Forequarter Replantation

Traumatic forequarter amputations are rare injuries in which the arm, clavicle, scapula, and proximal shoulder muscles are avulsed from the body. Historically, forequarter amputation has been treated with hemorrhage control, wound debridement, and soft tissue coverage. To our knowledge, successful forequarter replantation has not been previously reported. We present a rare case of forequarter amputation treated successfully with replantation. At the 4.5-year follow-up after replantation, the patient had antigravity elbow flexion, modest shoulder elevation, modest extrinsic finger function, and crude sensation. We discuss relevant technical considerations that indicate that, despite challenges, forequarter replantation can be achieved with success.

A prospective study comparing three different all-posterior surgical techniques in the management of thoracolumbar spinal tuberculosis

Background

Posterior only surgery has been widely performed in the treatment of thoracic and lumbar spinal tuberculosis. Surgical options include debridement with posterior instrumentation only or combined with anterior reconstruction. The aim of this study is to investigate and compare the clinical, functional and radiological outcomes using a single-stage posterior only surgery in thoracolumbar spinal tuberculosis by three different surgical techniques.

Methods

Patients undergoing posterior only surgery for thoracic and lumbar spinal tuberculosis were followed up prospectively and included. Three different procedures, Group-A: Posterior instrumentation with anterior cage reconstruction (n = 49), Group-B: Posterior instrumentation and anterior autologous bone-grafting (n = 21) and Group-C: Posterior column shortening without anterior-reconstruction (n = 52) were compared for kyphosis correction achieved, kyphosis at final follow-up and degree of correction lost. Neurological assessment was done using ASIA impairment Scale(AIS) grades. Functional assessment was done using Visual analogue score (VAS), Modified McNab criteria and NASS satisfaction score.

Results

A total of 122 patients were included in the study, Group-A (49), Group-B (21) and Group-C (52). Radiological correction of kyphotic deformity in anterior reconstruction, Group-A (20.17 ± 9.25⁰) was higher than 13.97⁰ ± 6.06⁰ and 14.27⁰ ± 6.47⁰ achieved in Groups B and C respectively. There was no significant difference in correction lost amongst the three groups (p-value, 0.76). Surgical duration, blood loss and hospital stay were significantly higher in the anterior reconstruction group (p-value, 0.001). Similarly, no significant difference was noted between the three groups in neurological and functional outcomes at 2 years.

Conclusion

Posterior only approach is eminently satisfactory for treating Thoracolumbar Spinal Tuberculosis (STB). All three groups had similar functional and neurological outcomes. However there was a better correction of deformity in patients with anterior cage reconstruction.

Are Modic changes 'Primary infective endplatitis'?-insights from multimodal imaging of non-specific low back pain patients and development of a radiological 'Endplate infection probability score'

PURPOSE

To probe the pathophysiological basis of Modic change (MC) by multimodal imaging rather than by MRI alone.

METHODS

Nineteen radiological signs found in mild infections and traumatic endplate fractures were identified by MRI and CT, and by elimination, three signs unique to infection and trauma were distilled. By ranking the Z score, radiological 'Endplate Infection Probability Score' (EIPS) was developed. The score's ability to differentiate infection and traumatic endplate changes (EPC) was validated in a fresh set of 15 patients each, with documented infection and trauma. The EIPS, ESR, CRP, and Numeric Pain Rating Scale (NRS) were then compared between 115 patients with and 80 patients without MC.

RESULTS

The EIPS had a confidence of 66.4%, 83% and, 100% for scores of 4, 5 and, 6, respectively, for end plate changes suggesting infection. The mean EIPS was 4.85 ± 1.94 in patients with Modic changes compared to - 0.66 ± 0.49 in patients without Modic changes (p < 0.001). Seventy-eight (67.64%) patients with MC had a score of 6, indicating high infection possibility. There was a difference in the NRS (p < 0.01), ESR (p = 0.05), CRP (p < 0.01), and type of pain (p < 0.01) between patients with and without MC.

CONCLUSION

Multimodal imaging showed many radiological signs not easily seen in MRI alone and thus missed in Modic classification. There were distinct radiological differences between EPCs of trauma and infection which allowed the development of an EIPS. The scores showed that 67.64% of our study patients with Modic changes had EPCs resembling infection rather than trauma suggesting the possibility of an infective aetiology and allowing us to propose an alternate theory of 'Primary Endplatitis'.

Safety and Feasibility of Very Early Bronchoscopy-assisted Percutaneous Dilatational Tracheostomy in Anterior Cervical Spine Fixation Patients

Background

Anterior cervical spine fixation (ACSF) is a common mode of stabilization of cervical spine injuries. These patients usually need a prolonged mechanical ventilation, so an early tracheostomy is beneficial for them. However, it is often delayed due to the close proximity to the surgical site, due to the concerns of infection, and increased bleeding. Percutaneous dilatational tracheostomy (PDT) is also considered a relative contraindication due to the inability to achieve adequate neck extension.

