Minimally invasive treatment for idiopathic chondrolysis of the hip: analysis of forty-one cases.

PURPOSE: Idiopathic chondrolysis of the hip is characterized by the loss of the articular cartilage of the hip joint with spectrum ranging from full recovery to fibrous ankylosis. Study assessed outcomes following intra-articular steroid injections, joint manipulation and traction immobilization. METHODS: Retrospective (2012-2021) review of 41 cases treated for idiopathic chondrolysis of hip, assessed pre-operatively and post-operatively (minimum 2-year follow-up) using Children's Hospital Oakland Hip Evaluation Score (CHOHES), visual analogue scale (VAS) and range of motion measurements. RESULTS: Twenty-five patients (62%) achieved painless mobility, 6 (14%) had hip stiffness without pain and 10 (24%) had painful and stiff hips at final follow-up. They had a mean age of 12.49 ± 2.4 years and a mean follow-up duration of 33.15 ± 13.1 months. Range of motion improved significantly (p < 0.05). VAS improved to 3.93 ± 1.3 from 7.8 ± 0.7. CHOHES improved from 29.12 ± 9.9 to 56.37 ± 17.6. CONCLUSION: Intra-articular steroid injection, manipulation and traction immobilization may effectively treat idiopathic chondrolysis of the hip by enhancing patient function and reducing the need for further surgical intervention.

Comparison between effects of instrument-assisted soft tissue mobilization and manual myofascial release on pain, range of motion and function in myofascial pain syndrome of upper trapezius - A randomized controlled trial.

Background: Myofascial pain syndrome (MPS) is a muscle pain disorder characterized by the presence of Myofascial Trigger Point (MTrP) within a taut band, local tenderness, referral of pain to a distant site, restricted range of motion, and autonomic phenomena. The upper trapezius is the muscle most often affected by MTrPs. Manual myofascial release (MFR) and Instrument-Assisted Soft Tissue Mobilization (IASTM) are techniques of soft tissue release that are used to resolve MPS. Fifty six percent of physiotherapists complain of pain in multiple areas due to the massage and manual therapy that they have to perform. Objective: The objective of this study is to find whether IASTM is better than manual MFR in treating patients with MPS in upper trapezius. Methods: This study was a single-blinded randomized controlled trial that included 31 participants, both males and females between the age groups of 18-50 years. Participants were randomly divided into two groups. Three sessions were given over a period of one week for both groups. Group A received IASTM along with conventional treatment and Group B received Manual MFR along with the conventional treatment. The outcome measures evaluated were pain, cervical range of motion, pain pressure threshold (PPT) of trigger points, and the neck disability index. Pre- and post-measurements were taken and the analysis was done. Results: Both the treatment methods significantly reduced pain, improved PPT, range of motion, and function. The effects between the groups showed that IASTM was significantly better than manual MFR to reduce pain. The improvement in PPT, range of motion and function were equal in both the groups. Conclusion: IASTM and manual MFR both are effective individually as treatment procedures for pain, PPT, range of motion, and function. Neither of the treatment options can be considered better that the other. The clinician can decide based on the availability of the instrument, training, patient's preference, and his/her comfort whether which of the two treatment methods should be used.

Efficacy of less Invasive modified O-arm navigated delta fixation in osteoporotic high-grade spondylolisthesis: "a LIMO delta technique".

