Joint awareness among total hip arthroplasty patients operated through anterior approach versus posterior approach: a systematic review and meta-analysis.

PURPOSE: The aim of this systematic review and meta-analysis was to compare joint awareness in patients who underwent total hip arthroplasty (THA) via the anterior approach (AA) versus the posterior approach (PA). The hypothesis was that patients who underwent THA via AA would have better forgetfulness of the artificial joint. METHODS: A comprehensive search of major literature databases and bibliographic details was conducted to identify studies evaluating the forgotten joint score (FJS-12) in total hip arthroplasty (THA) patients operated through the anterior approach (AA) and posterior approach (PA). Out of 234 studies identified, seven studies met the inclusion criteria for review. The Newcastle-Ottawa Scale was used to evaluate the quality of evidence and the risk of bias in the included studies. The FJS-12 was evaluated at three months, one year, and beyond 2 years. RESULTS: The mean FJS-12 at > 2 years was 82.03 in the AA group and 80.32 in the PA group. The forest plot analysis (n = 819 patients) revealed no significant difference in FJS-12 score between these two approaches (MD 2.13, 95% CI [- 1.17, 5.42], p = 0.21; I2 = 60%). However, the joint awareness was significantly lesser in the AA group at 3 months (MD 12.56, 95% CI [9.58, 15.54], p < 0.00001, I2 = 0%) and 1 year (MD 9.55, 95% CI [7.85, 11.24], p < 0.0001, I2 = 0%). CONCLUSIONS: After analyzing the available literature, it was found that THA patients operated through the AA approach have significantly lower joint awareness than those operated through the PA approach in the first year of surgery. However, there is no significant difference in joint awareness between these two approaches after 2 years. LEVEL OF EVIDENCE: III.

Tuberculosis of the spine and drug resistance: a review article.

Pott's spine is tuberculosis of spine caused due to hematogenous spread of mycobacterium from a primary focus. It constitutes about 50% of skeletal tuberculosis cases. Paradiscal type is the most common type of spinal tuberculosis. Untreated cases can lead to complications like a cold abscess, paraplegia, and deformity which may require surgical intervention. Rapid molecular methods have made the diagnosis of spinal tuberculosis and drug resistance faster and easier but it still remains a problem due to difficulties in sample collection and the paucibacillary nature of the Pott spine. Antitubercular drug therapy forms the mainstay of management. The emergence of MDR TB and XDR TB has posed a big challenge in the management of spinal tuberculosis. The literature regarding drug resistance in spinal tuberculosis and its management is lacking. We conducted a literature review of 29 studies and presented information on pathogenesis, diagnosis, and management of spinal tuberculosis and drug resistance. New shorter regimens for MDR and XDR TB are under trial in different parts of the world. We believe this article will provide information on spinal tuberculosis and drug resistance and help clinicians outline important research areas.

Long-term survival of CLS Spotorno femoral stem: a systematic review of literature.

BACKGROUND: CLS Spotorno is a time-tested femoral stem design with excellent early results; the present review was designed to assess the published evidence on CLS Spotorno stem in the literature to evaluate its long-term outcomes and compare it to two other popular stem designs the uncemented Corail™ and the cemented Exeter™ stems. RESEARCH QUESTION: Do CLS Spotorno stems provide adequate long-term rates of survival in terms of revisions and functional outcomes? METHODOLOGY: Medline, EMBASE and SCOPUS databases were searched for relevant articles and a total number of 670 hits were obtained, out of which 14 relevant studies were included in this review. Pooled analysis of revisions rates, subsidence and Harris Hip scores (HHS) were done. RESULTS: All the 14 studies were retrospective in design but had sufficiently large follow-up periods (12.3-27 years, mean 17.1 years). Of the 2459 hips reviewed, the documented revision rate was only 6.2%, with aseptic loosening reported in 3.1% and subsidence > 2 mm in 2.6% cases. The overall survival was similar to reported smaller cohorts of Corail (95% at 12 years) and Exeter stems (100% at 17 years). Varus malposition was seen in 10.6% cases, but it did not show any influence on implant survival or revision rates. Distal pedestal formation was seen in 172 of 805 hips across seven studies, while distal cortical hypertrophy was seen in 70 cases out of 398 hips; these were not related with stem malposition. The overall functional outcome was good, with mean HHS of 88.65 (95% CI = 86.08-91.23, p < 0.01). The improvement in scores from preoperative values (of 43.9 points) were comparable to Corail (43.8) and Exeter (45) stems. Thigh pain was seen in only 41 cases out of 1097 hips. CONCLUSION: Despite the limitations due to high heterogeneity of the cumulative data, the review suggests that CLS Spotorno femoral stems provides excellent long-term survival and good hip function. These outcomes are comparable to other commonly utilized femoral stems like the Corail and Exeter. LEVEL OF EVIDENCE: IV.