Objectives

The objectives of our study are to assess the:Feasibility of performing a very early percutaneous dilatational tracheostomy in cervical spine injury patients, post-anterior cervical spine fixation.Safety in doing so with regard to surgical-site infection, early, and late complications.Benefits with regard to outcome measures like ventilator days and length of stay (LOS) in the intensive care unit (ICU) and hospital.

Materials and methods

We performed a retrospective review of all patients who underwent anterior cervical spine fixation and bedside percutaneous dilatational tracheostomy in our ICU from 1st January 2015 to 31st March 2021.

Results

Out of the 269 patients admitted to our ICU with cervical spine pathology, 84 were included in the study. About 40.4% patients had injury above C5 level (n-34) and 59.5% had below C5 level. About 86.9% patients had ASIA-A neurology. In our study, percutaneous tracheostomy was done at an average of 2.8 days from the cervical spine fixation. Average length of ventilator days post-tracheostomy was 8.32 days, ICU stay was 10.5 days, and hospital stay was 28.6 days. One patient developed anterior surgical-site infection.

Conclusion

We conclude from our study that a very early percutaneous dilatational tracheostomy can be done in post-anterior cervical spine fixation patients as early as within 3 days without significant complications.

How to cite this article

Paul AL, Varaham R, Balaraman K, Rajasekaran S, Balasubramani VM. Safety and Feasibility of Very Early Bronchoscopy-assisted Percutaneous Dilatational Tracheostomy in Anterior Cervical Spine Fixation Patients. Indian J Crit Care Med 2022;26(10):1086-1090.

Use of antibiotic-impregnated beads in the treatment of lumbosacral surgical site infection: A retrospective case series

Background

Different adjuvant local-antibiotic techniques are described in management of surgical-site infections (SSIs). Antibiotic-laden polymethyl methacrylate (PMMA) spacers have been used in peri-prosthetic infections. However, their role in treatment of spinal SSIs is not well-recognised.

Methods

After approval from Institutional Review Board, we retrospectively evaluated the data of patients aged≥18 years, who were treated for SSIs of lumbo-sacral region (2010-2019). Among them, those who underwent treatment with the placement of cement beads (temporarily/permanently) were identified. This approach was utilised for post-surgical spondylodiscitis patients with significant, associated infection or abscess involving the paraspinal musculature. Only those with≥2 years' follow-up, were included.Patient demographic details, site of infection, details regarding laboratory/radiological investigations, management-protocol followed, pathogen grown, antibiotics used (their dosage and duration of use), complications encountered and outcome were recorded.

Results

13 patients [4 males, age:57.3 ± 12.4 years] were included. Seven had co-morbidities. One had upper-lumbar involvement, one sacral and others had lower-lumbar (L4/distally) disease. While 7 had recent-onset infection (≤2 months since primary surgery), 6 had chronic infection. In 2, 8, 2, and 1 patients, primary surgery was microdiscectomy, TLIF, PLF, and adult-deformity surgery, respectively.Nine underwent two-staged intervention and 4 underwent single procedure. Eleven had PMMA beads, while 2 underwent calcium sulphate bead insertion. Culture grew E coli in 3, Pseudomonas in 2; and E fecalis, K pneumoniae, MSSA and MRSA in one patient each. In 4 patients, beads were not removed. All patients underwent 2 weeks of parenteral antibiotics, followed by 8-12 weeks of oral medications. There was complete remission in all patients, except one who required additional VAC therapy.

Conclusion

Local antibiotic-laden bead application is an effective adjuvant strategy (along with debridement and systemic antibiotics) for the treatment of spinal SSI, where there is substantial infection involving the paraspinal musculature. It is cost-effective and often necessitates second procedure for bead removal.

Spinal Melorheostosis Associated with Intradural Fibrous Band and Extensive Lipomatosis Causing Thoracic Cord Tethering and Myelomalacia: A Unique Case Highlighting Importance of MRI in Management

Axial melorheostosis is rare with only few cases reported and even fewer with symptoms. While symptoms secondary to neural foramen or spinal canal stenosis caused by hyperostotic bone are common, only three symptomatic cases of spinal melorheostosis with associated intradural lipomatous lesions have been reported to date. In none of them the fibrous component of lipofibromatous lesion was identified preoperatively on magnetic resonance imaging. We report here a case of 18-year-old male who presented with thoracic myelopathy secondary to widespread spinal melorheostosis associated with extensive intradural lipomatosis and fibrous component in thoracic lipoma, causing tethering of thoracic spinal cord and myelomalacia. The patient was treated with T2 to T9 posterior instrumented stabilization followed by T3 to T8 laminectomy along with selective thoracic lipofibromatous tumor debulking. Detection of the fibromatous component in multilevel extensive intradural lipomatosis associated with melorheostosis is helpful in planning selection of the level of surgical excision and decompression.

