Comprehensive Spinal Tuberculosis Score: A Clinical Guide for the Management of Thoracolumbar Spinal Tuberculosis.

STUDY DESIGN: A newly proposed scoring tool was designed to assist in the clinical management of adult thoracolumbar spinal tuberculosis (TB). PURPOSE: To formulate a comprehensive yet simple scoring tool to guide decision-making in the management of adult thoracolumbar spinal TB. OVERVIEW OF LITERATURE: Spine surgeons have differing consensus in defining the threshold grade for clinico-radiological parameters when deciding between operative or conservative treatment for adult thoracolumbar spinal TB. Currently, the void in decision-making from the lack of well-defined guidelines is compensated by the surgeon's experience in treating these patients. To the best of our knowledge, no scoring system holistically integrates multiple facets of spinal TB to guide clinical decision-making. METHODS: The RAND/University of California, Los Angeles appropriateness method was employed among an expert panel of 10 spine surgeons from four apex tertiary care centers. Vital characteristics that independently influenced treatment decisions in spinal TB were identified, and a scoring tool was formulated. Points were assigned for each component based on their severity. The cutoff scores to guide clinical management were determined from the receiver operating characteristic curve based on the retrospective records of 151 patients treated operatively or non-operatively with improved functional outcomes at the 1-year follow-up. RESULTS: The components of the comprehensive spinal TB score (CSTS) are pain, kyphosis angle, vertebral destruction, and neurological status. A score classification of <5.5, 5.5-6.5, and >6.5 was established to guide the patient toward conservative, conservative/ operative, and operative management, respectively. CONCLUSIONS: The CSTS was designed to reflect the essential indicators of mechanical stability, neurological stability, and disease process stabilization in spinal TB. The scoring tool is devised to be practical and serve as a common language in the spine community to facilitate discussions and decision-making in thoracolumbar spinal TB. The validity, reliability, and reproducibility of this tool must be assessed through multicenter long-term studies.

Perineal injuries in patients with complex femoral fractures operated on a fracture table using traction and counter traction: A case series and review of the literature.

Introduction: PA fracture table with a perineal post for counter traction is frequently used in the surgical treatment of lower limb fractures. Nevertheless, persistent use of the perineal post has been linked to serious side effects. We discuss our experience treating genitoperineal wounds due to traction table. Methods: During a month, our facility treated 3 patients who had genitoperineal injuries related to the usage of a traction table. We assessed the clinical appearance of these perineal injuries, the length of the operation, the treatment strategy, the clinical results, and the length of the hospital stay. Result: After surgery, partial thickness necrosis in the region including the scrotum and perineum developed in all patients. Two patients who had necrotic tissue infections received surgical debridement. In all cases, the wound healed fully with secondary intention by continued cleaning, dressing, and appropriate antibiotics. Conclusion: Genitoperineal skin necrosis caused by a perineal traction post necessitates surgical debridement and prolongs hospitalization. Orthopaedic surgeons should utilize several techniques such as proper perineal post diameter, length of surgery, positioning of the limb during surgery, etc. to lower the likelihood of this problem.

Efficacy and Safety of Pregabalin Prolonged Release-Etoricoxib Combination Compared to Etoricoxib for Chronic Low Back Pain: Phase 3, Randomized Study.

