GeoGebra: A reliable and free software for measuring acetabular cup anteversion on digitalized plain radiographs.

OBJECTIVE: Although accurate measurement of cup anteversion in hip replacement requires CT scans, however, its routine application, especially during follow-up, remains economically and ethically unreasonable. Thus, several methods have been devised for making this measurement on plain radiographs. In recent years, several ways have been adopted using software on digital radiographs. We present one such method which uses open access mathematical software GeoGebra. METHODS: Anteversion was measured on 72 radiographs (36 cemented; 36 uncemented) by three different observers using this software. One observer repeated measurements at three weeks interval. RESULTS: The intraclass correlation coefficient for interobserver variability and intraobserver variability was 0.982 (0.973-0.989) and 0.986 (0.978-0.991) respectively. There was a significant difference in the reliability of the method for cemented and uncemented cups with higher reliability for cemented cups (p < 0.001). CONCLUSION: GeoGebra software can be used as a reliable alternative for measuring acetabular cup anteversion on good quality well centred digital radiographs of the pelvis.

Glenoid fossa fractures: Outcome of operative and nonoperative treatment.

BACKGROUND: Glenoid fossa fractures are rare injuries having a prevalence of 0.1%. These fractures may be managed operatively if substantially displaced. However, several fractures of glenoid fossa are managed nonoperatively, even if displaced, due to high incidence of associated injuries which may render patient unfit to undergo major orthopaedic surgery. There is a relative paucity of articles reporting on outcome of treatment of glenoid fossa fractures. We present our experience of treating these injuries over past decade with operative and nonoperative methods. MATERIALS AND METHODS: 21 patients of glenoid fossa fractures were included in this series with 14 males and 7 females. Patients with displacement of >5 mm who were fit to undergo surgery within 3 weeks of injury were operated using a posterior Judet's approach. Overall 8 patients with displaced fractures were operated (Group A) while 9 patients with displaced fractures (Group B) and 4 patients with undisplaced fractures (Group C) were managed nonoperatively. RESULTS: The mean age and followup period in this series was 29 years and 7.3 years respectively. In group A, average constant score was 87.25. The least constant score was observed for group B (58.55) while group C had an average constant score of 86. Brachial plexus injury and fracture-dislocations had poorer outcome. CONCLUSION: Operative treatment for displaced glenoid fractures is a viable option at centers equipped to handle critically ill patients and subset of patients with fracture-dislocation as opposed to fracture alone should always be treated operatively due to persistent loss of function.

Comparison of the oswestry disability index and magnetic resonance imaging findings in lumbar canal stenosis: an observational study.

STUDY DESIGN: Cross-sectional study. PURPOSE: The aim of the study was to determine relationship between the degrees of radiologically demonstrated anatomical lumbar canal stenosis using magnetic resonance imaging (MRI) and its correlation with the patient's disability level, using the Oswestry Disability Index (ODI). OVERVIEW OF LITERATURE: The relationship between the imaging studies and clinical symptoms has been uncertain in patients suffering from symptomatic lumbar canal stenosis. There is a limited number of studies which correlates the degree of stenosis with simple reproducible scoring methods. METHODS: Fifty patients were selected from 350 patients who fulfilled the inclusion criteria. The patients answered the national-language translated form of ODI. The ratio of disability was interpreted, and the patients were grouped accordingly. They were subjected to MRI; and the anteroposterior diameters of the lumbar intervertebral disc spaces and the thecal sac cross sectional area were measured. Comparison was performed between the subdivisions of the degree of lumbar canal stenosis, based on the following: anteroposterior diameter (three groups: normal, relative stenosis and absolute stenosis); subdivisions of the degree of central canal stenosis, based on the thecal sac cross-sectional area, measured on axial views (three groups: normal, moderately stenotic and severely stenotic); and the ODI outcome, which was also presented in 20 percentiles. RESULTS: No significant correlation was established between the radiologically depicted anatomical lumbar stenosis and the Oswestry Disability scores. CONCLUSIONS: Magnetic resonance imaging alone should not be considered in isolation when assessing and treating patients diagnosed with lumbar canal stenosis.

Isolated tuberculosis of sacrum with monoparesis: an atypical presentation.