PUMILIO competes with AUF1 to control DICER1 RNA levels and miRNA processing

DICER1 syndrome is a cancer pre-disposition disorder caused by mutations that disrupt the function of DICER1 in miRNA processing. Studying the molecular, cellular and oncogenic effects of these mutations can reveal novel mechanisms that control cell homeostasis and tumor biology. Here, we conduct the first analysis of pathogenic DICER1 syndrome allele from the DICER1 3'UTR. We find that the DICER1 syndrome allele, rs1252940486, abolishes interaction with the PUMILIO RNA binding protein with the DICER1 3'UTR, resulting in the degradation of the DICER1 mRNA by AUF1. This single mutational event leads to diminished DICER1 mRNA and protein levels, and widespread reprogramming of miRNA networks. The in-depth characterization of the rs1252940486 DICER1 allele, reveals important post-transcriptional regulatory events that control DICER1 levels.

Controlled repositioning and primary osteoplasty as a treatment option for the management of unstable slipped capital femoral epiphysis

The ideal management of an unstable slipped capital femoral epiphysis (SCFE) is still controversial. The currently available options are in-situ screw fixation with delayed corrective osteotomy, closed reduction and screw fixation and anatomic reduction by modified Dunn's procedure (MDP). We present the results of our technique of controlled re-positioning (CRP) with primary osteoplasty in which the epiphysis is repositioned to the preacute slip stage and a mini-open osteoplasty is done in the same sitting to avoid later femoro-acetabular impingement. We had 27 unstable slips which presented to our institution between 2015 and 2019, of which nine were treated with the above technique, and the rest 18 were treated with MDP. All of them were followed up for a minimum of 1 year. The mean intraoperative flexion-internal rotation before osteoplasty was -21.1° (-5° to -40°), which improved to +22.8° (+15° to +30°). Pre- and post-operative mean head-neck angles were 46.5° and 18.3°, respectively, with a decrease of 28.2°. At the final follow-up, the mean alpha angle was 45.1° and the mean head-neck offset ratio was 0.26. None of the patients had avascular necrosis or chondrolysis. The technique of CRP, screw fixation and primary osteoplasty is a viable treatment option for a subset of patients with unstable SCFEs. But, the decision is made intraoperatively and the parents need to be counselled about the need for an alternative procedure if repositioning is unsuccessful. Level of evidence: level IV - case series.

The phenomenon of vertebral body drift in neurofibromatosis and its implications for surgical safety

OBJECTIVE

To report on the phenomenon of body drift in neurofibromatosis scoliosis and discuss its implication on surgical safety.

MATERIALS AND METHODS

Ten dystrophic neurofibromatosis scoliosis (NF) and ten adolescent idiopathic scoliosis (AIS) were studied by radiographs, CT, and MRI. The curve characteristics and a detailed analysis of the morphology of the apical and three adjacent vertebral segments above and below were done. The coronal alignment and the presence of a drift of the vertebral body in relationship to the lamina were carefully studied in both groups and compared.

RESULTS

The mean cobb angle in the NF group was 77.6°, and 63.7° in the AIS group. All the studied vertebra in the NF group had extensive pedicle changes, which were more severe at the apical and periapical regions. Body drift was noted in 29 vertebral segments, with 9/10 of apical segments showing a significant drift. The body drift was associated with significant pedicle dystrophic changes and was independent of the curve magnitude. In comparison, in AIS, no body drift was noted despite a larger deformity and more severe vertebral rotation.

CONCLUSION

The 'body drift' phenomenon was unique to neurofibromatosis scoliosis and was secondary to severe pedicle morphology changes. This was present even in curves less than 60° and could result in cord injury while instrumenting the concave pedicle. Therefore, a thorough preoperative assessment and planning by a 3D CT are mandatory.

Factors determining loss of reduction in paediatric supracondylar humerus fractures treated by closed reduction and percutaneous pinning

Closed reduction and percutaneous pinning is the preferred surgical intervention for paediatric supracondylar humerus fractures (SCHF). Loss of reduction (LOR) is one of the infrequent complications associated with percutaneous pinning. We aim to analyse the various factors that could lead to LOR. We retrospectively reviewed records of all children with Gartland's type III and IV SCHF who were operated at our institution between 2014 and 2016. A defined set of radiologic indices were measured on postoperative and follow-up radiographs. Correlation between LOR (as defined by Skaggs) and radiologic indices, was calculated. In total 187 children who satisfied the inclusion criteria were included in the study. Major LOR was present in 8 patients (4.28%), mild LOR was seen in 21 patients (11.22%), and there was no LOR in 158 patients (84.49%). A pin-spread fracture width ratio of 0.37 had maximum sensitivity and specificity for predicting LOR. The convergent pin configuration had the highest rate of LOR of 15%, whereas it was about 3% in the crossed pin and lateral divergent pinning group. The incidence of iatrogenic ulnar nerve injury in our series was 4.76%, and all were in the cross pinning group. Pin-spread fracture width ratio is the most crucial factor determining LOR, and a ratio of less than 0.37 has a significantly higher rate of LOR. As the incidence of LOR is not significantly different between the lateral-only and crossed pin groups, a medial pin should be used judiciously to avert the risk of ulnar nerve injury. Level of evidence: Level IV.

