-shaped mononuclear neoplastic stromal cells and multinucleated osteoclast-like giant cells with their proportionate dispersion among the former. Zoledronic acid (a bisphosphonate) is being used in various cancers such as myelomas and metastasis, for osteoporosis with an aim to reduce the resorption of bone, and as an adjuvant treatment for the management of GCT of bone for reduction of local recurrence. We have carried out a prospective comparative study to assess the effect of intravenous infusion of zoledronic acid on histopathology and recurrence of GCT of bone. MATERIALS AND METHODS: The study was carried out in the biopsy proven GCTs in 37 patients; 15 males and 22 females, in the age range from 17 to 55 years. They were treated with extended curettage. Of these 37 patients, 18 were given three doses of 4 mg zoledronic acid infusion at 3-week intervals and extended curettage was performed 2 weeks after the last infusion whereas the other 19 were treated with extended curettage without zoledronic infusion. The post infusion histopathology of the curetted material was compared with the histopathology of initial biopsy. All the patients were evaluated at 3-month intervals for the first 2 years and then six monthly thereafter, for local recurrence and functional outcome of limb using the Musculoskeletal Tumor Society (MSTS) score. RESULTS: In postzoledronic infusion cases, the histopathology of samples showed abnormal stromal cells secreting matrix leading to fibrosis and calcification. The type of fibrosis and calcification was different from pathological calcification and fibrosis what is usually observed. There was a good marginalization and solidification of tumors which made surgical curettage easier in six cases in the study group. There was noticeable reduction in the number of giant cells and alteration in morphology of stromal cells to the fibroblastic-fibrocytic series type in comparison to preinfusion histopathology. Recurrence occurred in one case out of 18 patients in infusion group whereas in four cases among 19 patients in control group. The functional results were assessed, and the overall average MSTS score was 27.50 (range 24-30) and 27.00 (range 23.50-30) in the study and control groups, respectively. CONCLUSIONS: We observed that bisphosphonates reduce osteoclast activity and affects stromal cells in GCT, resulting in the reduction of their numbers and noticeable apoptosis. This results in better marginalization of the lesions and reduced recurrence. Extended curettage of friable GCT became easier and adequate which otherwise might not have been possible.

To compare the efficacy and safety of fixed dose combination of thiocolchicoside and aceclofenac versus chlorzoxazone, aceclofenac and paracetamol in patients with acute lower backache associated with muscle spasm.

BACKGROUND: The fixed dose combinations (FDCs) of muscle relaxants, non-steroidal anti-inflammatory drugs and paracetamol are commonly prescribed in the treatment of acute lower backache. AIM: The present study was undertaken with the aim of comparing the efficacy and safety of FDCs of thiocolchicoside and aceclofenac versus chlorzoxazone, aceclofenac and paracetamol in patients with acute lower backache associated with muscle spasm. MATERIALS AND METHODS: A total of 100 patients between ages range from 18 and 55 years having low back pain of ≤7 days duration were randomly divided into two groups. Group A was prescribed thiocolchicoside (4 mg) + aceclofenac (100 mg) while Group B was prescribed chlorzoxazone (500 mg) + aceclofenac (100 mg) + paracetamol (325 mg) orally twice daily for 7 days. Severity of pain at rest and on movement was recorded using visual analogue scale. Muscle spasm was evaluated by hand-to-floor distance and Lasegue's maneuver. Readings were noted on day 1 (baseline), day 3 and day 7. RESULTS: There was statistically significant reduction in severity of pain and muscle spasm on day 3 and day 7 in both groups. There was no statistically significant difference in pain relief and muscle spasm among the treatment groups but clinically showed better improvement in the Group A. The adverse drug reactions occurring during study showed a statistically significant better safety profile in the Group A than Group B. CONCLUSION: These findings confirm that FDC of thiocolchicoside and aceclofenac is a preferred option for patients with lower backache pain associated with muscle spasm.

Large para-articular osteochondroma of the knee joint: a case report.

A unique case of large intra-articular osteochondroma of the knee of a 15-year duration is presented along with a review of the literature. The tumor may have remained asymptomatic for such a long period because of its slow growth and stretch elongation of the quadriceps mechanism.

Locked intramedullary femoral nailing without fracture table or image intensifier.

The present retrospective study aims to evaluate the outcome in 41 patients of femoral shaft fractures, who had closed intramedullary nailing in lateral decubitus position without fracture table or image intensifier. Mean age was 33.2 (range, 18-70) years. The cannulated reamer in proximal fragment (as intramedullary joystick) and Schanz screw in the distal fragment (as percutaneous joystick) were simultaneously used to assist closed reduction of the fracture without the use of image intensifier. Closed reduction was successful in 38 patients. Open reduction was required in 3 patients. Schanz screw was used for closed reduction in 12 patients. Average number of intra-operative radiographic exposures was 4.4. Two patients had exchange nailing using large diameter nails. One patient had nonunion. Angular and rotatory malalignments were observed in seven patients. We are of the opinion that the present technique is a safe and reliable alternative to achieve closed locked intramedullary nailing and is best suited to stable, less comminuted (Winquist-Hansen types I and II) diaphyseal fractures of the femur.

Subungual exostosis of the great toe: a case report and tumor overview.

