Bicycle and cycle rickshaw injury in suburban India.

OBJECTIVES: To study pattern of injury associated with bicycle and cycle rickshaw. METHODS: Between June 2002 and June 2003, a hospital based prospective study was done of patients who presented with injury due to bicycle and cycle rickshaw in emergency department. Age, time of trauma, mode of trauma, contributing factors and type of injury were recorded. RESULTS: Out of total of 41 patients, 23 were injured from bicycle and 18 from cycle rickshaw. In the bicycle group all patients were either traveling on crossbar or rear fender. 91% had sustained injuries due to spokes and 83% had soft tissue injury. In the rickshaw group contributing factors to injury were traveling on rear board and school children traveling on overloaded rickshaw. 78% were injured by rear cogwheel-chain mechanism and 72% patients had only soft tissue injury. CONCLUSIONS: Bicycle and cycle rickshaw injuries have a unique pattern of injury particularly affecting individuals riding them in an unconventional way. Majority of them sustained extensive soft tissue injury to leg and ankle.

Local antibiotics: panacea for long term skeletal traction.

Long periods of skeletal traction are frequently needed in busy tertiary centres due to long waiting lists for surgery. A frequent complication is pin track infection, which leads to revision of pin insertion or switching over to skin traction. A prospective study was conducted on sixty patients with upper tibial pin insertion for various causes. Antibiotic (injection Cephazolin 0.5 g after sensitivity testing--250 mg on each side) was injected on thirty patients at the site of pin insertion and no antibiotic was injected in 30 controls. Only one stage one pin track infection was seen in the study group (3% cases), where as six cases had stage 1 infection, one case had stage 2 infection and two cases had stage 3 infections in the control group (30% cases). This study showed the usefulness of this modification in preventing morbidity in patients who are planned for long-term skeletal traction by temporarily suppressing the local flora.

Deep vein thrombosis after total hip and knee arthroplasty in Indian patients.

BACKGROUND: Deep vein thrombosis (DVT) is one of the most common complications of total hip (THA) and total knee arthroplasty (TKA). Though the reported incidence of DVT is very high, that of proximal DVT is low and that of fatal thromboembolism is very low. Hence the issue of prophylaxis for DVT remains controversial. The incidence of DVT is based on various studies in European and American populations. The Asian population is genetically and socially quite different from American and European populations, and the incidence of DVT can be quite different. Therefore a prospective study was initiated at our centre to determine incidence of DVT after THA and TKA in Indian patients. METHODS: A prospective study was conducted on 60 hips in 45 patients and 46 knees in 26 patients who underwent THA and TKA respectively, without any known risk factors for thromboembolic disease. DVT was studied by preoperative and postoperative serial colour Doppler ultrasonography. No prophylaxis was given to any of the patients. RESULTS: DVT was found in two patients who had undergone THA. No case of DVT was detected in any patient who had undergone TKA. CONCLUSION: These results suggest that the incidence of DVT in Indian patients is very low and is not comparable with American and European populations. It is therefore not cost effective to advise prophylaxis in Indian patients undergoing THA/TKA who have no known risk factors for DVT.

Deep vein thrombosis after total hip arthroplasty in Indian patients with and without enoxaparin.

PURPOSE: To study the incidence of deep vein thrombosis in Indian patients undergoing total hip arthroplasty with or without prophylaxis, and the effect of enoxaparin on deep vein thrombosis. METHODS: The study covered a total of 50 hips in 40 patients who underwent total hip arthroplasty. Patients were assessed for deep vein thrombosis using Doppler ultrasonography. The hips were numbered and divided into 2 groups: the odd-numbered hips did not receive any thrombo-prophylaxis, whereas the even-numbered hips received 40 mg of enoxaparin subcutaneously, once a day for 2 weeks, until the time of discharge. RESULTS: Deep vein thrombosis was not found in both groups. We found wound haematomas in 9 patients (all of whom were on enoxaparin) (p<0.05), superficial infection in 2 patients (one on enoxaparin, one not), and local bruising in 4 patients (all of whom were on enoxaparin). Major haemorrhage did not occur in any of the cases. CONCLUSION: The incidence of deep vein thrombosis in Indian patients is very low compared to that in European and American patients. Enoxaparin failed to provide any advantage to the patients. It is therefore not advisable to give prophylaxis/low-molecular-weight heparin for deep vein thrombosis to patients undergoing total hip arthroplasty without any risk factors.

Delayed internal fixation of fractures of the neck of the femur in young adults. A prospective, randomised study comparing closed and open reduction.

We have compared the results and complications after closed and open reduction with ternal fixation in young adults with displaced intracapsular fractures (Garden grades III and IV) of the neck of the femur. We also studied the risk factors which influenced nonunion and the development of avascular necrosis (AVN). A total of 102 patients aged between 15 and 50 years was randomised to receive either closed or open reduction. Both groups were compared for age, gender, time to surgery and posterior comminution as well as for union and complications. Using univariate and multivariate analysis the factors influencing nonunion and AVN were assessed. Of the 102 patients, 92 were available for review. There was no significant difference between the groups in terms of union (p = 0.93) and AVN at two years (p = 0.85). Posterior comminution, poor reduction and improper placement of the screws were the major factors contributing to nonunion. The overall incidence of AVN was 16.3% (15 of 92 patients) and it was not influenced by these factors. A delay of more than 48 hours before surgery did not influence the rate of union or the development of AVN when compared with operation within 48 hours of injury.