Can Scoliotic Discs Be Controls for Molecular Studies in Intervertebral Disc Research? Insights From Proteomics

STUDY DESIGN

Proteomic analysis of human intervertebral discs.

OBJECTIVES

To compare the characters of scoliotic discs and discs from magnetic resonance imaging (MRI)-normal voluntary organ donors controls used in disc research employing proteomics and establish "true controls" that can be utilized for future intervertebral disc (IVD) research.

METHODS

Eight MRI-normal discs from 8 brain-dead voluntary organ donors (ND) and 8 scoliotic discs (SD) from 3 patients who underwent anterior surgery for adolescent idiopathic scoliosis were subjected to tandem mass spectrometry, and further analysis was performed.

RESULTS

Mass spectrometry identified a total of 235 proteins in ND and 438 proteins in the SD group. Proteins involved in extracellular matrix integrity (Versican, keratins KRT6A, KRT14, KRT5, and KRT 13A1, A-kinase anchor protein 13, coagulation factor XIII A chain, proteoglycan 4) and proteins involved in transcription and DNA repair (Von Willebrand factor A domain-containing 3B, eukaryotic initiation factor 2B, histone H4, leukocyte cell-derived chemotaxin 2) were found to be downregulated in SD. Inflammatory proteins (C3, C1S), and oxidative stress response proteins (peroxiredoxin-2,6, catalase, myeloperoxidase, apolipoprotein E) were found to be upregulated in SD. These changes were reflected at the pathway level also.

CONCLUSION

Findings of our study confirm that scoliotic discs have an abundance of inflammatory, oxidative stress response proteins, which are either absent or downregulated in the ND group indicating that scoliotic discs are not pathologically inert. Furthermore, this study has established MRI-normal discs from voluntary organ donors as the "true" control for molecular studies in IVD research.

Influence of preoperative coronal and sagittal tibiofemoral subluxation in knee osteoarthritis on the outcome of primary total knee arthroplasty

BACKGROUND

The effect of osteoarthritis (OA) with tibiofemoral (TF) subluxation on patients undergoing total knee arthroplasty (TKA) has been less studied, and there have been no studies on sagittal knee subluxation which is a component of a three-dimensional problem. We aim to analyze the influence of preoperative coronal and sagittal knee subluxation with OA on other radiological parameters and the functional outcome in patients undergoing TKA.

METHODS

We retrospectively reviewed the 179-consecutive primary TKA in 151 patients from January 2017 to June 2017. The radiological parameters analyzed were the mechanical tibiofemoral angle (HKA), joint line congruence angle (JLCA) and coronal tibiofemoral (CTF) subluxation in long leg films. In the lateral view, posterior tibial slope, the settlement area of the femur over the tibia and the sagittal tibiofemoral (STF) subluxation were calculated. Preoperative and postoperative knee society and knee society functional scores were documented. Multivariate regression analysis was done to determine the association of preoperative radiological parameters with coronal and sagittal TF subluxation.

RESULTS

The average follow-up was 31 months (2.6 years). 102 knees (57%) had CTF subluxation (< 5 mm) within normal range, and 77 knees (43%) had CTF subluxation. There was a direct correlation between the magnitude of CTF subluxation and poor preoperative functional scores compared with the non-subluxation group (p < 0.05). CTF subluxation was not associated with the magnitude of varus deformity as it is correlated more with mild deformity (odds ratio [OR] 10.07, 95% confidence interval [CI] 3.47-29.25) than with moderate and severe varus deformity. The degree of the joint line convergence angle was positively correlated with the amount of CTF subluxation (p = 0.003). STF subluxation had a significant correlation with the posterior slope (p < 0.001), but not with the magnitude of varus deformity (p = 0.26).

CONCLUSION

Coronal and sagittal tibiofemoral subluxation had a significant association with poor preoperative clinical scores. The degree of CTF subluxation reduces with the increasing magnitude of varus deformity and JLCA. STF subluxation was associated with the posterior tibial slope. Patients who underwent posterior stabilized TKA had excellent clinical outcomes irrespective of preoperative knee subluxation.

