Characterization of the enzymatic and multifunctional properties of Acinetobacter baumannii erythrose-4-phosphate dehydrogenase (E4PDH).

Infections due to Acinetobacter baumannii (A. baumannii) are rapidly increasing worldwide and consequently therapeutic options for treatment are limited. The emergence of multi drug resistant (MDR) strains has rendered available antibiotics ineffective, necessitating the urgent discovery of new drugs and drug targets. The vitamin B6 biosynthetic pathway has been considered as a potential antibacterial drug target but it is as yet uncharacterized for A. baumannii. In the current work, we have carried out in silico and biochemical characterization of Erythrose-4-phosphate dehydrogenase (E4PDH) (EC 1.2.1.72). This enzyme catalyzes the first step in the deoxyxylulose-5-phosphate (DXP) dependent Vitamin B6 biosynthetic pathway i.e. the conversion of d-erythrose-4-phosphate (E4P) to 4-Phosphoerythronate. E4PDH also possesses an additional activity whereby it can catalyze the conversion of Glyceraldehyde-3-phosphate (G3P) to 1,3 bisphosphoglycerate (1,3BPG). Our studies have revealed that this enzyme exhibits an alternate moonlighting function as a cell surface receptor for the human iron transport proteins transferrin (Tf) and lactoferrin (Lf). The present work reports the internalization of Tf and consequent iron acquisition as an alternate strategy for iron acquisition. Given its essential role in two crucial pathways i.e. metabolism and iron acquisition, A. baumannii E4PDH may play a vital role in bacterial pathogenesis.

Orthopaedic surgery and its allied associations on social media: an observational study.

BACKGROUND: The use of social media in orthopaedic surgery and its allied associations has not been studied. There are various associations which are actively engaged in social media platforms to enhance their impact with their users across the globe. We evaluated the social media presence and extent of involvement of orthopaedics journals and their publishing companies, orthopaedics organizations, orthopaedics device firms, and health organizations. MATERIALS AND METHODS: We compiled a global list of orthopaedics journals and publishing companies, orthopaedics organizations, orthopaedics device firms and health organizations affiliated to orthopaedics (USA) through the internet and their reliable online links. All the categories and their contents were screened on various social media networking sites (Facebook, Twitter, and LinkedIn) in terms of their membership, likes, followers and active participation. Comparable variables were selected and compared. RESULTS: Orthopaedics journals corresponding to sports and health were more notable than others on social networking platforms, i.e., British Journal of Sports Medicine and American Journal of Sports Medicine. Medscape, Lancet, and Elsevier being the multispeciality health and information publishing companies have remarkable participation on Facebook, Twitter and LinkedIn. Medtronic has maximum followers on all discussed social networking sites. Mayo Clinic Rochester, Minnesota and Cleveland Clinic, Cleveland, Ohio were more admired than other orthopaedics hospitals on Facebook and Twitter in USA. American Academy of Orthopaedic Surgeons was the most popular society on Facebook and LinkedIn while American Orthopaedics Society for Sports Medicine was most talked about on twitter. CONCLUSIONS: Although the active involvement of orthopaedics journals and their publishers is lower than multispecialty publishing companies but increasing trends were found recently. Orthopaedics organisations and device firms were actively involved on social networking while orthopaedics multispeciality health organizations associated with renowned universities have huge likes or followers. The social networking has the potential to flourish these journals and organisations in the near future as large populations over the globe have been actively participating and growing in their numbers exponentially.

Outcome of monolateral rail fixator in infected nonunion of femur diaphysis developing after intramedullary fixation.

