Comparison of Topical Oxygen with Vacuum Assisted Closure in Wound Healing in a Low Resource Setting.

Background: The aim of this pilot study is to obtain preliminary results comparing topical oxygen therapy (TOT) and vacuum assisted closure (VAC) in terms of its ability to accelerate wound healing. Methods: This non-randomised prospective study included patients with age 16-50 years, wound size ≥ 16cm2 and present below knee joint within seven days of occurrence. Bates-Jensen wound assessment tool (BWAT) was used for evaluation at 8-day interval along with percent area reduction at final follow up. Results: Mean number of cycles required in VAC and TOT group were 1.97 (range 1-3) and 2.1 (range 1-3) (each cycle of 5 days) per patient respectively. Percent area reduction was significantly higher in the VAC group (34±9.7%) than TOT (11.3±3.8%) group at final follow up (p<0.05). TOT patients had better improvement in epithelialization compared to VAC at last follow up. More extensive debridement was needed in patients of TOT than VAC. There was no significant difference between final score in both groups. Conclusions: TOT appears to be comparable to well-established VAC in treatment of fresh traumatic wounds below the knee joint. Further large scale, multicentric and randomised studies comparing both these modalities of treatment should be the way forward.

A comprehensive 3D CT based classification of intertrochanteric fracture.

Introduction: Despite advancements in surgical techniques complications like implant failure is very common after the fixation of intertrochanteric fractures. Classifying these complex fractures based on plain radiographs underestimates the complexity of these fractures which in turn leads to complications. We propose a comprehensive classification of the intertrochanteric fractures based on 3D Non Contrast Computed Tomography (3D NCCT) scan. Material and methods: A total of 102 patients (51 males and 51 females) with intertrochanteric fractures were included in this study conducted over a time period of 22 months in a Tertiary care center in North India. NCCT proximal femur of the intertrochanteric fracture patients was done to formulate a new CT classification system and classify all fractures. Intra and inter-observer reliability was tested using kappa variance. Results: New classification system was proposed which included 3 main and a total of 6 groups. All the fractures were classifiable into the new system. Kappa variance of the study showed a good intra and interobserver reliability (0.95 and 0.90) proving clinical agreement of the classification. Conclusion: This new 3D-CT based classification has the advantages of being easy, comprehensible with high intra and inter-observer reliability. This 3DCT based classification can prove to be useful to detect occult intertrochanteric fractures undetectable in plain radiographs as well as choosing the optimum treatment plan.

Indigenous nutritional intervention for the recovery of a child with osteomyelitis: A clinical anecdote.

Diet plays an influential role in the cure of diseases and restoration of health as it supplies nutrients required for tissue repair. Better nutrition helps to fight against infection and cope with stress effectively. Diet is an essential component of treatment for a disease, injury, or infection and must meet altered dietary requirements of the body resulting from these conditions. While providing care to orthopedic patients, clinical outcomes such as wound healing, mobility, and functional ability are positively influenced by adding therapeutic nutrition to the patient care plan alongside routine care. There is a close relationship between nutrition, infection, and immunity so therapeutic nutrition must hold a significant place in the care plans of orthopedic patients to boost their immunity, and treat infection. This clinical anecdote provides insight into how the process of wound healing, especially in children with infective bone pathology, is enhanced by systematically planned dietary monitoring and dietary supplementation. An 8-year old, male child, diagnosed with osteomyelitis of the left tibia with septic arthritis (left knee) developed numerous complications including septic shock. Initiation of intensive dietary monitoring enabled the healthcare team to analyze the need for dietary correction. Hence, carefully planned dietary supplementation was implemented, which contributed to positive clinical outcomes such as enhanced wound healing, improved mobility, weight gain, and reduced length of hospital stay. Orthopedic nutrition must start from the preliminary assessment of patients at an outpatient clinic and must continue until the final follow-up.

Quantification of Volume Mismatch of Acetabulum and Femoral Head in Developmental Dysplasia of Hip.