Advanced disc degeneration, bi-planar instability and pathways of peri-discal gas suffusion contribute to pathogenesis of intradiscal vacuum phenomenon

PURPOSE

Intradiscal vacuum phenomenon (IDVP), despite being ubiquitous, is poorly understood. The dynamic passage of peri-discal gases into the degenerated disc is a commonly accepted theory. But the reasons behind its selective appearance in some discs are unevaluated.

METHODS

721 patients with chronic low back pain ± radiculopathy, were evaluated with AP and flexion-extension lateral radiographs and MRI. IDVP was classified based on its morphology and location. Radiographic parameters including sagittal translation, sagittal angulation, lateral listhesis, eccentric disc collapse, Pfirrmann's grade, disc height, Modic changes, anterior longitudinal ligament status, and primary spinal disease at the level of IDVP was analyzed.

RESULTS

IDVP was present in 342 patients, and they had a higher mean age (57.2 ± 12.5 years) than controls (p < 0.001). Eccentric disc space narrowing (26.5% vs 1.3%, p < 0.01), coronal listhesis (7.83% vs 1.1%, p < 0.001), sagittal angular motion difference (11.3 ± 4.6°, p < 0.001), higher mean disc degeneration (4.36 ± 0.69, p < 0.001), ALL disruption (30.3% vs 2.2%, p < 0.001) and Modic changes (88.6% vs 17.5%, p < 0.001) were significantly higher in IDVP discs (vs. non-IDVP). Binary logistic regression analysis indicated sagittal angular motion difference was the most predictive factor. IDVP was classified into three types-dense type (47.5%), linear (29.5%), dot type (23%). Dense type matched radiological correlations of IDVP while dot types behaved like non-IDVP discs.

CONCLUSION

Modic disc-endplate contacts, ALL disruption and coronal translation could be pathways for the passage of peri-discal gases into the degenerated disc. In the pathogenesis of IDVP, advanced disc degeneration, the presence of pathways of gas transfer and angular/coronal instability seem to play complementary roles.

Analysis of risk factors and treatment outcome in patients presenting with neglected congenital spinal deformity and neurological deficit

PURPOSE

Congenital spinal deformities (CSD) are uncommon; and usually present during early childhood. Rarely, patients have been reported to present with neglected CSD in association with myelopathy. The current study reports the largest series of patients with neglected CSD and major neuro-deficit; and discusses their long-term outcome.

METHODS

We retrospectively analysed patients with CSD who presented with myelopathy and underwent surgical management between January 2008 and January 2018. Only patients who had complete clinico-radiological records and completed minimum 2-year follow-up were included. Neurology was graded according to American Spinal Injury Association Impairment, Nurick and modified Japanese Orthopaedic Association scores. Radiological details like deformity type, location, magnitude, and underlying anomaly were recorded. A comparative analysis of parameters between pre-operative and final follow-up periods was performed.

RESULTS

Thirty three (age = 21.1 ± 11.9 years) patients with CSD and myelopathy were included. Mean duration since myelopathy was 5.2 ± 6.2 months. Thirty (91%) patients presented with kyphosis or kyphoscoliosis; and 18 had upper thoracic-level lesion (12 and 3 with mid- or low-thoracic and lumbar lesions). 16 (48.5%) and 12 (36.4%) presented with types 1 and 3 anomalies, respectively. Mean pre-operative mJOA and Nurick grades were 8.8 ± 2.4 and 3.4 ± 0.7. Based on ASIA score, 2, 5, 21 and five patients presented with grades A, C, D and E, respectively. All patients underwent surgeries from posterior-only approach. Mean follow-up was 4.7 ± 2.6 years. In kyphoscoliosis group, coronal and sagittal Cobb improved by 23.8° and 25.9°, respectively. Mean deformity improved by 19.6° and 15.6° in scoliosis and kyphosis groups, respectively. Neurological status improved in 5, remained stable in 23 and deteriorated in five patients. Mean mJOA and Nurick grades at final follow-up was 8.3 ± 3.1and 3.4 ± 0.9.

CONCLUSION

Major neurological deficit is a rare complication of neglected CSD. In our series, such a presentation was observed in patients with kyphotic or kyphoscoliotic deformities, type 1 or 3 vertebral anomalies and proximal thoracic vertebral lesions. Surgery can be valuable in these patients, as it not only stabilises deformity, but also provides the best chance of preventing neuro-deterioration.

The analysis of progression of disc degeneration in distal unfused segments and evaluation of long-term functional outcome in adolescent idiopathic scoliosis patients undergoing long-segment instrumented fusion

PURPOSE

To analyse the progression of disc degeneration in distal unfused lumbar segments in post-operative Adolescent Idiopathic Scoliosis (AIS) patients; and to evaluate pre-operative and post-operative radiological parameters associated with progressive disc degeneration.

