A systemic review and meta-analysis of pararectus versus ilioinguinal approach for the management of acetabular fractures.

PURPOSE: The complex anatomy of acetabular fracture needs a surgical approach that can achieve anatomical reduction with fewer complications for the fixation of these fractures. Current literature suggests that both Pararectus (PR) approach and Ilioinguinal (IL) approach can be used for the fixation of these fractures safely. However, superiority of the PR approach over the IL approach is not established. Hence, this meta-analysis aimed to compare the PR versus IL approach. METHODOLOGY: A literature search was performed on five databases Medline/PubMed, Scopus Embase, Cinhal, and Cochrane Library, from the inception to January 14, 2023. A qualitative and quantitative analysis was done for the five eligible studies from the literature search. Individual study characteristics data and outcomes were extracted, and Software version 5.4.1 of Review Manager was used for statistical analysis. RESULTS: Five articles, one Randomized trial (RCT), and four retrospective articles were included and analyzed in this meta-analysis. PR approach has a shorter surgical time [mean difference (MD) -48.4 with 95% CI -74.49, -22.30; p = 0.0003], less intraoperative blood loss (MD -123.22 with 95% CI -212.28, -34.15; p = 0.007), and smaller surgical incision (MD -9.87 with 95% CI -15.21, -4.52; p = 0.0003) than the IL approach. However, the meta-analysis failed to show a difference between the two surgical approaches concerning the quality of reduction, overall complications, nerve injury, vascular injury, heterotopic ossification, deep vein thrombosis, and pulmonary embolism. CONCLUSION: The PR approach has a shorter surgical duration, less blood loss, and a smaller surgical incision than the IL approach. However, both surgical approaches have equivocal results regarding fracture reduction quality, complication rates, and functional outcomes for acetabular fracture fixation. Hence, for acetabular fractures fixation, PR approach can be considered a safe and feasible alternative to the IL approach.

Functional outcome and analysis of factors affecting health-related quality of life of surgically managed pelvic ring fractures: a cross-sectional study.

INTRODUCTION: Pelvic ring fractures, particularly those involving the posterior pelvis, pose significant challenges due to their inherent instability. The posterior pelvic ring is critical in providing structural support and stability to the pelvis. This study evaluates the functional outcomes and health-related Quality of life (HRQOL) of patients who underwent internal fixation for unstable pelvic fractures. Various factors influencing the outcomes are also investigated. MATERIAL AND METHODS: A single-center cross-sectional study was conducted on patients with unstable sacral fractures treated with posterior tension band plate or sacroiliac plating with or without symphyseal plating between 2016 and 2020. Patient demographics, injury mechanisms, associated injuries, surgical details, complications, and return-to-work data were collected. HRQOL was assessed using specific pelvic fracture instruments and general HRQOL questionnaires. Logistic regression analysis was performed to identify factors associated with lower SF-12 and SF-36 scores RESULTS: The study included 54 patients, predominantly males (55.6%), aged 18-70 years, with high-energy trauma mechanisms, such as road traffic accidents and occupational injuries. The majority of patients had lateral compression pelvic fractures. Overall, the functional outcomes were favorable, with excellent or good outcomes observed in 86.1% of cases. Patients with associated injuries, such as abdominal, chest, or head injuries, were likelier to have lower SF-12 physical component scores. Sexual satisfaction scores remained stable for most patients post-surgery. DISCUSSION: This study highlights the favorable functional outcomes and HRQOL for patients undergoing fixation for unstable pelvic ring fractures. Younger, working-age males were the most commonly affected demographic. Associated injuries significantly affected physical HRQOL scores. Despite high-energy trauma, patients generally reported satisfactory sexual function post-surgery.

Does the pararectus approach have better outcomes and fewer complications than the modified Stoppa approach for the fixation of acetabular fractures in adults: A systematic review and meta-analysis?

