Management of long bone fractures in patients with pycnodysostosis.

Pycnodysostosis is a rare genetic condition that leads to generalised bony sclerosis and increased fracture risk. Orthopaedic specialists play a crucial role in managing affected children due to their susceptibility to frequent fractures. We had a case of a middle childhood female patient with pycnodysostosis and a femur fracture. Initially, an attempt using the Titanium Elastic Nailing System was made, but the sclerotic metaphyseal bone made it challenging. So, we opted for a 4.5 mm locked compressive plate, with multiple drill bits as a backup due to potential drill breakage. Though elastic nailing is preferred for paediatric long bone fractures, surgeons must be prepared for extremely sclerotic cortices and a narrow medullary canal when dealing with patients with pycnodysostosis. Open fixation and multiple drill bits in the toolkit are essential to overcome the potential obstacles during the procedure.

Demographic characteristics of patients who underwent anterior cruciate ligament reconstruction at a tertiary care hospital in India.

BACKGROUND: Anterior cruciate ligament (ACL) tears are common sports-related injuries. Their incidence is not the same either for all the sports or for the same sport across various nations. This information is maintained by many sports leagues in their registries. However, very few nationwide registries exist for such injuries. This study is carried out to know the demographic characteristics of patients who underwent ACL reconstruction at our hospital in India. AIM: To know the demographic characteristics of patients who underwent ACL reconstruction at a tertiary care hospital in India. METHODS: All the patients who underwent ACL reconstruction from January 2020 to December 2021 were retrospectively studied. Patients with multi-ligament injuries or a history of previous knee surgery were excluded. The patients' history was obtained from the hospital records, they were interviewed telephonically, and online questionnaires were given. Their demographic data was analyzed and compared to the existing literature. RESULTS: A total of 124 patients were operated on for ACL reconstruction during this period. The mean age of the patients was 27.97 years. One hundred and thirteen patients (91.1%) were male and 11 (8.9%) were female. The majority of the patients (47.6%) sustained this injury by road traffic accidents (RTA) followed by sports-related injuries (39.5%). The commonest presenting complaint was giving way of the knee in 118 patients (95.2%). The mean duration from the injury to the first hospital visit among the patients was 290.1 d. The mean duration from the injury to surgery was 421.8 d. CONCLUSION: ACL patients' demography is different in developing nations as compared to the developed world. RTA are the leading cause of ACL injuries and are followed by recreational sports as a cause. There is delayed access to healthcare leading to delayed diagnosis as well as even greater time to surgery. This, in turn, leads to poorer prognosis and longer rehabilitation. National registries for developing nations are the need of the hour due to the different demographics of ACL injuries in developing countries.

"Cage in Box" - A modification of AIIMS BOX technique for large gap nonunion in young patients with neglected femur neck fractures.

Neck of femur fractures have often been termed as "The Unsolved Fractures", since they have a guarded outcome even after improved understanding of biomechanics and biology of this area. Gap-nonunion is one such dreaded complication of this fracture, especially in younger (<60 years) population, where arthroplasty may not be the best go-to option. We have earlier described "The AIIMS BOX" technique to manage such cases of gap non-union in neglected neck femur fractures [1]. Here we intend to describe a more successful modification of this technique. We operated 7 cases of gap non-union with our new "Cage in Box" strategy and followed these cases for 5 years. 6 patients from this group achieved excellent to good outcomes and only 1 reported a poor outcome. All the patients, except the one with poor outcome, could walk without aid and do activities of daily living independently. 3 patients developed AVN but had no evidence of collapse. 3 patients also developed Coxa vara, but it was significant only in one case. 6/7 patients were able to squat. We describe this method in detail and feel this can be a viable option in the armamentarium of orthopedic surgeons, along with valgus osteotomy, vascularized and non-vascularized fibular strut graft as well as Meyer's Graft, to help them solve this unsolved fracture.

'Extended tibia osteotomy': a technical tip for removal of incarcerated reamer with broken guide wire bead during tibia nailing and literature review.

Intramedullary nailing has become a standard of care for tibia fractures. Reaming is an essential part of this technique due to its multiple advantages like a better fit and earlier union. In young bone, with a narrow cortical canal, incarceration and breakage of reamer is a possibility. This can be removed with a ball-tip guidewire. In our case, the broken incarcerated reamer was complicated by a broken ball-tip of the guidewire, leading us to invent a novel medial tibial osteotomy window for the reamer removal. This can be a handy tool for a stuck surgeon intraoperatively.