METHODS

A retrospective study of patients, who underwent surgery for AIS between 2006 and 2013 at a tertiary-care spine hospital, was conducted. Only patients aged between 11 and 18 years, who underwent deformity correction surgery with pedicle screw-only constructs, minimum of 6.5 year follow-up, and complete radiological data, and were included. On plain radiographs, coronal cobb's angle (CCA), apical translation, lower instrumented vertebra tilt (LIV tilt), LIV-Sacral angle, and sagittal spinal and pelvic parameters were measured. Disc degeneration was assessed on Magnetic Resonance Imaging (MRI) using Pfirrmann's grading. Total endplate score (TEPS) and facet degeneration (by Fujiwara's grading) were also measured. Based on the difference in progression of disc degeneration, patients were classified as Pfirrmann's grade static (PGS) and Pfirrmann's grade progressive (PGP) groups. Comparison of all pre- and post-operative parameters was made between PGS and PGP groups, and statistically analyzed. Functional evaluation was performed using SRS-22 score.

RESULTS

A total of 58 patients were finally included. The mean follow-up was 9.1 years. 43 (74.1%) and 15 (25.9%) patients were classified under PGS and PGP groups, respectively. Among the15 patients in PGP group, selected LIV was L4 in 8, L3 in 3, L1 in 3, and L2 in 1. Among them, 11 patients (73.3%) progressed from grade 1 to grade 2. In the remaining 4 (26.6%), Pfirrmann's grade progressed to ≥ 3. The progression of disc degeneration did not correlate with age or sex distribution (p = 0.3), pre-operative and post-operative TEP scores (p = 032), pre-operative disc or facet degeneration (p = 0.52), number of unfused spinal segments (p = 0.56), pre-operative or post-operative coronal (p = 0.42), or sagittal spinal (p = 0.27) or pelvic parameters (p = 0.14). The final functional outcome (SRS-22) was not significantly different between PGS and PGP groups (p = 0.67).

CONCLUSION

74% of AIS patients demonstrated no signs of progressive disc degeneration at an average follow-up of 9.1 years. 26% (15/58) of AIS patients demonstrated progressive disc degeneration, among whom, degeneration progressed by only 1 Pfirrmann's grade in 74% (11/15). In the remaining four patients, disc degeneration progressed to Pfirrmann's grades 3 or greater. There was no correlation between higher grades of disc degeneration and lower instrumented vertebra (LIV) or functional outcomes scores (SRS-22).

Pelvic osteotomies in hip dysplasia: why, when and how?

Acetabular dysplasia is a significant problem in the spectrum of developmental dysplasia of hip. In a younger child, positioning the femoral head into the acetabulum helps in reciprocal remodeling of the acetabulum and correction of dysplasia. In an older child, the remodeling potential is limited and often the acetabular dysplasia needs surgical intervention in the form of a pelvic osteotomy.

Thus, pelvic osteotomy forms an integral part of surgical management of hip dysplasia. The ultimate goal of these osteotomies is to preclude or postpone the development of osteoarthritis and add more years of life to the native hip.

Pelvic osteotomies play a pivotal role in normalizing hip morphology. The choice of pelvic osteotomy depends on the age of a child, the type of dysplasia and the status of the tri-radiate cartilage.

Several types of re-directional and reshaping pelvic osteotomies have been described in the literature to improve the stability and restore the anatomy and biomechanics of the dysplastic hip.

This article attempts to review the current indications for various pelvic osteotomies with a brief description of their techniques along with the outcomes and complications published thus far. Besides, the guidelines to choose the right pelvic osteotomy are also provided.

Reconstruction of Massive Segmental Distal Femoral Metaphyseal Bone Defects After Open Injury: A Study of 20 Patients Managed with Intercalary Gamma-Irradiated Structural Allografts and Autologous Cancellous Grafts

BACKGROUND

Our aim was to examine the outcome of gamma-irradiated intercalary structural allografts combined with autologous cancellous grafts in treating large metaphyseal bone defects of the distal femur following open injuries.

METHODS

We prospectively included 20 consecutive patients with large metaphyseal bone defects of >4 cm located in the region of the distal femur following open injuries treated between 2010 and 2018, with a mean follow-up of 2 years (range, 2 to 10 years). Of these patients,18 were men and 2 were women. The mean age was 39 years (range, 22 to 72 years). The mean length of the bone defects was 10.1 cm (range, 5.5 to 14.5 cm), and all were in the metaphysis of the distal femur. The surgical technique included initial early debridement and external fixation followed by reconstruction of the bone defect using structural allograft combined with autologous cancellous bone graft harvested from the iliac crest and locking plate fixation. Definitive fixation was performed at an average period of 22.5 days (range, 3 to 84 days) after injury. Osseous union, rate of infection, complications, need for secondary procedures, and functional outcome using the Lower Extremity Functional Scale (LEFS) at the final follow-up were assessed.