BACKGROUND: The pararectus approach is a minimally invasive surgical approach for anterior acetabulum fracture, with an advantage of the medial window of the modified Stoppa approach (MSA). However, it is unclear whether the pararectus approach is superior to MSA. We aimed this systematic review and meta-analysis to compare the outcomes and complications of pararectus and MSA. METHODS: We performed a data search by conducting an electronic search across databases of PubMed, Embase, Scopus, Cinahl, CNKI, and Cochrane Library and included seven comparative studies for analysis. Statistical analysis was performed using the RevMan software 5.4.1. The risk of bias was evaluated using the Cochrane Collaboration's risk of bias tool for RCTs and the MINORS tool for non-RCTs. RESULTS: Two randomized control trials (RCTs), one prospective study, and four retrospective studies were included. Meta-analysis revealed a better Matta's reduction quality [OR 1.58, 95% CI 1.06, 2.37; p = 0.03] and radiological outcome [OR 2.18, 95% CI 1.03, 4.60; p = 0.04] in MSA than in pararectus approach. However, the pararectus approach has less intraoperative blood loss [MD - 9.79 (95% CI - 176.75, - 6.83; p = 0.03)] and a shorter hospital stay [MD - 2.61 (95% CI - 5.03, - .18; p = 0.04)] than MSA. Both approaches have failed to show a difference concerning overall complication rates [OR 0.66 (95% CI 0.28, 1.55; p = 0.34)], postoperative infection, DVT, duration of surgery [MD - 15.09 (95% CI - 35.38, 5.20; p = 0.15)], functional outcome, and incision length. CONCLUSION: The pararectus approach offers an advantage with lesser operative blood loss and shorter hospital stay, whilst MSA stands out with better reduction quality and radiological outcomes. Nevertheless, both approaches exhibit no difference in complication rates, duration of surgery, incision length, and functional outcome. Hence, the pararectus approach can be considered an alternative to MSA; however, the existing literature fails to demonstrate a distinct advantage over MSA.

Perception of telemedicine among orthopedic surgeons and patients and an analysis of the factors governing its overall efficacy: Results from the COVID-19 pandemic.

Background: Providing health-care services through telemedicine for musculoskeletal ailments after the first wave of COVID-19 may help reduce the burden on the already-strained health-care system. Objectives: The objectives of this study were (1) to assess the satisfaction levels of orthopedic surgeons and patients with respect to telemedicine and (2) to determine the factors governing the overall efficacy of telemedicine consultations. Materials and Methods: A cross-sectional study was conducted to ascertain the perception of telemedicine (both doctors and patients) under the following domains - (1) information provided and ease of usage; (2) doctor-patient communication; (3) ease of prescribing and understanding treatment; and (4) audio-video quality of the consultation. The influence of these factors on overall satisfaction was determined using multinomial logistic regression analysis. Results: Of the 204 patients and 27 surgeons who completed the questionnaire, 77% (patients) and 89% (surgeons) were satisfied with the overall efficacy of telemedicine. Maximum satisfaction was noted with the ease of obtaining a telemedicine appointment (168/204). 68.6% of patients further stated they would prefer future visits virtually. While all four factors were found to have a significant correlation (P < 0.001) with the overall efficacy of teleconsultation services, the quality of the telephone call (odds ratio [OR] =90.15) and good doctor-patient communication (OR = 15.5) were found to be the most important of the lot. Conclusion: Our study not only demonstrates the high degree of satisfaction with telehealth services but is also able to pinpoint the areas where improvement is needed to enhance the overall experience with this technology.

Apixaban or enoxaparin: Which is better for thromboprophylaxis after total hip and total knee arthroplasty in Indian patients?

Both apixaban and enoxaparin are Food and Drug Administration-approved standard therapy for prophylaxis of deep-vein thrombosis; however, the superiority of one over the other is still controversial. With an objective to observe efficacy and safety outcomes of apixaban and enoxaparin in patients undergoing total hip (THA) and knee (TKA) arthroplasty, 96 patients undergoing THA/TKA (October 2018 to August 2019) were randomly allocated into 2 groups; (n = 48) apixaban; and (n = 48) enoxaparin. Efficacy outcomes and safety outcomes were recorded at 2 and 5 weeks post-TKA/THA. Follow-up functional scoring was done at 6 months postoperatively. Apixaban and enoxaparin were found to be equally efficacious in preventing venous thromboembolism; however, apixaban had a better safety profile. The apixaban group had nonsignificant higher tendency for wound discharge, atrial fibrillation and transient ischaemic attack. Enoxaparin had nonsignificant greater tendency for bleeding, wound dehiscence and pulmonary complications. Apixaban is a safe alternative to conventionally used enoxaparin for chemoprophylaxis in patients undergoing THA or TKA.