PURPOSE: In 1994, the technique of transdiscal screws fixation in spondylolisthesis was introduced but did not gained popularity as it failed to address problems with spinal sagittal imbalance, retroverted pelvis, pseudoarthrosis, implant failure and neural injury. Majority of problems were due to lack of clear indications; hence, in this study, with modification of traditional technique and use of O-arm navigation for selected group of patients, we have addressed the above problems and given good to excellent functional outcomes. METHODS: We did prospective study on 15 patients with osteoporotic high-grade spondylolisthesis Meyerding grade 3 & 4 admitted in period 2020-2021. Intraoperative assessment was done in form of blood loss, incision length, operative time and complications. The preoperative & postoperative assessment was done in the form of clinical and radiological parameters. RESULTS: The average follow-up was of 21.2 months (18-24 months). There was no significant difference between pre- & postoperative spinopelvic parameters. Intraoperative average blood loss was 100 ml (90-120 ml) with mean surgical time of 138 min (120-150 min). Incision length was about 5-6-cms-posterior midline with two paraspinal 1-cm incisions for transdiscal screws. Patients were mobilized on postoperative day-2. There was statistically significant improvement in mean ODI, COMI and VAS for LBP and radicular pain with no intra- or postoperative complication observed till latest follow-up with all patients showing solid monoblock fusion on 1-year follow-up CT scan. CONCLUSIONS: LIMO delta technique is a newly modified version of conventional transdiscal screw technique. Minimal incision, decreased blood loss & operative time with in situ 3-column rigid fixation and solid fusion minimizing risk of complications makes this novel technique safer, simpler & effective in osteoporotic HGS.

Prophylaxis for preventing venous thromboembolism in knee arthroscopy and soft tissue reconstruction: consensus statements from an international panel of experts.

PURPOSE: There is a lack of consensus regarding need for Venous Thrombo Embolism (VTE) prophylaxis following arthroscopic knee surgery and open soft tissue knee reconstruction. Clear cut guidelines like ones for trauma surgery and arthroplasty do not exist and the published literature is limited to case reports with a few society guidelines. Given this lack of consensus, we conducted a modified Delphi questionnaire of international experts to provide recommendations on this topic. METHODS: The consensus statements were generated using an anonymised 3 round modified Delphi questionnaire, sent to an international panel of 38 knee surgeons, with an 80% agreement being set as the limit for consensus. The responses were analysed using descriptive statistics with measures like mode, median and box plots. Feedback was provided to all panelists based on responses from the previous rounds to help generate the consensus. RESULTS: Six consensus statements were generated after the three rounds of Delphi. Patient factors, prolonged surgery duration and family history of thrombogenic events emerged as the main points to be taken into consideration for prophylaxis. CONCLUSION: It was established through this study, that there exists a select group of patients undergoing arthroscopic surgery that justify the usage of VTE prophylaxis. The expert responses to most of the questions in different scenarios favoured usage of VTE prophylaxis based on patient factors like advanced age, past history of VTE, smoking, oral contraceptive use etc. LEVEL OF EVIDENCE: Level V.

Validation of an on-screen application-based measurement of shoulder range of motion over telehealth medium.

BACKGROUND: Shoulder range-of-motion (ROM) assessment is vital for the follow-up evaluation of operated patients and for the outcome-based research studies. The aim of this study was to investigate the accuracy and reliability of a remote on-screen application (app)-based method of shoulder ROM measurement through a telehealth medium. MATERIALS AND METHODS: A consultant shoulder surgeon, a board-certified orthopedic resident, and a graduate medical doctor served as the examiners. The cohort consisted of 24 healthy volunteers and 16 symptomatic patients with expected shoulder ROM deficits. Shoulder ROM was first examined physically using a goniometer in the clinic and then over Zoom remote conferencing using the protractor extension app of the Chrome browser. RESULTS: Instrument validity was examined by comparing the goniometer method with the protractor app-based method of the expert shoulder consultant using Bland-Altman analysis. It showed only minor mean differences between the healthy volunteers and the patients in elevation (2.0° and 5.0°, respectively), abduction (2.0° and 3.0°, respectively), external rotation with the elbow adducted (1.9° and 0.2°, respectively), external rotation with the elbow abducted at 90° (0.4° and 4°, respectively), and internal rotation with elbow abducted at 90° (2.3° and 1.2°, respectively), with limits of agreement that were below the well-established minimal clinically important difference values. The intraclass correlation coefficient (ICC) values varied between 0.83 and 0.96 for the volunteers and between 0.90 and 0.98 for the patients, indicating excellent correlation between the 2 methods. The interobserver reliability between 2 examiners for the protractor app-based method as evaluated by ICC scores was excellent; it ranged between 0.86 and 0.98 for the volunteers and between 0.88 and 0.99 for the patients. Comparison of the protractor app-based method with the gold-standard goniometer method for the resident and the graduate doctor showed excellent ICC values. CONCLUSION: A protractor app-based method of measuring shoulder ROM over a telehealth medium is accurate and reliable compared with a clinical goniometer method. This validated method can be used during remote telehealth consultation with significant benefits of saving patients travel and time during the COVID-19 (coronavirus disease 2019) pandemic and even later.