RESULTS

After excluding 1 patient who was lost to follow-up, 19 patients with complete follow-up were available for analysis. Of those, 13 patients (68%) achieved complete union at both ends of the allograft with host bone without any further intervention. Three patients (16%) developed aseptic nonunion of the proximal end of the allograft requiring 1 additional procedure each to achieve union. Four patients (21%) developed a deep surgical site infection. Of those, 1 elderly patient required above-the-knee amputation following uncontrolled diabetes and infection. A second patient required 2 additional procedures, and a third patient needed 4 additional procedures to achieve union. The fourth patient developed infection after achieving union, and the infection subsided after debridement and implant removal. The mean LEFS score for all 19 patients was 55 (range, 41 to 75).

CONCLUSIONS

Use of allograft was a reasonable single-stage alternative solution for massive distal femoral bone defects, which united without additional surgery in two-thirds of the patients and without limb-length discrepancy.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Bilateral Unstable Severe Valgus Slipped Capital Femoral Epiphysis: A Case Report

CASE

Bilateral valgus slipped capital femoral epiphysis (SCFE) is a rare condition with few cases reported in the literature. However, there are no reports of bilateral unstable valgus SCFE. We report a unique case of bilateral acute-on-chronic unstable valgus SCFE with severe coxa valga in a 9-year-old girl. She was treated with bilateral capital realignment procedure along with subtrochanteric osteotomy and had a good clinical outcome.

CONCLUSION

We hitherto report a rare case of bilateral unstable valgus SCFE which was successfully managed. This report also highlights the importance of the need for additional osteotomies to address the deformity.

Reduced RBPMS Levels Promote Cell Proliferation and Decrease Cisplatin Sensitivity in Ovarian Cancer Cells

Worldwide, the number of cancer-related deaths continues to increase due to the ability of cancer cells to become chemotherapy-resistant and metastasize. For women with ovarian cancer, a staggering 70% will become resistant to the front-line therapy, cisplatin. Although many mechanisms of cisplatin resistance have been proposed, the key mechanisms of such resistance remain elusive. The RNA binding protein with multiple splicing (RBPMS) binds to nascent RNA transcripts and regulates splicing, transport, localization, and stability. Evidence indicates that RBPMS also binds to protein members of the AP-1 transcription factor complex repressing its activity. Until now, little has been known about the biological function of RBPMS in ovarian cancer. Accordingly, we interrogated available Internet databases and found that ovarian cancer patients with high RBPMS levels live longer compared to patients with low RBPMS levels. Similarly, immunohistochemical (IHC) analysis in a tissue array of ovarian cancer patient samples showed that serous ovarian cancer tissues showed weaker RBPMS staining when compared with normal ovarian tissues. We generated clustered regularly interspaced short palindromic repeats (CRISPR)-mediated RBPMS knockout vectors that were stably transfected in the high-grade serous ovarian cancer cell line, OVCAR3. The knockout of RBPMS in these cells was confirmed via bioinformatics analysis, real-time PCR, and Western blot analysis. We found that the RBPMS knockout clones grew faster and had increased invasiveness than the control CRISPR clones. RBPMS knockout also reduced the sensitivity of the OVCAR3 cells to cisplatin treatment. Moreover, β-galactosidase (β-Gal) measurements showed that RBPMS knockdown induced senescence in ovarian cancer cells. We performed RNAseq in the RBPMS knockout clones and identified several downstream-RBPMS transcripts, including non-coding RNAs (ncRNAs) and protein-coding genes associated with alteration of the tumor microenvironment as well as those with oncogenic or tumor suppressor capabilities. Moreover, proteomic studies confirmed that RBPMS regulates the expression of proteins involved in cell detoxification, RNA processing, and cytoskeleton network and cell integrity. Interrogation of the Kaplan-Meier (KM) plotter database identified multiple downstream-RBPMS effectors that could be used as prognostic and response-to-therapy biomarkers in ovarian cancer. These studies suggest that RBPMS acts as a tumor suppressor gene and that lower levels of RBPMS promote the cisplatin resistance of ovarian cancer cells.

Silent Otitis Media Presenting as Subperiosteal Abscess- A Case Report

Otitis media is an inflammation of mucoperiosteal layer of the middle ear cleft which occurs mostly due to eustachian tube dysfunction superadded with an infective etiology. It is said that younger children are more commonly affected due to the anatomical difference of eustachian tube in children from an adult, but adults are affected as well. Usually acute otitis media may settle following a course of antibiotics, however, it can lead to persistence of infection or becoming chronic and may lead to severe intra and extracranial complications. This report is about a 16-year-old male who presented with a painful swelling in right postauricular region for two weeks duration. The right ear had a diffuse swelling of size 6x1x5 cm in the postauricular region, tender on palpation, firm in consistency, and was fluctuant. Otoscopic examination of the right ear showed bulge out and intact tympanic membrane without active discharge and congestion. High Resolution Computed Tomography (HRCT) of temporal bone showed right otomastoiditis with erosion of the lateral cortex of the right mastoid. He underwent right cortical mastoidectomy under general anaesthesia. The patient was on follow-up for six months and no recurrence was noted.

