A molecular and morphological study of Otocryptis Wagler, 1830 (Squamata: Agamidae) reveals a new genus from the far south of the Western Ghats, Peninsular India.

In recent years, several studies have revealed significant unknown and cryptic diversity of agamids in peninsular India, particularly in the Western Ghats. Here, we examine the morphology, anatomy and genetics of the sole Indian representative of the otherwise Sri Lankan agamid genus Otocryptis from the Western Ghats. Our analyses reveal significant distinctions in O. beddomii Boulenger, 1885 with respect to the Sri Lankan members, the type species, O. wiegmanni Wagler, 1830, and O. nigristigma Bahir de Silva, 2005, warranting a new generic placement. To accommodate the divergent and allopatric O. beddomii from the Western Ghats, we erect a new genus Agasthyagama gen. nov. We re-characterise Agasthyagama beddomii (Boulenger, 1885) comb. nov. based on a syntype (ZSI 15733) and recently collected material. In effect, we restrict the genus Otocryptis, represented by two species, O. wiegmanni and O. nigristigma, to Sri Lanka. We also provide a re-appraisal of the genus Otocryptis sensu stricto, based on data from its type species O. wiegmanni. Our finding adds another endemic agamid genus to the Western Ghats, following Salea Gray, 1845, and the recently described Monilesaurus Pal, Vijayakumar, Shanker, Jayarajan Deepak, 2018, and Microauris Pal, Vijayakumar, Shanker, Jayarajan Deepak, 2018. In turn, this complements Sri Lankan agamid endemism with Otocryptis, in addition to the accepted endemic radiations of Lyriocephalus Merrem, 1820, Ceratophora Gray, 1835 and Cophotis Peters, 1861. From a systematic perspective, our erection of Agasthyagama gen. nov. likely completes the description of known genus-level diversity in the clade containing Otocryptis Wagler 1830, Sitana Cuvier, 1829 and the recently described Sarada Deepak, Karanth Giri, 2016.

Symptomatic medial humeral epicondylar fracture non-union- rare presentation of a relatively common injury.

BACKGROUND: Symptomatic non-union of medial humeral epicondylar fractures is a limited entity. Some studies recommend surgical excision of the fragment, but the results are controversial. The purpose of this study is to evaluate the outcome of open reduction and internal fixation of a medial epicondyle non-union fragment. MATERIALS AND METHODS: A retrospective study was conducted in all the patients, who were operated in our hospital between the year 2010 and 2015 for symptomatic medial humeral epicondyle non-union. Inclusion criteria were open reduction and internal fixation of symptomatic medial epicondyle non-union and minimum one year of follow-up from time of surgery. Exclusion criteria included other associated musculoskeletal disorders of the affected limb. Open reduction and internal fixation of the fragment was done in all patients and the ulnar nerve was decompressed and anteriorly transposed in cases where symptomatology was present. Outcome was assessed with radiograph, range/arc of motion, Visual analogue pain scoring and two functional outcome tools. RESULTS: Study sample consisted of 14 patients, with mean age at presentation of 14.9 years (range 6 to 50 years) with mean time since injury of 7.7 months (range 3 to 24 months). Patients presented with medial elbow pain and prominence, limited range of motion, valgus instability, and ulnar nerve compression. After open reduction and internal fixation, at a mean of three years after surgery (range 1.5 to 5 years), patients reported an improvement in visual analogue pain score from a mean of 7.29±1.3 to 0.21±0.4, and the difference was statistically significant (p=0.001). Mean postoperative Quick DASH (Disability of Arm, Shoulder, and Hand) score was 5.21±7.2. Mean Mayo Elbow Performance Score was 96.7±6.1. Improvement in arc of motion was statistically significant (p=0.001). Radiographic union was achieved in all patients except one who had fibrous union. Functional elbow range of motion was achieved in 13 out of 14 cases (92.8%) and ulnar nerve recovered in five patients and one patient required tendon transfer. CONCLUSION: Open reduction and internal fixation of symptomatic medial humeral epicondyle non-union gives excellent clinical and functional outcome in the majority of cases.

