Osteoperiosteal fibular strut grafting - A technique to improve union rates.

PURPOSE: Gap non-union of long bones are challenging problems in orthopaedic patients. Non-vascularized fibular grafting is a simple, cost effective, single stage procedure and is an accepted method of reconstruction for gap non unions in children. However, there is a risk of non-union when a long avascular strut of fibula is used. The periosteum, by itself has high biological activity and is helpful in osteointegration. Harvesting the fibula with the periosteum gives the advantage of mechanical and biological support in a gap non-union. METHODS: During 2020 to 2022, 13 patients presented to us with gap nonunion of long bones due to various aetiology. The mean age of the patients was six years with a mean bone gap of 4.2 cm. A modified technique of harvesting the fibula with the periosteum is described. The graft was stabilized with the recipient bone by intra medullary or extra medullary implants. RESULTS: Union occurred in average 12.7 weeks in all except one patient with congenital pseudoarthrosis of tibia. The fibula on the harvest site regenerated completely in all other patients. One patient had a superficial infection. Children were followed were an average of 17.5 months and there was no incidence of graft resorption or fracture. Osteoperiosteal fibula graft is a simple, effective and cost-effective procedure for the treatment of gap non-unions in children. It offers the advantage of both biological and mechanical support, with high union rates and low complication rates.

Management of post septic sequelae of hips with dislocation in children.

BACKGROUND: Limited literature guide management of post septic sequelae of hips with dislocation in children. We studied the functional and radiological outcome of open reduction of such sequelae in 11 children. Special emphasis was given to determine the influence of surgical correction and relocation of these hips. METHODS: Preoperative acetabular index (AI) on both sides was compared to quantify acetabular dysplasia. Radiological parameters like AI, centre edge angle (CEA), Reimer's index, centre head distance discrepancy (CHDD) and neck shaft angle (NSA) were calculated and compared with the unintervened side at follow-up. Outcome was assessed radiologically by modified Severin classification and clinically by Moon's criterion. RESULTS: Average age at open reduction was 20.6 months and further follow-up was 48.8 months. The mean pre-operative AI on intervened side (35 degrees) differed significantly from unintervened side (22.5 degrees). The follow-up AI on intervened side (26.5 degrees) improved significantly from the pre-operative values but residual dysplasia persisted. Mean values for other radiological parameters on intervened side at follow-up were CEA 16.1 degrees, Reimer's index 31.5%, CHDD 18.6% and NSA 119 degrees. Mean shortening of 2.3 cm was documented in ten patients at final follow-up. Triradiate cartilage fused in four out of 11 hips at follow-up. Radiological outcome according to modified Severin classification was good to fair in seven patients (types II and III) whereas poor in four patients (types IV and V). Functional outcome as per Moon's criterion was excellent to good in nine patients, fair and poor in one patient each. CONCLUSIONS: Open reduction potentially alters the natural history of post septic sequelae of hips with dislocation and contributes to better hip mechanics and function.

Enhancing trauma evaluation: Comparative analysis of post-mortem computed tomography and autopsy findings in abdominal stab wounds.

In cases of traumatic deaths, accurate assessment of injuries is essential for both legal and medical purposes. This case report compares the findings of post-mortem computed tomography with conventional autopsy methods in assessing abdominal stab wounds. A 34-year-old woman with multiple stab wounds in the abdomen underwent post-mortem examination, including computed tomography imaging. Computed tomography revealed specific breaches in the skin's continuity and internal injuries, including perforation of the stomach. A conventional autopsy confirmed the presence of multiple stab wounds and associated injuries to internal structures. However, additional injuries to major blood vessels, such as the abdominal aorta and inferior vena cava, were only detected during manual exploration of the peritoneal cavity. This case highlights the complementary roles of post-mortem computed tomography and conventional autopsy in evaluating traumatic injuries. While computed tomography imaging offers non-invasive visualisation of injuries, manual examination remains essential for identifying certain injuries, particularly those affecting major blood vessels. The integration of computed tomography imaging with traditional autopsy methods enhances the accuracy and reliability of forensic assessments in cases of traumatic deaths, particularly in complex cases involving multiple injuries. Understanding the strengths and limitations of these techniques is crucial for improving forensic investigations and ultimately enhancing medico-legal outcomes.