Correction to: Hemiarthroplasty for neck of femur fractures: to cement or not? A systematic review of literature and meta-analysis.

The original version of this article unfortunately contained a mistake. The correct information is given below. In abstract, the last sentence of the "Primary outcomes" section should read as: Mortality at 1 year was the same in both the groups.

Hemiarthroplasty for neck of femur fractures: to cement or not? A systematic review of literature and meta-analysis.

BACKGROUND: Management of fractures of neck of femur in the elderly is largely joint sacrificing, with hemiarthroplasties being the most common entity used. Cemented and uncemented, both the techniques, are universally accepted; however, the former has been more time tested, despite its theoretical disadvantage in the form of cement embolism leading to intra-operative complications. Uncemented stems have been ever evolving with newer designs to increase incorporation, stability and durability. They have their own reported sets of disadvantages like subsidence and fractures. However, overall there is no established gold standard out of the two. OBJECTIVE: The present systematic review and meta-analysis of current literature was conducted, so as to determine the superiority of one technique over the other by comparing the primary outcomes like hip function, residual pain, local and general complications and mortality. Additionally secondary outcomes like duration of surgery, blood loss and re-operations were analysed as well. METHODOLOGY: Three databases of PubMed, EMBASE and SCOPUS were searched for relevant articles of last 10 years that directly compare uncemented and cemented hemiarthroplasties, and based on our inclusion and exclusion criteria, article selection was done. RESULTS: We analysed a total of six randomised controlled studies dated from 2008 to 2017. PRIMARY OUTCOMES: There was a significant difference in post-operative ability to ambulate at 1 year, between 2 groups with odds ratio 0.45 (95% CI 0.29-0.67, p = 0.0001) favouring cemented hemiarthroplasty. Prosthesis-related complications like fractures and subsidence and general complications like lung complications were more in uncemented group. Mortality at 1 year was more in cemented group. SECONDARY OUTCOMES: Mean surgical time was lesser in uncemented cases. There was no difference in blood loss and re-operation rates. CONCLUSION: Cementing techniques are here to stay, until a better, durable and more stable uncemented stem evolves, that could lessen the complications related to uncemented surgeries and match the cemented implants in pain relief and ambulation.

Prognosticating acute traumatic spinal cord injury using Neurofilament (NF), Neuron Specific Enolase (NSE), Matrix Metalloproteinases (MMPs), and S-100B as biomarkers.

BACKGROUND: Spinal cord injury (SCI) can result in lifelong disability. Currently, the literature suggests that biomarkers are helpful in prognosticating SCI, but there is no specific biomarker to date. This is the first study that predicted the prognosis dynamically using biomarkers. AIM: To elucidate the role of biomarkers in prognosticating acute traumatic SCI. METHODS: Blood samples were obtained from 35 patients of acute traumatic SCI at presentation, immediate post-op, and at 6 weeks. At 6 months follow-up, patients were divided into two groups, i.e, improved and non-improved based on the improvement in the ASIA grade compared to presentation. A non-parametric test was used for comparing mean NSE, MMP-2, S100-B, and NF serum levels at presentation, immediate post-op, and 6 weeks post-op follow-up between the two groups. RESULTS: There was a significant difference (p = 0.03) in the NF values at presentation between the two groups. The difference of NSE values at 6 weeks was also significant (p = 0.016) between the two groups. S-100B levels were also significantly different between both groups at presentation (p=0.016), and at the immediate post-op stage (p=0.007). MMP-2 levels neither displayed any specific trend nor any significant difference between the two groups. CONCLUSION: Higher NF values at presentation, and higher S-100B levels at presentation and immediate post-operative period correlated with poor outcome. Also, increased NSE values after surgery are indicative of no improvement. These levels can be used at various stages to predict the prognosis. However, further studies are required on this topic extensively to know the exact cut-off values of these markers to predict the prognosis accurately. CLINICAL TRIALS REGISTRY NUMBER: REF/2020/01/030616.