INTRODUCTION: Consensus is lacking regarding management of posttraumatic infected diaphyseal nonunions of femur following intramedullary nailing. Present study reports outcomes of single stage standardised treatment protocol using monolateral rail external fixator/limb reconstruction system in this type of infected diaphyseal femoral nonunions. METHODS: This retrospective study included 26 patients with mean age of 31.7 years having posttraumatic infected diaphyseal femoral nonunions following intramedullary nailing and managed with radical debridement and monolateral rail fixator. The results were assessed by Association for the Study and Application of the Method of Ilizarov criteria. RESULTS: Mean intraoperative bone gap was 4.34 (range, 2-7) cm. Mean gain in bone length was 4.04 (range, 0-7) cm. Fracture united primarily in 22 cases and after freshening of edges, fixator adjustment and fibular grafting in three more patients. Infection persisted in one patient. Most common complications were superficial pin tract infection (15 patients) and loss of more than 30° knee flexion (13 patients). The bone results were excellent, good, and poor in 15, 9, and 2 patients, respectively. The functional results were excellent, good, fair, and poor in 11,13,1 and 1 patient, respectively. CONCLUSION: Single stage procedure including radical debridement, acute docking, distraction osteogenesis at corticotomy site and stabilization with monolateral rail fixator reliably achieves good to excellent bone and functional results, union and eradication of infection in majority of infected nonunions of femoral diaphysis developing after intramedullary fixation. We recommend acute docking in bone gap ≤ 5 cm.

Structural and impedance spectroscopic investigations of eco-friendly alkali phosphoborate glass-ceramics containing zirconium ion.

Glass-ceramics with novel composition xZrO2.7P2O5.19CaO.24Na2O.(50-x)B2O3 (x = 0, 2, 4, 6, and 8 mol%) have been synthesized using melt quench technique. The synthesized compositions were characterized and analyzed by X-ray diffraction, field emission scanning electron microscopy, infrared absorption, and impedance spectroscopy. X-ray diffraction profiles of prepared samples confirm the existence of phases corresponding to Na3Ca6(PO4)5 crystal (with crystallite size ~ 23 nm). Infrared absorbance spectra reveal the presence of phosphate and borate units (PO3, PO4, BO3, BO4) in the glass matrix. Different dielectric parameters such as dielectric loss, electric modulus, and tangent loss were evaluated. Their variations with temperature and frequency confirm the non- Debye relaxation behavior of prepared samples. A phenomenal description of the capacitive behavior was studied by considering the circuit having a parallel combination of constant phase element and bulk resistance. The conduction is found to be governed by overlapping large polaron tunneling (OLPT) and follow OLPT model. The results indicate that ZrO2 substituted alkali phosphoborate glass-ceramics can be used as eco-friendly and safe dielectric materials.

Functional and radiological outcomes of primary ring fixator versus antibiotic nail in open tibial diaphyseal fractures: A prospective study.

BACKGROUND: Management of open fractures of tibia is still a matter of debate due to high incidence of infections. Traditionally external fixators have been advocated in managing open tibial fractures. Due to limited efficacy of systemic antibiotics, recently antibiotic coated intramedullary interlocking nails have been developed for the management of open tibia fractures. Therefore, we conducted this prospective randomized study to compare the functional and radiological outcomes of primary ring fixator versus antibiotic coated nail in open diaphyseal tibial fractures. METHODS: The study included 32 patients with Gustilo-Anderson type II and type IIIA fractures of tibial diaphysis. Out of them 16 patients were managed with Ring External Fixator (Group I) and 16 were managed with OssiproÒ gentamicin intramedullary interlocking tibial nail (Group II). The radiological and functional outcomes were assessed at final follow-up according to and SMFA criteria. Statistical analysis of the data was performed using IBM SPSS statistics 2.0 software. Chi square test and independent student t-test were used and a P value <0.05 was considered statistically significant RESULTS: Union was achieved in 15 patients (93.8%) in group I and 13 patients (81.2%) in group II. Pin tract infection was seen in 6 patients (37.5%) in group I, whereas infection was present in 2 patients (12.5%) in group II. Bone results were excellent in 13 patients (81.3%), good in 2 patients (12.5%), poor in one patient (6.3%). In group II, bone results were excellent in 12 patients (75%), good in one patient (6.2%), poor in 3 patients (18.8%). At 1 year of final follow up, mean SMFA score was 24.41±5.87 in group I, whereas mean SMFA score was 23.703±8.02 in group II. CONCLUSION: Ring fixator as well as antibiotic coated tibial interlocking nail achieved comparable rates of union in the present study. Complication rates were similar in both the groups and the functional and radiological outcomes were comparable in both groups. Results of this study indicate that although ring fixation is an established option for management of open tibial fractures, antibiotic-coated intramedullary nail is also a reliable option in open Grade II and grade IIIA injuries. LEVEL OF EVIDENCE: Level II.