Bilateral Nonunion of Femoral Neck Fractures Because of Nutritional Osteomalacia: A Report of 2 Cases.

CASE: We report 2 cases of atraumatic, bilateral femoral neck fracture nonunions. Both the patients were relatively young and had underlying nutritional osteomalacia. In both cases, valgus intertrochanteric osteotomy was performed along with vitamin D and calcium supplementation. The patients were followed up for an average of 3 years and achieved bone union without any complications. CONCLUSION: Bilateral femoral neck fractures are rare, and bilateral nonunion of femoral neck fractures secondary to osteomalacia is even rarer. Valgus intertrochanteric osteotomy can salvage the hip. Correction of underlying osteomalacia by vitamin D and calcium supplementation preceeded surgical intervention in our cases.

Lockdown imposition due to COVID-19 and its effect on orthopedic emergency department in level 1 trauma center in South Asia.

Background: The coronavirus pandemic brought the entire world to a standstill. One of the most stringent lockdowns in the world was implemented in India. With the entire healthcare system being stretched, emergency orthopaedic services also take a hit. We studied the trends in patient presentation, testing, management, and restructuring of doctors at a tertiary care orthopaedic centre and compared them with the data from the same time period the previous year (2019). Method: Data was collected separately for all the 5 different phases of lockdown and unlock, as well as for the same duration of months in 2019, and was analysed for epidemiological trends. Results: A rapid fall in the total number of cases was seen during the lockdown, followed by a skewed rise during the unlock. Forearm, wrist, and hip fractures were the most common fractures. Once nucleic acid testing of all patients intended to be admitted was started, a steep rise in coronavirus positivity was seen. There was a reduction in the total number of cases compared to 2019, but it was not as significant as would have been expected due to the complete standstill of activity during the lockdown. Conclusion: During a pandemic, with the healthcare system under a crisis of workforce and infrastructure, there needs to be a separate task force for catering to orthopaedic emergencies since all fractures cannot be managed conservatively and the numbers of trauma-related patients did not show a stark fall as compared to normal months of last year. Level of evidence: Level 3 Retrospective Case Series.

Indigenous Proximal Femoral Nails and Their Novel Complications.

Pertrochanteric fractures are one of the commonest fractures in the geriatric age group. Management of these fractures has been revolutionized by the use of proximal femoral nails (PFN), with a screw or a helical blade for fixation in the femoral head. Multiple complications like Z-effect, screw cut out, head penetration, varus collapse, and so on are known with poor technique in proximal femoral nails antirotation (PFNA). We present a case where an indigenous implant presented to us a novel problem of helical blade breakage inside the bone in situ. Removal of this blade needed an open approach, extending the surgical time as well as blood loss. This led to poorer outcomes and the intraoperative struggle for the surgeon. We feel that all surgeons, especially when using indigenous implants, should be aware of such complications and thoroughly check the helical blade and its collapsing mechanism before inserting this in the bone.

Has the time to reinstate elective orthopedic procedures come?

BACKGROUND: The coronavirus pandemic changed how we manage and operate patients in orthopaedic practice. Although elective orthopaedic procedures were halted to prevent spread of the disease as well as sustain supplies of essential protective equipment and healthcare workers, trauma services were continued. We studied the orthopaedic trauma cases operated over 6 months of the pandemic, and discuss the protocols used to minimize disease spread. METHODS: Data was collected for all orthopaedic emergency cases operated at our centre from 1 st March - 10 th August 2020. During this time specific protocols were used for first aid, pre-operative care, inside the operation theatre, post-operative stay as well as for follow ups. RESULTS: A total of 851 patients were operated. A sharp decline in surgeries was seen during the lockdown. Average stay in the hospital was 4 days. Only 44% of the patients came for follow-up visits. None of the contacted patients or their relatives developed symptoms or tested positive for COVID after discharge. CONCLUSION: Multiple waves and various mutant strains of COVID-19 have made this pandemic longer than expected. Elective orthopaedic cases cannot be ignored for forever, as it leads to poor quality of life and an increasing burden of such patients. We suggest, that using the protocols used at our centre, we have successfully operated on cases without risking spread of the virus. Thus, we believe it's time to reinstate elective orthopaedic procedures, in a phased manner.

Management of Missed Type-2 Monteggia Fracture Equivalent in a 9-Year-Old Child: A Case Report.