The Mangalore aircrash of 22 May 2010: practical problems related to identification of the dead in a populous developing country.

It was a sad and emotional moment for the citizens of Mangalore, India when the "Dubai to Mangalore" Air India Express Boeing 737-800 flight IX-812 crashed at the Mangalore International Airport on 22 May 2010, killing 158 people on board. Identification of the victims was difficult as most of the bodies were charred beyond easy recognition. The practical problems faced by the legal authorities in identifying the charred victims in a populous and developing country like India are discussed in this paper.

Unilateral limb orthosis for maintenance of deformity correction following treatment of clubfoot with Ponseti technique: a systematic review.

The systematic review study aimed to investigate the following details in the clubfoot children treated with the Ponseti technique: (1) to review the various designs and prescriptions of unilateral limb orthosis described in literature; (2) to find the outcome following use of this orthosis, especially patient adherence and recurrence; (3) comparison with standard bilateral limb foot abduction orthosis. A literature search was performed for articles published in 'Pubmed (includes Medline indexed journals)' electronic databases for broad key words: 'Clubfoot or CTEV or congenital talipes equinovarus', 'orthosis or brace or splint'. Included were studies that addressed the treatment of idiopathic clubfoot in children up to 2 years of age using the Ponseti technique and use of unilateral limb orthosis for the subsequent maintenance phase. We excluded studies reporting Ponseti technique for nonidiopathic clubfoot, child age older than 2 years at the time of primary treatment, studies where unilateral limb orthosis was used as a tool for primary correction of all or some components of clubfoot and design descriptions of orthosis without practical usage data. Of the 1537 articles from the database, 10 articles were included in the final review. Most studies were retrospective, underpowered and had a short term follow-up. In some series, the use of this orthosis was driven by personal experiences and regional preferences rather than a just scientific explanation. The tested designs were variable and nonstandardized. Being less restrictive, unilateral limb orthosis may have an edge over bilateral limb orthosis in terms of patient adherence. The available comparative studies however showed inferiority of unilateral orthoses when compared to the bilateral limb orthosis in preventing recurrences in clubfoot treatment. There is insufficient evidence to support use of unilateral limb orthosis for maintenance of deformity correction following treatment of clubfoot with the Ponseti technique. Their use was found associated with high recurrence rates.

Dimeglio's derotation of calcaneo pedal block and Pirani's talar head reduction: a quantitative matching.

We aimed to determine the quantitative value of derotation of calcaneo pedal block (DCPB) of Dimeglio system equivalent to talar head reduction of Pirani system. We also compared the ankle dorsiflexion obtained post tenotomy for different measures of DCPB. The study involved 53 idiopathic clubfoot children (86 feet) treated with Ponseti technique. Percutaneous Achilles tenotomy to correct ankle equinus was performed when forefoot adduction, heel varus were corrected and ankle dorsiflexion was <10°. Pirani's coverage of lateral head of talus was taken as a determinant of adequate DCPB and to perform tenotomy. Mean patient age at enrollment was 60.9 ± 71.1 days. The median pre and posttreatment Dimeglio scores were 13 (range 4-20) and 0 (range 0-3), respectively. DCPB at the time of talar head reduction was 53.8 ± 9.8°. In 85% feet, talar head reduction was obtained by DCPB 60° and all were reduced by 70°. The average ankle dorsiflexion improved significantly with DCPB ≥ 50°. The measure at which DCPB matched with talar head reduction of Pirani system was variable (40-70°). In all feet, talar head was reduced by 70° DCPB. Post tenotomy, ankle dorsiflexion was better with DCPB ≥ 50°.