INTRODUCTION: Currently available treatments for chronic lower back pain (CLBP) do not adequately address both nociceptive and neuropathic components of pain. We evaluated efficacy and safety of fixed-dose combination (FDC) of low-dose pregabalin prolonged release 75 mg-etoricoxib 60 mg to address both pain components. METHODS: This randomized phase 3 trial conducted at 12 centres across India evaluated efficacy (based on mean change in numeric rating scale [NRS], Roland-Morris disability questionnaire [RDQ], visual analogue scale [VAS], patient global impression of improvement [PGI-I], clinical global impression of improvement [CGI-I] and rescue medication consumption) and safety of FDC in comparison to etoricoxib alone in adult patients with CLBP. Treatment duration was 8 weeks. RESULTS: Of the 371 patients screened, 319 were randomized and considered for efficacy and safety analysis. Both treatment groups had no significant difference in terms of demography and baseline disease characteristics. Significantly better outcomes with FDC compared to etoricoxib were observed at week 4 onwards. At week 8, both groups showed significant reduction in mean NRS score from baseline (- 4.00 ± 1.65 in FDC; - 2.92 ± 1.59 in etoricoxib) with mean NRS score being significantly less in the FDC group compared to etoricoxib group (3.26 ± 1.56 vs 4.31 ± 1.56; p < 0.0001). The FDC was more effective than etoricoxib in terms of significantly greater reduction in RDQ score (- 9.28 ± 4.48 vs - 6.78 ± 4.34; p < 0.0001) and VAS score (- 37.66 ± 18.7 vs - 28.50 ± 16.31; p < 0.0001) at week 8. The FDC was also better in terms of significantly more patients reporting their condition as 'very much better' (36.9% vs 5.0%; p < 0.0001) and clinicians reporting patient's condition as 'very much improved' (36.3% vs 5.7%; p < 0.0001). Overall, study medications were well tolerated. CONCLUSION: FDC of pregabalin and etoricoxib provided significant benefits in reducing pain and improving functional status compared with etoricoxib alone in patients with CLBP. Pregabalin prolonged release-etoricoxib FDC could be one of the treatment options for early and sustained pain relief and improvement in quality-of-life in treating CLBP as it addresses both neuropathic and nociceptive components of pain. TRIAL REGISTRATION: CTRI/2018/10/015886.

Low back pain is one of the most common causes of loss of productivity worldwide. About 60% of Indians suffer from low back pain at some point. Low back pain that persists for more than 3 months is classified as chronic low back pain which mostly includes both nociceptive and neuropathic components. Monotherapies, if prescribed, are not completely effective, as they generally only target either nociceptive or neuropathic components of pain. Multiple drugs are usually needed at multiple times a day, at higher doses for optimal effectiveness, and in most cases they have significant side effects if taken over prolonged periods and also add to the pill burden. To minimize treatment-associated adverse effects, and to increase treatment compliance, while addressing both the components of pain, we developed a fixed-dose combination of low-dose pregabalin prolonged release and etoricoxib. A phase 3 trial was designed to assess the efficacy and safety of the fixed-dose combination in comparison with etoricoxib alone in treating chronic low back pain. The combination demonstrated statistically and clinically significant improvement in patient-reported outcomes­pain, functionality and quality of life­as early as 4 weeks after starting the medication. No severe or serious adverse effects were reported. Thus, the combination of low-dose pregabalin prolonged release and etoricoxib could provide an option for optimal management of chronic low back pain. This would provide multiple benefits, such as addressing both nociceptive and neuropathic components of chronic low back pain, reducing drug-related adverse effects because of low dose, reducing pill burden and thereby increasing drug compliance.

A Solitary Ventral Scapular Osteochondroma causing Pseudo-winging of Scapula: A Case Report.

INTRODUCTION: Winging of scapula is defined as a failure of dynamic stabilizing structures that anchor the scapula to the chest wall, leading to prominence of the medial border of scapula. It could be primary, secondary, or voluntary. Primary winging could be true winging due to neuromuscular causes or pseudo-winging due to osseous or soft-tissue masses. A scapular osteochondroma is a very rare presentation site and causes pseudo-winging leading to pushing away of the scapula away from the chest wall presenting as medial border prominence. Here, we are reporting a rare case of a scapular osteochondroma causing a pseudo-winging of the scapula. CASE REPORT: A 2-year-old male child presented with painless, immobile, and non-fluctuant swelling over the left scapular region, insidious in onset and progressive in nature. On examination, a non-tender, immobile swelling was palpable with a painless and unrestricted range of motion at the shoulder joint. After evaluating radiographs and CT scan, the patient was diagnosed to have a ventral scapular osteochondroma leading to pseudo-winging of the scapula. CONCLUSION: Despite the rarity, a differential diagnosis of a scapular osteochondroma should be kept in mind while examining a young child presenting with a winged scapula.

Wedge Osteotomy with Tens Nailing in Monostotic Fibrous Dysplasia of Tibia - A Case Report.