Arthroscopic Subtalar Arthrodesis as a Treatment Strategy for Subtalar Arthritis: A Systematic Review.

Arthroscopic subtalar arthrodesis is a relatively new technique which is increasingly being used by foot and ankle surgeons as an alternative to open surgery. However, there is still a lack of consensus with respect to the efficacy of the procedure. The purpose of this review was to ascertain (1) whether arthroscopic subtalar arthrodesis improves the functional outcome of treated patients and (2) how do the 2 techniques of subtalar arthroscopy (posterior and lateral) compare with each other. MEDLINE and Cochrane Library databases were accessed by 2 independent reviewers. Inclusion/exclusion criteria were predefined. National Institute of Health risk of bias assessment tool was used to determine the methodological quality of the included studies. A total of ten studies with 234 patients (240 feet) were included. The most common indication for arthroscopic subtalar fusion was posttraumatic subtalar arthritis. Weighted pre- and postoperative American Orthopaedic Foot and Ankle Society scores were 47 and 80.7, respectively. Average time to fusion was 10.2 weeks and weighted mean fusion rate was 95%. Pain secondary to prominent hardware and nonunion were the most common complications. Although improvement in functional scores was higher and complication rate lower with the posterior group, a better fusion rate was seen with the lateral approach. Arthroscopic fusion techniques have shown to be an effective alternative to open surgery. While there was a trend for better functional outcome with the posterior approach, randomized control trials comparing the 2 techniques are needed to better assess their respective outcomes.

Does a staged treatment of high energy tibial plateau fractures affect functional results and bony union? A case series.

PURPOSE: Tibial plateau fracture (TPF) is a devastating injury as it shatters lower articular surface of the largest joint. Apart from bony injury, TPF can lead to great soft tissue envelope compromise which affects the treatment plan and outcome. In the present study, clinical results were assessed in cases of high energy TPFs treated in staged manner. METHODS: Twenty-three (20 males and 3 females) patients of high energy communited TPFs (Schatzker type V and VI) were consecutively treated.1 All the patient had compromise of overlying skin conditions. They were all successively scheduled for staged treatment plan which comprised of application of bridging knee external fixator on the first day of admission and definitive internal fixation after skin and soft tissue overlying the fracture were healed. Schatzker type I, II, III and IV were excluded from the study. Primary survey was done and patient who had head injury, chest and abdominal injury, pelvic injury and contralateral limb injury and open fractures were excluded from the study. The patients were also evaluated in terms of wound complications, axial and rotary alignment of limb, fixation failure, articular congruity and range of motion of the knees and post injury employment. Statistical analysis was done using SPSS software. RESULTS: Maximum follow-up period was 13 months. All the fractures were united at final follow-up. Clinical evaluation was done with the Tegner Lysholm knee scoring scale.2 Excellent results were found in 78% cases and good and fair results in 22% cases. There was significant correlation between range of motion and the Tegner Lysholm knee score (p < 0.001, Pearson correlation coefficient = 0.741). The correlation between the score and the radiographical union duration was significant (p = 0.006, Pearson correlation coefficient = -0.554). CONCLUSION: A staged treatment plan allows healing of soft tissue envelope, with avoidance of dreadful complications such as compartment syndrome and chronic infection. In addition, a staged treatment strategy does not hamper the fracture reduction, bony union and the functional results.

Discovery of a Novel Yadav-Kunal Reflex in Context of Upper Motor Neuron Lesions: A Report of Three Cases.