Septic sequelae of hip in children: long-term clinicoradiological outcome study.

The presented retrospective study is a report of 18 patients (23 hips) with infantile post sepsis hip sequelae. There were two groups of patients. The observation group comprised of 6 patients (8 hips). The intervention group included 12 patients (15 hips) of which 12 hips had been surgically intervened for the sequelae and 3 contralateral hips which were again serially observed. The sequelae hips were classified by Choi's radiological types. The clinical evaluation was done by modified Moon's criteria. The average patient age at follow-up was 9.3 years. There were 3 type I (13%), 10 type II (43%), 2 type III (8%), and 8 Choi type IV (35%) at presentation. The Choi radiological type showed propensity to change over time/following intervention. At follow-up, there 3 type I (13%), 17 type II (74%), and 3 type IV (13%) hips. At follow-up, there were seven excellent, seven good, and four fair results. The observation group had mostly type I or II and intervention group IIIB or IV Choi types. Findings common to both groups: same Choi radiological type fared different clinically, multiple joint involvement contributed to deterioration of function and late changes in acetabulum or proximal femur lead to deterioration of clinical function. The sequelae of septic hips likely to be kept under supervised observation were Choi type I or II. In select types, intervention changed the natural history of septic sequelae significantly.

Outcome of acute septic dislocation of hip in children reduced at arthrotomy.

BACKGROUND: Pathological dislocation of hip following episode of septic arthritis is a long recognized complication. We determined clinicoradiological outcome in 14 children presenting with acute septic dislocation of hip and reduced at the time of emergency arthrotomy and drainage. METHODS: The retrospective study was conducted at a tertiary care health centre located at suburb of a low income country. The study involved a 10 years chart review of children with confirmed septic arthritis of hip presenting with complication of acute joint dislocation and treated with open reduction at the time of arthrotomy and surgical drainage. All included patients were provided postoperative abduction splintage for minimum 3 months. The clinical evaluation at final follow up was done using modified Moon's criteria for outcome assessment. The radiological outcome was analyzed in terms of containment (Severin class), sequelae (Choi radiological types) and effect on acetabular development (acetabular index, AI). The AI on normal and reduced sides was compared statistically. RESULTS: Average patient age at the time of presentation was 7.2 months and follow up available was 32 months (range, 12-70 months). Functionally, 5 had excellent and 6 had good outcomes at the final follow up. Two patients had fair whereas 1 had poor outcome. Seven hips were Severin class II, 4 class III and 2 class IV and 1 was class VI. One patient had Choi type IA, 3 type IB, 8 type IIA, 1 type IIB and only 1 had type IVA at follow up. The mean AI of reduced hip was 23.4° and was significantly higher than that of unaffected side (mean 15.7°). CONCLUSIONS: The complication of acute septic dislocation of hip in children may not have a sinister prognosis as commonly believed. These hips however were associated with significant acetabular dysplasia in the follow up period.

Clinicoradiological outcomes following pembersal acetabular osteotomy for developmental dysplasia of hip in young children: A series of 16 cases followed minimum 2 years.