CASE: A 9-year-old girl presented with a painful stiff elbow consequent to an injury she had sustained 4 months ago. The radiographs were suggestive of a type 2 Monteggia equivalent injury. She underwent an open reduction of the radial neck fracture and proximal ulna extension osteotomy to restore radiocapitellar alignment. At one-year follow-up, the child had a painless elbow with a good functional outcome. CONCLUSION: Monteggia lesions can be frequently missed and result in significant morbidity. Obtaining appropriate radiographs for a comprehensive understanding of the injury and proper surgical planning is important for achieving a good functional outcome in such injuries.

Application of 3D Printing in Hip and Knee Arthroplasty: A Narrative Review.

INTRODUCTION: Ideal surgical positioning and placement of implants during arthroplasty are crucial for long-term survival and optimal functional outcomes. Inadequate bone stock or defects, and anatomical variations can influence the outcomes. Three-dimensional printing (3DP) is an evolving technology that could provide patient-specific instrumentation and implants for arthroplasty, taking into account anatomical variations and defects. However, its application in this field is still not adequately studied and described. The present review was conceptualised to assess the practicality, the pros and cons and the current status of usage of 3DP in the field of hip and knee arthroplasties and joint reconstruction surgeries. METHODS: A PubMed database search was conducted and a total number of 135 hits were obtained, out of which only 30 articles were relevant. These 30 studies were assessed to obtain the qualitative evidence of the applicability and the current status of 3D printing in arthroplasty. RESULTS: Currently, 3DP is used for preoperative planning with 3D models, to assess bone defects and anatomy, to determine the appropriate cuts and to develop patient-specific instrumentation and implants (cages, liners, tibial base plates, femoral stem). Its models can be used for teaching and training young surgeons, as well as patient education regarding the surgical complexities. The outcomes of using customised instrumentations and implants have been promising and 3D printing can evolve into routine practice in the years to come. CONCLUSION: 3D printing in arthroplasty is an evolving field with promising results; however, current evidence is insufficient to determine significant advantages that can be termed cost effective and readily available.

Orthopedic Residency in a Tertiary Care Hospital of India: Positives, Negatives and Perspectives for Change.

BACKGROUND: Orthopaedic residency training is a 3-year period of preparation that converts a raw medical student into a proficient orthopaedic surgeon. Due to wide variations at different centers in India, the program in a tertiary hospital is presented, in an attempt to improve the overall levels of training. MATERIALS AND METHODS: PGIMER has produced many good surgeons who are well settled across the country and the world. A survey of the postgraduates of the last 30 years was done to highlight the perceptions about the program. An overview of the program was also added to the narrative to highlight the positive aspects of the training. RESULTS: 132 Orthopaedic passed-out residents from PGIMER could be contacted. 97% of them rated their residency experience as excellent or good, and stated that they would recommend this program to new residents. Key points highlighted by them were the readiness of trainees for any surgical contingency after graduation, continuation of the mindset for research, and their prompt acceptability into their subsequent places of work due to their place of graduation. DISCUSSION: Converting an orthopaedic resident into a competent surgeon involves knowledge upgrades and impartation of skills; these are not limited to the theory of orthopaedics, but involve the thought processes and the planning as a surgeon, the attitude towards patient management, and a continuously inquisitive scientific mind. The shortcomings and strengths of the residency program in PGIMER are discussed; international standard methodology limited to this institute like formal log books, mentorship program, hands-on skill development through courses, etc. is something that is recommended to be mandatory in all residency programs. CONCLUSION: The PGIMER Orthopaedic residency program could act as a basic model for other Indian medical schools, with any appropriate modifications. Standardization of Orthopaedic residency programs could allow upgrading to International levels.

Ruptured Popliteal Cysts Mimicking Deep Vein Thrombosis in Well-Functioning Total Knee Replacements: Report of Two Cases and Review of Literature.