Results and complications of head-preserving techniques in chronic neglected shoulder dislocation: a systematic review.

BACKGROUND: Humeral head-preserving procedures may be needed for chronic neglected shoulder dislocation because the presenting age of the patient is often reported to be less than 45 years. The aim of this systematic review was to evaluate the results of the various head-preserving procedures for chronic anterior dislocation (CAD) and chronic posterior dislocation (CPD). This review also aimed to evaluate the results of conservative neglect for CAD. METHODS: PubMed, Embase, and Cochrane library databases were queried for studies that reported on results of head-preserving procedures for CAD or CPD and for studies that reported on the results of conservative neglect for CAD. Case reports, review articles, acute dislocations, and fracture-dislocations were excluded. The results of the different techniques were pooled for further evaluation. RESULTS: Seventeen studies were selected for qualitative analysis. These were further subdivided into 9 studies for the CAD group and 11 studies for the CPD group. In the CAD intervention group, 53 shoulders in 7 studies were managed by 5 different head-preserving techniques. The choice of procedure to stabilize the shoulder after open reduction varied between coracoid transfer, capsulolabral repair, remplissage, and Putti-Platt procedure and acromiohumeral K-wire fixation. High resubluxation rates and early arthrosis were reported after open reduction techniques for CAD. In the CAD conservative group, 8 shoulders in 2 studies were managed by conservative methods. In the CPD group, the 2 most common techniques, McLaughlin or modified McLaughlin and bone grafting, were used to treat 74 shoulders in 7 studies and showed good functional outcomes. CONCLUSION: The choice of open reduction and stabilization technique for CAD was highly variable between the different studies and led to a wide variation in the reported outcomes with a high number of complications such as resubluxation and early arthrosis. The conservative treatment of CAD led to poor functional results. The choice of treatment for CPD was mostly between 2 techniques-McLaughlin and modified McLaughlin reconstruction or the bone graft reconstruction-and they consistently led to good functional outcomes with less complications.

Surgical correction of Sprengel's deformity by modified Woodward procedure: outcomes in twenty eight patients.

PURPOSE: Sprengel's deformity is a congenital failure of the descent of the scapula with main concerns regarding cosmetic deformity and restricted function of the affected shoulder. The purpose of this study was to present the results of Modified Woodward procedure in 28 patients with Sprengel's shoulder. METHODS: Twenty-eight patients (9 males, 19 females) of Sprengel's shoulder treated with modified Woodward procedure from 2010 to 2016 were retrospectively studied. Clinical assessment was done using Cavendish grading and Rigault's classification for radiographic evaluation. RESULTS: Mean age at the time of surgery was six years and three months. Mean follow-up was 20 months. We found a mean increase in abduction of 34.2° (15-50) and flexion of 20.6° (10-25), mean scapular lowering of 2.3 cm (0.5-4.5 cm), and a Cavendish grade I in 18 (65%), grade II in 10 (35%). Thus, we had 65% satisfactory results in terms of cosmesis and 85% with the function of the affected limb. Rigault grading improved by one grade in 16 children and by two grades in 12 children. Subjectively, all parents were satisfied with the cosmetic appearance of the achieved scapular lowering. We had one case of delayed superficial wound healing which resolved spontaneously. CONCLUSION: Modified Woodward procedure for Sprengel's shoulder deformity gives good cosmetic correction and improvement in shoulder function with minimal complications. This procedure is good for selective cases of Cavendish grade II with cosmetic concerns and all cases of Cavendish grade III and IV.

Effects of muscle energy technique on pain, range of motion and function in patients with post-surgical elbow stiffness: A randomized controlled trial.