PURPOSE: Pembersal acetabular osteotomy is a relatively less practised procedure for developmental dysplasia of hip in young children. We retrospectively studied the acetabular correction and clinico-radiological outcome with this osteotomy in 16 children (16 hips) aged less than 4 years. METHODS: Postoperative correction of acetabular dysplasia was measured by acetabular index (AI). At follow up, following radiological parameters were documented: Centre edge angle (CEA), Reimer's index (RI) and acetabular depth to width ratio (D/W ratio). Avascular necrosis of hip, stability, and premature fusion of triradiate cartilage (TRC) were also recorded. Overall containment was assessed by modified Severin classification and function by Mckay clinical grade. RESULTS: The mean age at time of surgery was 25 months. Mean follow up was 54 months. The postoperative AI (17.6 ± 5.6°) improved significantly from preoperative values (37.5 ± 5.0°) (p < 0.0001). Mean follow up AI on the operated side was 15.3 ± 6.9° as compared to 14.7 ± 4.4° on the normal side (p = 0.78). Follow up CEA (24.9 ± 11.3°), Reimer's index (14.3%), D/W ratio (40.9%) did not differ significantly from the normal side. Early closure of TRC was not found in any of hips. All hips were clinically stable. As per modified Severin's classification, 7 hips were Type Ia, 7 Type IIa and 2 had residual dysplasia. Twelve (75%) hips had excellent clinical outcome, 2 (12.5%) good outcome and 2 (12.5%) had fair outcome. CONCLUSIONS: Pembersal osteotomy is a safe and effective option for correction of acetabular dysplasia during open reduction of DDH in young children. It improves the AI and femoral head coverage, and promotes formation of a congruent and stable hip joint.

Relapses in clubfoot treated with Ponseti technique and standard bracing protocol- a systematic analysis.

PURPOSE: The analysis determined the relapses in clubfoot children treated with Ponseti technique and standard bracing protocol and their correlation with overall follow up duration using pooled data from various series. It also tested the prescribed timelines of 5 and 7 years for slow-down/cessation of relapses in clubfoot children. METHODS: A systematic literature search was performed for articles published in "Pubmed (includes Medline indexed journals)" electronic databases using key words: "Clubfoot or CTEV or congenital talipes equinovarus", "Ponseti" for years 1st January 2001 to 15th November 2020. Included were studies that addressed treatment of idiopathic clubfoot using the standard Ponseti technique, followed a well defined brace protocol (maintenance of corrected deformity using a central bar based brace and prescribed duration mentioned), reported a minimum mean follow up of 4 years and having relapse as one of their outcome measure. Studies reporting Ponseti technique for non-idiopathic clubfoot, child's age older than 1 year at the time of primary treatment, clubfoot with previous interventions before Ponseti treatment, where relapse and residual deformities were not identified distinctly in follow up, abstract only publications, letter to the editors, case reports, technique papers and review articles were excluded. The following characteristics of clubfoot patients in the selected articles were included for analysis: Patient numbers/feet treated with Ponseti technique; follow up years (<5; 5-7 and >7 years; overall) and corresponding relapse percentages for patients. RESULTS: There were total 2206 patients in the included 24 studies. Average follow up was 6 years. The average relapse rates for clubfoot patients in the pooled data stood at 30%. The overall relapse rates increased with a longer follow up and the curve befitted a linear regression equation with weak positive correlation (Pearson correlation coefficient = 0.08). The relapse rates in follow up categories of <5 years (26.6 ± 15.6%), 5-7 years (30.8 ± 16.3%) and >7 years (28.4 ± 6.2%) were similar statistically (Analysis of variance, ANOVA). CONCLUSIONS: Approximately 1 in 3 clubfoot patients suffer relapse post Ponseti technique and standard bracing protocol. A weak positive correlation was observed for relapses when correlated with increasing follow up years. The relapses however tend to slow down after initial growth years. There is a need to educate the care receivers regarding the possibility of late relapses despite proper Ponseti treatment and accordingly to keep them under supervised follow up for longer periods.

Apparent partial hanging.

A careful analysis of circumstances and investigations of death scene are required before commenting on the manner of death in a case of hanging. Hanging may result from either complete or incomplete suspension of the body. Two cases of hanging are reported where discrimination in eyewitness's account and death scene investigation report was evident regarding type of hanging (complete/partial). The use of term apparent partial hanging is proposed in such cases. Body position in hanging is one of the numerous factors that determine the strength of the neck compression by the ligature and thus should be considered in the evaluation of dying process and pathomorphologic feature of hanging. The cases also put a probable explanation to the higher incidence of partial hangings in different studies. We believe that incidence of true partial hangings may be much lower than that reported in the literature.