Safety and Efficacy of Tranexamic Acid in Hip Hemiarthroplasty for Fracture Neck Femur: a Systematic Review and Meta-analysis.

Purpose: Although numerous systematic reviews and meta-analyses have established the efficacy of tranexamic acid (TXA) in hip fracture surgeries, the included studies in those reviews have included all types of surgical interventions ranging from fixation to arthroplasty. Hip hemiarthroplasty is usually indicated in the elderly patients with femoral neck fracture and these patients have associated severe comorbidities and cognitive impairment. These subsets of patients with femoral neck fracture needs appropriate perioperative care and judicious use of antifibrinolytics. There is no meta-analysis evaluating the safety and efficacy of intravenous TXA in these patients. Methods: Searches of PubMed, Embase and Cochrane Central Register of Controlled Trials databases revealed 102 studies on TXA in hip fracture surgeries. After screening, eight studies were found to be suitable for review. The primary objective of this meta-analysis was to compare blood transfusion rate between TXA vs. control in hip hemiarthroplasty. The secondary objectives were total blood loss, postoperative haemoglobin, surgical duration, length of hospital stay and side effects (VTE, readmission and 30 days mortality). Results: There were one RCT, one prospective cohort study and six retrospective studies. All studies recruited the elderly patients. Intravenous (IV) TXA administration resulted in significant reduction in requirement of blood transfusion (12.7% vs. 31.9%; OR 0.28; 95% CI 0.17-0.46; p < 00,001; I 2 = 73%). The TXA group had significantly decreased total blood loss (MD - 100.31; 95% CI - 153.79, - 46.83; p < 0.0002). The postoperative Hb in the TXA group was significantly higher than the control group (MD 0.53; 95% CI 0.35, 0.71; p < 0.00001). There was no significant difference in the incidences of VTE (0.97% vs. 0.73%, OR 1.27; p = 0.81; I 2 = 64%) and readmission rate (9.2% vs. 9.64%; OR 0.79; p = 0.54), but 30-d mortality rate was significantly lower in the TXA group (3.41% vs. 6.04%; OR 0.66; p = 0.03). Conclusions: Intravenous TXA is efficacious in the reduction of blood loss and transfusion need in hip hemiarthroplasty surgery for hip fracture, without increased risk of VTE. The blood conservation protocol led to decreased 30 days mortality in these fragile elderly patients. Level of evidence: III.

Isolated Retropulsion of C5 Cervical Vertebral Body without any Displacement of Facet Joints: A Case Report on an Unusual Presentation of Cervical Spine Injury.

