Effect of Coronavirus Disease 2019 Pandemic on Spinal Surgery Patients: Our Experience at a Tertiary Care Center.

Introduction: In December 2019, a cluster of atypical cases of pneumonia was reported in Wuhan, China, which was later designated as Coronavirus disease 2019 (COVID-19) by the World Health Organization (WHO) on Feb 11, 2020. We all are facing a global pandemic, and it is very important to be clear that there is no correct roadmap to navigate this difficult situation. It is imperative to state that this global pandemic impacted the spine care services of our institute. In the present study, we have assessed the spine surgeries performed by orthopedic surgeons in terms of volume and etiologies during the COVID-19 pandemic and compared the data with a pre-COVID period. Materials and Methods: We retrospectively collected data from all patients who underwent spinal surgeries at our institute under the department of orthopedics from August 20, 2019 to August 20, 2020 (a total of 12 months duration). The data was then divided into two groups-pre-COVID period (August 20, 2019-February 19, 2020-6 months) and during the COVID pandemic (February 20, 2020-August 20, 2021-6 months). Results: A total of 140 patients underwent surgery at our institute from August 20, 2019 to August 20, 2020. Of these, 91 patients underwent surgery during the pre-COVID period, and 49 patients underwent surgery during the COVID pandemic. In this devastating phase of the pandemic, our department's total number of surgeries significantly declined to 46.15%. The routine surgeries performed during the pandemic phase show a steep fall from 59.34% in the pre-COVID period to 10.20%. Conclusion: This paper is meant to focus attention on the exorbitant reduction in the operative workflow of the spine patients during the COVID-19 pandemic at a tertiary healthcare institute. It is the need of the hour that orthopedic surgeons maintain equilibrium while providing the best possible treatment to their patients and limiting the spread of the COVID-19 pandemic.

The impact of COVID-19 lockdown on the clinical and radiological outcomes of both-bone forearm fractures treated by compression plating at a tertiary care centre in India: a retrospective study.

BACKGROUND: The COVID-19 pandemic has affected everyone's life. In India, the nationwide lockdown was enforced from March 25, 2020. It has significantly affected the healthcare delivery system. Both-bone forearm (BBFA) fractures are commonly encountered as an emergency. Surgical management with plate fixation is often the primary mode of management in adults and adolescents. During the first wave of the COVID-19 pandemic, follow-up of patients with BBFA fractures who had undergone surgery before the lockdown was severely affected. To understand the effect of lack of regular follow-up on the outcome of BBFA fracture patients, in this study, we assessed their radiological, functional, and clinical outcomes at least 12 months after surgery. This study examined if a lack of routine follow-ups in surgically treated BBFA fracture patients has any impact on their short-term outcomes. METHODS: We included 30 patients with BBFA fractures who were operated prior to the COVID-19 lockdown and assessed their radiological, functional, and clinical outcomes 12 months after surgery. Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score, Patient-Rated Wrist Evaluation (PRWE) score, Grace and Eversmann's score, and Mayo Elbow Performance Index (MEPI) score were assessed subjectively. Fracture site tenderness, and wrist, forearm, elbow, and grip strength range of motion (ROM) were objectively evaluated. Radiological union was recorded using standard forearm anteroposterior and lateral radiography. RESULTS: At follow-up, 28 patients had union at the fracture site, and two patients had a nonunion. A significant reduction was observed in the mean ROM of the injured forearm compared with the uninjured forearm in supination (17.76% less), pronation (31.4% less), dorsiflexion (32% less), palmar-flexion (24.6% less), elbow flexion-extension arc (2.5% less), and grip strength (18% less). The percentage reduction in pronation and dorsiflexion was higher than that in supination and palmar-flexion, respectively. Grace and Eversmann's score was excellent in 16 patients, good in 4, acceptable in 7, and poor in 3 patients. The mean QuickDASH score was 6 ± 6.6. The mean PRWE and MEPI scores were 7 ± 4.5 and 87.16, respectively. The MEPI score was excellent in 21 patients, good in 6, fair in 2, and poor in 1 patient. CONCLUSION: The clinical, functional, and radiological outcomes of adult patients with BBFA fractures who were treated with compression plating were satisfactory. Inadequate follow-up during the COVID-19 first wave in India had minimal to no effect on their short-term outcomes.

Cadaveric Study to Define the Anatomy of the Medial Patellofemoral Ligament (MPFL) and Its Variant Patterns.