Tuberculosis is a major health problem in developing nations. Spine is the most commonly affected site for skeletal tuberculosis but involvement of sacrum is rare. Isolated involvement of sacrum has been reported in literature but none of the reports has mentioned its clinical presentation as monoparesis. Our case presented with symptoms of sensory and motor deficit in right lower limb. The magnetic resonance imaging spine and non contrast computerized tomogram revealed a sacral lesion but were inconclusive of diagnosis. Histological examination after computed tomography guided biopsy revealed the condition as tuberculosis. Anti tubercular treatment was started after confirmation of diagnosis and continued for 18 months. Erythrocyte sedimentation rate and C-reactive protein drooped to normal range and patient was symptom free at two-year follow up. This case report intends to emphasize that sacral tuberculosis, being itself a rare condition, may present atypically as monoparesis.

Early, reliable, utilitarian predictive factors for fat embolism syndrome in polytrauma patients.

BACKGROUND: Fat embolism is one of the apocalyptic pulmonary complications following high energy trauma situations. Since delay in diagnosis may have devastating consequences, early, easily accessible and relatively inexpensive investigations for risk stratification may prove useful, especially in developing nations. MATERIALS AND METHODS: This prospective trial included a total of 67 young polytrauma patients, in whom the role of nine easily available, rapidly performable clinical or laboratory investigations (or observations noted at admission) in predicting the later occurrence of fat embolism syndrome were assessed. All the patients also underwent continuous monitoring of oxygen saturation with pulsoximetry. RESULTS: The correlation between initial serum lactate (within 12 hours of injury) and hypoxia was statistically significant. There was a trend towards correlation with FES(by Gurd's criteria) (P=0.07), Sensitivity of 24-hour monitoring of oxygen saturation in predicting later pulmonary deterioration approached 100%. CONCLUSIONS: The combination of three factors including polytrauma (with NISS >17), serum lactate >22 mmol/l at admission (within 12 hours of injury) fall in oxygen saturation (SaO2 below 90% in the initial 24 hours) predict the development of post-traumatic pulmonary complications, especially the fat embolism syndrome.

Predictors of early outcome in unstable pelvic fractures.

OBJECTIVE: To define the preoperative and intraoperative variables which may affect the immediate postoperative outcome in surgically managed patients with unstable pelvic fractures. METHODS: This study was performed prospectively from January 2009 to June 2011 on 36 consecutive patients admitted to the trauma ward of Postgraduate Institute of Medical Education and Research, Chandigarh, with unstable pelvic injuries. RESULTS: In the present study of 36 patients, 29 were managed surgically. Surgical duration was 2 hours in patients operated on within 1 week and 3.4 hours in those operated on after 1 week. The blood loss was 550 ml when surgery was done after a week, but when done within a week it was 350 ml. The average blood loss through Pfanenstial approach was 360 ml, through posterior approach was 408 ml and through combined approach was 660 ml which was significantly high. CONCLUSION: Anterior approach to the pelvis would cause significantly more amount of blood loss than posterior approach and external fixation. Surgical approaches do not have any influence on the surgical duration or the infection rate. The blood loss significantly increases when the surgical time is more than 1 h. The infection rate is not influenced by the duration of surgery. Presence or absence of associated injuries to the head, chest or abdomen is the main determinants of patient's survival and it greatly influences the duration of hospital stay.

Acutely presenting kissing lesions of the ankle: an atypical Trevor's disease and literature review of other unusual presentations of the disease.

Trevor's disease, an intra-articular variant of osteochondroma, has been reported previously in various unusual forms. The present article describes acutely presenting, intra-articular kissing lesions in a 4-year-old girl. A high index of suspicion and elaborate awareness on the part of the treating surgeon are essential to diagnose as well as manage such cases.

Functional outcome of ankle fracture patients treated with biodegradable implants.

BACKGROUND: Biodegradable devices have been developed to overcome the disadvantages of metallic implants especially the need for their subsequent removal, though they have their own drawbacks like poor mechanical properties and tissue reactions. Aim of this prospective study was to access the outcome of bimalleolar fractures fixed with biodegradable plates and screws. METHODS: A prospective study was conducted between July 2006 and November 2008 comprising of sixteen patients with unilateral bimalleolar fractures. Fibula fractures were fixed with biodegradable plates and medial malleoli with screws. Patients were followed at two weeks, six weeks, three months, six months, twelve months and eighteen months. Final evaluation was done using Olerud Molander ankle score. RESULTS: Six patients had excellent results; four patients had good results and six patients had fair performance. No patient in this series had a poor outcome. One patient had both pain and swelling at 14 weeks postoperatively which settled down with debridement and antibiotics. None of the patients needed implant removal. CONCLUSION: Biodegradable plates and screws when used to fix bimalleolar fracture along with restricted weight bearing, provide satisfactory fracture healing, good functional results and reduce the need of implant removal.