INTRODUCTION: Titanium elastic nailing (TENS) with wedge osteotomy for the management of monostotic fibrous dysplasia (FD) of tibia is done in a 6-year-old male patient. CASE REPORT: This is a case describing monostotic FD of right tibia in a 6-year-old male patient. The patient's parents noticed a diffuse swelling in the right leg a few days after birth. It was managed conservatively till 3 years of age when the patient started complaining of pain in his right leg and difficulty in walking and running. The patient developed gradual and progressive anterior bowing in the right leg in the next 3 years. The patient was diagnosed with monostotic FD of the right tibia based on clinical and radiological findings. Wedge osteotomies were done in the tibia and fibula with TENS nailing as a definitive procedure for this patient. DISCUSSION: Management of monostotic FD of the right tibia with TENS nailing and wedge osteotomy can be a possible modality of definitive management with complete pain relief and deformity correction. CONCLUSION: Correction of deformities secondary to FD requires meticulous pre-operative planning and execution. But with proper planning, even major deformities as in our case, procedures as simple as wedge osteotomy and TENS nailing can give excellent outcomes.

Long-standing case of osteochondromatosis of the hip treated with uncemented modular bipolar hemiarthroplasty: A case report.

INTRODUCTION: Synovial chondromatosis is a rare synovial disorder characterized by the presence of benign loose bodies in the joint space. The affliction of the hip joint is rare. This entity usually goes undiagnosed as it is largely asymptomatic till complications such as secondary osteoarthritis secondary to degenerative changes, subluxation of hip, and fracture neck of femur ensue. CASE REPORT: A 46-year-old farmer presented with a 9-year long history of the left hip pain with restriction in flexion, extension, and internal rotation. He was diagnosed with synovial chondromatosis and had a history of undergoing arthroscopic debridement following which he was asymptomatic but relapsed after 6 months. We performed excision with uncemented modular bipolar hemiarthroplasty after confirming the diagnosis on plain radiographs and computed tomography. Significant recovery in the range of motion was noted postoperatively and the patient showed no signs of relapse in the follow-up period of 18 months. CONCLUSION: Treatment of synovial chondromatosis of the hip joint poses a challenge due to its complex anatomy.

Diagnosis and Arthroscopic Treatment of Synovial Chondromatosis of Glenohumeral Joint: A Case Report.

INTRODUCTION: Synovial chondromatosis is a rare benign entity with the presence of cartilaginous or osseous loose bodies in the synovium. It commonly involves the larger joints such as the knee, hip, ankle and rarely the shoulder joint manifesting with pain, swelling, and restriction of movements. The treatment of choice is surgical intervention in symptomatic patients using either the open or the arthroscopic approach. CASE REPORT: Here, we report a rare case of synovial chondromatosis affecting the right shoulder joint in a 23-year-old male with a 5-year disease duration who presented with progressive pain and restriction in movements which were impacting his routine activities. The loose bodies were removed using the arthroscopic approach combined with a partial synovectomy, and intra-articular methylprednisolone post procedure. The patient showed an excellent recovery in joint mobility within 4 weeks post-operatively, and there were no clinical signs of recurrence during a 6-month follow-up period. CONCLUSION: We believe that arthroscopic surgery is effective in the treatment of patients with synovial chondromatosis with advantages such as good visualization, lesser morbidity, and early return of functional activities.

Total Hip Replacement and Distal Femur Shaft Non-union in a Case of Below-knee Amputation - A Case Report.

INTRODUCTION: Primary total hip replacement (THR) surgery for the neck of femur (NOF) fracture in a case of below-knee amputation with distal femur shaft non-union is rare. CASE REPORT: This case describes the traumatic right NOF fracture in a 49-year-old male patient with distal femur shaft non-union. The patient has a history of ipsilateral below the knee amputation along with right distal femur shaft fracture managed with retrograde femur nailing 10 months back following a road traffic accident. The NOF fracture was managed by primary THR as the definitive procedure after distal femur nail removal and distal femur plating with allograft for non-union. CONCLUSION: Primary THR with distal femur plating and allogenic bone grafting in such cases provides satisfactory outcomes. It allows for early ambulation and rehabilitation of the patient.

A Case Report of Humerus Shaft Osteomyelitis Secondary to Local Skin Infection Treated with Saucerization.

Introduction: Osteomyelitis of the humerus shaft after local skin infection is rare clinical entity, all the principles of tibia and femur osteomyelitis are used in the humerus osteomyelitis. Early detection is best done by the magnetic resonance imaging. Surgical debridement and curettage with IV antibiotics gives good clinical outcome in the patient. Case Report: A 35-year-old female presented with discharging sinus over posterior aspect of the humerus for 1 year. Diagnosis done based on X-ray and clinical examination. The patient managed with local debridement and saucerization, on follow-up patient is doing all the daily activities and no sign of recurrence at 18 months post-operative. Conclusion: Local debridement saucerization and course of IV antibiotics according to culture sensitivity give good clinical outcome in cases of humerus osteomyelitis.