Introduction: The sub axial cervical spine is a common site for traumatic spine injury, the injury of which can be life-threatening and can also result in permanent disability. Subaxial cervical spine injury has been classified by Allen and Ferguson (earliest classification), subaxial cervical spine injury classification system (SLICS) and AO spine classification. Allen and Ferguson system has significant inter-observer variations and is difficult to apply clinically at times. SLICS does not guide in the choice of surgical approach and score can vary between individuals because of different magnetic resonance imaging interpretations for discoligamentous injury. AO spine classification system has low agreement rate for intermediate morphology types (A1-4 and B) and not all injury patterns fit in the AO spine classification system like the case presented herein. In this case report, we address an unusual presentation of the flexion-compression mechanism of injury. This fracture morphology does not fit in any of the above mentioned classification system, so we are reporting this case and this is the first report of this kind in the literature. Case Report: An 18-year-old male presented to our emergency department with a history of fall of heavy object on his head from above. On presentation, the patient was in shock and respiratory distress. The patient was intubated and resuscitated gradually. Non-contrast computed tomography of the cervical spine showed isolated retropulsion of the C5 body without any displacement of facet joints or pedicle fracture. This injury was also associated with a fracture of the posterosuperior portion of the C6 vertebral body. The outcome was the death of the patient 2 days after injury. Conclusion: The cervical spine is a common segment of the spine that is prone to injuries due to its anatomy and flexibility. The same injury mechanism can lead to varied and unique presentations. Each classification system for cervical spine injury has its drawback, cannot be universalized, and more research is needed to develop a classification system with an international agreement for diagnosing, classifying, and treating the injury for better patient outcomes.

Locked Plating Versus Retrograde Intramedullary Nailing for Distal Femur Fractures: a Systematic Review and Meta-Analysis.

Modern advances in techniques and implants have allowed for a better operative fixation for distal femoral fractures. Both locked plating and retromedullary nail have allowed surgeons to stabilize these fractures with minimal soft tissue dissection and preserve blood supply. Although both the implants have been used extensively for such types of fractures, the superiority of one implant over the other is still doubtful. Therefore, we conducted this meta-analysis to compare locked plating and retrograde intramedullary nailing in distal femoral fractures. Based on prisma guidelines, electronic databases, including PubMed, Embase, Scopus, and Ovid Medline were searched using a well-defined search strategy. Outcome measures which were studied included blood loss, implant failure, infection, knee range of motion, malunion, non-union, pain, surgical duration and union time Surgical duration (95% CI 2.90 to 17.13, p <0.01) and blood loss (95% CI 69.60 to123.18, p <0.01) favoured plating group and the difference is significant. But while analysing parameters like implant failure, knee range of motion, non-union and union time, our analysis favoured nailing group, but the difference is not significant. Overall, both locked plating and retrograde intramedullary nailing are comparable with respect to union and complications in distal femur fractures, but we need further larger and high quality randomized studies to evaluate the difference.

Minimally Invasive Surgery versus Open Surgery for Adolescent Idiopathic Scoliosis: A Systematic Review and Meta-Analysis.

Minimally invasive surgery (MIS) is being recommended over more invasive methods. MIS advantages are less time in the operating room, less blood loss, a shorter recovery time, and shorter length of stay. A systematic review and meta-analysis were performed using the literature from minimally invasive and open surgery for adolescent idiopathic scoliosis (AIS). We conducted this analysis to see whether MIS has advantages over traditional surgery. A systematic review was conducted using PubMed, Embase, and Scopus to find articles comparing minimally invasive and open surgery techniques for AIS patients. Data extraction and meta-analysis were completed. The primary data points collected were correction rate and functional outcomes, including perioperative and postoperative parameters. A total of six studies were included in the final analysis. The MIS group had 123 patients, and the open surgery group had 150 patients. The correction rate and functional outcomes favored the open surgery group with a mean difference of 4.60 (95% confidence interval [CI], 0.08 to 9.12) and 0.11 (95% CI, 0.04 to 0.17), respectively. The duration of surgery, blood loss, number of patients requiring transfusion, and analgesic requirements favored the MIS group with a significant difference. Open surgery is better than MIS in achieving a better correction rate and good functional outcomes. MIS is better over open surgery when perioperative parameters are considered.

Application of Modest Hypothermia in Patients with Acute Traumatic Cervical Spine Injury: A Pilot Study.