What factors contribute to Choi IV sequelae? A retrospective analysis of 15 septic hips.

PURPOSE: Choi IV sequela is one of the most severe outcomes of septic hips. We undertook a retrospective chart review of 15 such hips in 13 patients to identify factors contributing to the formation of this sequelae. METHODS: The study specifically focused on patient demographics (patient's age; time to arthrotomy from initial symptoms; causative organism; post arthrotomy duration when Choi IV changes were obvious) and radiological findings at the time of arthrotomy. RESULTS: The average patient's age at time of infection was 2.9 years. Five children were infants. The time to arthrotomy from initial symptoms was mean 21.6 days. Multifocal involvement was seen in 2 patients. Concurrent arthritis and osteomyelitis was present in 8 (53%) and pathological subluxation or dislocation in 9 hips (60%). Methicillin-sensitive Staphylococcus aureus was isolated in 7 and Methicillin-resistant Staphylococcus aureus in 4 patients. The Choi IV findings were established on average 3.8 months post arthrotomy. CONCLUSIONS: Delay in treatment, post septic dislocation and concurrent femoral osteomyelitis were factors associated with Choi IV septic sequelae. The pathology occurred irrespective of age.

Hallux length and deep medial crease in complex clubfeet: Do they recover?

OBJECTIVE: The shortened hallux and deep medial crease are a significant cosmetic deformity in complex clubfeet. We quantitatively determined the correction of hallux length and deep medial crease following treatment of complex clubfeet. METHODS: A chart review of 11 patients (17 feet) with complex clubfeet treated with modified Ponseti method was undertaken. Pretreatment clinical photographs and Pirani scores were compared with those obtained at a recent follow-up to analyze outcomes. Hallux length was matched with 2nd toe and graded similar to Pirani score. RESULTS: Mean patient age at enrollment was 26.8 weeks. Average follow up was 22.6 months. Pre treatment and follow up Pirani score averaged 5.8 and 0.2 respectively. The average number of cast utilized was 7. Incomplete/non correction of hallux was observed in 6 feet (35%), of which 4 suffered an equinus relapse. Deep medial crease corrected in all. CONCLUSIONS: The study describes a clinical method of hallux length quantification in complex clubfeet. Medial crease recovered in all feet. The recovery of hallux length was delayed in some patients and might indicate persistent posteromedial soft tissue contracture/fibrosis in these feet.

Correlation of age and severity scores to the number of Ponseti casts in Indian infants with clubfeet.

PURPOSE: World over, age and various severity scores are among the foremost variables studied in relation to the number of casts in clubfoot. We studied the correlation between child's age at presentation, initial Pirani, Dimeglio scores to the number of Ponseti casts in Indian clubfoot children. Further, we matched Pirani versus Dimeglio scores at different severities of deformity to derive a correlation between them. METHODS: We included 90 idiopathic clubfeet in 55 infants and scored them according to Pirani and Dimeglio grading systems. Syndromic, neurological, surgically intervened, atypical or complex clubfeet were excluded from the study. The number of casts before percutaneous tenotomy was counted. Correlations were calculated between corrective casts and age, Pirani, Dimeglio scores and their individual components. RESULTS: Mean age of children was 63.7 days and average number of casts applied was 3.2. Age at presentation and number of casts had no correlation with r = 0.034 (p < 0.001). The correlation between initial Pirani score (average 5.39) and Dimeglio score (average 13.4) to number of casts was 0.35 (p < 0.001)and 0.56 (p < 0.0001) respectively. Among individual components of Pirani score, medial crease and rigid equinus had maximum correlation to the number of casts whereas empty heel sign had the lowest. For Dimeglio score, equinus and varus correlated the most and posterior crease the least. Pirani and Dimeglio scores were highly correlated (r = 0.87) to each other except for very supple or severe deformity. CONCLUSIONS: In infancy, the age at presentation had no bearing on number of casts. Both scoring systems had positive correlation in terms of corrective casts for our population. The Dimeglio fared slightly better than Pirani scores.