A new method of measuring acetabular cup anteversion on simulated radiographs.

PURPOSE: Optimal positioning of acetabular components is crucial for maintaining stability of THA. Postoperative assessment of acetabular anteversion is a vital but difficult task. Various methods have been devised with good results for measuring anteversion on plain radiographs but these methods are either too complicated or require special objects like scientific calculators, special protectors, tables, etc. A new simplified method of measuring anteversion on plain radiographs was created based on basic geometry. METHODS: Anteversion of acetabular components was estimated on computer generated images of the acetabular cup by our method and compared with two previously established methods of Liaw and Pradhan. Measurement was done at 400 different positions of acetabular cup and compared with actual values. Another analysis was done after adding the femoral head to the acetabular component, thus obscuring some of the acetabular rim. RESULTS: Mean and standard deviation of error for our method was 0.77° ± 0.75° as compared to 0.93° ± 0.86° and 0.72° ± 0.68° for the methods of Liaw and Pardhan, respectively, with no significant differences from actual values. Maximal errors for our method, Liaw's and Pradhan's method were 3°, 4°, and 2.91°, respectively. On analysis, after the adding femoral head, there was a significant error of measurement with Liaw's method, while our method as well as Pardhan's remained accurate. All methods showed high inter- and intraobserver reliability. CONCLUSION: Our new simplified method of measuring acetabular anteversion on plain radiographs is acceptable in comparision to other established methods and requires only routinely used goniometer and calliper.

Closed reduction and percutaneous screw fixation for tibial plateau fractures.

PURPOSE: To evaluate treatment outcomes of closed reduction and percutaneous screw fixation for tibial plateau fractures. METHODS: 48 men and 8 women aged 19 to 61 (mean, 36) years underwent closed reduction and percutaneous screw fixation for closed tibial plateau fractures with <5 mm depression. According to the Schatzker classification, patients were classified into type I (n=9), type II (n=22), type IV (n=5), and type V (n=20). Closed reduction was achieved using manual ligamentotaxis with traction in extension under image intensifier control. Reduction was fixed percutaneously with cancellous screws (6.5 mm) and washers. Functional outcome (pain, walking capacity, extension lag, range of motion, and stability) was evaluated using the Rasmussen score. A total score of 28 to 36 was considered as excellent, 20 to 27 as good, 10 to 20 as fair, and <10 as poor. RESULTS: Patients were followed up for a mean of 2.8 (range, 1-4) years. The mean length of hospital stay was 5 (range, 2-15) days. All the fracture united radiographically after a mean of 3 (range, 2.5-4.2) months. Respectively in Schatzker types-I, -II, -IV, and -V fractures, outcomes were excellent in 6, 10, 2, and 2 patients, good in 2, 9, 3, and 14 patients, fair in 1, 3, 0, and 2 patients, and poor in 0, 0, 0, and 2 patients. Outcome was satisfactory (good-to-excellent) in 89%, 86%, 100%, and 80% of the respective fracture types of patients. The mean Rasmussen score was 25.7 for all patients; it was 27.7 for type I, 26.3 for type II, 28.6 for type IV, and 23.4 for type V fractures. The mean Rasmussen score was significantly lower in 12 patients with ligament injury than in 44 patients without ligament injury (19.8 vs. 27.3, p<0.001). No patient had any complication (infection, wound dehiscence or hardware problem). CONCLUSION: Closed reduction and percutaneous screw fixation for tibial plateau fractures is minimally invasive. It reduces the length of hospital stay and costs, enables early mobilisation with minimal instrumentation, and achieves satisfactory outcomes.

Giant cell tumor of distal phalanx of great toe. A case report.

Giant cell tumors are locally aggressive benign osseous neoplasms of unknown origin. They mostly occur after skeletal maturity in 3rd or 4th decade and commonly involve long bones although occasional occurrence at other sites has been reported. It is rare to see these tumors involving the phalangeal bone of foot. We report a case of giant cell tumor involving the distal phalanx of great toe in a 27 year old female who presented with swelling of great toe of right foot. Radiography showed an expansile lesion in distal phalanx of great toe. En bloc resection of phalanx was done. Biopsy showed giant cell tumor and regular follow up of this patient for two years showed no recurrence of tumor. Giant cell tumor at such a location is unusually aggressive and needs regular follow up to detect local recurrence.