BACKGROUND: Elbow is a very functional joint. Elbow stiffness is a significant cause of disability hampering the function of the upper extremity as a whole. Muscle Energy Techniques (METs) are relatively pain-free techniques used in clinical practice for restricted range of motion (ROM). OBJECTIVE: To study the effects of MET on pain, ROM and function given early in the rehabilitation in post-surgical elbow stiffness. METHODS: An RCT was conducted on 30 patients post elbow fracture fixation. Group 1 was given MET immediately post removal of immobilization while Group 2 received MET 1 week later along with the rehabilitation protocol. Pain (Visual Analogue Scale), ROM (goniometry) and function (Disability of Arm, Shoulder and Hand questionnaire) were assessed pre and post 3 weeks. RESULTS: Group 1 showed greater improvement than Group 2, mean flexion and extension change between groups being 11 . 7 ± 2 . 8 , 95%CI(5.9,17.4) and 8 . 5 ± 2 . 0 , 95%CI(4.4,12.7), respectively. VAS and DASH scores improved better in Group 1, mean change being 1 . 2 ± 0 . 2 , 95%CI(0.6,1.8) and 18 . 2 ± 2 . 2 , 95%CI(13.5,22.8) for VAS and DASH scores, respectively. CONCLUSION: MET can be used as an adjunct to the rehabilitation protocol to treat elbow stiffness and can be given safely in the early stages of post elbow fracture rehabilitation managed surgically with open reduction and rigid internal fixation.

Reliability and validity of a new clinical test for assessment of the sacroiliac joint dysfunction.

BACKGROUND: Dysfunctional sacroiliac joint (SIJ) has been cited as a source of low backache (LBA). Numerous non-invasive clinical tests are available for its assessment having poor validity and reliability which challenges their clinical utility. Thus, introduction of a new clinical test may be necessary. OBJECTIVE: To assess reliability and validity of a new clinical test for the assessment of patients with SIJ movement dysfunction. METHODS: Forty-five subjects (23 having LBA of SIJ origin and 22 healthy asymptomatic volunteers) with mean age 28.62 + ∕- 5.26 years were assessed by 2 blinded examiners for 3 different clinical tests of SIJ, including the new test. The obtained values were assessed for reliability by intraclass correlation, kappa coefficient and percentage agreement. Validity was assessed by averaging sensitivity and specificity. Positive and negative predictive values and accuracy were assessed. RESULTS: The new test demonstrates good intra- ( r = 0.81 ) and inter-rater ( r = 0.82 ) reliability with substantial agreement between raters ( k > 0.60 ) . It has 79.9% validity, 82% sensitivity, 77% specificity, 79% positive-predictive, 80% negative-predictive value and accuracy. CONCLUSION: The new "Shimpi Prone SIJ test" has a good intra- and inter-rater reliability with a substantial rater agreement and a good validity and accuracy for the assessment of patients with SIJ movement dysfunction.

Variation in practice preferences in management of open injuries of extremities-an international survey by SICOT research academy.

PURPOSE: Open fractures are challenging injuries and there is a lot of variation in practice preferences which may reflect the wide variations in outcome in different units across the world. A survey was done amongst the international community of SICOT membership to document the practice preferences and variations. METHODS: An online questionnaire containing 23 questions which were sub-divided into three sections covering the various aspects of open injury management was sent by email to orthopaedic trauma surgeons across the world. A total of 358 responses were evaluated and presented in this manuscript. RESULTS: The SICOT study confirmed wide variation in practice protocols. About 94.7 % of orthopaedic surgeons around the world use the Gustillo Anderson scoring system for assessment of open injury and 50.6 % of surgeons prefer lavage in operation theatre. For lavage, 84.6 % of surgeons preferred normal saline and for antibiotic prophylaxis, 48.3 % used a combination of second generation cephalosporin, metronidazole and an aminoglycoside for a minimum of three to five days. In 88 % of patients, orthopaedic surgeons performed the initial debridement and 69.2 % surgeons aimed for debridement within six hours. Regarding wound management, 43.9 % units preferred and were capable of soft tissue cover within 72 hours and about 26.3 % surgeons combined definitive fixation along with plastic procedure. CONCLUSION: Our study documented wide variations in practice preferences across the world and showed that information and awareness about current guidelines and practices will help many to update themselves in terms of basic questions about open fracture care.