BACKGROUND: The medial patellofemoral ligament (MPFL) is one of the major soft tissue stabilizers on the medial side of the knee joint, extending from the medial condyle of the femur to the medial aspect of the patella. Different kinds of literature described different sizes and different origins and insertions of MPFL. Injury of MPFL causes patellar instability and dislocation. We reported the anatomy and morphology of MPFL and its implications in the repair of MPFL. The aim of the study was also to look at the variant forms of the MPFL.   Methodology: A total of 40 lower limbs fixed in formalin were dissected to study the MPFL of the knee. After reflecting the deep fascia and retinaculum on the medial side of the knee joint the MPFL was exposed. For better learning the lower medial part of vastus medialis was reflected, so that the part of MPFL undercover was exposed. RESULTS:  Different forms of MPFL were seen like two straps 12.5%, broad rectangle 20%, and triangular shaped 67.5% MPFL. The origin of MPFL was found between the adductor tubercle and medial epicondyle of the femur and insertion was seen extending from the proximal medial half of the patella to the tendinous aponeurosis of vastus medialis obliquus (VMO) and vastus intermedius muscle (VIM). CONCLUSIONS: This is the first study that described three variant patterns of MPFL in accordance with their morphological appearance. This knowledge will be helpful to the surgeons for easy identification and repair of the MPFL.

Femoral Neck Nonunion Associated With Delayed Union of Ipsilateral Femoral Shaft Fracture.

We report the case of a 36-year-old man, who presented to us five months after the initial trauma. He had been treated elsewhere with a cephalomedullary femoral nail. He described severe pain in his right thigh and groin that confined him to a wheelchair. He had shortening of the right lower limb and painful restriction of movements of the right hip. Radiographs demonstrated hypertrophic callus with a gap at the femoral shaft while the neck fracture was in varus malalignment with bone resorption; the neck fracture been fixed using two hip screws that were missing the nail. The patient was managed with removal of the previous hardware, reamed retrograde nailing and Pauwels' intertrochanteric valgus osteotomy fixed using a 120o double-angled condylar blade plate. Both the fracture sites were not opened. Postoperatively, the femoral shaft showed radiographic evidence of union at three months, while the femoral neck and the intertrochanteric osteotomy site had united at five months. As per the Friedman and Wyman criteria, our patient has a "good" outcome at the four-year follow-up.

Morphologic Features of the Distal Femur and Proximal Tibia: A Cross-Sectional Study.

Background The asymmetric medial and lateral condyles of the distal femur and proximal tibia have a direct influence on the biomechanics of knee joint and prostheses design. This study aimed to determine the morphologic data, that is., anteroposterior (AP) and mediolateral (ML) widths, and the radius of curvature (ROC) of the geometric arcs of the distal femur and proximal tibia. Methods One hundred and seventeen adult dry bones (57 femurs and 60 tibias) were studied. Aspect ratios (AP/ML) were calculated. The AP and ML widths were measured using digital Vernier Caliper with a measuring range of 0-150 mm, resolution of 0.01 mm, and accuracy ± 0.02 mm. The geometric arcs of femoral and tibial condyles were divided into three parts namely anterior 1/3rd, distal (femur) or middle (tibia) 1/3rd and posterior 1/3rd and were estimated in the sagittal plane for the femur and transverse plane for tibia using the ROC gauges. Results For the femur, the mean AP length for medial and lateral condyles was 55.62 mm and 57.93 mm, respectively, while the mean ML width was 73.45 mm. For the tibia, the mean AP length for medial condyle (MC) and lateral condyle (LC) was 47.74 mm and 43.46 mm, respectively. The mean aspect ratios for the distal femur and proximal tibia were 1.26 and 1.45, respectively. The mean aspect ratios for MC and LC of the femur were 0.50 and 0.52, respectively, whereas, for tibia, they were 0.61 and 0.71, respectively. The mean ROC for femoral MC - 20.77 mm, 31.42 mm, and 19.68 mm and for LC - 21.48 mm, 64.40 mm and 19.06 mm for the anterior, distal and posterior arcs, respectively. The mean ROC for tibial MC - 22.42 mm, 22.49 mm and 19.94 mm, and LC - 19.92 mm, 21.79 mm and 20.95 mm for the anterior, middle and posterior arcs, respectively. Conclusions The morphologic data accumulated in this study for both the distal femur as well as the proximal tibia would provide guidelines and help the manufacturers of joint prostheses to address the potential for compromised implant fit and re-design and make available 'anatomic' knee prostheses appropriate for the local population which would not only improve function but also prolong the longevity of the prostheses.

Correlation Between the Thickness of Anterolateral Ligament and Lateral Collateral Ligament of the Knee.