Objectives: The sustained subluxation or dislocation of the femoral head over time does not permit normal development of acetabulum and results in predictable pattern of acetabular growth disturbance that is termed hip dysplasia. The primary aim of this study is to analyze and quantify the volume mismatch between acetabulum and femoral head of affected side as compared to normal hip. Methods: A prospective observational study was conducted by including isolated untreated unilateral idiopathic developmental dysplasia of hip (DDH). After routine clinical and radiographic examination, computed tomography (CT) of both hips was done with pre-determined radiation dosage within safe limits for the pediatric age group in 18 patients of median age 2 years (range 1-5 years). Results: A significant difference was noted between acetabular index (p<0.001), acetabular volume (p<0.001), femoral head volume (p<0.001), and acetabular anterior sectoral angle (p=0.002) of the affected and the normal hips. As compared to the normal side, the acetabulum is 2.6 times smaller than the normal side and femoral epiphysis volume by 3.8 times. A significant negative correlation (r=-0.66, p=0.04) was noted between posterior acetabular sectoral angle and acetabular volume of affected hip. Conclusion: CT is an important investigation in evaluation of late-presenting DDH. The absence of femoral head in its orthotopic location affects the volume of acetabulum as well as that of femoral head. The abnormality of the volume of acetabulum which is seen as related to the dysplasia should be studied and assessed in detail in a child of late-presenting DDH. This would guide us toward the coverage defect and type of osteotomy to be performed.

Infection and utilization rates of bone allografts in a hospital-based musculoskeletal tissue bank in north India.

BACKGROUND: The bone bank unit of interest in this article was established in January 2018, in a tertiary care teaching institute of north India. Aim of this article is to describe the sources of allografts obtained, discard rates of allografts and infection rates in the recipients after use. MATERIAL AND METHODS: All the relevant details of donors and recipients were maintained, and donors were screened for standard inclusion and exclusion criteria before obtaining the grafts. Aerobic culture was performed before storage and just prior to use. Samples with incomplete documentation, incomplete donor screening or positive cultures were discarded. Data on surgical site infection in recipients was collected from hospital records retrospectively. Initially ELISA based serological tests were used for screening. Donor has to undergo these tests again after 6 months to account for the window period of proliferation of viruses. Nucleic acid amplification tests (NAAT) for these viral agents were introduced in the hospital in May 2018. RESULTS: Allografts from a total of 196 donors were obtained in the bone bank over 2 years. Major source of bone was femoral heads harvested during total hip arthroplasty or hemi-arthroplasty. 44(22.4%) grafts had to be discarded. 95 allografts were used in 88 patients during this time. Most common indication for use was surgery for bone tumors (40%), followed by complex primary or revision arthroplasty (30.5%). Three (3.4%) recipients developed deep infection postoperatively. CONCLUSION: Frozen allograft bone from hospital based bone banks is a reliable source of allografts. When meticulous precautions for sterility are followed, risk of infection is low. Monitoring of such bone banks should fall within a framework of the local legislature. Incomplete documentation is the major reason for wastage of the samples obtained. NAAT may be useful in screening of donors, as it reduces the wastage and the holding time of the allografts.

Symptom Interval in Cases of Benign Cystic Lesions of Bone and its correlation with Surgical Intervention.

INTRODUCTION: Benign lesions in bone are less studied in terms of progression and prognosis. There is presently no literature studying symptom interval (SI) in neoplastic bone lesions or determinants of delay in Indian setting. The literature is also sparse on SI in benign lesions of bone, since benign bone lesions have seemingly less menacing symptoms and slow progression as compared to their malignant counterparts. Social and cultural issues peculiar to the region of study have an impact on the symptom interval of benign bony lesions. METHOD: A prospective, observational study was conducted at a tertiary level University teaching hospital from December 2017 to August 2019. The study included 55 patients presenting with benign cystic lesions of bone. Appropriate radiological investigations along with tissue biopsy were done. All the patients were enquired as per a preformed questionnaire to determine the delay and its determinants. RESULT: Out of the 55 patients included in the study, wide variety of cystic lesions was observed with varied presentation and delay. Median SI of 175 days (range 27-3705 days) was observed in the present study. However, it was found that longer SI did not have a statistically significant effect on the type of procedure done (p = 0.206) though diagnostic delay was significantly related to the intervention required (p = 0.004). It was observed that tumor behavior at the time of presentation such as histopathological diagnosis (p = 0.000), presence of cortical breach (p = 0.001), stage of tumor (0.001), and articular involvement (p = 0.000) remained as some of the most important factors in determining the prognosis and outcome in case of benign cystic lesions of bone.