Comparison between antegrade intramedullary nailing (IMN), open reduction plate osteosynthesis (ORPO) and minimally invasive plate osteosynthesis (MIPO) in treatment of humerus diaphyseal fractures.

INTRODUCTION: The three currently used methods of treatment: namely open reduction plate osteosynthesis (ORPO), Minimally invasive plate osteosynthesis (MIPO), antegrade intramedullary nailing(IMN) are all reported as satisfactory procedures for treatment of humeral shaft fractures. However none of the published reports have a comparison of superiority of one procedure over the other. We evaluated the clinical, radiological and functional outcome of the three procedures. MATERIALS AND METHODS: We studied adult patients with humerus shaft fractures over a period of 2 years from May 2014 to May 2016 in a level 1 trauma center. Forty-four were treated with IMN, 34 treated with ORPO, and 34 with MIPO. The null hypothesis tested in this study is that there is no difference between IMN, ORPO, MIPO with respect to union time, surgical time, complication rate, non-union rate and functional outcome. Functional outcome was studied by comparing the UCLA shoulder and MEP scores in the three groups. RESULTS: 112 patients were studied consisting of 83 males and 29 females with mean age of 39 years (range 18-70). IMN group showed early union with mean of 12.73 weeks compared to MIPO (14.45 weeks) and ORPO(13.58 weeks), (p<0.05). MIPO had no events of non-union, as compared to ORPO (5 non-unions) and IMN (10 non-unions), (p=0.04). The range of movement at the shoulder with the UCLA score was significantly better with a score of 32.26 in MIPO as compared to 27.54 in IMN and 28.82 in ORPO (p<0.05). The difference in MEPS score in the three groups was not significant (p=0.31). IMN required a mean of 117.95 minutes intraoperatively as compared to 131 and 150.58 mins in MIPO, ORPO respectively. CONCLUSION: MIPO is overall better with respect to non-union, functional outcome and complications rate. The surgical time depends on the surgeons' skill and learning curve. Thus considering the advantages and risks involved in the various procedure and surgical acumen, each case should be individualized to have a good outcome. We advocate that MIPO can be safely used as an alternative in treating these fractures.

Use of a raft construct through a locking plate without bone grafting for split-depression tibial plateau fractures.

PURPOSE: To review the outcome after open reduction and internal fixation using a periarticular raft construct through a locking plate without bone grafting for split-depression tibial plateau fractures. METHODS: Records of 38 knees in 31 men and 7 women aged 25 to 75 (mean, 42.7) years who underwent open reduction and internal fixation using a periarticular raft construct through a locking plate without use of a bone graft or bone substitute for split-depression (>5 mm) proximal tibial plateau fractures (Schatzker type II or AO/OTA type 4.1 B3) were reviewed. The integrity of the articular surface was assessed using radiographs. The Rasmussen radiological score and clinical score, the Lysholm knee score, and the Tegner activity score were also assessed. RESULTS: The mean follow-up period was 22.8 (range, 6-36) months. All patients achieved bone union after a mean of 13.2 (range, 8-26) weeks. The mean range of motion was 118º (range, 100º-130º). The Rasmussen radiological score was excellent in 27 patients, good in 9, and fair in 2. The Rasmussen clinical score was excellent in 15 patients, good in 21, and fair in 2. The Lysholm knee score was excellent in 26 patients, good in 8, and fair in 4. 32 of the 38 patients recovered to their preoperative Tegner activity scores. Only one patient with severe comminution had loss of reduction after full weightbearing. CONCLUSION: Fixation using a periarticular raft construct through a locking plate without use of a bone graft or bone substitute for split-depression proximal tibial plateau fractures is a viable option.

Limb lengthening over plate.