Background Persistent anterolateral rotatory instability (ALRI) following the anterior cruciate ligament (ACL) reconstruction has led to a renewed interest in defining the role of anterolateral complex (ALC) of the knee. Methods We explored the anterolateral corner of 34 cadaveric knees to define the anterolateral ligament (ALL) in all its dimensions and measured the thickness of lateral collateral ligament (LCL) at the lateral meniscus level (tLCL) in ALL-intact and ALL-deficient knees. Results ALL was present in 27/34 (79%) of the knees. We found complete ALL in 13 cadavers bilaterally. ALL was absent bilaterally in three cadavers; it was present on one side and absent contralaterally in one cadaver. In ALL-intact knees, the average tLCL was 2.05 mm, whereas, in ALL-deficient knees, it was 2.57 mm. This difference in tLCL was statistically significant. Conclusions Our study adds new data to the recent voluminous research on ALL. We have examined the correlation between the thickness of ALL and LCL and documented alterations in the thickness of LCL in ALL-intact knees. These findings would help in designing reconstructive procedures for the combined ACL injury with ALRI.

Adapting Policy Guidelines for Spine Surgeries During COVID-19 Pandemic in View of Evolving Evidences: An Early Experience From a Tertiary Care Teaching Hospital.

Introduction The recent novel coronavirus disease 2019 (COVID-19) pandemic has brought the world to a standstill. This outbreak not only affected healthcare systems but the resultant economic losses were also enormous. COVID-19 has demanded that the health care systems globally evolve, develop new strategies, identify new models of functioning, and at times, fall back on the old conservative methods of orthopedic care to decrease the risk of disease transmission. Although, the majority of hospitals are refraining from performing elective surgeries, emergent and urgent procedures cannot be delayed. Various strategies have been developed at the institute level to reduce the risk of infection transmission among the theatre team from an unsuspected patient (asymptomatic and presymptomatic) during the perioperative period. Material and methods The present study is a part of an ongoing project which is being conducted in a tertiary level hospital after obtaining research review board approval. All patients admitted either for vertebral fracture or spinal cord compression from February 2020 to May 2020 were included. The present study included 13 patients (nine males and four females) with an average age of 35.4 years The oldest patient was of 63 years which is considered a risk factor for developing severe COVID-19 infection.  Results Eight patients (61.5%) presented with spinal cord injury (SCI) due to vertebral fracture with fall from height (87.5%) as the most common etiology. Among the traumatic SCI patients, six (75%) were managed surgically with posterior decompression and instrumented fusion with pedicle screws while two patients (25%) were managed conservatively. There were four patients (30.8%) of tuberculosis of the spine of whom two (50%) were managed with posterior decompression, debridement, and stabilization with pedicle screws, samples for culture, biopsy, and cartridge-based nucleic acid amplification test (CBNAAT) were collected during the procedure; for the remaining two patients (50%), a trans-pedicular biopsy was performed to confirm the diagnosis for initiation of anti-tubercular therapy. Prolapsed intervertebral disc causing cauda equina syndrome was the reason for emergency surgery in one patient (7.7%). COVID-19 severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) reverse transcription-polymerase chain reaction (RT-PCR) test was performed in four patients (30.8%), in whom the most common symptom was fever (two patients (50%)). These patients were residents of high prevalence area for COVID-19 infection. Sore throat (25%), fatigue (25%), and low oxygen saturation (25%) were present in one patient which prompted us to get the COVID-19 test. All patients were reported negative for COVID-19. Conclusion The structural organization and the management protocol we describe allowed us to reduce infection risk and ultimately hospital stay, thereby maximizing the already stretched available medical resources. These precautions helped us to reduce transmission and exposure to COVID-19 in health care workers (HCW) and patients in our institute. The aim of this article is that our early experience can be of value to the medical communities that will soon be in a similar situation.

Thoracic Pedicle Morphometry of Dry Vertebral Columns in Relation to Trans-Pedicular Fixation: A Cross-Sectional Study From Central India.

Introduction Trans-pedicular screw fixation is one of the main modalities of spinal instrumentation today. It is particularly challenging in the thoracic spine due to the narrow pedicle dimensions especially in the upper and mid-thoracic levels. We aimed to study the anatomical variations like pedicle dimensions and angulation in transverse and sagittal planes. Material and methods We conducted an anatomical investigation on 20 dry vertebral columns (14 male and six female), from T1 to T12 levels. The measurements included pedicle width, height, and transverse and sagittal angles of the pedicle. Numerical variables were summarized using mean and standard deviation. Results T12 vertebra was found to have the widest pedicle width (mean 7.89 ± 0.70 mm) and the widest pedicle height (mean 15.45±0.78 mm) while T5 vertebra (mean 3.65±0.40 mm) had the narrowest pedicle width. T1 vertebra had the maximum transverse angle of the pedicle (mean 30.37±2.56 degree); whereas, T2 vertebra had the maximum sagittal angle (mean 19.22±2.24 degree). Conclusion We have reported detailed pedicle measurements including their angulation for the thoracic spine in dry vertebral columns of central India. The pedicles are directed more medially from T1 to T10 levels and are almost neutral at T11 and T12 levels. These findings would not only be of immense help to the spinal surgeons but also help in designing implants and instrumentations specific for the thoracic spine for the central Indian population as well as aiding surgeons to perform more precise and, therefore, safe surgical procedures.