Prospective randomized comparison of bone transport versus Masquelet technique in infected gap nonunion of tibia.

AIM: The present prospective randomized study compared the bone transport technique (BT) and Masquelet technique (MT) in the treatment of infected gap non-union of the tibia. PATIENTS AND METHODS: Total 25 patients with infected gap non-union of the tibia with bone gap upto 6 cm were randomised into BT group (group I, 13 patients) and MT (group II, 12 patients). The mean age was 31.77 years in group I and 39.67 years in group II. The mean intra-operative bone gap was 3.92 cm in group I and 3.79 cm in group II. Monolateral fixator was applied in nine patients each in both groups, while four and three fractures were stabilized with ring fixators in group I and II, respectively. Mean follow-up was 31.62 months and 30.42 months in group I and II, respectively. Bone and functional results were compared using the association for the study and application of the method of Ilizarov (ASAMI) criteria. RESULTS: The average fixator period was 9.42 and 16.33 months in group I and II, respectively (p < 0.001). Union was achieved in 12 (92%) patients and 6 (50%) patients in group I and II, respectively. The functional results were excellent (eight and two), good (four and six), fair (zero and three) and poor (one and one) in group I and II respectively, (p 0.23). The Bone results were excellent, good and poor in nine, three and one patients in group I, and three, three and six patients in group II respectively, (p 0.109). CONCLUSIONS: The functional and bone results were comparable but more reliable in bone transport than the Masquelet technique. The fixator duration and incidence of non-union were higher in MT group. Ilizarov bone transport technique should be preferred in infected non-union of the tibia with bone loss upto 6 cm.

Correlation of Clinical Findings in Acute Spinal Injury Patients with Magnetic Resonance Including Diffusion Tensor Imaging and Fiber Tractography.

INTRODUCTION: Many types of research are being carried out in the fields of understanding of the pathogenesis, early recognition, and improving the outcomes after spinal cord injury (SCI). Diffusion tensor imaging (DTI) is one of the modalities used in vivo microstructural assessment of SCI. The aim of the present study is to evaluate the role of DTI imaging and fiber tractography in acute spinal injury with clinical profile and neurological outcome. METHODS: The study was carried out on twenty-five patients of acute spinal cord injury who presented within 48 hours of injury and completed minimum of six months follow-up. RESULTS: The mean age of patients was 37.32±13.31 years and male & female ratio of 18:7. Total MIS score was 91.64±6.0 initially which improved to 96.92±3.68 after 3 months and 99.4±1.35 after 6 months. Total SIS score was similar at all the time intervals i.e. 224±0. Maximum subjects 14(56%) were classified into AIS C and 5(20%) into AIS D whereas only 6(24%) subjects were having no deficit (AIS E). At the end of 6 months, 13(52%) subjects had no deficit (AIS E). Mean fractional anisotropy (FA) initially was 0.451 (± 0.120) but after 6 months, it increased to 0.482 (± 0.097) (p<0.001). The mean apparent diffusion coefficient (ADC) initially was 3.13 (± 2.68) but after 6 months, it decreased to 3.06 (± 2.68) and this change was found to be statistically highly significant (p<0.001). Mean anisotropy index (AI) initially was 0.420 (± 0.245) but after 6 months, it increased to 0.430 (± 3.41) and this change was found to be statistically significant (p<0.01). CONCLUSIONS: DTI is a sensitive tool to detect neurological damage in SCI and subsequent neurological recovery. FA correlated with ASIA impairment scale. It can be useful as an adjunct to conventional MRI for better evaluation and predicting prognosis in SCI patients.