UNLABELLED: Subungual exostosis is an acquired, benign, and solitary bone tumor of the distal phalanx occurring beneath or adjacent to nail. A 18-year-old man presented with a lump, ulceration, and pain on his right big toe. This complaint was present for the past 2 years. Initially, lump and pain were present, and since the past 6 months ulceration and superadded infection occurred. Plain radiograph showed a calcified lesion that was continuous with the phalangeal cortical surface in the distal dorsal aspect of the big toe. Excisional biopsy with complete nail removal and reconstruction of the tip of the toe were done. Histopathology confirmed the diagnosis of subungual exostosis. Clinical or radiological recurrence was not observed after 26 months of follow-up. The case is reported to present the tumor overview and to highlight that the diagnosis of this benign lesion should not be missed. Clinical and radiological features allow early diagnosis and treatment thus preventing the lesion to progress to the stage of onycholysis. LEVEL OF EVIDENCE: Therapeutic, Level IV.

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.

Simultaneous use of cannulated reamer and schanz screw for closed intramedullary femoral nailing.

Introduction. Closed reduction is a critical component of the intramedullary nailing and at times can be difficult and technically challenging resulting in increased operative time. Fluoroscopy is used extensively to achieve closed reduction which increases the intra-operative radiation exposure. Materials and Methods. Sixty patients with femoral diaphyseal fractures treated by locked intramedullary nailing were randomized in two groups. In group I, fracture reduction was performed under fluoroscopy with a cannulated reamer in the proximal fragment or with simultaneous use of a cannulated reamer in the proximal fragment and a Schanz screw in the distal fragment. Patients in group II had fracture reduction under fluoroscopy alone. Results. Closed reduction was achieved in 29 patients in group I and 25 patients in group II. The guide wire insertion time, time for nail insertion and its distal locking, total operative time, and total fluoroscopic time were 26.57, 27.93, 68.03, and 0.19 minutes in group I, compared with 30.87, 27.83, 69.93, and 0.24 minutes in group II, respectively. The average number of images taken to achieve guide wire insertion, for nail insertion and its locking and for the complete procedure in group I, respectively, was 12.33, 25.27, and 37.6 compared with 22.1, 26.17, and 48.27, respectively, in group II. Conclusion. The use of cannulated reamer in proximal fragment as intramedullary joystick and Schanz screw and in the distal fragment as percutaneous joystick facilitates closed reduction of the fracture during closed intramedullary femoral nailing with statistically significant reduction in guide wire insertion time and radiation exposure.

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.

Extensive hydatidosis of the femur and pelvis with pathological fracture: a case report.

BACKGROUND: Hydatid cysts caused by Echinococcus sp can produce tissue cysts anywhere in the body. Skeletal cystic lesions are rare, yet because of their unusual presentation diagnosis can be missed. CASE REPORT: We report a case of extensive hydatidosis of the femur with pathological fracture and involvement of the pelvis bone, without involvement of abdominal viscera, in a 51-year-old woman. The patient presented with swelling and deformity of the upper and middle third of the left thigh. The diagnosis was confirmed clinico-radiologically and the patient was treated with hindquarter amputation and chemotherapy. The patient died of sepsis and extensive bedsores one month after surgery. CONCLUSIONS: Orthopedic surgeons should be alert to this morbid condition and this disease should be suspected in cystic lesions affecting any organ of the body in pathological fractures with non-union, especially in endemic areas of the world. Early diagnosis helps in eradication and salvage of the bone; misdiagnosis and delayed diagnosis are always fraught with the danger of amputation, recurrence, and sepsis.

Ipsilateral femoral neck and shaft fractures: a retrospective analysis of two treatment methods.

BACKGROUND: No consensus exists regarding the optimal treatment of ipsilateral femoral neck and shaft fractures. The three major issues related to these fractures are the optimal timing of surgery, which fracture to stabilize first, and the optimal implant to use. In an effort to find answers to these three key issues, we report our experience of managing 27 patients with ipsilateral femoral neck and shaft fractures by using two different treatment methods, i.e., reconstruction-type intramedullary nailing and various plate combinations. MATERIALS AND METHODS: We divided patients into two groups. Group I included 15 patients (13 males and 2 females) who were operated with cancellous lag screws or dynamic hip screws (DHS) for fractured neck and compression plate fixation for fractured shaft of the femur. Group II included 12 patients (11 males and 1 female) who were operated with reconstruction-type intramedullary nailing. RESULTS: Mean age was 33.2 and 37.9 years in group I and II, respectively. Mean delay in surgery was 5.9 and 5.4 days in group I and II, respectively. Average union time for femoral neck fracture in groups I and II were 15.2 and 17.1 weeks, respectively; and for shaft fracture these times were 20.3 and 22.8 weeks, respectively. There were 13 (86.6%) good, 1 (6.7%) fair and 1 (6.7%) poor functional results in group I. There were 10 (83.3%) good, 1 (8.3%) fair and 1 (8.3%) poor functional results in group II. CONCLUSIONS: Both of the treatment methods used in the present study achieved satisfactory functional outcome in these complex fractures. Fixation with plate for shaft and screws or DHS for hip is easy from a technical point of view. Choice of the treatment method should be dictated primarily by the type of femoral neck fracture and the surgeon's familiarity with the treatment method chosen. The femoral neck fracture should preferably be stabilized first, and a delay of 5-6 days does not affect the ultimate functional outcome.

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.