Introduction: Numerous reflexive responses have been documented as alterations to the Babinski sign within upper motor neuron lesions. However, scant attention has been given to reflexes beyond these, which exhibit independence from the extensor plantar response. These reflexes predominantly form polysynaptic arcs, with nociceptive stimuli acting as afferents. Case Report: The reflex was serendipitously discovered in an 18-year-old female patient who presented with spastic paraplegia with bowel and bladder involvement, as a consequence of an aneurysmal bone cyst of the D3 (dorsal) vertebrae, and the same was named after the authors as "Yadav-Kunal reflex" which can be defined as: "In individuals with spastic paraparesis, forcibly plantarflexing the toes will result in sudden jerky flexion of the knee and hip on the same side." This novel reflex was further investigated and validated in two additional patients with spastic paraplegia: one, a 45-year-old female with D9-D10 Pott's spine and bowel and bladder involvement, and the other, a 65-year-old male with D10-D11 compressive myelopathy and bowel and bladder involvement. This reflex was meticulously tracked until the abatement of spasticity following surgical intervention. Notably, its manifestation was evident in individuals experiencing spastic paraparesis, dissipating concomitantly with the resolution of spasticity - a direct clinical correlation. Conversely, the reflex was conspicuously absent in cases of flaccid paraplegia. Conclusion: Spasticity, characterized by an increase in muscle tone on swift stretching movements, is a manifestation of a stretch reflex disorder. This condition is primarily induced by lesions affecting upper motor neurons. The activation of muscle spindles in toe dorsiflexors (primarily governed by the L5 nerve) occurs during forceful elongation caused by plantarflexion.

Pathological fracture treated with total femoral replacement in a case of chondrosarcoma involving the entire-length femoral shaft.

INTRODUCTION AND IMPORTANCE: We here present a case of chondrosarcoma of the diaphysis of the femur with extensive involvement of the length of the bone and with the pathological fracture at the mid-shaft level. Total femur replacement was done in this case with a bipolar head and repair of abductors and hip flexors to the implanted prosthesis. CASE PRESENTATION: An elderly female in her late 60s presented to the trauma department with sudden onset pain and inability to bear weight on her left lower limb following a trivial slip and fall. The Radiographs revealed a pathological spiral mid-shaft displaced fracture of the femur with an extensive mixed lesion throughout the femur. Magnetic Resonance imaging revealed involvement of more than 90% of the femur with lesion extension into the quadriceps and hamstrings. Histopathology confirmed grade-II conventional chondrosarcoma. Metastatic work-up showed no distant spread. Wide-local resection and total femur endo-prosthetic reconstruction were done. No recurrence or infection was evident at the 18-month follow-up. In elderly non-metastatic pathological fractures, limb salvage with endo-prosthetic reconstruction can be a preferred treatment. CLINICAL DISCUSSION: This case is unique in describing a rare presentation of chondrosarcoma of the diaphysis of the femur, which eventually landed in a pathological fracture. The fracture may increase the tumour's aggressiveness, but wide-margin resection should be the mainstay treatment for primary or recurrent chondrosarcoma, irrespective of pathological fracture. CONCLUSION: In well-indicated cases (no distant spread - N0M0 disease), Total Femur Replacement (TFR) is an excellent option for limb salvage in tumours with extensive involvement of the femur.

Unusual presentation of adamantinoma with synchronous involvement of entire-lengths of the tibia and fibula in an elderly man: A case report.

INTRODUCTION AND IMPORTANCE: Adamantinoma is a rare primary low-grade malignant bone tumor with a median age of 20 to 30 years with a specific predilection to the lower 2/3rd shaft of the tibia. We present an unusual presentation of a giant adamantinoma with synchronous involvement of almost entire lengths of the tibia and fibula and extensive to the skin in a geriatric man. CASE PRESENTATION: An elderly male patient in their late 50s presented to us with a grossly deformed left leg with a fungating mass over the left leg for 5 years. X-rays showed a lytic sclerotic lesion with a honeycomb appearance involving the entire length of the tibia and fibula. Magnetic Resonance Imaging showed a heterogeneous altered signal intensity (T1 isointense and T2 heterogeneous hyper-intense lesion) large lobulated lesion involving the entire length of the leg with lytic destruction of the entire tibia and fibula and associated remodeling. The histopathological examination revealed an Invasive tumor composed of both epithelial and mesenchymal elements. On immunohistochemistry, tumor cells were positive for D240 and negative for CD31. After confirming the diagnosis of adamantinoma of tibia and fibula radical resection of the tumor was planned and performed in the form of above-knee amputation. The patient was disease-free at 18 months of the latest follow-up and walking with the above knee prosthesis comfortably without any assistance. CLINICAL DISCUSSION: Two morphological patterns of adamantinoma on MRI have been described, a solitary lobulated focus and a pattern of multiple small nodules in one or more foci. Our case has demonstrated the second type of morphology. Histologically, this case presented with "classical basaloid type epithelial cells embedded in osteofibrous dysplasia-like stroma." CONCLUSION: The diagnosis of adamantinoma was based on the clinical-radiological findings and histo-morphology, and should be confirmed by immunohistochemistry for demonstrating epithelial cells. Ultra-structural analysis and Cytogenetic studies may be required in the cases of unusual presentation of these tumors. Wide local resection is the preferred treatment.