Effect of muscle energy technique and static stretching on pain and functional disability in patients with mechanical neck pain: A randomized controlled trial.

BACKGROUND: Mechanical neck pain is one of the common musculoskeletal disorders. Muscle energy technique (MET) may be a useful intervention for treating such disorder. OBJECTIVE: The aim of this study was to compare the effect of MET with passive stretching on pain and functional disability in people with mechanical neck pain. METHODS: A randomized controlled trial was undertaken. Sixty patients with mechanical neck pain were randomly allocated to either the MET group or control group. The former group received MET, and the latter group received static stretching. Both groups received conventional therapy. Treatment was given once a day for 6 days. A visual analogue scale (VAS) was used to measure the intensity of pain, and functional disability was assessed using the neck disability index (NDI) was immediately before treatment and again on the 6th day. RESULTS: VAS and NDI scores showed a significant improvement in both MET and stretching groups on the 6th day postintervention (p < 0.05). However, both VAS and NDI scores showed better improvement in the MET group as compared to the stretching group (p < 0.025). CONCLUSION: Muscle energy technique was better than stretching technique in improving pain and functional disability in people with mechanical neck pain.

Assessment of clinical outcome of percutaneous needle quadriceps tenotomy in the treatment of congenital knee dislocation.

PURPOSE: Treatment of congenital knee dislocation (CDK) depends on the severity and flexibility of the deformity. Various modalities of treatment ranging from serial cast, open quadricepsplasty and minimally invasive quadricepsplasty have been described. We describe percutaneous needle quadriceps tenotomy for treatment of flexible CDK and present our result of retrospective case series. METHODS: This was a retrospective study of 12 patients (20 knees) with flexible CDK. Eight patients with bilateral and four with unilateral deformities. The mean age of intervention was 14.5 days (range, 4-55 days). None of the patients were syndromic. All procedures were done within eight weeks of age. The outcome was measured using knee evaluation score and complications in view of extensor lag, instability and knee flexion deformity. Ultrasound was performed to check for integrity of quadriceps mechanism. RESULTS: The mean pre-operative hyperextension was 50° (range, 30-70°). All patients were able to achieve >90° flexion intra-operatively. The mean knee flexion at walking age was 135° (range, 130-140°). Knee evaluation score showed good results in nine patients and fair result in three patients. There was no extensor lag, knee flexion deformity or infection. One patient of anterior instability had ACL aplasia which was documented on MRI. Ultrasound performed at walking age showed normal functioning of quadriceps mechanism. CONCLUSIONS: Percutaneous needle tenotomy of quadriceps is a effective, simple and safe procedure for flexible, non syndromic CDK presenting early. It avoids complications associated with the open surgical procedure and causes less extensor scarring. However its effectiveness in stiff/hyperlax variants associated with syndromes is yet to be determined.

Intra- and inter-rater reliability of maximum inspiratory pressure measured using a portable capsule-sensing pressure gauge device in healthy adults.

BACKGROUND: Measurement of maximum inspiratory pressure is the most prevalent method used in clinical practice to assess the strength of the inspiratory muscles. Although there are many devices available for the assessment of inspiratory muscle strength, there is a dearth of literature describing the reliability of devices that can be used in clinical patient assessment. The capsule-sensing pressure gauge (CSPG-V) is a new tool that measures the strength of inspiratory muscles; it is easy to use, noninvasive, inexpensive and lightweight. OBJECTIVE: To test the intra- and inter-rater reliability of a CSPG-V device in healthy adults. METHODS: A cross-sectional study involving 80 adult subjects with a mean (± SD) age of 22±3 years was performed. Using simple randomization, 40 individuals (20 male, 20 female) were used for intrarater and 40 (20 male, 20 female) were used for inter-rater reliability testing of the CSPG-V device. The subjects performed three inspiratory efforts, which were sustained for at least 3 s; the best of the three readings was used for intra- and inter-rater comparison. The intra- and inter-rater reliability were calculated using intraclass correlation coefficients (ICCs). RESULTS: The intrarater reliability ICC was 0.962 and the inter-rater reliability ICC was 0.922. CONCLUSION: Results of the present study suggest that maximum inspiratory pressure measured using a CSPG-V device has excellent intraand inter-rater reliability, and can be used as a diagnostic and prognostic tool in patients with respiratory muscle impairment.

