Benign lytic lesions of the femoral neck: mid-term results of extended curettage and sartorius muscle pedicle bone grafting.

INTRODUCTION: Benign lytic lesions of bone encompass a group of neoplastic or developmental disorders of human skeleton. They may involve different sites with varied clinical presentation and pattern of aggressiveness for which the treatment strategy needs to be tailored accordingly. Planning a treatment protocol for a lytic lesion in the femoral neck is a matter of concern for the operating surgeon with due consideration to the risks involved. PATIENTS AND METHOD: This prospective study comprised of 16 patients (9 females and 7 males) with an average age of 23.37 years (range 14 to 35) who presented with lytic lesion in the neck of femur. Only those lesions which were involving the anterior or the inferior aspect of the femoral neck in which the destruction was more than 50 % of the cortex in a single view or there was a pathological fracture were included in this study. There were six cases of giant cell tumour, five cases of fibrous dysplasia, four cases of aneurysmal bone cyst and one case of benign fibrous histiocytoma. All the lesions were operated using anterior approach, and after extended curettage, the cavity was packed with bone chips and sartorius-based muscle pedicle bone grafting (MPBG) was done. Four patients presented with pathological fracture in which the fibula strut grafting was done in addition to MPBG. The patients were assessed using Musculoskeletal Tumour Society (MSTS) score. The mean follow-up period was 32 months (range 26-74 months). RESULTS: The average time to clinical healing was 8 weeks (range 6-12 weeks) in patients without pathological fracture at the presentation. At final follow-up, the average MSTS score was 28.2 and full radiological consolidation had occurred in all but one patient who developed recurrence. There was no evidence of avascular necrosis or pathological fracture in any of the cases. CONCLUSIONS: Sartorius muscle pedicle bone grafting using anterior approach is a good and reliable option in patients presenting with benign lytic lesion in the neck of femur.

Ipsilateral dislocation of the radial head associated with fracture of distal end of the radius: a case report and review of the literature.

Dislocation of the radial head in adults is uncommon. A simultaneous dislocation of the radial head and fracture of the ipsilateral distal end of radius with no other associated injuries is extremely rare. As far as we know, such an injury after an unusual mode of injury has been seldom reported in the English literature. We report such a case without any associated injuries or comorbidity. Closed reduction was performed within two hours after injury and results were satisfactory. Immobilisation was continued for 3 weeks. Gradual mobilisation was started after removal of the plaster under the supervision of a physiotherapist. At 6 months'follow-up, the patient had no residual pain at the elbow with full flexion and extension. Almost full supination with a restriction of last 10 degrees of pronation was achieved. There was no evidence of instability of the elbow.

Pseudoarthrosis of medial tibial plateau fracture----role of alignment procedure.

Nonunion in tibial plateau fractures is very rare. Limited literature is available on Pubmed search on intraarticular tibial nonunion. Most of the cases reported have been following failed surgical treatment and none was neglected fractures. Three patients of isolated and neglected medial tibial plateau nonunion with almost similar demographic profile are reported in this paper. All the three patients were managed by minimally invasive compression fixation using lag screws supplemented with limb realignment procedure of high tibial osteotomy. We discussed the injury mechanism, management and rehabilitation in such cases and reviewed the available literature regarding such a presentation.

Evaluation of functional outcome and comparison of three different surgical modalities for management of intertrochanteric fractures in elderly population.

INTRODUCTION: The purpose of this study was to compare the role of the various surgical modalities ie, Hemiarthroplasty (HA), Dynamic Hip Screw (DHS), Cephalo-medullary nail (CMN) in the management of intertrochanteric fractures in elder patients with comparison of the results and assessment of the complications encountered with each method. METHODS: Total 105 adult patients having intertrochanteric fractures managed during July 2013 to December 2018 at tertiary trauma care centre and followed for minimum 12 months were included in the study. Patients were divided into three groups. Primary hemiarthroplasty was done in 35 patients (group A) while DHS and PFN was done in 35 patients each in group B and group C respectively. Functional evaluation was done using Modified Harris Hip score (HHS) at different intervals while ambulatory function was measured using the Parker Mobility Score. RESULTS: The mean age of patients was 72.14±2.9 years. Mean operative time and blood loss in group A was significantly higher than the other two groups. Hemiarthroplasty group could ambulate earlier than DHS/PFN group. Mean HHS at final follow up was 85.40±7 in group A while in group B and group C these values were 76.36±16.45 and 86.85±10.52 respectively. HHS was significantly higher (P, 0.01) in hemiarthroplasty group in comparison to DHS group. Post-operative complications were comparable in all the groups. CONCLUSION: We support the use of hemiarthroplasty for unstable intertrochanteric fracture in elderly patients with lesser failure rates, early mobilization and better functional outcomes. Early mobilization and less hospital stay should be the goal of every surgical procedure in the elder population.