BACKGROUND: The limb lengthening over plate eliminates the associated risk of infection with limb lengthening over intramedullary nail. We present our experience of limb lengthening in 15 patients with a plate fixed on the proximal segment, followed by corticotomy and application of external fixator. MATERIALS AND METHODS: 15 patients (7 females, 8 males) were included in this consecutive series. The average age was 18.1 years (range 8-35 years). Fifteen tibiae and one femur were lengthened in 15 patients. Lengthening was achieved at 1 mm/day followed by distal segment fixation with three or four screws on reaching the target length. RESULTS: The preoperative target length was successfully achieved in all patients at a mean of 4.1 cm (range 1.8-6.5 cm). The mean duration of external fixation was 75.3 days (range 33-116 days) with the mean external fixation index at 19.2 days/cm (range 10.0-38.3 days/cm). One patient suffered deep infection up to the plate, three patients had mild procurvatum deformities, and one patient developed mild tendo achilles contracture. CONCLUSION: Lengthening over a plate allows early removal of external fixator and eliminates the risk of creating deep intramedullary infection as with lengthening over nail. Lengthening over plate is also applicable to children with open physis.

Antegrade interlocking nailing for distal femoral fractures.

PURPOSE: To assess outcomes of antegrade interlocking nailing for supracondylar or intercondylar fractures of the distal femur. METHODS: Records of 10 women and 20 men aged 20 to 70 (mean, 48.7) years who underwent antegrade interlocking nailing for distal femoral fractures were reviewed. 23 patients had closed fractures and 7 had open fractures; 6 had associated fractures of the forearm or tibia. According to the AO/ASIF system, fractures were classified as types A1 (n=13), A2 (n=6), A3 (n=3), and C1 (n=8). The affected leg was put in an extension shoe for traction, and reduction was achieved with the help of percutaneous lag screws. The nail was inserted from the tip of the greater trochanter and centred in both anteroposterior and lateral planes. The nail was modified to have 3 screw slots in the mediolateral plane and one screw slot in the anteroposterior plane distally for stability in multiple directions. Postoperatively early mobilisation and partial weight bearing were allowed. Patients were assessed using the modified knee-rating scale of the Hospital for Special Surgery. RESULTS: The mean time to bone union was 13.1 (range, 10-18) weeks. The mean follow-up period was 18.8 (range, 11-30) months. Three patients were lost to follow-up; outcomes in the remaining patients were excellent in 20 and good in 7. The mean range of knee flexion was 106 (range, 90-120) degrees. One patient developed a flexion deformity of 10 degrees. All patients attained full quadriceps strength. No patient had ligamentous instability, nerve injuries, superficial or deep infections, or implant failure. Three patients had malunion, which was located in the meta-diaphyseal segment and not in the intraarticular segment. Hence, there was no functional problem or shortening. The mechanical axis was not deviated. CONCLUSION: Antegrade interlocking nailing achieved good-to-excellent outcomes for distal femoral fractures.

Management of thromboangiitis obliterans using distraction osteogenesis: A retrospective study.

BACKGROUND: Thromboangiitis obliterans (TAO), also known as Buerger disease, is characterized by thrombosis in medium-sized arteries and veins along with a marked inflammatory response. TAO can be managed by using the principle of distraction osteogenesis to induce neoangiogenesis. We report thirty patients of TAO in the age-group of 20-50 years were treated with the Ilizarov method. MATERIALS AND METHODS: Patients with severe rest pain (n=30), absent distal pulsation (n=30) and ulcer (n=6) and/or gangrene of the toes (n=4), who had failed the conservative pharmacological modalities of treatment were included. A lateral tibial corticotomy was performed and distraction applied by use of olive wire. A two-ring frame was used for all cases. RESULTS: Of the 30 cases, 25 patients became pain free while 1 had partial relief of pain. The four patients worsened on treatment and developed frank infection were amputed. The average distraction was 1.8±0.3 mm (range: 1.5-2.2 cm). The mean consolidation period was 98±11 days, after which the fixator was removed. The total duration of treatment was 122±23 days. There were two cases of osteomyelitis in our series; both healed after debridement and both patients had good result, with relief of pain. The ulcers started healing by 4-6 weeks. CONCLUSION: The principle of the distraction osteogenesis including neoangiogenesis can be used for treatment of TAO and has an acceptable complication rate.