Parosteal Lipoma of the Proximal Phalanx of Hand.

Parosteal lipomas are rare benign tumors accounting for less than 0.1% of all primary bone tumors. Only 3 cases of parosteal lipoma have been previously described affecting the distal and middle phalanges. We describe a case of parosteal lipoma in a 45-year-old man involving the proximal phalanx of the right middle finger. The tumor was marginally excised with the osseous attachment. There was no clinical or radiological recurrence at a follow-up of 2 years, with full range of movement at the proximal interphalangeal joint.

Functional Outcome of High Tibial Osteotomy in Patients with Medial Compartment Osteoarthritis Using Dynamic Axial Fixator -a prospective study.

INTRODUCTION: Medial Compartment Osteoarthritis of the knee is becoming a widespread problem. The surgical options include high tibial osteotomy, unicompartmental knee replacement, and total knee replacement. Replacement surgeries are not advised in the younger age group, so in these patients, high tibial osteotomy is the only option. In this study, we have assessed the functional and radiological outcomes of high tibial osteotomy done by hemicallostasis method. METHOD: We report the outcome of 30 patients (30 knees) who underwent hemicallostasis with a dynamic external fixator for medial compartment osteoarthritis of the knee. The radiological assessment was done with the help of Hip Knee Ankle angle. The functional scoring was done via Oxford knee score, IKDC, KOOS, and WOMAC score. RESULTS: At a mean follow up of 35 months, the preoperatively mean HKA angle was 172 ± 30. The mean HKA angle postoperatively was 184 ± 10. Appropriate correction of the HKA angle was achieved in 24 of 30 patients (80%). Whereas, there was under correction in 3 patients (10%) and overcorrection in 3 (10%) patients. All the functional scores showed significant improvement in the postoperative scores. There was a positive correlation between the HKA angle and oxford, IKDC, KOOS, and WOMAC Score. Complications like superficial pin tract infection were seen in 3 (10%) patients, deep infection in 1 (3%), and early union of osteotomy in 1 (3%) patient leading to revision of the osteotomy. . CONCLUSION: HTO is effective in improving pain, function, activity of daily living, and quality of life in patients suffering from medial compartment Osteoarthritis of the knee. Hip Knee Ankle Angle is an important parameter to restore for better functional outcomes. The Advantage of using a dynamic axial fixator is the precision in achieving calculated correction without any implant in the bone once the correction is achieved along with good healing rates.

Primary hyperparathyroidism with extensive brown tumours and distal humerus fracture-A case report.

INTRODUCTION: A brown tumour is benign bony lesion caused by localized, rapid osteoclastic turnover, resulting from hyperparathyroidism. In this report, we present a case of 25-year-old woman with multiple swelling and bone pain. Plain radiographs of the affected bones revealed multiple erosive bone tumours, which were diagnosed as brown tumours associated with primary hyperparathyroidism. CASE REPORT: A 25 year old female presented with swelling in left elbow since 1 month along with multiple swelling in body. Patient had pain in left elbow after trivial fall. X-ray showed lytic lesion of left elbow with pathological fracture. Biopsy was suggestive of brown tumour of distal humerus. DISCUSSION: We managed this case with reconstruction of defect with fibula grafting and plating. CONCLUSION: Pathological fracture in young adult should always be properly investigated. A high index of suspicion is necessary to diagnose unusual presentation of Primary Hyperparathyroidism.

Solitary Osteochondroma of Posterior Elements of the Spine: A Rare Case Report.

INTRODUCTION: Osteochondromas are the most common benign tumors of the bone accounting for 35% to 40% of all benign bone tumors. They present in two distinct clinical forms - solitary osteochondroma and multiple osteochondromas. Solitary osteochondroma accounts for 85% of all osteochondroma and is commonly seen in childhood and adolescence. They more frequently affect the appendicular skeleton and are rarely found in spine. Biopsy and imaging help in diagnosis and en bloc resection is the treatment of choice in symptomatic patients. CASE REPORT: We present a case of a 6-year-old girl who presented with swelling over back for 4 years. Radiological evaluation and biopsy were done and the patient was diagnosed with osteochondroma of the left lamina and spinous process of dorsal 12th vertebral body which was managed with extraperiosteal en bloc excision. CONCLUSION: Osteochondroma of the lamina and spinous process of vertebrae is rare and can be effectively treated by extraperiosteal en bloc resection and has a good post-operative outcome.