Unstable trochanteric fractures: the role of lateral wall reconstruction.

The sliding compression device, a widely used implant in unstable proximal femoral fractures, suffers from two major limitations: excessive collapse and screw cut-out. Commonly attributed reasons for these are lateral wall comminution and single-point fixation, respectively. We report our experience of stabilising 74 unstable trochanteric fractures, of which 46 cases underwent lateral wall reconstruction using a trochanteric stabilising plate (TSP) in combination with a dynamic hip screw (DHS), and 34 cases with an intact lateral wall had a DHS with an additional anti-rotation screw providing two-point fixation. Fracture consolidation was observed in all cases at an average of 13.56 weeks. Overall functional hip score as per the Salvati and Wilson scoring system was >30 points in 55 patients. Lateral wall reconstruction is an important component in stabilisation of unstable trochanteric fractures and a combination of TSP with a DHS appears to be a useful device to achieve this. Addition of an antirotation screw is likely to enhance the stability further by providing two-point fixation.

Comparative study of medial opening wedge high tibial osteotomy using fixator-cum-distractor device or locking plate in medial unicompartmental osteoarthritis of knee.

OBJECTIVE: The aim of our study was to evaluate the role of medial opening wedge high tibial osteotomy (MOWHTO) in medial unicompartmental osteoarthritis of the knee and compare two different fixation devices for stability, duration, outcome, and complications. METHODS: Fifty-seven patients (60 knees) of age < 60 yrs and either sex with medial unicompartmental osteoarthritis of the knee were divided into 2 groups. Twenty-four patients (25 knees) in Group I underwent MOWHTO using fixator-cum-distractor and 33 patients (35 knees) in Group II underwent MOWHTO using locking plate osteosynthesis. The results were assessed by VAS, KOOS and WOMAC score. RESULTS: Mean age of the patients in Group I was 53.13 ±â€¯5.20 years and 51.32 ±â€¯6.91 years in Group II. Mean preoperative varus deviation was 11.97 ±â€¯3.34° in Group I and 11.78 ±â€¯3.05° in Group II which was corrected to 3.27 ±â€¯1.75° and 3.56 ±â€¯1.47° valgus respectively. All the patients achieved full weight bearing by 35th day postoperatively in Group I with the mean of 30.27 ±â€¯2.71 days and 38th day in Group II with the mean of 30.32 ±â€¯3.08. The VAS, KOOS, and WOMAC score improved significantly postoperatively in both the groups. CONCLUSION: The difference between the two methods of fixation was statistically insignificant. Fixator-cum-distractor is minimally invasive giving good control over the final limb alignment; however, it is cumbersome with less patient compliance and has complications like pin tract infection. Locking plate provides better fixation stability than fixator-cum-distractor even without bone grafting; however, it is an invasive procedure requiring more soft tissue exposure and precise amount of wedge removal.

Joint salvage using sandwich technique for giant cell tumors around knee.

The most common site for giant cell tumors (GCT) is knee, where the tumor characteristically extends right up to the subarticular bone plate. Extensive curettage with preservation of the joint should be done wherever possible. The alternatives for filling the void left after curettage are either bone graft or bone cement. Sandwich technique uses the advantages of both, taking care to prevent damage to articular cartilage. This study was done to evaluate the results of sandwich technique in tumors around the knee joint. It was a prospective study of 26 consecutive patients (15 females and 11 males) with Campanacci grade II and grade III GCT around the knee, which qualified the inclusion criterion and underwent knee reconstruction with sandwich technique, after extended curettage of the tumor. The mean age of the patients at the time of surgery was 32.73 ± 11.30 years (range, 18-62 years), and the mean follow-up was 3.87 ± 1.26 years (range, 6.5-2 years). At final follow-up, the functional evaluation was done using Musculoskeletal Tumor Society (MSTS) score and measuring range of motion around the knee. Three patients had recurrence of tumor; in one case, we were able to salvage the joint and repeat sandwich surgery was performed, and in the other two cases, the joint was breached; therefore, we resorted to resection arthrodesis. At final follow-up, the mean functional arc of motion around the knee and the mean MSTS score in patients without arthrodesis was 123.52 ± 10.21 degrees (range, 100-130 degrees) and 27.04/30, respectively; all patients were able to do their activities of daily living with ease. Sandwich technique is a good reconstruction procedure in GCT around knee joint with good survival rate, minimal complications, and good functional outcome.

Limited laminectomy and restorative spinoplasty in spinal canal stenosis.