Introduction: This prospective randomized controlled study aimed to examine the role of modest systemic hypothermia in individuals with acute cervical spinal cord injury (SCI) regarding neurological improvement. Studies have shown that the application of hypothermia is safe and that it improves neurological outcomes in patients with traumatic spine injury. Hypothermia helps in decreasing a secondary damage to the cord. Methods: Twenty cases of acute post-traumatic cervical SCI with AISA were selected and randomly divided into two treatment groups: Group A-Hypothermia with surgical decompression and stabilization; and Group B-Normothermia with surgical decompression and stabilization. American Spinal Injury Association (ASIA) motor and sensory scores were evaluated at presentation; post-surgery; and at a 2-week, 6-week, and 12-week follow-up. Results: At the final follow-up, the change in ASIA motor scores of Group A was 46 (11.5-70.5) and Group B 13 (4.5-58.0), whereas ASIA sensory scores were 118 (24.75-186.5) and 29 (15.25-124.0) in Group A and Group B, respectively. ASIA scores between the two groups were statistically significantly different at a 2-week follow-up (ASIA motor p=0.04, ASIA sensory p=0.006), showing early improvement in the hypothermia group. There was no significant difference between the two groups on further follow-up. Conclusions: Hypothermia can be applied safely to subjects with acute SCI. Our study showed that hypothermia was beneficial in the early improvement of functional outcomes in acute cervical SCI.

Effects of type 2 diabetes on the viscoelastic behavior of human trabecular bone.

Type 2 diabetes (T2D) is a well-known disease that impaired bone mechanical properties and increases the risk of fragility fracture. The bone tissue is a viscoelastic material that means the loading rate determines its mechanical properties. This study investigates the impact of T2D on the viscoelastic properties of human bone and its association with microstructure and biochemical properties. INTRODUCTION: Viscoelasticity is an important mechanical property of bone and for this the interaction of individual constituents of bone plays an important role. The viscoelastic nature of bone can be affected by aging and diseases, which can further influence its deformation and damage behavior. METHODS: The present study investigated the effects of T2D on the viscoelastic behavior of trabecular bone. The femoral heads of T2D (n = 26) and non-T2D (n = 40) individuals with hip fragility fractures were collected for this investigation. Following the micro-CT scanning of all bone samples, the stress relaxation and dynamic mechanical analysis (DMA) tests were performed to quantify the viscoelasticity of bone. Further, a correlation analysis was performed to investigate the effects of alteration in bone microstructural and biochemical parameters on viscoelasticity. RESULTS: The stress relaxation and frequency sweep responses of T2D and non-T2D trabecular bone specimens were not found significantly different. However, the storage modulus, initial stiffness, and initial stress were found lower in T2D bone. The significant correlation of percentage stress relaxed is obtained between the mineral content (r= - 0.52, p-value = 0.003), organic content (r = 0.40, p-value = 0.02), and mineral-to-matrix ratio (r = - 0.43, p-value = 0.009). Further, storage and loss modulus were correlated with bone volume fraction (BV/TV) for both groups. The stress relaxation and frequency sweep characteristics were not found significantly connected with the other chemical, structural, or clinical parameters. CONCLUSION: This study suggests that T2D does not affect the time-dependent response of human femoral trabecular bone. The viscoelastic properties are positively correlated with organic content and negatively correlated with mineral content.

Bioaerosols in orthopedic surgical procedures and implications for clinical practice in the times of COVID-19: A systematic review and meta-analysis.

INTRODUCTION: Orthopedic surgical procedures (OSPs) are known to generate bioaerosols, which could result in transmission of infectious diseases. Hence, this review was undertaken to analyse the available evidence on bioaerosols in OSPs, and their significance in COVID-19 transmission. METHODS: A systematic review was conducted by searching the PubMed, EMBASE, Scopus, Cochrane Library, medRxiv, bioRxiv and Lancet preprint databases for studies on bioaerosols in OSPs. Random-effects metanalysis was conducted to determine pooled estimates of key bioaerosol characteristics. Risk of bias was assessed by the RoB-SPEO tool; overall strength of evidence was assessed by the GRADE approach. RESULTS: 17 studies were included in the systematic review, and 6 in different sets of meta-analyses. The pooled estimate of particle density was 390.74 µg/m3, Total Particle Count, 6.08 × 106/m3, and Microbial Air Contamination, 8.08 CFU/m3. Small sized particles (

Efficacy of antifibrinolytics in reducing blood loss during hip reconstruction surgery in cerebral palsy children. A systematic review and meta-analysis.