Multifocal lower limb hemangioendothelioma in a young female: a case report and review of the literature.

A 26-year-old female presented with pain and swelling of distal thigh and distal leg. She was diagnosed with multifocal epitheloid hemangioendothelioma (EHE) and was successfully treated with wide resection of femoral and tibial lesions followed by their reconstruction using vascularised fibular graft and local bone grafting. One year into follow-up, the patient remained asymptomatic with full Range Of Motion (ROM) and full weight bearing walking. This case illustrates a unique multifocal presentation of hemangioendothelioma and early surgical intervention leading to complete recovery, highlighting the importance of early diagnosis and intervention to help improve prognosis and quality of life of the patient.

Short segment posterior fixation of unstable thoracolumbar vertebral fractures with fractured vertebra augmentation with intermediate pedicle screw - a clinicoradiological analysis.

INTRODUCTION: Unstable thoracolumbar burst fractures are routinely encountered in orthopedic practice. Recently, short-segment fixation with pedicle screw augmentation of the fractured vertebra for unstable thoracolumbar burst fractures has gained popularity. Nonetheless, the maintenance of the kyphotic correction during the follow-up period remains controversial. This study aimed to examine the clinical-radiological outcomes, complications, and functional outcomes of fractured vertebrae augmentation with intermediate pedicle screws in short-segment instrumentation in acute thoracolumbar spine fractures. METHODS: This retrospective study was conducted in the Department of Orthopedics, All India Institute of Medical Sciences, Jodhpur, using medical records from January 2021 to October 2022. Parameters such as local kyphosis correction, loss of kyphotic correction at final follow-up, anterior body height correction (%), and loss of correction (%) at final follow-up were measured as primary outcomes. Various other parameters such as operative time, blood loss, length of hospital stay, and visual analog scale were measured as secondary outcomes. RESULTS: The mean correction obtained via surgery in the immediate postoperative period was 13.7±2.3 degrees. The mean loss of correction at the final follow-up was 4.1±2.0 degrees, and the mean final local kyphotic angle was 7.2±2.4 degrees (P<0.05). The mean correction obtained via surgery in the immediate postoperative period was 37.2%±9.0%. The mean loss of correction at the final follow-up was 10.5%±5.3%, and the mean final anterior vertebral body height maintained was 72%±11.0% (P<0.05). CONCLUSION: Short-segment posterior fixation with pedicle screw augmentation achieves good correction of local kyphotic angle and anterior vertebral height in the immediate postoperative period, but some loss of correction at final follow-up is common. In our study, the loss of correction corresponded directly to the load-sharing score.

Corona Mortise- anatomical variants and implications in pelvic-acetabular surgery: An evidence based review.

Background: Corona Mortise is the name given to the anastomotic vessels forming a communication between external and internal iliac vascular systems. These channels have a high tendency to cause uncontrollable bleeding if injured and are particularly at risk during the anterior approach to acetabulum. While previous studies have described them as arterial or venous connections or both, there is still a lack of consensus regarding exact nature and location of these vessels, which make their timely identification all the more challenging. Objective: The present review is aimed at performing a comprehensive review of existing literature and discuss the anatomy and implications of correct identification of Corona Mortise in pelvic-acetabular surgery. Conclusion: Corona Mortise is more commonly venous than arterial. This not only makes haemorrhage control more challenging but also precludes the use of pre-operative angiography. However, most authors do not recommend a change in surgical approach for fear of damaging these vessels.

Effect of platelet-rich plasma on healing of autologous graft after anterior cruciate ligament reconstruction: a randomized control trial.

Aim: This study aimed to assess the effect of platelet-rich plasma (PRP) on anterior cruciate ligament (ACL) graft healing at graft tunnel interface and ACL graft 6 months post-reconstruction. Material & methods: A randomized trial involving 87 patients was conducted, dividing them into PRP and non-PRP groups. Magnetic resonance imaging (MRI) and functional outcome measures were used to evaluate graft healing. Results: Out of the 87 patients, 80 were analyzed. The PRP group exhibited superior clinical and radiological outcomes compared with the non-PRP group, as indicated by Figueroas score, Lysholm score and knee range of motion. Conclusion: These findings demonstrate that PRP can be used as an adjunct therapy for ACL reconstruction, enhancing graft healing and improving patient outcomes. CTRI approval (Reg. No - CTRI/2018/11/016263).