HISTORIQUE: La mesure de la pression inspiratoire maximale est la méthode la plus utilisée en pratique clinique pour évaluer la force des muscles inspiratoires. Même si de nombreux dispositifs sont conçus pour effectuer cette mesure, très peu de publications décrivent la fiabilité de ceux qui peuvent être utilisés pour l'évaluation clinique des patients. Les capsules manométriques (CM-V), un nouvel outil, mesurent la force des muscles inspiratoires. Ils sont faciles à utiliser, non invasifs, peu coûteux et légers. OBJECTIF: Vérifier la fiabilité intraévaluateurs et interévaluateurs d'un CM-V chez des adultes en santé. MÉTHODOLOGIE: Des chercheurs ont réalisé une étude transversale par randomisation simple auprès de 40 adultes (20 hommes, 20 femmes) pour les tests de fiabilité intraévaluateurs et de 40 adultes (20 hommes, 20 femmes) d'un âge moyen (± ÉT) de 22±3 ans pour les tests de fiabilités interévaluateurs. Les sujets ont effectué trois efforts inspiratoires soutenus pendant au moins trois secondes. La meilleure des trois lectures servait à la comparaison intraévaluateurs et interévaluateurs. La fiabilité intraévaluateurs et interévaluateurs a été calculée au moyen de coefficients de corrélation intraclasse (CCI). RÉSULTATS: Le CCI de fiabilité intraévaluateurs était de 0,962 et le CCI de fiabilité interévaluateurs, de 0,922. CONCLUSION: D'après les résultats de la présente étude, la pression inspiratoire maximale mesurée au moyen de la CM-V a une excellente fiabilité intraévaluateurs et interévaluateurs et peut être utilisée comme outil diagnostique et pronostique chez les patients ayant un déficit des muscles respiratoires.

Functional Outcome of Mechanical Alignment in Total Knee Arthroplasty Surgery: A Short-Term Cohort Study at an Indian Tertiary Care Hospital.

Background: In severe arthritis cases, goal of total knee arthroplasty (TKA) management is to attain pain-free joint and restore the overall limb alignment. There are limited short-term studies published from Indian hospitals that investigated the importance of neutral mechanical component alignment in TKA patients. Methods: Retrospective and prospective study was conducted at the Department of orthopaedics, Sancheti Institute for Orthopaedics and Rehabilitation, Pune from June 2020 to September 2022. Enrolled patients were assessed preoperatively and postoperatively using clinical examination, radiological assessment and functional outcomes through the Oxford knee score, Knee society score and VAS score. Results: 204 patients enrolled, and 267 knees were evaluated for the study. Osteoarthritis was the commonest diagnosis (254 knees, 95.13%). Pre-operatively, 92.13% knees were varus, 4.87% valgus and 3% neutral while post-operatively, 51.69% were varus, 16.1% were valgus, and 32.32% were with neutral axis. Majority of patients with a pre-operative neutral axis converted to varus axis (62.5%), while most valgus axis cases preoperatively converted to a neutral axis (53.84%). For pre-operative varus subgroup, the majority patients with < 10° pre-operative axis converted to neutral (41.28%). Majority patients with 10°-20° pre-operative axis remained varus (60.53%) and with > 20° pre-operative axis remained varus (78.26%). Functional outcome parameters were significantly improved at follow-up (P < 0.05). Conclusion: Short-term postoperative functional scores were significantly improved in postoperative cases, with the postoperative alignment of 0° ± 3° relative to the mechanical axis was achieved. Thus, postoperative neutral mechanical alignment of 0° ± 3° can be the standard of care for patients undergoing TKA.

Osteoporosis - An Imminent Ethical and Legal Debacle?