Microsurgical DREZotomy in Spastic Cerebral Palsy: Poor Man's Baclofen Pump.

BACKGROUND: Using an intrathecal baclofen (ITB) pump for severe refractory spastic cerebral palsy is not a viable option in resource-constraint settings. Therefore authors assessed the role of microsurgical dorsal root entry zone-otomy (MDT) as an alternative for patients in whom the circumstances did not allow ITB pump placement. METHODS: A prospective clinical study was conducted from August 2016 to July 2020. All patients of spastic cerebral palsy (with III-IV Ashworth grade) who underwent MDT were included. Preoperative and postoperative Ashworth grade and Gross Motor Function Classification System level were assessed along with any change in power, sensation, and bladder functions postoperatively. At last follow-up, the patients' main care providers were asked to rate the effect of surgery (on scale of 0-5) on ease of providing care related to 6 activities of daily living. RESULTS: Seven patients (5 males, 2 females) of spastic cerebral palsy with an age range of 6-21 years underwent MDT over the study period. Six patients had spastic diplegia, and 1 had spastic hemiplegia. Preoperative Ashworth grade in all patients was 3-4 in various involved muscle groups. Four patients with spastic diplegia underwent MDT at L3-S1 level bilaterally, 2 patients with spastic diplegia and spastic bladder underwent MDT at L3-S4 level bilaterally, and 1 patient with right-sided spastic hemiplegia underwent MDT at C5-T1 level and L3-S1 level on the right side. Postoperative Ashworth grade in all patients improved to 0-1. The improvement in mean Ashworth grade was from 3.14 ± 0.378 preoperatively to 0.29 ± 0.488 (P value = 0.000). Most care providers reported improvement in their ability to do physiotherapy, position, clothe, ambulate, and maintain patient's personal hygiene. Care providers of 6 patients reported that they were likely to recommend MDT to another similar patient. CONCLUSIONS: MDT is a cost-effective tool in deceasing limb spasticity in spastic cerebral palsy, especially for those who cannot afford ITB placement.

A prospective study on transfer of pronator teres to extensor carpi radialis brevis for forearm and wrist deformity in children with cerebral palsy.

We prospectively evaluated the clinical and functional outcomes of pronator teres to extensor carpi radialis brevis transfer in children with cerebral palsy. Patients were followed-up at 6 months postoperatively, and functionally assessed using the House classification, Manual Ability Classification System (MACS) and Upper Extremity Functional Index (UEFI). Fifteen children with a mean age of 8.1 years underwent tendon transfers. All patients were of Gschwind and Tonkin Grade 2 for pronation deformity; eight patients were of Zancolli's classification Group 1 and seven, Group 2 for wrist flexion deformity. The average gain in active supination was 67°, and wrist extension 15°. An increase of 7.0 in the UEFI score was recorded, although no significant improvement in MACS and House classification was observed. We conclude that the pronator teres to extensor carpi radialis brevis transfer improves upper limb function through effective correction of forearm pronation and wrist flexion deformities.Level of evidence: II.

Assessment of severity of clubfoot in walking children by combined multiple tools: A new classification system.

INTRODUCTION: Clubfoot is one of the most common congenital deformities that cause mobility impairment. In developing countries, however, due to lack of appropriate medical care, treatment is either not initiated or incompletely performed. Due to lack of consensus for evaluation of deformities in such patients, there is no standardized treatment protocol yet developed. So, a new evaluation system is devised to assess the deformity in untreated or previously managed conservatively clubfoot of walking children. METHODS: It was a prospective, observational study, conducted from December 2017 to July 2019. Patients from age 1-5 years, with unilateral deformity and previously managed conservatively were included. Patients having atypical clubfoot, syndromic clubfoot, or previously surgically intervened were excluded. Pre-treatment severity was graded with Diméglio score. Anthropometric, Foot Imprinting, Radiographic angles, and Ultrasonographic measurements were taken. Parameters taken were assessed and correlated with gradings of Diméglio score. RESULTS: 37 patients with mean age of 2.14 ± 0.87 years were included. Diméglio score was 11.57 ± 2.15 with 28 patients in 'severe' category. Talocalcaneal index and Tibiocalcaneal angle were correlating with the equinus whereas Bean shape ratio and Talocalcaneal index were correlating with varus deformity. Derotation of calcaneoforefoot block gradings correlating with Foot bimalleolar angle, Talo-first metatarsal angle, and MMN (medial malleolus to navicular distance) Ratio. FBM (Foot Bimalleolar) Angle, Talo-first metatarsal angle, MMN Ratio, and Medial soft tissue thickness were correlating with forefoot adduction. Following the correlation, a new classification system was devised to assess the severity of deformity at presentation. CONCLUSION: It is essential to develop an objective methodology to evaluate the severity of the clubfoot; whether the foot is responding to manipulation and casting; to detect the early signs of recurrences and predict the outcomes. The evaluation system should take into consideration the complex characteristics of the deformity and its three-dimensional aspects.

