Out Patient Department practices in orthopaedics amidst COVID-19: The evolving model

Severe Acute Respiratory Syndrome COVID-19 was declared as a pandemic on 11^th March 2020 by the World Health Organization and consequent lockdown imposed in several areas resulted in a marked reduction in orthopaedic practices. Although some guidelines for patient care in orthopaedic practice have been published, overall, publications focusing exclusively on guidelines on starting orthopaedic outpatient departments (OPD) after the COVID-19 lockdown amidst the on-going pandemic are lacking. We hereby propose the evolving knowledge in changes in OPD management practices for orthopaedic surgeons in the COVID- 19 era. The emphasis on online registration (e-registration) should be given impetus and become the new norm supplemented by telephonic and spot registration for the uneducated patients. The review highlights the safety of patient and orthopaedic surgeons in OPD by screening and maintaining hygiene at various levels. The article also mentions the duties of the help desk, OPD hall supervisor and the new norms of air conditioning, ventilation, safe use of elevators, sanitization of OPD premises and biomedical waste disposal. The optimum and safe utilization of human & material resources, DO's and DON'Ts for patients & health staff have also been proposed. The reorganization of plaster room, the precaution during plastering, fracture clinic, dressing and injection room services are discussed as per evolving guidelines. This article will also give deep insight into the OPD plan & telemedicine graphically. The authors suggest updating and downward permeation of existing e-infrastructure of government health services that is up-gradation of existing tertiary level online registration services, a paperless model of OPD consultation & dispensation. The future updating of Aarogya Setu App (https://mygov.in/aarogya-setu-app/) for convenient online OPD registration and dispensation has been discussed and proposed. This review will help in containing the spread of COVID 19 and build upon the health gains achieved after lockdown. The easy concept of CCCATTT has been introduced, and the OPD Plan has also been suggested. We have endeavoured to holistically detail an orthopaedic OPD setup and its upkeep in COVID-19 pandemic, but since the knowledge of COVID 19 is ever-evolving it needs replenishment by regular education for health staff.

Excision of Osteosarcoma of Patella without Extensor Mechanism Reconstruction: A Case Report

INTRODUCTION

Osteogenic sarcoma of patella is extremely rare and only few cases have been reported in the literature so far. Limb salvage, particularly reconstructing extensors of the knee, is a matter of debate in available literature. Henceforth, we would like to present this uncommon case of patellar osteosarcoma in a young female managed by chemotherapy and wide excision without extensor mechanism reconstruction.

CASE REPORT

A 25-year-old female had a history of painless swelling around the left knee for 6 months, which was progressively increasing in size. It was diagnosed as osteoblastic osteosarcoma patella radiologically, confirmed by open biopsy. The patient was managed by recommended protocol comprising neoadjuvant chemotherapy followed by tumor excision, thereafter chemotherapy in post-operative period. However, no reconstruction of the extensor mechanism was done. At 1-year follow-up, the patient was able to perform activities of daily living without any discomfort. She was able to ambulate unaided with no extensor lag.

CONCLUSION

For managing a case with osteosarcoma patella, chemotherapy along with optimal excision comprising total patellectomy without extensor mechanism reconstruction is a viable option.

Virtual preoperative planning and 3D printing are valuable for the management of complex orthopaedic trauma

PURPOSE

The technology of 3D printing (3DP) exists for quite some time, but it is still not utilized to its full potential in the field of orthopaedics and traumatology, such as underestimating its worth in virtual preoperative planning (VPP) and designing various models, templates, and jigs. It can be a significant tool in the reduction of surgical morbidity and better surgical outcome avoiding various associated complications.

METHODS

An observational study was done including 91 cases of complex trauma presented in our institution requiring operative fixation. Virtual preoperative planning and 3DP were used in the management of these fractures. Surgeons managing these cases were given a set of questionnaire and responses were recorded and assessed as a quantitative data.

RESULTS

In all the 91 cases, where VPP and 3DP were used, the surgeons were satisfied with the outcome which they got intraoperatively and postoperatively. Surgical time was reduced, with a better outcome. Three dimensional models of complex fracture were helpful in understanding the anatomy and sketching out the plans for optimum reduction and fixation. The average score of the questionnaire was 4.5, out of a maximum of 6, suggesting a positive role of 3DP in orthopaedics.