Osteoporosis is a condition characterized by a decrease in bone density. Its prevalence is on the rise and is only going to continue to rise further. Fragility fractures such as neck of femur fracture fractures and intertrochanteric fractures are among the most common fractures encountered by orthopedic surgeons today. Yet, the management of these fragility fractures has unfortunately fallen short of addressing the etiology behind the fracture. Orthopedic surgeons routinely perform arthroplasty or osteosynthesis for stabilization of these fractures, but rarely do they address the coexisting osteoporosis. We explore the factors, leading to this scenario, the practical hurdles faced, the ethical and legal considerations on the matter, and the road ahead. We believe that this is a topic which should be discussed further among orthopedic surgeons to arrive at practical solutions and change in perspectives. The aim of this article was to encourage a debate on the matter, increase awareness about the current situation, and help change the trend in the management of osteoporosis in developing countries like India.

What does a department need to get involved in clinical trials?

Clinical trials are conducted to evaluate the usefulness of a drug, medical treatment, surgical intervention, radiological procedure, behavioral intervention, or preventive health care strategy. Clinical trials are challenging, time-consuming, and need careful planning and execution. There are certain requirements for an academic unit to be ready for conducting quality research, especially clinical trials. These include logistical concerns, infrastructure, appropriately trained human resources, conformity with ethical compliances and regulatory compliances as per the laws governing the respective geographical regions. Infrastructure requirements include research division space, robust data archival system, archival of imaging data, laboratory services, information technology division and facilities for the appropriate consenting process. Human resources such as principal investigators, data managers, clinical research assistants and biostatisticians are needed to execute the clinical trial as per the study design. Adherence to ethical and regulatory standards; during the conduct of the clinical trial are imperative. Strict compliance with prevailing governing laws in the country is a prerequisite for a department to get involved in clinical trials. The department also needs to put in place an institutional ethics committee; the composition of which is often governed by regulatory laws. The ethical aspects of the trial undergo a formal scrutiny by an Institute ethics committee that ensures quality care to the patient, and safeguards the patient's rights and privileges. The academic unit of any department forms the core for possible research and pursuit of clinical trials. A department with rich clinical experience and expertise in the filed aids in the execution of quality research. The academic department must consider grant writing and multiple center collaborative research projects in due course of time to further enhance the quality of clinical trials and research output.

A Case of Symmetrical Bilateral Bifocal Femur Fracture with Bilateral Patella Fracture - A Case Report!

Introduction: Bilateral bifocal femur fractures occur as a result of high-velocity trauma mainly road traffic accidents with dashboard injuries or fall from height. These fractures can result in high morbidity or mortality as they are usually presented with hypovolemic shock or fatal fat embolism syndrome. Case Report: We present a 47-year-old male with a history of fall from 35 feet. He sustained a symmetrical intertrochanteric femur fracture with a diaphyseal femur fracture with a bilateral patella fracture. There was no evidence of any head injury or spinal fracture. The patient reached the emergency room in hypotension and was maintaining saturation on room air. The patient was admitted to the intensive care unit; hypotension was corrected overnight and was operated on after 24 h with bilateral intramedullary long proximal femoral nail and tension band wiring for the bilateral patella fractures. At 1-year follow-up, he was able to do his daily activities with minimal limitation. Conclusion: Bilateral bifocal femur fractures result from a high-velocity trauma. In such injuries, careful evaluation of all the systems should be performed to find out concomitant injuries. Single-staged surgical intervention decreases the morbidities of the subsequent surgeries, helps in a rehabilitation hospital stay as well as financially suitable for the patient.

Labral Support Shelf Acetabuloplasty for Late Presenting Perthes Disease: Outcomes in Indian Patients.

