A Rare Case of Periprosthetic Fracture with Fracture of Femoral Stem around a Bipolar Hemiarthroplasty.

Introduction: The incidence of periprosthetic fractures (PPF) around a total hip arthroplasty continues to increase with the rise in number of arthroplasties performed. However, fracture of the femoral stem has become very rare since the development of modern prosthetic designs. We present a rare case of an 80-year-old man who sustained a periprosthetic femur fracture with a fracture of the femoral stem component around a bipolar hemiarthroplasty. Case Report: This man sustained a Vancouver type B1 periprosthetic femur fracture with a fracture of the femoral stem component around a fully cemented bipolar hemiarthroplasty done 10 years back. This patient was treated with removal of the broken femoral stem and osteosynthesis with a plate and cerclage wire plus revision to a longer stem prosthesis. Conclusion: PPF with a fracture of the femoral stem around a hemiarthroplasty is a rare and uncommon occurrence. A combination of osteosynthesis with revision arthroplasty with a longer stem proved to be a suitable treatment with satisfactory results. However, regular follow-ups post-arthroplasties are advocated to identify complications at an earlier stage.

An algorithm for selection of full endoscopic approach for symptomatic nerve root decompression.

Background Context: Both Transforaminal (TF) and Interlaminar (IL) endoscopic approaches are established techniques of decompression for lumbar compressive radiculopathy. In the absence of adequate literature, there is always some dilemma in selecting the approach for endoscopic decompression leading to long learning curves and high chances of inadequate decompression, iatrogenic instability, dural tear, or dysesthesia. Hence authors propose a new surgical nomenclature and algorithm for selection of endoscopic approach. Methods: This retrospective study included 396 of 626 consecutive patients who met the inclusion criteria, who underwent either TF (n=302) or IL (n=202) full endoscopic spine surgery. MRI findings of every patient were classified as per FAPDIS (Facet angle, Anterior pathology, Posterior pathology, Dorsal, Inferior, and Superior migration) algorithm. Inter-observer variations were calculated. The targeted nomenclature was used to define the selection of endoscopic TF or IL approach for symptomatic nerve root decompression. All patients were followed up for preop and postop 6 months VAS and Oswestry Disability Index score for validation of FAPDIS algorithm. Results: Median age: 46.8 years; Sides and levels operated 330 single-level ipsilateral, 54 multiple-level ipsilateral, 6 single-level bilateral, and 6 multiple-level bilateral. Interobserver agreement in the selection of TF approach was 0.873 and IL approach was 0.882. Interobserver variability was also calculated for each FAPDIS factor, selection of P3 and P4 pathology was the main reason for disagreement. All other FAPDIS factors show good to excellent correlation. The overall VAS score decreased from a preoperative value of 9 to 1 at 6 months follow-up (p-value < 0.001), and the overall Oswestry Disability Index score improved from 89 to 12 (p-value <.001). Conclusions: The author's new FAPDIS surgical nomenclature and algorithm is a reliable tool for describing the symptomatic nerve root compression for the selection of endoscopic surgical approach to achieve adequate decompression of offending neural structure with minimum challenges to minimize perioperative complication rate.

An Unusual Midfoot Dislocation Involving Naviculocuneiform and Calcaneocuboid Joint Following Low-Energy Injury: A Case Report.

INTRODUCTION: Midfoot injuries involving naviculocuneiform and calcanealcuboid joints are very rare. These injuries result from high-energy crushing trauma and most often causes dislocation of the midfoot in plantar direction. CASE REPORT: A 30-year-old female sustained an injury to the left foot after a fall from a very low height. A radiograph of the left foot demonstrated naviculocuneiform joint and calcaneocuboid joint fracture-dislocation. This unusual pattern of injury required open reduction and internal fixation with K-wires after a failed attempt of closed reduction. K-wires were removed after 8 weeks. At 24 months follow-up, she achieved a complete range of movements of left foot and ankle without any complications. CONCLUSION: Injuries involving naviculocuneiform and the calcaneocuboid joint can occur following low-energy impact. Such complex injuries should be diagnosed and treated as early as possible. Initial open reduction and stable anatomical fixation are the keys to achieve a good functional outcome in such kind of injuries.