CONCLUSION

3DP is useful in complex trauma management by accurate reduction and placement of implants, reduction of surgical time and with a better outcome. Although there is an initial learning curve to understand and execute the VPP and 3DP, these become easier with practice and experience.

Unusual presentation of chondroblastoma mimicking Trevor's disease

Chondroblastoma is a benign bone tumor, represents 1%–2% of all primary bone tumors, typically seen in patients 10–25-year-old and more common in males. It occurs most frequently in the distal femur, proximal tibia, and proximal humerus. Soft tissue extension is extremely rare. Adjacent joints may develop effusions, but the tumor mass protruding into the joint has never been seen in case of chondroblastoma. We report a rare case of intra-articular chondroblastoma arising from proximal tibia in a 16-year-old boy and growing into the knee joint mimicking an intra-articular osteochondroma.

Fibrodysplasia ossificans progressiva - can we diagnose it right at the outset?

Sharma A, Maini D, Agarwal G, Sharma P, Maini L. Fibrodysplasia ossificans progressiva - can we diagnose it right at the outset? Turk J Pediatr 2019; 61: 958-962. Fibrodysplasia ossificans progressiva (FOP) is a rare autosomal dominant disorder with no definitive treatment options available yet, except for physiotherapy and bisphosphonates. Due to its initial presentation with multiple lumps in the body, it is often misdiagnosed as a benign tumour most commonly being an osteochondroma or Olliers syndrome. Delay in diagnosis not only delays the management but can also expose the patient to unnecessary interventions. Moreover, earlier diagnosis can also make the patient aware of the precautions to be taken. So our remark is `can we diagnose this disease right at the outset`? We present a case of a 10 year old boy, who had all the classical features of FOP yet was misdiagnosed. Therefore, classical hallmark features of this disease are highlighted in this case report which can be picked up easily by any clinician to reach to a definitive diagnosis as early as possible avoiding unnecessary iatrogenic insult.

Cervical pedicle screw guiding jig, an innovative solution

Pedicle screws are one the commonest used modality in spinal instrumentation. However, the method of pedicle screw fixation in cervical spine as compared to thoracic and lumbar spine is still technically demanding because it carries the risk of catastrophic damage to the surrounding neurovascular structures We have utilized virtual planning and 3D (3-dimension) printing to develop a patient specific jig to guide the accurate placement of pedicle screws. A patient with bifacetal dislocation C7 over D1 classified as flexion-distraction injury type 3 who was planned for decompression and fusion by posterior instrumentation at C6, C7, D1 and D2 was selected. A CT scan with 1 mm cuts was used to produce DICOM images of the same. Using these DICOM images virtual planning was done on MIMICS and 3 MATICS software to create patient specific jigs. These jigs were then 3D printed using a 3D printer and used for accurate placement of pedicle screws intra-operatively after adequate sterilization. Our procedure is low cost but high technology based. It is simple, accurate, and very cost effective. The technology transfer is very easy and can be adopted easily.

A synergic approach of X-ray powder diffraction and Raman spectroscopy for crystal structure determination of 2,3-thienoimide capped oligothiophenes

This work presents a Raman based approach for the rapid identification of the molecular conformation in a series of new 2,3-thienoimide capped quaterthiophenes.

Total hip replacement in tuberculosis of hip: A systematic review

Total hip replacement (THR) in patients with tuberculous arthritis of the hip is controversial. The timing of surgery, type of prosthesis, reactivation of the disease, high complication rates and the long-term survival of the reconstruction are the major conc erns. There is little information regarding this concern in the literature. We conducted a systematic review of published studies on Total Hip Replacement in patients with Tuberculosis of the hip. A search of Pubmed and Google Scholar database articles published between January 2000 and July 2017 was performed. Thirteen articles were identified, comprising 226 patients. The mean follow-up was 5.48 years. Antituberculosis treatment was given for atleast 2 weeks pre-operatively and continued post-operatively for between six and 18 months after THR. Three patients had reactivation of infection. At the final follow-up, the mean Harris hip score was 89.98. Total Hip Replacement in tuberculosis of hip is safe and efficient way to save the joint function. The most important factors to achieve success include the accurate diagnosis, efficient pre- and postoperative anti-tuberculosis therapy, thorough debridement, two stage procedure for patients with sinus(es).