Comparison of Clinico-radiological Outcomes of Monolateral Fixator in Infected Non-union of Tibia Based on Bone Gap Quantification.

INTRODUCTION: Monolateral rail fixators are more comfortable to the patients and have a lesser learning curve compared to ring fixators. Guidelines are still lacking for rational use of monolateral fixator for bone transport. This retrospective study aimed to analyze and compare the clinico-radiological outcomes of monolateral fixator in infected non union of tibia based on bone gap quantification. MATERIALS AND METHODS: This retrospective study included 35 patients of post traumatic infected osteocutaneous defects of tibia operated from May 2013 to May 2016. Group I having bone gap of 6 cm or less (n = 20) and group II with > 6 cm bone gap (n = 15). The mean age was 29.56 (range 18-62) years in group I and 29.67 (range 20-65) years in group II. The mean bone gap was 4.62 (2-6 cm) in group I and 7.6 cm (6.5-10 cm) in group II (P < 0.00001, Mann-Whitney test). The results were assessed by Association for the Study and Application of the Method of Ilizarov (ASAMI) criteria. RESULTS: Union was achieved primarily in 90% (n = 18) cases in group I and 73.34% (n = 11) cases in group II. The bone result was excellent, good, fair/poor in 14, 5, 1 in group I; and in 4, 6, 5 in group II, respectively (P = 0.020, Chi-square test). The functional results were excellent, good, fair/poor in 15, 4, 1 in group I; and 5, 8, 2 in group II, respectively (P = 0.0479, Chi-square test). CONCLUSION: We recommend use of monolateral fixator in patients with infected diaphyseal non union of tibia with bone gap ≤ 6 cm. Use of monolateral fixator in patients with bone gap > 6 cm is associated with higher incidence of residual problems and complications.

Recent advances in digital image manipulation detection techniques: A brief review.

A large number of digital photos are being generated and with the help of advanced image editing software and image altering tools, it is very easy to manipulate a digital image nowadays. These manipulated or tampered images can be used to delude the public, defame a person's personality and business as well, change political views or affect the criminal investigation. The raw image can be mutilated in parts or as a whole image so there is a need for detection of what type of image tampering is performed and then localize the tampered region. Initially, single handcrafted manipulated images were used to detect the only image tampering present in the image but in a real-world scenario, a single image can be mutilated by numerous image manipulation techniques. Nowadays, multiple tampering operations are performed on the image and post-processing is done to erase the traces left behind by the tampering operation, making it more difficult for the detector to detect the tampering. It is seen that the recent techniques that are used to detect image manipulation are based on deep learning methods. In this paper, more focus is on the study of various recent image manipulation detection techniques. We have examined various image forgeries that can be performed on the image and various image manipulation detection and localization methods.

Magnetic Resonance Imaging of Trunk Musculature and Intervertebral Discs in Patients with Spinal Cord Injury with Thoracolumbar Vertebral Fractures: A Prospective Study.

