An unusual case of symmetric quadruple limb fractures

A 19-year-old man had an accidental fall from the 2nd floor and sustained multiple injuries. On radiological evaluation, the patient had symmetrical quadruple limb involvement with bilateral humerus shaft, bilateral olecranon, bilateral femur shaft, and bilateral patella fractures. The patient was actively managed using damage control orthopaedics, and a sequence of skeletal fixation was planned based on the hemodynamic stability and periodical serum lactate assessment. Symmetrical quadruple limb fractures are very rare, which could be associated with higher mortality. A meticulous clinical evaluation, periodical blood parameter assessment and strict adherence to the principles of damage control orthopaedics can be conducive to prevent life-endangering complications.

Intracapsular fracture of the proximal femur in a bilateral above-knee amputee: A case report with technical tips for intraoperative positioning and literature review

Intracapsular fractures of the proximal femur are one of the most common fractures of the lower limbs. Most cases require osteosynthesis with suitable implants, and intraoperative positioning of the patient on the fracture table is a prerequisite to facilitate fracture manipulation, traction, reduction and fluoroscopy assessment. However, positioning the limbs of bilateral above-knee amputees for internal fixation of related proximal femoral fractures is a difficult task, which requires customized inventory for effective limb positioning and fracture manipulation. This study reported a rare case following a crush injury of bilateral lower limb in a road traffic accident, and described some technical tips of acute femoral neck fractures in bilateral above-knee amputation. The patient was managed with immediate guillotine amputation and later secondary wound closure followed by internal fixation of the right-sided femoral neck fracture with multiple cancellous cannulated screws.

Bipolar clavicular dislocation treated with biological anatomical repair and reconstruction: A case report with a literature review of management options

Bipolar clavicular dislocation is rare, and therefore its management is contentious. With an increase of patient's physical demand and a near-normal shoulder function, there has been a shift in the paradigm of its management from a conservative one to a stabilized one of anatomical open reduction. Proposed methods of fixation have also evolved with the advent of more biological fixation devices, which elude implant or fixation related complications. This case report highlights the salient features of this rare case and details the management options along with the benefits of biological anatomical repair and reconstruction.

P-381 A novel natural cycle proliferative phase/progesterone replacement(NC/PR) protocol for endometrial preparation for frozen-thawed embryo transfer(FET) Can it improve pregnancy outcomes : a prospective comparative study

Study question

Can a novel protocol for endometrial preparation- NC/PR-FET, lead to better pregnancy outcomes than artificial cycle (AC)-FET, with similar ease of cycle monitoring and scheduling?

Summary answer

NC/PR-FET protocol gave comparable clinical pregnancy rates (CPR), significantly less early miscarriage rates (MR) and significantly more live birth rates (LBR) compared to AC-FET protocol.

What is known already

AC-FET is the most common protocol for endometrial preparation due to flexibility, easy monitoring, and high pregnancy rates albeit with evidence of higher obstetrical risks e.g., miscarriage, pre-eclampsia versus NC-FET. This risk could be due to suboptimal hormonal administration in AC-FET leading to impaired endometrial maturation, predecidualization, and altered endometrial function. Studies indicate, estradiol may have a stronger negative effect(versus progesterone) on the endometrial transcriptome. Hence, we studied a novel protocol with NC-estrogen (but with progesterone similar to AC-FET), for better endometrial maturation, predecidualization along with simple monitoring and flexible ET scheduling. Previously, a proof-of-concept case-series has been reported.

Study design, size, duration

The prospective comparative study was conducted at a tertiary center (Jan2019-Dec2021) with 126 patients (both autologous [AO] and donor oocytes [DO]):79 (AC-FET) and 47 (NC/PR-FET) with similar ICSI, vitrification, ET protocols. 2 or 3 Grade A cleavage stage embryos were transferred. CPR, implantation rates(IR), early MR (≤13 weeks, miscarriages/clinical pregnancies) and LBR (≥28 weeks, LBs/ETs) were compared. Serum progesterone was studied on day 5 post-ET. Antenatal care and most deliveries were at the same institute.