3D printing in designing of anatomical posterior column plate

BACKGROUND

Acetabulum has a complex anatomy due to which anatomical acetabular plates are still under developmental phase. Although intra-operative contouring of reconstruction plate is done as a standard practice, it is associated with increased operative time and morbidity of patient. We have designed an acetabular plate for posterior fixation from experience of previous studies performed in our institute on acetabular fracture fixation which should be appropriate for most of the patient of Indian origin. Apart from avoiding intra-operative contouring of acetabular plates it also helps in preventing intra articular screw penetration.

METHODS

We selected five consecutive patients with acetabular fracture needed to be operated from posterior approach and designed patient specific plate template from virtual surgical planning and 3D printing. These plate templates were then matched with our acetabular plate design and were used intra-operatively. Many parameters were assessed to evaluate accuracy of our plate design in those five patients.

RESULT

All the plate templates appear to match our designed plate and no intra-operative contouring was required with our plate design.

CONCLUSION

This was a pilot study and we need a large sample size to study accuracy of our acetabular plate design which might avoid intra-operative contouring, decreasing morbidity of patient and prevent wastage of resources in pre-operative planning and computer designing.

Subacute posttraumatic ascending myelopathy: A case report and review of literature

Subacute posttraumatic ascending myelopathy is a rare disorder, unrelated to syrinx formation or mechanical instability, which may gradually emerge within the first 1-2 weeks after a spinal cord injury and may lead to diagnostic and prognostic dilemmas. We present a case of 24-year-old female with unstable wedge compression fracture of L1 vertebrae with signal changes in the upper lumbar cord causing complete paraplegia below D9 with bladder and bowel involvement. In the subsequent week, she developed a delayed progressively increasing neurological deficit with cord signal abnormality on MRI extending cephalad from the injury site to the upper dorsal cord. The patient had no initial clinical improvement initially but showed a delayed recovery over months.

Three-dimensional printing and patient-specific pre-contoured plate: future of acetabulum fracture fixation?

PURPOSE

Due to the complexity of acetabulum, achieving anatomical contouring intra-operatively is difficult for surgeon. A 3D (dimensional) real model can facilitate us both in contouring the plate pre-operatively and in better pre-operative planning. Patient-specific pre-contoured plate in acetabular fracture has been studied by few researchers but randomized case-control study was lacking. Hence, we conducted a case-control study to evaluate the accuracy of patient-specific pre-contoured plate.

MATERIALS AND METHODS

Prospective randomized case control study was conducted. 21 patients were included. 10 patients were distributed in "case" group and remaining 11 in "control" group.

INCLUSION CRITERIA

Displaced acetabulum fractures with displacement of ≥3 mm in adults who reported within 3 weeks of injury. Exclusion criteria were: Open fractures, associated Morel-Lavallée lesion and patients with >3 weeks old fracture. In case group, patient-specific real 3D model of fractured acetabulum was generated using rapid prototyping technology and plates were contoured pre-operatively. Control group was treated using intra-operative contoured plates. Both the groups were compared using parameters: Blood loss, Surgery time, post-operative reduction on X-ray, post-surgical residual displacement and reduction achieved as evaluated by CT scan.

RESULTS

Reduced blood loss (100 ml less in case group) and surgical time (12 min less in case group) and better post-operative reduction were observed in case than control. In control group, 4 patients even had step of 2-3 mm, which was not seen in case group. All the pre-contoured plates fitted well to the pelvis intra-operatively. Reduction achieved as evaluated by CT was more in "case" group with statistically significant outcomes (p < 0.05).

CONCLUSION

Patient-specific pre-contoured plate made using 3D model is a better implant than intra-operatively contoured plate. Real-time 3D pelvis model is an accurate technique for pre-operative planning in acetabular fractures.