Management of Forearm Deformity by Limb Reconstruction System in Children with Multiple Exostosis - A case Report.

INTRODUCTION: Osteochondroma is the group of benign bone tumours, which are composed of spongy bone covered by a cartilaginous cap. Patients with distal ulnar osteochondromas frequently cause forearm deformities with relative ulnar shortening, wrist joint deviation, and varus bowing. Surgical ulnar lengthening is necessary to restore the carpal balance. CASE REPORT: We report the case of multiple exostosis in a 13-year-old male with the right distal ulna osteochondroma with long-standing and progressive ulnar shortening and radial bowing treated with a limb reconstruction system. Our case is Type I Masada managed with excision of distal ulna osteochondroma and gradual ulnar lengthening without osteotomy of the radius. CONCLUSION: Progressive ulna deformity can lead to increasing pain, joint instability, limited motion, and functional decline. For Type I, Masada ulnar lengthening is necessary, but over correction is inadvisable due to possible ulnocarpal impaction syndrome. As significant remodeling effects on the radius were observed, simultaneous radial correction can be delayed.

Ceramic liner fracture in ceramic on ceramic Total hip arthoplasty: A case report.

INTRODUCTION: Revision rates of total hip arthoplasty have decreased after introducing total hip arthroplasty using ceramic component due to reduce wear and osteolysis. CASE REPORT: 29 year old male case of bilateral hip avascular necrosis operated for bilateral hip THA presented 30 months after with complaint of squeaking, x-ray showing left ceramic liner fracture without any history of trauma. Revision of ceramic liner and head with ceramic on polyethylene was done. DISCUSSION AND CONCLUSION: Ceramic on ceramic articulation has the lowest wear rate among various articulations. However, there is a concern about ceramic implant fracture; therefore ceramic with polyethylene bearing could be a good choice.

Surgical Treatment of Tenosynovitis of Extensor Tendons of Fourth Compartment of Wrist in Nonrheumatoid Patients-A Case Series of 10 Patients in India.

Purpose Proliferative tenosynovitis of the extensor tendons is a very common painful wrist condition that can occur both in presence and absence of rheumatoid arthritis (RA). This study aims to evaluate a series of patients without RA, having extensor tendon tenosynovitis, its pathology, and results of surgical treatment. Materials and Methods A consecutive series of 10 patients without RA, having tenosynovitis of fourth extensor compartment were treated surgically and evaluated in the study. All patients were operated upon by a single surgeon, and intraoperative specimens were sent for histopathologic evaluation by a single pathologist. The functional outcome of the patients was evaluated by comparing the post- and preoperative wrist extension. Results All patients presented with painful mass over dorsum of the wrist, overlying the fourth extensor compartment. On clinical examination, there was severe limitation of active wrist extension with extended fingers and improvement in wrist extension on flexing the fingers. All patients had significant improvement in wrist extension after surgery. The histopathologic examination of the intraoperative samples revealed similar findings of tenosynovitis in all cases, which was different than that seen in RA. Conclusion This study reveals a distinct tenosynovitis in a group of patients without RA resembling traumatic tenosynovitis on histopathologic examination. Radiologic and intraoperative findings reveal presence of nodular mass in the affected tendon due to proliferative tenosynovitis, which blocks effective proximal excursion of the tendon, leading to decreased wrist extension. This study shows that surgical treatment in the form of tenosynovectomy gives excellent relief to these patients. Type of Study This is a Level IV, therapeutic study.

Immunohistochemistry on pattern of ocular & adnexal tumours in a tertiary eye care centre of Northeast India.