BACKGROUND: Implant wear and loosening with eluding metal/polythene debris are commonly implicated in the occurrence of Baker's cysts in post-operative total knee replacement (TKR) patients, who present with post-operative pain and swelling, mimicking deep venous thrombosis. However, we present two symptomatic cases presenting with ruptured Baker's cysts post-TKRs, with no evidence of implant loosening or wear. CASES REPORT: The 1st patient was a 55-year-old male, who underwent TKR for Grade 4 bilateral knee osteoarthritis and presented with acute onset of pain and swelling over the left popliteal fossa, which progressed to involve the calf. Radiographs showed no sign of infection or loosening, and venous color Doppler and magnetic resonance imaging (MRI) showed a hy-poechoic collection in the intermuscular plane at the upper part of popliteal fossa. Histological examination of the aspirated fluid showed mixed features of cystic fluid and a resolving hematoma. There was complete resolution of the 4 months with rest and graduated physiotherapy.The 2nd patient was a 51-year-old female who developed the cystic swelling 2 years after the surgery, and the ultrasound showed hypoechoic echoes in a Baker's cyst-like collection. Cytological findings were suggestive of hemorrhagic nature of the aspirate, without any evi-dence of polyethylene debris, and the cultures were sterile. She became asymptomatic over 4 weeks with conservative management; the swelling resolved after 3 months. CONCLUSION: Majority of the cases in literature show implant loosening as cause of popliteal cysts after TKRs, however present cases highlight alternative mechanisms, and there are good chances of self-resolution of cysts with conservative treatment in such cases.

Can High-Sensitivity C-Reactive Protein Levels Predict Functional Outcome Following Epidural Steroid Injection in Patients with Lumbar Disc Disease?

STUDY DESIGN: Prospective cohort study. PURPOSE: Inflammatory cytokines produced at the site of disc herniation are considered as pain generators in patients with lumbar disc disease. Whether a high-sensitivity C-reactive protein (hs-CRP) assay can be used in order to predict the quantum of inflammation surrounding nerve roots is a matter of investigation. This study aimed to evaluate the association of hs-CRP level and functional outcomes measured by the Modified Oswestry Low Back Pain Disability Questionnaire (MODY) before and after epidural steroid injection (ESI) in patients with lumbar disc disease. OVERVIEW OF LITERATURE: Although many studies examining the role of hs-CRP levels and lumbar pain have been published previously, the results are equivocal, and there is no clear consensus regarding which patients will benefit from an ESI. METHODS: This was a prospective study, with 77 patients in the study group and 23 participants in the control group. Baseline hs-CRP levels were obtained for both groups. Study group patients received a single ESI and were subjected to detailed pre- and postprocedure evaluation using MODY scores. For this group, hs-CRP levels were measured at 1 and 2 months after injection. RESULTS: Out of 77 patients, 52 had acute and 25 had chronic low back pain. Thirty-six patients with acute pain obtained significant improvement, while 16 had an insignificant response to the ESI. None of the chronic cases had a significant response. The mean baseline hs-CRP (mg/L) among the study group (29.83±10.43) was significantly higher than for the controls (10.26±2.783). The baseline hs-CRP among acute cases, where post ESI MODY score at 2 months had significant reduction, was 32.19±5.126, and those with insignificant reduction was 18.13±7.949 (p<0.001). CONCLUSIONS: Baseline hs-CRP levels can be used to prognosticate the outcome following ESI in patients with acute lumbar disc disease, with radicular pain refractory to physiotherapy and analgesics.

Surgical strategy for correction of severe, rigid, post-tubercular cervical kyphosis: an experience of two cases.

STUDY DESIGN: Case series. OBJECTIVES: To describe a novel surgical strategy for severe, rigid post-tubercular cervical kyphosis with treatment outcomes in two patients. BACKGROUND DATA: Spinal tuberculosis is a common cause of kyphotic deformity in the developing world with 3-5% of non-operatively managed patients ending up with kyphosis exceeding 60°. Ventral, dorsal and combined approaches have been described for cervical kyphosis, but there is no established surgical strategy for severe, rigid post-tubercular cervical kyphosis. METHODS: We operated on two girls with severe, rigid cervical kyphosis with preoperative kyphosis measuring 98° and 62°. Our surgical strategy included a three-step approach in the same sitting-(1) An anterior approach to osteotomize the fused vertebral body mass, decompress the spinal cord ventrally and place a temporary cage to stabilize the spine, (2) A posterior approach to osteotomize the fused facets and decompress the cord dorsally. With the completion of the osteotomy, a combination of pedicle screws and lateral mass screws was used to correct the deformity via an anterior opening, posterior closing type of osteotomy. This was followed by, (3) An anterior approach to replace the corpectomy cage with a larger one supplemented with an anterior cervical plate. RESULTS: Our 540° approach achieved a substantial improvement in each of the clinical and radiological parameters we measured, viz. C2-C7 lordosis angle, C2-C7 sagittal vertical axis, neck tilt and Neck Disability Index. CONCLUSION: For severe, rigid post-tubercular cervical spine kyphosis, a three-step, anterior-posterior-anterior procedure can be used for achieving acceptable correction, improving symptoms and avoiding further progression. LEVEL OF EVIDENCE: IV.