Three-dimensional printing and patient-specific pre-contoured plate: future of acetabulum fracture fixation?

PURPOSE

Due to the complexity of acetabulum, achieving anatomical contouring intra-operatively is difficult for surgeon. A 3D (dimensional) real model can facilitate us both in contouring the plate pre-operatively and in better pre-operative planning. Patient-specific pre-contoured plate in acetabular fracture has been studied by few researchers but randomized case-control study was lacking. Hence, we conducted a case-control study to evaluate the accuracy of patient-specific pre-contoured plate.

MATERIALS AND METHODS

Prospective randomized case control study was conducted. 21 patients were included. 10 patients were distributed in "case" group and remaining 11 in "control" group.

INCLUSION CRITERIA

Displaced acetabulum fractures with displacement of ≥3 mm in adults who reported within 3 weeks of injury. Exclusion criteria were: Open fractures, associated Morel-Lavallée lesion and patients with >3 weeks old fracture. In case group, patient-specific real 3D model of fractured acetabulum was generated using rapid prototyping technology and plates were contoured pre-operatively. Control group was treated using intra-operative contoured plates. Both the groups were compared using parameters: Blood loss, Surgery time, post-operative reduction on X-ray, post-surgical residual displacement and reduction achieved as evaluated by CT scan.

RESULTS

Reduced blood loss (100 ml less in case group) and surgical time (12 min less in case group) and better post-operative reduction were observed in case than control. In control group, 4 patients even had step of 2-3 mm, which was not seen in case group. All the pre-contoured plates fitted well to the pelvis intra-operatively. Reduction achieved as evaluated by CT was more in "case" group with statistically significant outcomes (p < 0.05).

CONCLUSION

Patient-specific pre-contoured plate made using 3D model is a better implant than intra-operatively contoured plate. Real-time 3D pelvis model is an accurate technique for pre-operative planning in acetabular fractures.

White luminescence achieved by a multiple thermochromic emission in a hybrid organic-inorganic compound based on 3-picolylamine and copper(i) iodide

Three copper(i) complexes have been obtained by the reaction of CuI with 3-picolylamine in acetonitrile solution and characterized by X-ray powder diffraction, both from synchrotron and laboratory radiation. Photophysical investigations in the solid state revealed highly efficient thermally-activated delayed fluorescence (TADF) with photoluminescence quantum yields (PLQYs) up to 18%. Notably, the complex [Cu₂I₂(3pica)]_∞ displays a strong luminescence thermochromism due to the presence of both ^1,3(X + M)LCT excited states and a lower-lying cluster-centered (³CC) one, leading to multiple emission at room temperature; as a result, a white luminescence is achieved with a PLQY of 4.5%.

Non-union fracture neck femur in a toddler: Reconstructed by valgus osteotomy - A minimally invasive approach

BACKGROUND

Non-union is one of the devastating complications of fracture neck of femur. Though a very rarely encountered entity in a toddler (1-3 years paediatric age group), non-united femoral neck fractures are reported in developing countries because of mismanagement by quacks and delay in referrals. For operative treatment, many different procedures have been described, including close/open reduction and internal fixation using K-wires, cannulated screws, fibula or nails. There is no evidence in the literature that one or other implant influences the rate of postoperative complications, such as avascular femoral head necrosis or coxa vara. But, still the choice of fixation implant is debatable.

CASE REPORT

We present a case of 3-year-old child of non-union femoral neck fracture treated with valgus osteotomy. Choice of implant was kept to bare minimum to reduce the cost of implant and magnitude of surgery, which made the surgery minimally invasive, which is not the case in other studies. Two solid cancellous screws and a Kirschner wire (K-wire) were used to acheive fixation. Implant was removed after one year. The patient was followed up for 2 years and was found to be asymptomatic clinically with restoration of neck shaft angle and no signs of AVN.

CONCLUSION

Our method of intertrochanteric valgus osteotomy and internal fixation stabilized using K-wire and screws is a technically simple yet effective method of treating difficult fracture neck femur. Although a larger series and multicentric trails are needed, yet we would safely recommend extension of this technique to unstable fractures, to minimize the incidence of complications, cost and magnitude of surgery.