BACKGROUND: Cerebral palsy (CP) children undergoing hip reconstruction are more prone to blood loss during surgery due to poor nutritional status, antiepileptic medication intake, depletion of clotting factors, and the extent of surgery involved. We conducted this present review to analyze whether antifibrinolytics during hip surgery in CP children would reduce surgical blood loss and transfusion requirements. METHODS: Three databases (PubMed, EMBASE, and Cochrane library) were searched independently for publications mentioning the use of antifibrinolytics during hip reconstruction surgery in CP children. The primary outcome was to compare the surgical blood loss with and without antifibrinolytics use. Secondary outcomes were transfusion requirements, drop in hemoglobin level, length of hospital stay, and complication rates. RESULTS: All five studies (reporting 478 patients) published on this topic were found eligible based on inclusion criteria and were included for final analysis. Primary outcome: In three of the included studies, antifibrinolytics use resulted in a significant reduction in total blood loss with a mean difference (MD) of -151.05 mL (95% CI -272.30 to -29.80, p = 0.01). In the other two studies although statistically not significant, antifibrinolytics use reduces estimated blood loss (MD: 3.27, 95% CI -21.44 to 14.91, p = 0.72). Secondary outcomes: We observed that in the antifibrinolytics group, there was a reduction in total blood transfusion requirements (OD: 0.70, 95% CI 0.35 to 1.37, p = 0.29), and a drop in haemoglobin level (MD: 0.16, 95% CI -0.62 to 0.30, p = 0.49) but statistically not significant. No adverse effects related directly to antifibrinolytics were noticed in all five studies. CONCLUSION: Only two out of five included studies favored the use of antifibrinolytics in CP children undergoing hip reconstruction. The evidence synthesized on this meta-analysis is also not sufficient enough to support its routine use in this cohort of children for hip reconstruction surgery. High-quality studies with adequate sample size to determine the effective and safe dosage, timing, and cost involved of different antifibrinolytics are the need of the hour. LEVEL OF EVIDENCE: Ⅲ.

Orthopedic Residency in a Tertiary Care Hospital of India: Positives, Negatives and Perspectives for Change.

BACKGROUND: Orthopaedic residency training is a 3-year period of preparation that converts a raw medical student into a proficient orthopaedic surgeon. Due to wide variations at different centers in India, the program in a tertiary hospital is presented, in an attempt to improve the overall levels of training. MATERIALS AND METHODS: PGIMER has produced many good surgeons who are well settled across the country and the world. A survey of the postgraduates of the last 30 years was done to highlight the perceptions about the program. An overview of the program was also added to the narrative to highlight the positive aspects of the training. RESULTS: 132 Orthopaedic passed-out residents from PGIMER could be contacted. 97% of them rated their residency experience as excellent or good, and stated that they would recommend this program to new residents. Key points highlighted by them were the readiness of trainees for any surgical contingency after graduation, continuation of the mindset for research, and their prompt acceptability into their subsequent places of work due to their place of graduation. DISCUSSION: Converting an orthopaedic resident into a competent surgeon involves knowledge upgrades and impartation of skills; these are not limited to the theory of orthopaedics, but involve the thought processes and the planning as a surgeon, the attitude towards patient management, and a continuously inquisitive scientific mind. The shortcomings and strengths of the residency program in PGIMER are discussed; international standard methodology limited to this institute like formal log books, mentorship program, hands-on skill development through courses, etc. is something that is recommended to be mandatory in all residency programs. CONCLUSION: The PGIMER Orthopaedic residency program could act as a basic model for other Indian medical schools, with any appropriate modifications. Standardization of Orthopaedic residency programs could allow upgrading to International levels.

Is Minimally Invasive Plating Osteosynthesis Better Than Conventional Open Plating for Humeral Shaft Fractures? A Systematic Review and Meta-Analysis of Comparative Studies.