Pyogenic Vertebral Body Osteomyelitis in a Child: A Case Report.

INTRODUCTION: Pyogenic vertebral body osteomyelitis is rarer in children in comparison to adults. A rare case of pyogenic vertebral body osteomyelitis in a 10-year-old male is presented which was managed conservatively with antibiotics on the basis of antibiogram of blood culture. With 6 weeks of antibiotic therapy and at 12-month follow-up, the patient has no symptoms with no affection of any activity. This should be considered as a differential diagnosis in pediatric patients presenting with atypical symptoms related to spine and hip. CASE REPORT: A 10-year-old child presented with a 7-day history of progressively increasing insidious onset pain in the lower back radiating to the right hip, with an associated limp and restriction of floor level activities and activities of daily living. On examination, the child had tenderness at L3, L4, and L5 vertebral level and normal neurology in both lower limbs. A pseudoflexion deformity 20° was also noted in the right hip with normal range of motion in other planes. Keeping a differential of infective etiology of either hip or spine, routine blood investigations, blood culture, and radiological evaluation were done which included X-rays of lumbosacral spine and hip, ultrasound of bilateral hips and abdomen, and magnetic resonance imaging (MRI) of lumbosacral spine. The blood investigations showed an increase in white blood cell count, erythrocyte sedimentation rate, and high-sensitivity C-reactive protein, with the isolation of methicillin-sensitive Staphylococcus aureus in blood culture. Ultrasonography of hip showed mild effusion in the right hip and collections in the psoas; MRI confirmed the findings with an enhancement of L4 vertebral body. CONCLUSION: Pyogenic vertebral body osteomyelitis is a rare diagnosis in children that should be considered in patients with atypical symptoms. MRI is the investigation of choice with prompt antibiotic therapy instituted on time which leads to healing without any sequelae.

Short-term outcome of lamina-sparing decompression in thoracolumbar spinal tuberculosis.

OBJECTIVE: The authors sought to assess the outcomes of lamina-sparing decompression using a posterior-only approach in patients with thoracolumbar spinal tuberculosis (TB). In patients with spinal TB with paraplegia, anterior decompression yields excellent results because it allows direct access to the diseased part of the vertebra, but the anterior approach has related morbidities. Posterior and posterolateral decompression mitigate approach-related morbidities; however, these approaches destabilize the already diseased segment. Lamina-sparing decompression through a posterior-only approach is a modification of posterolateral and anterolateral decompression that allows simultaneous decompression and instrumentation while preserving the posterior healthy bony structure as much as possible. METHODS: Thirty-five patients with spinal TB underwent lamina-sparing decompression and instrumentation. Outcomes were determined by using a visual analog scale (VAS) and the Oswestry Disability Index (ODI) for functional assessment, the American Spinal Injury Association (ASIA) impairment grade for neurological assessment, blood loss and duration of surgery for surgical outcome assessment, and Cobb angles to measure kyphosis correction. RESULTS: In total, 35 patients (12 men and 23 women) with an average age of 35.8 ± 18.7 (range 4-69) years underwent lamina-sparing decompression. Eight patients had dorsal, 7 had dorsolumbar, 7 had lumbar, 9 had multifocal contiguous, and 4 patients had multifocal noncontiguous spinal TB; 33 patients had paradiscal Pott's spine (tuberculous spondylodiscitis), and 2 had central-type disease. The average preoperative Cobb angle was 28.4° ± 14.9° (range 0°-60°) and the postoperative Cobb angle was 16.3° ± 11.3° (44° to -15°). There was loss of 1.6° ± 1.5° (0°-5°) during 16 months of follow-up. Average blood loss was 526 ± 316 (range 130-1200) ml. Duration of surgery was 228 ± 79.14 (range 60-320) minutes. Level of vertebral instrumentation on average was 0.97 ± 0.8 (range 0-4) vertebra proximal and 1.25 ± 0.75 (0-3) distal to the diseased segment. Neurological recovery during the immediate postoperative period occurred in 23 of 27 patients (85.1%). All patients had recovered at the final follow-up at 16 months. The preoperative ODI score improved from 76.4 ± 17.9 (range 32-100) to 6.74 ± 17.2 (0-60) at 16 months. The preoperative VAS score improved from 7.48 ± 1.16 (6-10) to 0.47 ± 1.94 (0-8). Surgical site infection occurred in 2 patients, and 1 patient had an intraoperative dural tear that was successfully repaired. One patient developed implant loosening at 3 months, which was managed by extended instrumentation. CONCLUSIONS: To achieve stability, lamina-sparing decompression allows fixation of lower numbers of vertebrae proximal and distal to the diseased segment. This method has a fair outcome in terms of kyphosis correction, good functional and neurological recovery, shorter surgical duration than conventional methods, and less blood loss.