STUDY DESIGN: This study is a prospective clinical study. PURPOSE: This study aims to evaluate the characteristics of trunk musculature and intervertebral discs by using magnetic resonance imaging in patients with spinal cord injuries (SCIs) with thoracic and lumbar fractures. OVERVIEW OF LITERATURE: Muscle atrophy is an immediate consequence of SCI and is associated with secondary complications. At present, there are limited clinical data on muscle and disc responses to fractures of the thoracic and lumbar spine. METHODS: A total of 51 patients with a mean age of 31.75±10.42 years who suffered traumatic SCI were included in this study. Complete neurological examinations (American Spinal Injury Association grading) and magnetic resonance imaging (MRI) were performed at the time of admission and at 3-6 months after injury to study the neurological status and disc and trunk parameters. The type of management (operative or conservative) was decided on the basis of clinical, radiological, and MRI evaluations, and a robust rehabilitation program was initiated. RESULTS: Disc parameters including disc angle, skin angle, cross-sectional area (CSA), and disc height and trunk parameters (mean trunk width, mean trunk depth, and CSA of the lumbar muscles) decreased significantly (p <0.001) during the first 3 months after SCI. However, improvements were observed in disc and muscle parameters at the 6-month follow-up, but these parameters did not return to normal levels. Neither initial neurological status (complete vs. incomplete) nor type of management (operative vs. conservative) had a significant effect on these parameters. CONCLUSIONS: Spinal trauma leads to alterations in the morphology of the vertebral column, spinal cord, intervertebral discs, and paraspinal muscles in the initial phase of injury. The extent of these changes may determine the initial neurological deficit and subsequent recovery. Although this study did not identify any statistically significant effect of neurological status or management strategy on these parameters, rehabilitation was found to result in the improvement of these parameters in the later phase of recovery. Future studies are required to evaluate the exact causes of these alterations and the potential benefits of rehabilitation strategies and to minimize these changes.

Circular external fixation as definitive treatment for open or comminuted femoral fractures: Radiologic and functional outcomes.

INTRODUCTION: Ring external fixation can be a definitive treatment of high energy femoral fractures. A retrospective analysis of outcomes is presented. MATERIALS AND METHODS: 23 patients with open or comminuted femoral fractures treated with circular external fixators were included. Mean age was 33 (range, 13-81) years. Lesions were classified according to AO/ASIF. 12 fractures were open. Mean follow up period has been 26.3, (range 20-144) months. The results were assessed according to the modified criteria of Association for the Study and Application of the Method of Ilizarov. Knee functional results were assessed with Hospital for Special Surgery knee scoring system. RESULTS: 22 fractures united primarily, one showed nonunion. Knee stiffness developed in two patients. No patient had deep pin tract infection. Bone results were quoted as excellent, good, fair and poor in 19, 1, 1 and 2. The functional results were excellent, good, and fair in 16, 6, and 1, on the basis of ASAMI criteria. Mean HSS knee score has been 90.1 (range 60-100). CONCLUSION: Circular external fixation can achieve reliable rates of union and good to excellent functional outcome in open or comminuted femoral fractures. A strict rehabilitation protocol was effective in preserving knee joint function.

Demographic Study of Orthopedic Trauma among Patients Attending the Accident and Emergency Department in a Tertiary Care Hospital.

BACKGROUND: Trauma causes a major burden on the health system and economy of the country. A better understanding of the epidemiology of trauma can be of great help in planning preventive and curative strategies. MATERIALS AND METHODS: A total of 4834 patients of trauma presenting during 1 year were included in this observational study. Demographic profile and other related criteria were noted, and data were statistically analyzed. RESULTS: Male to female ratio was 5:1; most affected age group was 25-44 years in males and 45-64 years in females; 23.2% were illiterate; and professionals and students were most commonly affected. Road traffic accident (RTA), fall, and assault were the three most common causes; two wheelers were the most common accident causing vehicle. Nearly 17.7% were below poverty line and 67.6% reached hospital within 12 h. Medicolegal cases were 29.7%; only 29.3% reached hospital by ambulance and 3.72% were hemodynamically unstable. Only 3.6% received prehospital care and 16.23% were under alcohol influence. About 23.18% of RTA victims were pedestrians; city roads were the most common accident site. Head injury (25.85%) was the most common associated injury. Fractures were most common in hand (9.72%). The injury severity score (ISS) and New ISS were worse in the patients who were not using seat belt/helmet or were under influence of alcohol. The rate of death and associated injuries was also higher in this group. CONCLUSION: Trauma is a major preventable cause of mortality and morbidity mainly affecting the productive age group of the society.