This study investigated the effects of platelet-rich plasma (PRP) on the healing of the anterior cruciate ligament (ACL) after knee reconstruction surgery. The ACL is an important ligament for knee stability, and its tear is a common sports injury. PRP, a substance found in blood, has been used to speed up healing in various surgeries. In this study, 80 patients who underwent ACL reconstruction were randomly assigned to receive either PRP or standard treatment. After 6 months, the group treated with PRP showed improved healing and better knee function compared with the non-PRP group. These findings suggest that PRP can help accelerate ACL healing and improve outcomes for patients.

Quality of life and self-reported disability in patients with osteoarthritis: Cross-sectional descriptive study.

BACKGROUND: Osteoarthritis (OA) is a chronic disease in which the cartilage in the joints deteriorates and the bones rub against each other, causing pain, stiffness, and restricted range of motion. This is an age-related condition that affects initially isolated joints or joints on one aspect of the body. The aim of the study is to identify quality of life and self-reported disability in patients with osteoarthritis. MATERIALS AND METHODS: A cross-sectional descriptive study was conducted in Orthopedic O.P.D. of tertiary care hospital. Study was conducted on 150 samples with convenience sampling at orthopedic O.P.D. Data were collected with standardized tools SF-36 with domains physical functioning (PF), role physical (RP), vitality (VT), mental health (MH), role emotional (RE), social functioning (SF), bodily pain (BP) general health (GH), and Western Ontario and McMaster Universities Arthritis Index (WOMAC) questionnaires with domains pain, stiffness, and functional disability. Descriptive statistics and inferential statistics were used for data analysis such as mean, frequency, percentage, standard deviation, and Chi-square test. RESULTS: Out of 150 samples, 103 were females, 114 were Hindu, and 131 were married. Highest mean score in RE domain of SF-36 was 60 with SD 38.43 indicating that patients had low impact on quality of life, whereas lowest mean score was 35.33 with SD 32.67 indicating that patients had severe impact in RP domain. In WOMAC index, patients had highest pain in climbing stairs, stiffness during morning, and functional difficulty during doing heavy domestic work, whereas lowest pain in resting, stiffness in evening, and functional difficulty during lying in bed. CONCLUSION: Patients with OA had poorer quality of life in domains PF, RP, VT, BP, and GH. Patients with osteoarthritis showed highest self-reported disability in terms of pain in climbing stairs, stiffness during morning, and functional difficulties in doing heavy domestic duties.

Proximal Tibia Primary Leiomyosarcoma: A Case Report and Review of Literature.

The paper at hand presents a unique case of leiomyosarcoma (LMS) involving the left leg in a 56-year-old patient. This individual experienced pain and the presence of a mass for approximately eight months before seeking medical attention. A diagnostic biopsy revealed the presence of multinucleated pleomorphic cells arranged in intersecting fascicles upon immunohistochemistry (IHC) staining for vimentin, caldesmon, and smooth muscle actin. The rarity of LMS in the extremities highlights the need for further understanding and research to determine the most suitable treatment approaches for such patients. In this specific case, the patient underwent tumor excision followed by reconstruction using a megaprosthesis. This report emphasizes the importance of considering unique treatment strategies when dealing with rare neoplasms like LMS in the extremities. As medical knowledge continues to evolve, gaining insights into the optimal management of such cases will be crucial for improving patient outcomes and overall prognosis.

Pain Management in Osteoporosis.

The most prevalent metabolic bone disease, osteoporosis, is characterized by a decrease in bone mineral density and alterations to the bone's microstructure, both of which can result in fragility fractures. It affects a significant section of the population. Acute or chronic pain from these fractures is typical in elderly adults with other coexisting conditions. Since the antiresorptive medication only partially reduces pain, other analgesics are required for effective pain management. NSAIDs or selective COX-2 inhibitors can reduce acute pain, but persistent neuropathic pain is difficult to manage with these drugs. Opioids have their adverse effects and safety concerns, although they can be used to address acute or chronic pain. Hence, a multifaceted approach is to be implemented, including pharmacological and nonpharmacological therapy and surgical treatment in a selected number of cases. This chapter briefly describes the etiology of pain, its mechanism, and pain management in osteoporotic patients.