Arcing injuries in a fatal electrocution.

Electric arc injuries tend to be very severe and can cause skin burns by direct heat exposure or by igniting clothes. It produces intense heat, and fatal lesions can occur even when the victim is several feet from the arc. A fatal case of accidental high-voltage electrocution is reported, where multiple skin to bone-deep oval and circular lesions of varying dimensions caused by arcing was present.

Middle finger length--a predictor of stature in the Indian population.

Stature is an important indicator for identification. There are numerous means to establish stature and their significance lies in the simplicity of measurement, applicability and accuracy in prediction. The present study was conducted on 500 north and south Indian subjects in Manipal, India, to establish the stature of an individual using the middle finger length. Measurements were analysed statistically to establish the relationhip between a person's middle finger length and their stature. The study shows that the middle finger length bears a significant relation to stature and can be an important tool for stature estimation. Significant differences in measurements and formulae for males and females were found. These differences were insignificant when values were compared between subjects of the same sex in north and south Indians and also between the dominant and non-dominant hand.

Suicide pact by hanging: a case report.

A suicide pact is an agreement between two people to end their lives. The presence of an over-dependent relationship and a threat to the maintenance of closeness are strongly associated with the attempt. We present a case of a suicide pact where a 19-year-old female and a 20-year-old male who were lovers committed suicide by hanging because of opposition to their marriage from the family members.

Evaluation of Vacuum Assisted Closure Therapy for Soft Tissue Injury in Open Musculoskeletal Trauma.

INTRODUCTION: The application of controlled levels of negative or sub atmospheric pressure for a prolonged period of time on a wound had shown to accelerate removal of excess fluid and promote hyperaemia, which eventually promote wound healing. AIM: The study was conducted with the aim to evaluate the effectiveness of Vacuum Assisted Closure (VAC) therapy for soft tissue injury in open musculoskeletal trauma. MATERIALS AND METHODS: Twenty cases of complex musculoskeletal wound involving different parts of body were included in this progressive randomized study. In patients, aggressive debridement was done before the application of VAC therapy. Controlled negative pressure was uniformly applied to the wound. Dressings were changed after every 4 to 5 days. The evaluation of results included healing rate of the wound, eradication of infection, complication rate, and number of secondary procedures. RESULTS: VAC therapy over the wound was administered for an average of 20.4 days ±6.72 days (range 14 to 42 days). There was decrease in wound size attained by VAC therapy ranged from 2.6 to 24.4cm(2), with an average reduction of 10.55 cm(2). Three wounds were infected at the start of VAC therapy. However, all patients were cleared of bacterial infection by the end of VAC therapy. CONCLUSION: VAC therapy using negative pressure promote Wound healing by increasing local capillary perfusion and increased rate of granulation tissue formation, decreases the duration of wound healing and requires fewer painful dressing change.

Periligature injuries in hanging.

Hanging is a common mode of suicide while ligature strangulation is a common way of homicide. Ligature marks (patterned abrasion caused by ligature material) can be of great significance to the forensic pathologist in determining the cause and manner of death. Ligature material usually produces a prominent mark over the bight area, which is opposite to the knot and an inverted 'V' pattern at the site of the knot. Apart from ligature mark, sometimes findings such as rope burns & nail marks may be seen around the ligature mark and can be termed as 'periligature injuries'. Nail marks over the neck are usually suggestive of throttling. But they can also be self inflicted by the victim while trying to extricate himself/herself from the strangling grip of hanging or ligature strangulation. Such injuries, when present may mislead the forensic pathologist in drawing conclusion as to whether it is due to hanging or manual strangulation. Rope burn is caused by friction of rope against skin leading to blister formation. Thus it is an antemortem feature. We present two cases of hanging with periligature injuries.