Dislodgement of Telescopic Nail from the Epiphysis: A Case Report with an Analysis of Probable Mechanism.

Telescopic nails such as Fassier-Duval (FD) nails have become the standard treatment for stabilizing long bones and correcting deformities in osteogenesis imperfecta (OI). These nails do not require repeat surgery for their replacement when the bones outgrow them. However, they are not completely free from complications. The prohibitive costs of the original implants have led to design modifications being introduced in locally manufactured telescopic nails. While these low-cost devices work well in most cases, they can lead to complications resulting from their design flaws. We present here the complication observed in a locally manufactured telescopic nail with a design similar to the FD nail. The male component of the nail got dislodged from the distal tibial epiphysis, resulting in its proximal migration. We discuss the probable mechanism of this complication and propose possible design changes that can bring down the rates of such incidences.

Neglected bilateral radial head fracture with a rare presentation: A case report.

Isolated radial head fractures are rare and comprise about 2% of all fractures around the elbow. Bilateral radial head fractures are even rarer and few cases have been reported. We present a case of bilateral elbow effusion in a 28-year-old male patient. An initial diagnosis of inflammatory arthritis was made but on investigation it turned out to be a case of bilateral radial head fracture. The patient was managed conservatively with 10 days of immobilisation in above elbow slab followed by active elbow range of movement exercises. On follow-up at 6 months, the patient had near normal range of movements without pain or elbow instability.

Risk of nerve injury during arthroscopy portal placement in the elbow joint: A cadaveric study.

BACKGROUND: Elbow arthroscopy has become a routine procedure now. However, placing portals is fraught with dangers of injuring the neurovascular structures around elbow. There are not enough data documenting the same amongst the Indians. We aimed to determine the relative distances of nerves around the elbow to the arthroscopy portals and risk of injury in different positions of the elbow. MATERIALS AND METHODS: Six standard elbow arthroscopy portals were established in 12 cadaveric upper limbs after joint distension. Then using standard dissection techniques all the nerves around the elbow were exposed, and their distances from relevant portals were measured using digital vernier caliper in 90° elbow flexion and 0° extension. Descriptive statistical analysis was used for describing distance of the nerves from relevant portal. Wilcoxon-signed rank test and Friedman's test were used for comparison. RESULTS: There was no major nerve injury at all the portals studied in both positions of the elbow. The total incidence of cutaneous nerve injury was 8.3% (12/144); medial cutaneous nerve of forearm 10/48 and posterior cutaneous nerve of forearm 2/24. No significant changes were observed in the distance of a nerve to an individual portal at 90° flexion or 0° extension position of the elbow. CONCLUSION: This study demonstrates the risk of injury to different nerves at the standard portals of elbow arthroscopy. In practice, the actual incidence of nerve injury may still be lower. We conclude that elbow arthroscopy is a safe procedure when all precautions as described are duly followed.

Prevalence and Patterns of Coexistence of Multiple Chronic Conditions: A Study from Indian Urban Outpatient Setting.

BACKGROUND: Chronic diseases are a common cause for seeking care in a hospital, however little is known about prevalence and spectrum of multiple chronic conditions (MCC) in Indian context. Estimates for coexistence of MCC range from one-fourth of all primary care attendees in Spain to two-thirds of all medicare attendees in the United States. This study was designed to estimate the similar prevalence and patterns in an Indian outpatient setting. MATERIALS AND METHODS: This study was performed at All India Institute of Medical Sciences Bhopal between May and June 2013, a hospital which had just started outpatient services in this period. All consecutive patients that presented to Medicine, Neurology, and Orthopedics clinics were sought to be included in the study, and information about their current diagnoses was abstracted from their outpatient records. All patients with one or more chronic disease diagnosis were asked about their monthly out-of-pocket expenditure. We performed a descriptive analysis of the demographic, medical diagnoses, and out-of-pocket expenditure variables. RESULTS: A total of 785 patients were included in the study, and 286 (36%) of them had one or more chronic disease diagnosis. Of these, 103 (13%) had a single chronic disease, while 183 (23%) had more than one chronic disease diagnosis. Among those with MCCs, chronic vascular diseases in combination, followed by combinations of chronic vascular and immunological diseases were common patterns. There was a significant rising trend in average out-of-pocket expenditure with increasing number of chronic disease diagnoses. CONCLUSION: Co-existence of multiple chronic diseases is common in those who seek hospital-based care. This fact has important implications for education and clinical decision making in primary care.