Evaluation of the muscle morphology of the obturator externus and piriformis as the predictors of avascular necrosis of the femoral head in acetabular fractures

Avascular necrosis (AVN) of femoral head is a recognised complication of fracture dislocation of the hip joint but is not studied frequently in relation to acetabulum fractures. The aim was to establish the relationship between obturator externus and piriformis muscle morphology in acetabulum fractures and potenital development of AVN of the femoral head. Twenty-five fractures were included in this prospective study and were subjected to radiological assessment and computed tomography of the pelvis. Magnetic resonance imaging (MRI) of the hip was performed to assess the morphology of obturator externus and piriformis, and findings were compared intraoperatively (in 15 cases). Serial radiographs were taken at monthly intervals to assess the development of avascular necrosis. The patients with no evidence of AVN on radiographs at 6 months had additional MRI scans to look for such changes. Three patients developed AVN of femoral head and two had complete tears of piriformis and/or obturator externus muscles on the pre-operative MRI with the findings confirmed intraoperatively (p = 0.013). None of the patients without changes of AVN at 6-month follow-up had complete tears of either or both muscles. Of these patients, there was one case each of T-type fracture, isolated posterior wall fracture with hip dislocation, and posterior wall with transverse fracture of the acetabulum. Complete tears of obturator externus and/or piriformis muscles are a strong predictor of future development of AVN of the femoral head.

A Rare Case of Glomus Tumor of the Great Toe: An Analysis of Behavior at This Rare Site

Glomus tumor, originally known as an angioneuromyoma, is a benign neoplasm arising from specialized structures called glomus bodies, involved in thermoregulation. Although it has been reported at a number of sites in the body, this rare tumor is most commonly seen in the subungual areas of the digits of the hand. Only a handful of lesions have been reported in the toes. Because most foot conditions are treated by podiatrists and dermatologists, orthopaedic surgeons are generally unaccustomed to making early diagnoses. The purpose of this case report is to alert the attending surgeon regarding the possibility of glomus tumor as a cause of chronic toe pain. Also it has been observed that the behavior of this tumor varies with the site of occurrence-whether digital or extradigital. So we have extensively reviewed all similar reports in the literature to analyze the behavior of this tumor at this unusual location, apart from comparing it with the more common finger variety, to ensure it possibly is not a misclassification like the chemodectomas that were earlier thought to be glomus tumors.

LEVELS OF EVIDENCE

Therapeutic Level IV: Case Study.

Customized iliac prosthesis for reconstruction in giant cell tumour: A unique treatment approach

Giant cell tumour (GCT) of flat bones of pelvis is extremely rare. GCT of the ilium and ischium represent less than 0.05% of all GCT. Iliac bone GCT has been treated traditionally by intra-lesion curettage with bone grafting, wide resection with or without reconstruction and hemi-pelvectomy in very aggressive tumours. None of the above treatments were without morbidities. Reconstruction using bone grafts and bone cement has also been inadequate. In GCT, where life expectancy is not decreased significantly, surgical treatment should be aimed at giving optimum functional outcome. We are reporting here a rare case of giant cell tumour of ilium bone in a 25-year-old female and its unique treatment approach. We designed a computed tomography (CT) based customized iliac prosthesis using Materialise Mimics and 3-Matic software. 3D model of pelvis was generated from the CT. After deciding the extent of resection on affected side, we virtually mirrored an identical portion of opposite ilium to the affected side. Connecting plates were made over the mirrored part and merged with it. Multiple relevant holes were made to attach various muscles to the prosthesis. Prosthesis was made in medical grade titanium by using Computerized Numerical Control (CNC) machine. The method is called as computer based subtractive manufacturing. Wide resection was done and the prosthesis was placed using multiple 3.5 millimetres screws through the connecting plates. Muscles were stitched to relevant holes using ethibond suture. Post-operative course was unremarkable. Patient was made to walk with full weight bearing after 5 weeks. Powers of abductors at 6 months is 4/5 and patient walks normally without a limp.