Spinal holocord epidural abscess evacuated with double thoracic interval laminectomy: a rare case report with literature review.

Introduction: Holocord spinal cord epidural abscess is an uncommon condition that may result in serious neurological complications. Prompt diagnosis and early treatment is of paramount importance for an optimum clinical outcome. This case report describes a novel technique of interval laminectomy at two sites in the thoracic spine and surgical decompression with the help of infant feeding tubes in a case of holocord spinal epidural abscess (HSEA). Case presentation: An 18-year-old male presented to the emergency department with high-grade fever and low back ache of 2 weeks duration and loss of bowel and bladder control for 4 days. Neurological examination revealed intact motor power and sensation in all four limbs at presentation; however, there was a rapid deterioration to complete quadriplegia within 24 h. A diagnosis of holocord epidural abscess was made. Emergent decompression via interval thoracic laminectomy was done and appropriate antimicrobial therapy was instituted. At 10 months of follow-up, the individual showed complete neurological recovery. Discussion: The technique used in this case is unique with respect to the level of laminectomy and the manoeuvre employed for pus evacuation. Complete neurological and functional recovery was achieved despite complete paralysis pre-operatively. The outcome indicates that there may be good prognosis for individuals with HSEA accompanied with neurological deficit and emergent surgical decompression.

Primary Bone Lymphoma: A Rare Case of Anaplastic Large Cell Lymphoma in Calcaneus in a Child.

INTRODUCTION: Primary bone lymphomas are rare, and primary anaplastic large cell lymphomas (ALCLs) of bone in a child are even rarer. A case of primary ALCL of calcaneus in a 7-year-old child is presented. CASE REPORT: Child aged 7 years presented with fungating swelling over his right heel which was associated with fever. The diagnosis was established by immunohistochemistry (CD30, ALK) of the biopsied specimen. Treatment was done by chemotherapy and subsequent radiotherapy. At 12-month follow-up, the child was ambulant with complete resolution of the swelling. CONCLUSION: Masses arising from the foot and ankle can be a diagnostic challenge, and both infection and neoplasm should be considered in its differentials.

Neglected Monteggia fracture dislocations in children: a systematic review.

Monteggia fractures are uncommon and frequently missed injuries in children. This article aims to study, in a systematic manner, the surgical management and complications of treatment of chronic radial head dislocations. After screening of relevant abstracts, a total of 28 studies were included in the systematic review. A narrative synthesis of various treatment modalities has been discussed. This article concludes that open reduction should be attempted unless dysmorphism of the radial head restricts it. Open reduction with ulnar osteotomy with or without annular ligament reconstruction is the most commonly performed procedure and is expected to result in reduced pain and elbow deformity.

Biological modalities for treatment of acute spinal cord injury: a pilot study and review of the literature.