Giant bone island of femur complicating replacement arthroplasty: a report of two cases.

Bone islands are hamartomatous malformations in the bone that are known to be asymptomatic in nature. Two cases are presented in which the presence of bone islands in the femur led to difficulty with the introduction of a femoral prosthesis. In one case, this led to fracture of the medial part of the cortex, which was fixed with a screw prior to insertion of the prosthesis. In the second case, a window was made in the femur to remove hard bone sufficient for insertion of the prosthesis. This was closed with steel wires prior to insertion of the cemented femoral stem. These cases illustrate the problems that can be encountered during surgery in the presence of bone islands. The surgeon should evaluate the site, size, and location of bone islands during preoperative planning before performing surgery.

Atlantoaxial rotatory fixation secondary to tuberculosis of occiput: a case report.

STUDY DESIGN: A case of nontraumatic rotatory fixation of the atlantoaxial joint associated with tuberculosis of the occipital bone in an adult. OBJECTIVES: To report a rare case of atlantoaxial rotatory subluxation associated with tuberculosis of the occipital bone in an adult and to discuss the mechanism of fixation. SUMMARY OF THE BACKGROUND DATA: Atlantoaxial rotatory fixation in adults is rare and has been reported due to variety of causes. To the authors' best knowledge no case has been reported secondary to tuberculosis of the skull bone. METHODS: A 20-year-old male presented with resistant torticollis with a duration of 5 months. RESULTS: The patient had type 1 atlantoaxial rotatory fixation secondary to tuberculosis of the occipital bone. The subluxation was partially reduced by conservative means, and healing of the occiput lesion was achieved. Thereafter, the patient had no restriction of cervical spine motion and had no reoccurrence of subluxation at a follow-up of one and a half years. CONCLUSIONS: Effusion in the atlantoaxial joint secondary to infection in the occiput due to close proximity with the joint led to the laxity of ligaments and contributed to the subluxation.

Pedicle morphology of the lower thoracic, lumbar, and S1 vertebrae: an Indian perspective.

STUDY DESIGN: Analysis of morphometric data obtained from computed tomography scans in relation to the lower thoracic, lumbar, and S1 pedicle in patients from the Indian subcontinent. OBJECTIVES: To record the surgically relevant parameters of transverse pedicle isthmus width, transverse pedicle angle, and depth to anterior cortex along the midline axis and the pedicle axis and to compare the results with those of similar studies in literature. SUMMARY OF BACKGROUND DATA: Most studies reported are for white populations. Considerable differences are documented in the few reports in Oriental populations compared with Western populations. To the authors' knowledge, no similar study has been published for patients from the Indian subcontinent. METHODS: Computed tomography scans of the lower thoracic and lumbosacral spine of patients from the Indian subcontinent were reviewed. We selected and analyzed 86 vertebrae in 31 patients. Parameters recorded were transverse pedicle isthmus width, transverse pedicle angle, and depth to anterior cortex along the midline axis and the pedicle axis. RESULTS: The mean transverse pedicle isthmus width was least at the T9 level (5.02 mm). Of the pedicles at T9, 46.15% had a diameter of less than 5 mm, followed by T10 (12.5%), T11 (11.11%), and L1 (11.11%). Of the pedicles at T9, 76.92% had a diameter of less than 6 mm, followed by T11 (33.33%), L1 (33.33%), T10 (25%), T12 (25%), L2 (20%), and L3 (5.56%). The mean transverse pedicle angle faced laterally at T11 (-2.97 degrees ) and T12 (-3.00 degrees ), being least at T12. The depth to the anterior cortex was more along the pedicle axis at all levels except T11 and T12, consistent with the laterally facing pedicles at these levels. CONCLUSIONS: Significant differences exist between the pedicles of Indian and white populations. It is suggested that preoperative computed tomography scans of the patients must be evaluated to choose the appropriately sized implant and avoid inadvertent complications. Preparation of the pedicle intraoperatively should take into account the orientation of the transverse pedicle angle.

Fine-needle aspiration cytology, frozen section, and open biopsy: relative significance in diagnosis of musculoskeletal tumors.

Fine-needle aspiration cytology (FNAC) is a minimally invasive technique used extensively in diagnosis of various tumors. Frozen section biopsy is known for its usefulness in assessing adequacy of margins of resection intraoperatively. This study assesses the usefulness and significance of these procedures in tumors of musculoskeletal origin. This study includes 91 patients and all the patients were subjected to a preoperative FNAC test on an outpatient basis. An open biopsy was done in every case under appropriate anesthesia and representative tumor tissue was sent for frozen section analysis. Out of 91 patients, FNAC was feasible in 78 patients. Out of the 78 patients aspirated, a type-specific diagnosis was made in 79.5% of cases (62 out of 78). Frozen section was possible in 85 cases. The percentage of specific diagnosis by frozen section in this study is 85.9% (73 out of 85) and overall diagnostic accuracy of 96.5% (82 out of 85). FNAC and frozen section are reliable diagnostic modalities, in the presence of clinico-radiological correlation, in the diagnosis of musculoskeletal tumors.