Prospective randomized comparison of quality of regenerate in distraction osteogenesis of ring versus monolateral fixator in patients with infected nonunion of the tibia using digital radiographs and CT.

AIMS: In this randomized study, we aimed to compare quality of regenerate in monolateral versus circular frame fixation in 30 patients with infected nonunion of tibia. PATIENTS AND METHODS: Both groups were comparable in demographic and injury characteristics. A phantom (aluminium step wedge of increasing thickness) was designed to compare the density of regenerate on radiographs. A CT scan was performed at three and six months postoperatively to assess regenerate density. A total of 30 patients (29 male, one female; mean age 32.54 years (18 to 60)) with an infected nonunion of a tibial fracture presenting to our tertiary institute between June 2011 and April 2016 were included in the study. RESULTS: The regenerate mineralization on radiographs was comparable in both groups at two, four, six, and ten months' follow-up but the rail fixator group had statistically significant higher grades of mineralization when compared with the circular frame group at eight and 12 months' follow-up. The regenerate mineralization was also higher in the rail fixator group than in the circular frame group on CT at three and six months, although this difference was not statistically significant. CONCLUSION: Overall, the regenerate mineralization was higher in the monolateral than the circular frame group. A monolateral fixator may be preferred in patients with infected nonunion of the tibia with bone defects up to 7 cm. Cite this article: Bone Joint J 2019;101-B:1416-1422.

Implantless patellar fixation in medial patellofemoral ligament reconstruction.

PURPOSE: The medial patellofemoral ligament (MPFL) acts as primary restraint to lateral patellar dislocation and its rupture has been reported in almost all cases of acute patellar dislocation. Various surgical techniques have been described for MPFL reconstruction, using many femoral and patellar fixation techniques and different grafts. This article details our technique for MPFL reconstruction using semitendinosus graft which avoids the use of implant at patellar end. METHODS: Twenty patients (8 males and 12 females) with complaints regarding acute and chronic lateral patellar instability were evaluated and treated by MPFL reconstruction procedure. The mean age of patients was 21 years (range 17-34 years). MPFL reconstruction was performed using semitendinosus graft passing through two parallel, obliquely directed tunnels created in patella. Fixation of graft was done with an interference screw only at the femoral end. Mean follow-up period after intervention was 26.4 months (range 23-30 months). Results were evaluated using Kujala score. RESULTS: All patients gained adequate patellar stability and full arc of motion. No incidence of patella fracture was noted. There were no postoperative complications related to the procedure. There was no recurrence of instability in patella at final follow-up. CONCLUSION: Passing the graft through the tunnels in patella without use of any implant has given excellent functional outcome and moreover has the advantages of less implant-related complications and cost-effectiveness.

A Prospective Study of Clinicoradiologic-Urodynamic Correlation in Patients with Tuberculosis of the Spine.

INTRODUCTION: Involvement of spinal cord in spinal tuberculosis (TB) has been associated with bladder disturbances on which literature is scarce. The present study aimed at evaluating the urodynamic profile, its correlation with clinical and radiological features, and the prognosis with treatment in these patients. MATERIALS AND METHODS: Thirty patients of spinal TB were prospectively evaluated clinically, radiologically, and urodynamically in this single center prospective study. All patients underwent urodynamic assessment at presentation; and those with bladder dysfunction on initial urodynamics were followed with sequential testing at 3, 6, and 12 months. RESULTS: Patients were divided into two groups on the basis of the absence (Group 1, n = 14) or presence (Group 2, n = 16) of bladder dysfunction. The magnitude of deformity (P = 0.011), sensory deficit (P = 0.025), and tenderness (P = 0.030) at presentation was found to be significantly more in Group 2 and involvement of posterior elements, reduction in disc height, endplate erosion, and nerve root were significantly higher. The initial urodynamic assessment showed delayed sensations in 23.3% and early sensations in 13.3%, respectively; decreased bladder compliance in 3.33%; underactive detrusor in 16.6%, and overactive in 13.3% of cases. The sphincter was dyssynergic in 13.3% of cases. Statistically significant (P < 0.001) improvement in sensory parameters of bladder, detrusor contractility, and compliance with treatment was observed. Thirteen (81.3%) patients of Group 2 showed overall improvement on serial urodynamics after chemotherapy. Patients with bladder disturbances had poorer functional recovery at 6 and 12 months. CONCLUSION: Significant bladder comorbidity is associated with spinal TB and its presence can be recognized as a poor prognostic factor. Urological morbidity is strongly linked to the nerve root and posterior element involvement; reduction in disc height; and end plate erosion. Clinical/neurological improvement correlates with marked radiological and urological improvement.