OBJECTIVE: Paraplegia due to traumatic spinal cord injuries is one of the devastating effects of dorsolumbar vertebral fractures. Treatment modalities for such fractures, such as stabilization, have no effect on the neurological recovery. Thus, various pharmacological and biological treatment modalities have been used. The more recent trend of using autologous stem cells from the iliac crest has been used in some clinical trials with varying success. Thus, more clinical studies are required to study the effect of this novel approach METHODS: This is a prospective hospital-based cohort study (level IV). The study was conducted in the Dept. of Orthopaedics, University College of Medical Sciences and GTB Hospital, Delhi from November 2010 to March 2012. Ten patients who had sustained traumatic dorsolumbar vertebral fractures with complete paraplegia were recruited for this study. Under suitable anaesthesia, at the beginning of surgery, 100 ml of bone marrow was aspirated. This was centrifuged and buffy coat isolated and then transferred into a sterile tube and sent to the operating room on ice packs. After surgical decompression and stabilization, the buffy coat isolate was injected into the dural sleeve at the site of the injury using a 21G needle. All the patients were evaluated for neurological improvement using the American Spinal Injury Association (ASIA) score and Frankel grade at 6 weeks and 3 months postoperatively. RESULTS: The evaluation at 6 weeks showed some improvement in terms of the ASIA scores in 2 patients but no improvements in their Frankel Grade. The other 8 patients showed no improvements in their ASIA scores or their Frankel Grades. The current pilot study has shown that there has been no improvement in most of the recipients of the transplant (n=8). Some patients (n=2) who did show some improvement in their sensory scores proved to be of no significant functional value as depicted by no change in their Frankel Grades. CONCLUSION: The outcome of current study shows that although this modality of treatment is safe for the patients, it provides no additional benefits on improvement of quality of life among these patients.

Association of facet tropism with lumbar disc herniation.

PURPOSE: Facet tropism is defined as asymmetry between left and right facet joints and is postulated as a possible cause of disc herniation. In the present study, the authors used a 3-T MRI to investigate the association between facet tropism and lumbar disc herniation at a particular motion segment. They also examined whether the disc herniated towards the side of the more coronally oriented facet joint. METHODS: Sixty patients (18-40 years) with single level disc herniation (L3-L4, L4-L5, or L5-S1) were included in the study. Facet angles were measured using MRI of 3-T using the method described by Karacan et al. Facet tropism was defined as difference of 10° in facet joint angles between right and left sides. Normal disc adjacent to the herniated level was used as control. We also examined if disc herniated towards the side of more coronally oriented facet. RESULTS: Twenty-five herniations were at L4-L5 level and 35 at L5-S1. Statistical analysis was performed using the Fischer Exact Test. At L4-L5 level, 6/25 cases had tropism compared to 3/35 controls (p = 0.145). At L5-S1 level, 13/35 cases had tropism as compared to 1/21 controls (p = 0.0094). Of 19 cases having tropism, the disc had herniated towards the coronally oriented facet in six (p = 0.11). CONCLUSION: The findings of the study suggest that facet tropism is associated with lumbar disc herniation at the L5-S1 motion segment but not at the L4-L5 level.

Radiography and sonography of clubfoot: A comparative study.

BACKGROUND: Congenital talipes equinovarus is a common foot deformity afflicting children with reported incidence varying from 0.9/1000 to 7/1000 in various populations. The success reported with Ponseti method when started at an early age requires an imaging modality to quantitate the deformity. Sonography being a radiation free, easily available non-invasive imaging has been investigated for this purpose. Various studies have described the sonographic anatomy of normal neonatal foot and clubfoot and correlated the degree of severity with trends in sonographic measurements. However, none of these studies have correlated clinical, radiographic and sonographic parameters of all the component deformities in clubfoot. The present study aims to compare the radiographic and sonographic parameters in various grades of clubfoot. MATERIALS AND METHODS: Thirty-one children with unilateral clubfoot were examined clinically and graded according to the Demeglio system of classification of clubfoot severity. Antero-posterior (AP) and lateral radiographs of both normal and affected feet were obtained in maximum correction and AP talo-calcaneal (T-C), AP talo-first metatarsal (TMT) and lateral T-C angles were measured. Sonographic examination was done in medial, lateral, dorsal and posterior projections of both feet in static neutral position and after Ponseti manouever in the position of maximum correctability in dynamic sonography. Normal foot was taken as control in all cases. The sonographic parameters measured were as follows : Medial malleolar- navicular distance (MMN) and medial soft tissue thickness (STT) on medial projection, calcaneo-cuboid (C-C) distance, calcaneo-cuboid (C-C) angle and maximum length of calcaneus on lateral projection, length of talus on dorsal projection; and tibiocalcaneal (T-C) distance, posterior soft tissue thickness and length of tendoachilles on posterior projection. Also, medial displacement of navicular relative to talus, mobility of talonavicular joint (medial view); reducibility of C-C mal alignment (lateral view); talonavicular relation with respect to dorsal/ ventral displacement of navicular (dorsal view) and reduction of talus within the ankle mortise (posterior view) were subjectively assessed while performing dynamic sonography. Various radiographic and sonographic parameters were correlated with clinical grades. RESULTS: MMN distance and STT measured on medial view, C-C distance and C-C angle measured on lateral view and tibiocalcaneal distance measured on posterior view showed statistically significant difference between cases and controls. A significant correlation was evident between sonographic parameters and clinical grades of relevant components of clubfoot. All radiographic angles except AP T-C angle were significantly different between cases and controls. However, they did not show correlation with clinical degree of severity. CONCLUSION: All radiographic angles except AP T-C angle and sonographic parameters varied significantly between cases and controls. However, radiographic parameters did not correlate well with clubfoot severity. In contrast, sonography not only assessed all components of clubfoot comprehensively but also the sonographic parameters correlated well with the severity of these components. Thus, we conclude that sonography is a superior, radiation free imaging modality for clubfoot.