Functional Outcome of Right-sided Thoracotomy for Tuberculosis of the Dorsal Spine.

INTRODUCTION: In pathologies of the spine involving dorsal vertebrae, it is a routine practice to go for left-sided thoracotomy. It is so because in this approach, we encounter the aorta before reaching the concerned dorsal vertebra which is easy to handle as compared to the inferior vena cava on the right-sided approach. This is because the aorta is a structure with thick muscular wall. However, there are conditions which demand right-sided thoracotomy for better outcome such as idiopathic scoliosis and dorsal spine tuberculosis (TB). The selection of side of thoracotomy should be done on case-to-case basis. STUDY DESIGN: This was a prospective study of 10-year duration. PURPOSE: The purpose of the study was to analyze whether it is more rational to do thoracotomy from the right side than left for dorsal spine TB. MATERIALS AND METHODS: The study was performed on 102 dorsal Koch patients with neurological deficit who required surgical decompression. Magnetic resonance imaging of those patients was analyzed. Seventy-two patients had predominant right-sided lesion. Left and central types of predominant results were in 19 and 11 patients, respectively. Among these 102 patients, 82 were operated with right-sided thoracotomy, whereas 20 were operated for left-sided thoracotomy. Preoperative and postoperative kyphosis angle (K angle), average surgical time, mean blood loss, and visual analog scale (VAS) score were calculated. The SPSS 17 software was used for the statistical analysis. RESULTS: Right thoracic approach turned out to be better approach than left in dorsal Koch spine. The average surgical time and mean blood loss were less in the right thoracotomy than left. Postoperative K angle and VAS were improved in the right thoracic approach as compared to left. CONCLUSION: Tubercular debris in the dorsal spine predominantly is on the right side, and right thoracotomy gives better results as there is better decompression of lesion.

Surgical Management of Hirayama Disease: A Rare Entity with Unusual Clinical Features.

Hirayama disease (HD) is a rare type of cervical myelopathy in young males due to neck flexion causing cervical cord atrophy and asymmetric flattening with preferential involvement of anterior horn cells of the spinal cord. This is due to forward displacement of the cord during neck flexion getting compressed between the posterior part of the vertebral body and the posterior dura. The spinal cord involvement occurs due to repeated flexion and extension motion of the neck leading to selective spinal cells injury and atrophy. Most cases report an asymmetric lower motor neuron type of weakness predominantly involving the forearm and hand muscles. We report here a case of HD in an 18-year-old male who presented to us with weakness and wasting in the right hand. The patient was progressively symptomatic over a period of 1 year before presentation. The etiology and the exact cause of HD largely remain debatable and rely on the understanding of few theories which have been put forward. The natural history of this disease reaches a plateau in terms of neurological involvement after 2-5 years and is considered a self-remitting disorder. The patient was initially managed with a cervical collar immobilization but symptoms were largely not improving which was attributed to poor brace compliance. The patient was then managed surgically with a posterior lateral mass instrumentation without fusion in a lordotic alignment at the levels of maximal dural shift anteriorly. The patient improved neurologically following the surgery and maintained the intact status at the last follow-up.

Arthroscopic Anterior Cruciate Ligament Reconstruction in a Case of Multiple Osteochondromatosis: A Case Report.

INTRODUCTION: Osteochondroma is the most common benign bone tumor and usually occurs in the metaphyseal region of the long bones. Anterior cruciate ligament (ACL) tear is the most common ligament injury of the knee joint, and reconstruction of the ACL is the most commonly performed procedure in the knee joint nowadays. CASE PRESENTATION: A 26-year-old male with multiple osteochondromas around the knees, shoulders, and ankles presented with a chronic ACL injury. Reconstruction of ACL using quadrupled hamstring tendon grafts was done. Anterior drawer and Lachman tests were negative postoperatively. The Cincinnati score increased from 180 to 310 at 3-month follow-up. This is a novel case report to describe ACL injury in a case of osteochondromatosis managed by an arthroscopic ACL reconstruction. The problems faced are discussed. CONCLUSION: Our report highlights the fact that ACL tear may occur in a patient having osteochondromas around the knee. ACL reconstruction can be performed in routine fashion in such patients with particular attention to careful harvesting of grafts and tunnel placements.