The Ilizarov method in infected nonunion of fractures.

Thirty patients with infected non-union of long bones were treated with radical resection of the necrotic bone and bone transport or compression/distraction osteosynthesis. Non-union, infection, deformity, bone gap and shortening were all addressed simultaneously using the Ilizarov principles. There were 15 cases with bone loss ranging from 4 to 12 cm (median bone gap of 7 cm), 10 cases of stiff non-union (six of which had an associated deformity) and five cases of mobile non-union. The median time in the Ilizarov frame was 150 days. Median follow up time after frame removal was 23.5 months. Bone grafting at the docking site was only required in three cases (10%). There were three cases of refracture (10%) and three cases of recurrence of infection (10%). The bone result was excellent in 21 patients (70%), good in three (10%), fair in none (0%) and poor in six (20%). The functional results were excellent in eight patients (26.7%), good in 12 (40.0%), fair in three (10%) and poor in seven (23.3%). It is difficult to precisely define the indications for preservation and reconstruction of severe injuries. The surgical team has to take into account the length, disability, complications and cost of treatment. Patients must be aware of the limitations of functional results and the possible difficulty of return to work despite the reconstructive attempt.

Displaced intra-articular fractures of distal radius: a comparative evaluation of results following closed reduction, external fixation and open reduction with internal fixation.

Fractures of the distal end of the radius are common injuries and are the commonest bony injury around the wrist. Management of these fractures has remained controversial as far as modality of treatment is concerned. In this study 90 adult cases of acute displaced intra-articular fractures of the lower end of the radius were classified according to Frykman's and AO classifications after obtaining radiographs in antero-posterior and lateral planes. These were randomly treated by one of three methods: (1) closed reduction and plaster immobilisation, (2) external fixation and (3) open reduction and internal fixation, and were followed for an average of 4 yr. In the final functional assessment (Sarmiento) the results were (1) plaster 43% good and excellent, 50% fair and 7% poor, (2) external fixator 80% good and excellent, 20% fair and poor results, (3) open reduction and internal fixation 63% good and excellent, 26% fair, 11% poor. We recommend that displaced severely comminuted intra-articular fractures should be treated with an external fixator.

Spinal epidural abscess - a report of six cases.

Six cases of spinal epidural abscess are presented. All patients were young with no predisposing conditions. All were treated with laminectomy and intravenous antibiotics. The patients with no neurological deficit recovered completely, while patients with pre-existing neurological deficit had a poorer outcome. Emphasis is given to early detection and surgical management to prevent irreversible damage to the spinal cord.

Comparative efficacy and tolerability of nimesulide and piroxicam in osteoarthritis with specific reference to chondroprotection: a double blind randomised study.

The aim of the study was to assess the efficacy, tolerability and chondroprotection afforded by nimesulide, a selective cyclooxygenase-2 inhibitor and piroxicam in a randomised, double blind, controlled clinical trial in 90 patients suffering from osteoarthritis of the knee joint. A significant improvement in the osteoarthritis severity index at 2 weeks (p < 0.01) and an improvement in physicians assessment of global arthritic condition at 4 weeks (p < 0.01) was seen with both the treatments. A significant decrease in articular index of joint tenderness (p < 0.05) at 8 weeks and in self assessment of handicap at 4 weeks (p < 0.05), in comparison to baseline, was observed only in patients receiving nimesulide. Rescue therapy was required by a greater percentage of patients being administered piroxicam. Functional capacity improved in 64% of the patients on nimesulide and 74.5% of the patients receiving piroxicam. Adverse effects were observed in 6 patients on nimesulide and 9 patients receiving piroxicam. No significant difference was found in any of the efficacy and tolerability parameters between the two treatment groups. Magnetic resonance imaging evaluation of the knee joint of 10 patients showed no significant change in the articular cartilage and associated joint structures after 6 months of therapy with both the treatments. The results show that nimesulide and piroxicam are comparable in efficacy and tolerability in patients suffering from osteoarthritis.

Management of displaced femoral neck fractures in young adults (a group at risk).

25 young adults (age 15-50 years) with femoral neck fractures were operated on an ordinary operating table, using a Watson-Jones approach. Open reduction of the fracture site through an anterior capsular incision was performed and fixation with three cancellous screws was done. Patients were regularly assessed for clinical and radiological evidence of non-union and avascular necrosis. Average follow-up was 32 months. Non-union was seen in one case (4 per cent) and evidence of avascular necrosis was seen in three cases (12 per cent). The results were compared with available published series of similar fractures, treated by closed and open reduction technique. The comparison showed that in young adults, primary open reduction and internal fixation of femoral neck fractures can be recommended as the treatment of choice.

Lymphedema of the lower extremity as a complication of local burns.

Lymphedema of an extremity is a rare complication of local burns, due to intact deep lymphatics. Here we present a case of delayed lymphedema of the foot, developing due to deep scarring after local burns.