Radiomorphological Manifestations of Femoral and Tibial Cortical Bones at Different Stages of Limb Lengthening.

BACKGROUND: There has been a lot of research done on Ilizarov's limb lengthening; however, very few publications focus on the quantitative assessment of the distractional bone regeneration in tibial and femur lengthening. Data regarding quality of the bone after lengthening are needed to consider the time of frame removal and develop a rehabilitation program. MATERIALS AND METHODS: Computed tomography (CT) assessment of a parent bone was performed on 136 patients with limb length discrepancy and bone deformity of various etiologies before and after lengthening. Transosseous osteosynthesis technique with the Ilizarov's external fixation was used for limb lengthening and deformity correction in all the cases. A 64-slice scanner was used for CT assessments. Specific Roentgen-negative units of the Ilizarov apparatus and techniques for interpreting CT findings were employed for artifact-free densitometric assessment. RESULTS: Cortical density of the femur and tibia in patients with limb length discrepancy and bone deformity of various etiologies was shown to have differences as compared to the contralateral limb. The lengthening process was accompanied by decreased cortical density of the segment being lengthened, and the decrease in the density was greater in the areas adjacent to the distractional bone regeneration. The cortical structure underwent characteristic changes. Osteonal density of the cortical bone was higher in the norm and at long term followup as compared to the density of external and internal plates. CONCLUSION: Cortical bone of the femur and tibia in patients with limb length discrepancy and bone deformity of various etiologies showed various preoperative local densities of external, internal, and osteon layers. The cortical bone demonstrated heterogenic structures with resorption areas of various magnitude and density, with minimal values at the boundary with regenerate bone during distraction and fixation with frame on and at short-term followup. Complete organotypical restructuring of the bone was shown to occur at a 1-to-3-year followup depending on the etiology of the disease and amount of lengthening performed.

Proximal femoral resection and Tensor Fascia Lata flap for recalcitrant trochanteric pressure ulcers.

Introduction: Trochanteric pressure ulcers (PrUs) are difficult to treat and are often complicated by infection spreading to the hip joint. We review three cases from India where proximal femoral resection and pedicled Tensor Fascia Lata (TFL) flapping was used in the management of infected deep trochanteric ulcers communicating to the hip joint. Case presentation: Three patients had a total of four trochanteric PrUs communicating to the hip joint. Proximal femoral resection along with radical debridement of the pressure ulcer (PrU) was the first step in our surgical protocol. Serial debridements were performed to make the resulting cavity healthier and ready for the subsequent flap surgery. TFL flapping was done to cover the raw area of the PrU and the donor site was closed either primarily or with a split skin graft. All patients were males with AIS A spinal cord injury (SCI) and stage 4 PrUs in the trochanteric region. One patient had bilateral trochanteric ulcers. There was complete healing of all PrUs with improvement in wheelchair mobility, and general health. Discussion: PrUs are a common complication of patients with SCI and are often considered one of the most neglected issues of health care delivery in India. Proximal femoral resection with pedicled TFL muscle flap is a versatile and reliable procedure for the coverage of recalcitrant trochanteric PrU with hip joint involvement. Minimal donor site morbidity occurs.

Proximal Tibial Osteochondroma Leading to Chronic Compartment Syndrome.