Autonomic status and pain profile in patients of chronic low back pain and following electro acupuncture therapy: a randomized control trial.

Pain is a syndrome characterized by several neurophysiological changes including that of the autonomic nervous system. Chronic low back pain (LBP) is a major health problem and is a frequent reason for using unconventional therapies especially acupuncture. This study was conducted to evaluate the autonomic status and pain profile in chronic LBP patients and to observe the effect of electro acupuncture therapy. Chronic LBP patients (n=60) were recruited from the Department of Orthopaedics, GTB Hospital, Delhi. Age and sex matched healthy volunteers were selected as controls (n=30). Following a written consent, LBP patients were randomly allocated into two study groups - Group A received 10 sittings of electro acupuncture, on alternate days, at GB and UB points selected for back pain, while the Group B received a conventional drug therapy in the form of oral Valdecoxib together with supervised physiotherapy. Controls were assessed once while the patients were assessed twice, before and after completion of the treatment program (3 weeks). The autonomic status was studied with non-invasive cardiovascular autonomic function tests which included E: I ratio, 30:15 ratio, postural challenge test and sustained handgrip test. Pain intensity was measured with the visual analogue scale (VAS) and the global perceived effect (GPE). Statistical analysis was performed using repeated measure's ANOVA with Tukey's test. Pain patients showed a significantly reduced vagal tone and increased sympathetic activity as compared to the controls (P<0.05 to P<0.001 in different variables). Following treatment, both the study groups showed a reduction in vagal tone together with a decrease in the sympathetic activity. There was also a considerable relief of pain in both groups, however, the acupuncture group showed a better response (P<0.01). We conclude that there is autonomic dysfunction in chronic LBP patients. Acupuncture effectively relieves the pain and improves the autonomic status and hence can be used as an alternative/additive treatment modality in these cases.

Autogenous non-vascularized fibula for treatment of giant cell tumor of distal end radius.

INTRODUCTION: Giant cell tumor of distal end of radius is treated by wide resection and intralesional procedures with former having better results. The various modalities for the defect created are vascularized/non-vascularized bone graft, osteoarticular allografts and custom-made prosthesis. We report outcome of wide resection and non-vascularized fibular grafting in biopsy-proven giant cell tumors. PATIENTS AND METHODS: Nine patients with mean age of 40 years with Campanacci grade II giant cell tumor of distal radius were managed with radical excision of the tumor and reconstruction with ipsilateral free fibular graft. RESULTS: Mean follow-up time was 56 months. One patient developed recurrence and was treated by amputation. All other patients showed a good union at fibular graft-radius junction. In wrist, average range of motion achieved at last follow-up was 40° of dorsiflexion, 30° of palmar flexion, 45° each of supination and pronation. Major complications encountered included graft fracture (2), wrist subluxation (2), tourniquet palsy (1), aseptic graft resorption (1) and tumor recurrence (1). CONCLUSION: Reconstruction after wide excision by non-vascularized fibular graft is a viable alternative for giant cell tumors of the lower end of radius though it is a challenging procedure and may be accompanied by major complications.