Role of Telemedicine in Otorhinolaryngology during COVID-19 Pandemic in a Tertiary Care Centre of Tamil Nadu: A Prospective Cohort Study

Introduction: Telemedicine is the practice of using telecommunication technology to provide healthcare services to patients in remote areas. Teleconsultation is used in various specialties of medicine, especially during the COVID-19 pandemic situation. But in developing countries like India, it is less practicable in surgical specialties like Otorhinolaryngology. Aim: To determine the eligibility and effectiveness of telemedicine practice in otorhinolaryngology during the COVID-19 pandemic in a tertiary care centre of Chengalpattu district, Tamil Nadu, India. Materials and Methods: A prospective cohort study was conducted at Chettinad Hospital and Research Institute, Tamil Nadu, India from September 2021 to February 2022 which involved 90 patients who requested a consultation for various ear, nose, and throat complaints. Based on history, a provisional diagnosis was made and treated. Feedback forms contained 11 questions were sent during the revisit and analyses were made. Statistical analysis were done using mean, proportion and Chi-square test. Results: This study included 49 (54.4%) male and 41 (45.6%) female patients with a mean age of 40.68 years. Only 23 (25.6%) patients had no problem seeing the doctor clearly and 19 (21.1%) had no trouble hearing the doctor. Only 4 (4.4%) patients accepted teleconsultation and will use teleconsultation services again. Conclusion: This study concluded that teleconsultation practice was not satisfactory for the majority of patients in the field of otorhinolaryngology. The inability to arrive at the definitive diagnosis and subsequent therapeutic procedures by using telemedicine was the limitation.

Modic changes are associated with activation of intense inflammatory and host defense response pathways - molecular insights from proteomic analysis of human intervertebral discs

BACKGROUND CONTEXT

Patients with modic changes (MC) form a distinct clinical subset with reports of higher intensity of pain, poor clinical and surgical outcomes and higher incidence of recurrence. MC also is an independent risk factor for increased post-operative surgical site infection.

PURPOSE

This study aimed to investigate the biological changes at molecular level, in discs with MCs. We also aim to identify biological biomarkers and potential targets for molecular therapy.

STUDY DESIGN

Experimental analysis MATERIALS AND METHODS: Nucleus pulposus (NP) from 24 patients undergoing microdiscectomy for disc herniation [14 discs with MC and 10 without modic changes (NMC)] were procured. The overall expression of proteins, biological processes, protein-protein and metabolite interactions were analysed and compared. Host defense response proteins (HDRPs) and immunological pathways activated in patients with MC were documented and analysed.

RESULTS

Label-free proteomic approach with stringent filters revealed a total of 208 proteins in MC and 193 in NMC groups. 45 proteins were specific to MC; 30 to NMC and 163 common to both. Downregulated proteins in MC belonged to components of extracellular matrix such as collagens (COL- 6A1, 6A2, 6A3, 11A1, 12A1, and 20A1), and proteoglycans (versican (VCAN), and biglycan (BGN)). Inflammatory molecules [plasminogen (PLG), angiogenin (ANG), fibroblast growth factor-binding protein 2 (FGFBP2), tetranectin (CLEC3B), cartilage acidic protein 1(CRTAC1), kininogen (KNG-1), chitinase-3-like protein 2 (CHI3L2), and ferritin (FTL) were expressed only in the MC group. The significantly altered pathways in MC included Fc Fragment of IgG Receptor IIIa (FCGR3A)-mediated phagocytosis, regulation of Toll-like receptors (TLR) by endogenous ligand, neutrophil and platelet degranulation. 50 HDRPs were identified in the study, 14 of which were specific to MC and included acute phase reactants, antimicrobial peptides, complement cascade proteins, inflammatory molecule and stress response proteins. Metabolite-protein interaction analysis revealed a significant interaction between 19 proteins, specifically involving ubiquitin mediating proteasome degradative pathway and an association with the metabolite-glutamic acid in the MC group. Accumulation of glutamic acid in MC discs was confirmed by quantitative amino acid analysis using High-performance liquid chromatography.

CONCLUSION

Our study confirms that MC represents an intense inflammatory status and activation of host defense response and immunological pathways. Downstream effects leading to ubiquitin mediated proteasomal degradation of ECM proteins and the resulting metabolites such as glutamic acid could cause excessive pain and needs further investigation.

CLINICAL SIGNIFICANCE

We have documented the expression of inflammatory molecules, immune mechanisms and host defense response proteins which throw molecular insights into the pathological mechanisms of MC. Further, ubiquitin mediated proteasomal degradation and accumulation of glutamate in discs with MC might serve as targets for molecular therapy.