Outcome Analysis of Anterior Reconstruction with Rib Grafts in Tuberculosis of the Thoracic Spine.

INTRODUCTION: Tricortical iliac bone is the gold standard as an autograft for the reconstruction of the anterior column in tuberculosis (TB) of the thoracic spine. However, the quantity of graft needed is significant. It creates a considerable defect in the pelvic bone, causing graft site complications, including pain, pelvic instability, fractured ilium, herniated muscle, or abdominal contents. To prevent these donor site morbidities, ribs that were removed during the versatile approach were used for anterior reconstruction. The aim of this study was to assess the clinical and radiological results of the reconstruction of the anterior column of the spine with the help of an excised rib during the versatile approach. SUBJECTS AND METHODS: This retrospective study was undertaken at a tertiary care center with a study duration of 14 years. Between January 2004 and December 2016, 52 patients with thoracic Koch's spine had anterior column reconstructed with multiple rib grafts. A single surgeon performed all operations. Indications for the surgery in these patients were the presence of neurologic deficit (49 patients) and vertebral column instability (3 patients). The preoperative kyphosis angle and visual analog scale (VAS) score were compared with postoperative values using a paired t-test. RESULTS: All patients underwent a minimum follow-up of 18 months and were evaluated clinicoradiologically. Good bony fusion with neurological recovery was achieved in all cases. The VAS score for back pain improved significantly postsurgery. There was one case of graft buckling treated conservatively. DISCUSSION: Appropriate anterior reconstruction forms the cornerstone of successful surgical management of spinal TB. The "Versatile approach" used offers anterior and posterior access in the lateral position. In these patients, we obviated the need for iliac crest graft using multiple segments of the rib for anterior column reconstruction. This meticulous rib grafting technique gives good functional outcome in terms of solid bony fusion. CONCLUSION: Meticulous rib grafting technique gives 360° bony fusion and good functional outcome in surgery for thoracic spinal TB. It has the advantage of avoiding the complications associated with a tricortical iliac crest graft.

X-ray and Computed Tomography Scan-Based Morphometric Analysis of Skull Baselines in Indian Population.

INTRODUCTION: The study aims at providing an overview of morphometric measurements of the skull baselines in normal Indian population and compares these dimensions with those of other races and ethnicities. This study will help in defining "normal" baseline values for Indian population. It will also compare dimensions as measured on X-ray and computed tomography (CT) scan to assess the reliability of X-ray as a diagnostic modality for the assessment of the skull baselines in Indian population. MATERIALS AND METHODS: Retrospective study with a sample size of 116 patients and duration of 30 months. RESULTS: The mean value for distance between dens tip and Chamberlain line on CT was 0.498 mm and on X-ray was 0.528 mm and for the distance between dens tip and McGregor line on CT was 0.213 mm and on X-ray was 0.228 mm. The mean distance between the dens tip and McRae line was 4.67 1.69 mm on CT scan and 4.7 1.76 mm on X-ray. CONCLUSION: There was not a single patient in whom the dens tip crossed the McRae line. Any protrusion of the dens tip beyond the foramen magnum is abnormal. Hence, the McRae line is easiest to understand and remember. Furthermore, the Chamberlain and McGregor lines rely on identifying the hard palate, which may not be included in routine X-ray, CT, and magnetic resonance imaging studies depend on the field of view. Hence, we recommend the use of McRae line for screening purposes while evaluating pathologies of the craniovertebral junction. X-ray is a reliable diagnostic technique for assessing morphometry of the skull baselines in an emergency or rural setting if facility for CT scan is not available.