Introduction to Osteoporosis, Osteomalacia, and Fragility Fractures.

Background: Osteoporosis is a disease of the bones leading to decreased bone mineral density, leading to fragility fractures. This article is an overview of osteoporosis, osteomalacia and fragility fractures and serves as an introductory article for this special issue on osteoporosis. Methods: This is a short, comprehensive account of the given conditions with concepts and a review from the recent literature. The authors provide relevant references from the literature in the bibliography. The sections herein have also been deliberated in the meetings of experts of osteoporosis. Results: An overview of osteoporosis, osteomalacia and fragility fractures is provided, including definitions and summaries of aetiology, pathophysiology, diagnosis, prevention, and management. A detailed account of some of these topics will be provided in subsequent chapters. Conclusion: Osteoporosis is a silent disease with the potential to cause significant morbidity and mortality if not detected early. It is important to differentiate from and diagnose associated osteomalacia to provide accurate therapy. It is also important to identify the type of fragility fractures and initiate treatment for bone strengthening to prevent subsequent fractures.

Sacrococcygeal chordoma-illustrative cases and our experience.

Chordoma is an uncommon malignant bone tumour of low metastatic potential, the commonest site of which being sacrum. We intend to report two cases of giant sacrococcygeal chordoma managed surgically. The first patient presented with natal cleft swelling since past 3 years which on examination had a size of 12*10*14 and was mildly tender, non reducible, non pulsatile and non fluctuant. The swelling had a variegated surface and extended from sacral region till 2 cm above anal verge. The second patient presented with low backache with radiation to the left lower limbs along with numbness in posterior aspect of left thigh. Physical examination in the second patient was near similar to that in first case except the decreased perianal sensation with otherwise normal neurology in the second patient. The imaging and histopathology was consistent with sacroccocygeal chordoma in both cases. Both patients underwent wide margin resection with preservation of both S2 and right S3 roots. Effective management of sacrococcygeal chordoma requires early diagnosis, accurate preoperative staging, definitive and adequate surgical resection with proved tumour-free cut margins while in those declining surgery, radiotherapy can be considered as an alternative.

Primary Synovial Chondromatosis of the Ankle in a Child: A Rare Case Presentation and Review of Literature.

Introduction: Synovial chondromatosis is not a common condition and involvement of the ankle joint is quite rare. We found only one case of synovial chondromatosis of the ankle joint among the pediatric population. We present a case of a 9-year-old boy with synovial chondromatosis of the left ankle. Case Report: A 9-year-old boy had synovial osteochondromatosis in the left ankle joint, which caused pain, swelling, and restriction of movement of the left ankle. Radiological examinations showed variable size calcific foci adjacent to the medial malleolus and medial ankle joint space with mild soft-tissue swelling. The ankle mortise space was well-maintained. The magnetic resonance imaging of the ankle joint revealed a benign synovial neoplastic process and a few focal marrows containing loose bodies. The synovium was thick, and there was no articular erosion. The patient was planned and underwent an en bloc resection. A lobulated pearly white mass arising from the ankle joint was observed intraoperatively. Histological examination also showed attenuated synovium with osteocartilaginous nodule with binucleated and multinucleated forms of chondrocyte typical of osteochondroma were appreciated. Endochondral ossification, mature bony trabeculae with intervening fibro adipose tissue, was noted. The patient had remarkable relief of clinical complaints and was almost asymptomatic at the time of the first follow-up. Conclusion: Synovial chondromatosis may present with diverse clinical manifestations according to the different stages of the disease as described by Milgram; like joint pain, limitation of movements, swelling due to the close proximity of important structures including joints, tendons, and neurovascular bundles. A simple radiograph with a characteristic appearance is usually sufficient in confirming the diagnosis. In pediatric patients, overlooking these conditions may result in growth abnormality, skeletal deformities, and several mechanical problems. We suggest that when dealing with the case of swelling in or around the ankle, the differential diagnosis should include synovial chondromatosis.