BACKGROUND & OBJECTIVES: Ocular and adnexal tumours are important causes of morbidity in India and globally. Immunohistochemistry (IHC) is a vital molecular pathology tool, which helps to diagnose a tumour with more accuracy. The present study was undertaken to document the profile of ocular and adnexal tumour with IHC at a tertiary eye care center in Northeast India. METHODS: This was a prospective and laboratory-based study. Histopathological and IHC study of the ocular and adnexal tumour was carried out from 2012 to 2014. Selection of pathological cases was made on the result of the histological diagnosis. All samples were subjected to IHC using kits for different antibodies as per indications. RESULTS: In total, 645 tumours were included in our study, with 449 benign conditions and 196 were malignant tumours. Total IHCs were done in 87 tumours and 238 of antibodies were used. Non-Hodgkin's lymphomas (B-cell, low-to-intermediate type and mucosal-associated lymphoid tumours) were the most common tumor. INTERPRETATION & CONCLUSIONS: Clinical utility of the IHCs in different ophthalmic tumours can enable pathologists to make an accurate diagnosis and thus help in the overall management of the patient care. IHC may be carried out using various methods and some of the methods practiced are time consuming and tedious. In this study, kit methods were used which were found to be simpler and less time-consuming.

Functional and radiological outcome in management of compound tibia diaphyseal fracture with AO monolateral fixator versus Limb reconstruction system.

INTRODUCTION: Tibia being the most common fractured long bone represents 36.7% of all long bone fractures in adults with open fracture comprises 23.5% of all tibial shaft fracture. The lack of the muscular covering over anteromedial aspect of the tibia and poor blood supply predispose open tibial fractures to a 10-20 fold increased risk of developing infection than open fracture in any other anatomical areas and a nonunion rate as high as 28% has been reported in the literature. METHODS: We did a prospective study at our institute from 2014-2016 comprising 40 patients with compound tibia diaphyseal fracture managed with AO monolateral external fixator (Group 1) (n = 20) and Limb reconstruction system (Group 2) (n = 20) as primary and definitive tool. Final assessment for bone results and functional results were done using ASAMI (Association of the study and application of the method of Ilizarov) score. RESULTS: In our study bony outcome by ASAMI score shows 6 (30%) patients had Excellent, 5 (25%) patients had Good and 9 (45%) had Poor bony outcome from Group I. In group II, 12 (60%) patients had Excellent, 4 (20%) patients had Good, 2 (10%) patients had Fair, and 2 (10%) had Poor bony outcome. The functional outcome by ASAMI score shows 3 (15%) patients had Excellent, 8 (40%) patients had Good, 5 (25%) patients had Fair, 3 (15%) had Poor bony outcome from Group I. In group II, 9 (45%) patients had Excellent, 7 (35%) patients had Good, 2 (10%) patients had Fair, and 2 (10%) had Poor functional outcome. CONCLUSION: Limb reconstruction system (LRS) offers several advantage over AO monolateral external fixator such as ease of application, versatility, stronger fixation, less fixator related complications, early weight bearing and early bony union for management of compound tibia diaphyseal fracture as primary and definitive tool.

Management of fracture dorso-lumbar spine in a pregnant female by surgery in prone position.

Surgical management of thoraco-lumbar spine fracture in pregnancy has specific concerns during surgery like positioning, approach, and radiation exposure to fetus. We report a case of burst fracture of 12th thoracic vertebrae with paraplegia in a young female with 26 weeks of gestation. Surgery was performed in prone position on a Toronto frame. This report also discusses the management of thoraco-lumbar spine fracture in pregnancy with review of literature.

Comparison of two radiological methods in the determination of skeletal maturity in the Indian pediatric population.

To determine a more precise and reliable method between Greulich-Pyle (GP) and MacKay's (MK) method for the determination of skeletal age in an Indian pediatric population. We carried out a cross sectional study for the assessment of skeletal age on the basis of examination of hand and wrist radiographs of 106 patients (1-15 years of age) who presented with soft tissue injury to hand by the GP and the MK method. These radiographs were evaluated by a radiologist and an orthopedic surgeon independently. In girls, the mean age difference between chronological and skeletal age was 8 months by the GP method, whereas it was 17 months by MK method. For boys, the mean age difference was 10 months by the GP method and by MKs method, it was 20 months. By the GP method, 44% of the boys showed a more reliable estimate of age whereas it was 10% by the MK method. However, the same for girls was 25% by the GP method and 16% by the MK method. The inter-rater reliability for the raters was found to be κ=0.68 and this was statistically significant (P<0.001), 95% confidence interval (0.504-0.848). We concluded that the GP method appeared to be more reliable in the determination of skeletal age in the Indian pediatric population.