INTRODUCTION: The aim of systematic review and meta-analysis was to find out whether minimally invasive plate osteosynthesis (MIPO) is better than open reduction and internal plate fixation (ORIF) in terms of functional outcome, achieving union (union time and incidence of non-union), intraoperative parameters (surgical duration, blood loss, and radiation exposure), and complications (iatrogenic radial nerve palsy and infection) for humeral shaft fractures. MATERIALS AND METHODS: We searched online databases (Pubmed, Embase, Scopus, and The Cochrane Library) from inception till 3rd September 2020 for articles comparing MIPO with ORIF for humeral shaft fractures. The methodological quality of randomized controlled trials (RCTs) was done by Cochrane Risk of Bias assessment tool 2 (RoB2) and of non-randomized studies (case-control and cohort studies) by Methodological Index for non-randomized studies (MINORS). Meta-analysis was performed using Review Manager 5.4 software. RESULTS: 11 studies (5 RCTs and 6 non-randomized comparative studies) involving a total of 582 patients (MIPO-290, ORIF-292) meeting our inclusion criteria were included in the study. There was no statistically significant difference in pooled analysis of functional outcome scores between MIPO and ORIF. Union time was significantly lesser (mean difference = 3.12 weeks) and incidence of non-union lower (odd's ratio = 0.27) in MIPO group. Surgical duration and intraoperative blood loss were significantly lesser in MIPO group. Iatrogenic radial nerve palsy and infection were higher in ORIF group. CONCLUSIONS: This study showed that MIPO gives similar functional outcomes as compared to ORIF but causes significantly lesser blood loss, requires lesser operative duration and has a lesser incidence of major complications. TRIAL REGISTRATION: International prospective register of systematic reviews (PROSPERO)-CRD42020208346, Date of registration 09/10/2020. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s43465-021-00413-6.

Mycobacterium tuberculosis Infection of the Spine Secondary to Oxygen - Ozone Therapy for Prolapse Intervertebral Disc: A Scoping Review.

Introduction: Ozone therapy is one of the evolving, yet far from conclusive, alternative minimally invasive treatment option in the management of herniated disc in the cervical and lumbar spine. It causes the decrease in the volume of herniated disc by dehydration. Case Report: We hereby present the first reported case of Mycobacterium infection of the spine secondary to ozone therapy with the aim to caution the surgeons regarding the complications of intradiscal ozone therapy. Conclusion: Lack of proper, adequate, and recommended precautions if not taken can inoculate the varied microorganisms into the intradiscal space leading to devastating and unforeseen complications.

Comparing Three Modalities of Treatment for Frozen Shoulder: A Prospective, Double-Blinded, Randomized Control Trial.

PURPOSE: To compare the effects of three modalities of pain management i.e. SSNB (suprascapular nerve block) with NIR (non invasive rehabilitation), IAI (intra articular injection) with NIR and, NIR alone in idiopathic frozen shoulder patients. METHODS: A double blinded randomized clinical trial was conducted. 60 cases of idiopathic frozen shoulder were selected and randomly divided into three treatment groups; group 1: NIR, group 2: NIR + SSNB, group 3: NIR +IAI. Range of motion, pain score and disability (SPADI: shoulder pain and disability index) score were evaluated pre-treatment and at 12 weeks follow up. RESULTS: All three groups were homogenous and comparable regarding their age, sex ratio, pretreatment pain score, disability score and range of motion. There was significant improvement (p < 0.05) post treatment in all three groups with respect to pain score, disability score and range of motion. SSNB with NIR group patients demonstrated better improvement in all parameters examined, which was statistically significant in pain score, disability score and internal rotation but was statistically equivalent for total range of motion and external rotation as compared to shoulder injection group. CONCLUSION: SSNB in combination with non invasive rehabilitation is an effective and safe mode of treatment for idiopathic frozen shoulder. Present study also proves that SSNB with NIR is a more effective mode of treatment for idiopathic frozen shoulder as compared to NIR alone or in combination with IAI.Level of evidence: Level 1.