STUDY DESIGN: Prospective cohort study. PURPOSE: Evaluation of the clinico-radiological outcome and complications of limited laminectomy and restorative spinoplasty in spinal canal stenosis. OVERVIEW OF LITERATURE: It is critical to achieve adequate spinal decompression, while maintaining spinal stability. METHODS: Forty-four patients with degenerative lumbar canal stenosis underwent limited laminectomy and restorative spinoplasty at our centre from July 2008 to December 2010. Four patients were lost to follow-up leaving a total of 40 patients at an average final follow-up of 32 months (range, 24-41 months). There were 26 females and 14 males. The mean±standard deviation (SD) of the age was 64.7±7.6 years (range, 55-88 years). The final outcome was assessed using the Japanese Orthopaedic Association (JOA) score. RESULTS: At the time of the final follow-up, all patients recorded marked improvement in their symptoms, with only 2 patients complaining of occasional mild back pain and 1 patient complaining of occasional mild leg pain. The mean±SD for the preoperative claudication distance was 95.2±62.5 m, which improved to 582±147.7 m after the operation, and the preoperative anterio-posterior canal diameter as measured on the computed tomography scan was 8.3±2.1 mm, which improved to 13.2±1.8 mm postoperatively. The JOA score improved from a mean±SD of 13.3±4.1 to 22.9±4.1 at the time of the final follow-up. As for complications, dural tears occurred in 2 patients, for which repair was performed with no additional treatment needed. CONCLUSIONS: Limited laminectomy and restorative spinoplasty is an efficient surgical procedure which relieves neurogenic claudication by achieving sufficient decompression of the cord with maintenance of spinal stability.

Proximal humeral reconstruction using nail cement spacer in primary and metastatic tumours of proximal humerus.

Limb salvage surgery for malignant tumours of proximal humerus is an operative challenge, where the surgeon has to preserve elbow and hand functions and retain shoulder stability with as much function as possible. We treated 14 consecutive patients with primary malignant or isolated metastasis of proximal humerus with surgical resection and reconstruction by nail cement spacer. There were 8 females and 6 males, with a mean age of 28.92 years (range 16-51 years) and a mean follow-up of 30.14 months (range 12-52 months). The diagnosis was osteosarcoma in 8 patients, chondrosarcoma in 4 patients and metastasis from thyroid and breast carcinoma in 1 patient each. One of our patients had radial nerve neuropraxia, 1 developed inferior subluxation and 3 developed distant metastasis. Two patients died of disease and one developed local recurrence leading to forequarter amputation, leaving a total of 11 patients with functional extremities for assessment at the time of final follow-up which was done using the Musculoskeletal Tumour Society (MSTS) score. Though we were able to preserve the elbow, wrist and hand functions in all patients, the abductor mechanism, deltoid muscle and axillary nerve were not salvageable in any of cases. The mean MSTS score at the time of final follow-up was 19.09. Thus, proximal humeral reconstruction using nail cement spacer is a technical simple, cost-effective and reproducible procedure which makes it a reliable option in subset of patients where the functions around the shoulder cannot be preserved despite costlier prosthesis.

Neglected locked vertical patellar dislocation.

Patellar dislocations occurring about the vertical and horizontal axis are rare and irreducible. The neglected patellar dislocation is still rarer. We describe the clinical presentation and management of a case of neglected vertical patellar dislocation in a 6 year-old boy who sustained an external rotational strain with a laterally directed force to his knee. Initially the diagnosis was missed and 2 months later open reduction was done. The increased tension generated by the rotation of the lateral extensor retinaculum kept the patella locked in the lateral gutter even with the knee in full extension. Traumatic patellar dislocation with rotation around a vertical axis has been described earlier, but no such neglected case has been reported to the best of our knowledge.

Microteaching in dental education.

Health professionals acknowledge that their education does not prepare them for teaching. However, society's increasingly high expectations of them demand that they be taught teaching techniques/skills and trained effectively. Microteaching is a teaching-simulation exercise that will provide immediate supportive feedback. It can be useful in honing soft emotional intelligence skills, presentation skills, and interpersonal skills. This focused approach encourages growth through practice and critique. The "teach, critique, reteach" model gives the faculty member immediate feedback and increases retention by providing an opportunity to learn good teaching values.

Degenerative lumbar spinal stenosis-results of expansive laminoplasty.

Expansive laminoplasty, a procedure used more and more often for cervical myelopathy, was carried out in patients with lumbar spinal stenosis in the Department of Orthopaedics, Paraplegia, Physical Medicine and Rehabilitation of our institute. Twenty-five such clinico-radiologically proven cases were operated upon. For radiological evaluation, computed tomography (CT) was used. Expansive laminoplasty decompresses the nerve roots by osteoplastic enlargement of the lumbar spinal canal, with the maintenance of spinal stability. These advantages were confirmed during the follow-up of 3 to 5 years. Using CT, the spinal canal was found to be enlarged to a nearly rectangular shape and the average enlargement was 124%. The visual analogue scale (VAS) was used for subjective pain assessment before and after the surgery. The ultimate outcome was assessed by the Surin et al. criteria (Spine 17:1-8, 1992).