Osteochondroma is the most common benign tumour of bone seen in 3% of the general population. Complications such as neurological compromise, skeletal defects, vascular lesions, and compartment syndrome occur in about 4% of osteochondromas. We bring forth the case of a 16-year male who presented with the complaints of swelling in calf region associated with symptoms of claudication and paraesthesias in leg after exertion and absence of any such complaints at rest. Radiographs revealed a bony pedunculated mass originating from the posterior tibial metaphyseal region causing compression of posterior soft tissue structures. Excision biopsy of the mass was done by posterior approach with an L-shaped incision. The aim of this case report was to draw attention to the early signs of vascular compromise by osteochondroma in this region in order to prevent serious complications in future by early decompression.

Outcome Of Distally Based Sural Artery Flap For Distal Third Of Leg And Foot Defects.

BACKGROUND: Due to precarious blood supply, skin coverage for defects of leg, heel, dorsum of foot and the ankle has been a complicated task for plastic surgeons & orthopaedic surgeons. The present study aimed to prospectively evaluate the outcome of distally based sural flap for coverage of defects distal third of leg, ankle & foot. METHODS: In this study 15 patients with soft tissue defects on distal third of leg in (n=2), heel (n=4), medial malleolus (n=3), lateral malleolus (n=1), Achillis tendon (n=2), anterior ankle (n=2) and in dorsum of foot (n=1) were operated for coverage of defect by distally based sural flap. All the cases were done as secondary procedures. RESULTS: All the flaps showed good results except five minor complications. Three flaps showed superficial skin necrosis and two showed partial tip necrosis. CONCLUSIONS: Distally based sural artery flap is very useful in covering the defects of lower leg, heel and dorsum of foot. It is reliable, easy to raise with minimal morbidity to the patient. This flap does not sacrifice any of the major vessels of the limb and hence it is very safe flap.

To evaluate the role of platelet-rich plasma in healing of acute diaphyseal fractures of the femur.

PURPOSE: New research is focusing on the use of autologous growth factors to increase the effect of bone fracture healing while decreasing the amount of healing time for the patient. Platelets have been demonstrated to be the natural storage vessel for several growth factors and cytokines that promote blood coagulation, tissue repair, and the process of bone mineralization. The present study aims to evaluate the role of platelet-rich plasma (PRP) in healing of acute femoral shaft fractures radiologically. We hypothesize that it provides artificial hematoma and releases various growth factors. METHODS: This prospective randomized study was carried out in 72 patients of traumatic fracture of the femoral shaft operated with interlocking nails (closed or open). Patients were divided into two groups: study group A (n = 33) treated with intramedullary nailing & PRP injection/gel application in the same setting; and control group B (n = 39) treated with intramedullary nailing without PRP application. Both groups were further divided into two subgroups. Study group included subgroup A1 (n = 14) operated with closed intramedullary nailing and PRP injection at the fracture site under radiological control, and subgroup A2 (n = 19) operated with open intramedullary nailing and PRP gel along with fibrin membrane application at the fracture site; while control group included subgroup B1 (n = 16) operated with closed intramedullary nailing, and subgroup B2 (n = 23) operated with open intramedullary nailing. Radiological assessment of fracture healing was done by measuring the cortex to callus ratio every month till union at 6 months. RESULTS: Measurements of mean cortex to callus ratio revealed significant difference between the groups A & B at third and fourth months. Measurements of mean cortex to callus ratio did not reveal significant difference between the subgroups at first and sixth months. A statistically significant difference was observed between subgroups A1 & B2 and B1 & B2 at the second month; between subgroups A1 & B2, A2 & B2 and B1 & B2 at the third month; and between subgroups A1 & B2 at fourth and fifth months. CONCLUSION: PRP has no effect on femoral shaft fracture healing treated with closed intramedullary nailing. However, PRP and matrix scaffold provided by fibrin membrane may provide an artificial hematoma effect in the initial phase of healing in open or failed closed intramedullary nailing.