Introduction: The treatment of late-presenting Perthes disease with extrusion is controversial and debatable. One of the options available is the labral shelf acetabuloplasty (LSA). Aim: The aim of the study was to evaluate the results of LSA in late-presenting Perthes disease in terms of clinic-radiological outcome measures. Materials and Methods: A retrospective analysis of prospectively collected data of patients with late presenting Perthes disease (Elizabethtown stage 2B onwards) treated by LSA by 2 experienced paediatric orthopaedic surgeons was performed. Data was collected of clinical parameters such as hip range of motion(ROM) and Harris Hip score and radiological parameters such as acetabular height, width and volume, shelf width, Centre Edge angle(CEA) and the lateral extrusion. Results: Thirty-five patients (28 males and 7 females) treated between 2012 to 2019 were analyzed. Majority were in Elizabethtown stage 3A (23) followed by 2B and 3B (12 each). At a mean follow up of 36 months, the hip ROM and the Harris Hip Score (from 65 ± 3.5 to 81.33 ± 7.12) improved significantly and there was a statistically significant improvement in terms of all radiological parameters. Majority of the hips were in Stulberg grade 3 (20) followed by grade 1 and 2 (7 each) and Stulberg 4 (1). There were no major complications in any of the patients of the series. Conclusion: Labral support shelf acetabuloplasty is a valuable surgery for late presenting Perthes disease and helps in maintenance of good coverage and allows restoration of range of motion over time.

"Critical pedicle wall" breaches analysis in complex spinal deformity using O-arm navigation.

Background: Free-hand and fluoroscopic-guided pedicle screw placement has been associated with higher rates of pedicle breaches (frequency range 15-40% especially in deformed pedicles). Neurological complications are more "critical" (i.e., frequent and significant) with medial and inferior pedicle-wall breaches due to the proximity of the neural elements. Here, we analyzed the effectiveness of O-arm navigation in minimizing "critical" pedicle wall breaches and their complications in 21 complex spinal deformity cases. Methods: Twenty-one complex spinal deformity cases were prospectively managed with O-arm-navigated posterior-instrumented fusions. Preoperative assessment included; evaluation of the type of scoliosis, the magnitude of the deformity, and the anatomy of the pedicles - (i.e., classified using Watanabe et al.). The O-arm was used to confirm and grade both the intraoperative and postoperative location of screws. Other variables analyzed included; duration of surgery, estimated blood loss, complications, and radiation exposure. Results: In 21 patients, 259 (63.45%) of 384 pedicles were instrumented; we observed 22 of 259 pedicle screw breaches. Significant (>2 mm) breaches were observed in two medial and one inferior wall cases that required revision; the overall biomechanically significant screw breach rate was (3/259) 1.2% with an accuracy rate of 98.8%. Pedicle screw placement resulted in another 14 nonsignificant (<2 mm) breaches; ten were medial and four involved the inferior wall. As anterior, lateral, and "in-out-in" trajectory pedicle screws beaches were nonsignificant, they were not included in our analysis. Conclusion: O-arm navigation decreased the incidence of medial and inferior (i.e., >2 mm "critical") pedicle screw breaches applied in 21 patients with deformed pedicles due to scoliosis. Further, the O-arm minimized the operating time, decreased the estimated blood loss, and reduced the incidence of complications.

Relative role changing of lateral collateral ligament on the posterolateral rotatory instability according to the knee flexion angles: a biomechanical comparative study of role of lateral collateral ligament and popliteofibular ligament.

PURPOSE: This cadaveric study assessed the relative role of the lateral collateral ligament (LCL) and popliteofibular ligament (PFL) in limiting tibia external rotation. METHODS: Eight paired cadaveric knees were divided into two groups. The specimens were mounted on a rotational wheel and 5 Nm external rotation torque was applied before and after cutting the ligaments at 0°-30°-60°-90° knee flexion. Three cutting steps were applied: (1) PT (popliteus tendon)-, (2) LCL-, (3) PFL in group I, and (1) PT-, (2) PFL-, (3)LCL in group II. Increased external rotation at each step was taken as the ratio of final external rotation at the end of step 3. Repeated measure ANOVA and a Mann-Whitney U test were used for statistical analysis. RESULTS: At step 2, the ratio of increased external rotation after cutting the LCL (group I) was similar to the ratio after cutting the PFL (group II) at 0° and 30° flexion, but that of group I was lower than group II at 60° and 90° flexion (p = 0.029 and p = 0.029). At step-3, the ratio after cutting the LCL (group II) was less than the ratio after cutting the PFL (group I) at 90° flexion (p = 0.029). CONCLUSION: The PFL and LCL play equally important roles in limiting external rotation at the knee extended position (0°, 30°) but the LCL contribution becomes smaller than PFL at the flexed position (60°, 90°).