Participants/materials, setting, methods

Patients were non-smokers with normal hysteroscopy. In AC-FET, oral estradiol (6-8mg) was initiated from day 1-2 (for 10-17 days). In both groups, when endometrium ≥7mm and S.progesterone<1ng/ml, intramuscular progesterone was initiated(daily till day 4 post-ET, then every 3rd day till week 8). ET was scheduled on day 4 of intramuscular progesterone, and concurrently, vaginal progesterone was added (till week 10). Chi-square, t-tests, and multiple regression was used for statistical analysis and 2-tailed P <.05 indicated statistical significance.

Main results and the role of chance

Mean age and BMI were comparable in NC/PR-FET and AC-FET groups: 34.48±4.69 years vs. 33.58 ± 5.62 years (P =.35) and 26.27 ± 3.62 kg/m2 vs. 27.34 ± 4.61kg/m2 (P =.18) respectively. Similarly, the source of oocytes (%AO) and % singletons were also comparable in NC/PR-FET and AC-FET groups: 57.4% vs. 46.8% (P = .25), and 78.1% vs. 75% (P= .75) respectively. There were 3 ectopic pregnancies overall. The CPRs and IRs were comparable: 68.09% (NC/PR-FET) vs. 60.76% (AC-FET) (P=.41) and 32.30% (NC/PR-FET) vs. 28.96% (AC-FET) (P=.45) respectively.

The early MR was significantly more in AC-FET vs. NC/PR-FET: 29.17% vs. 6.25% (P =.012). Consequently, LBRs were significantly more in NC/PR-FET vs. AC-FET: 59.57% vs. 39.24% (P =.028). After adjusting for age, BMI, AO/DO, this difference remained significant (AOR 2.66; 95% CI 1.21-5.81; P =.014)

Mean serum progesterone was comparable in all patients in both groups: 38.50 ± 13.6ng/ml (NC/PR-FET) vs. 40.98 ± 28.64 ng/ml (AC-FET) (P =.57). Serum progesterone levels were also comparable in patients who were pregnant in both groups: 38.51 ± 14.79 (NC/PR-FET) vs. 42.25 ± 32.63 (AC-FET) (P =.53).Also, in the AC-FET group serum progesterone was comparable in patients who aborted,44.23 ± 31.60 vs. those who didn’t, 41.48 ± 33.44 (P =.79).

Limitations, reasons for caution

This was a single center study. Due to limited sample size, we could not control for many potential confounders (e.g., multiple pregnancies). For the same reason, we could not compare obstetrical risks as a study outcome.

Wider implications of the findings

This study shows significantly better pregnancy outcomes with a novel NC/PR-FET protocol vs. AC-FET. This needs to be validated in larger studies. Since suboptimal hormone administration in AC-FET could be causal factor for pre-eclampsia, larger studies can test if the NC/PR-FET protocol can lead to better obstetrical outcomes.

Trial registration number

not applicable

Patella Locking Star-Plate as Salvage to the Failed Tension Band Wiring for a Patella Fracture: A Case Report

The integrity of the patella is pivotal for the efficient functioning of the knee extensor mechanism. Thus, patella fracture management cannot be neglected and utmost priority should be determined for its preservation and maintenance of knee functioning. Tension band wiring (TBW) is the most widely and commonly used mode of fixation of patella fractures with consistently favourable outcomes. However, the complications associated with the same could be challenging and may compromise the integrity of the patella. This case report highlights the salvage of the failed TBW for a patella fracture with biomechanically stronger angular stable Star-shaped patella plate.

Sequence of Fixing Fractures Involving all the Three Major Joints of the Upper Limb: A Case Report

A 29-year-old lady accidentally fell from the first floor at home, sustained multiple fractures all on the left side which were the proximal humerus fracture, inter-condylar distal humerus fracture, intra-articular distal end radius fracture, and acetabulum fracture. She was actively managed following Advance Trauma life Support (ATLS) protocol and once stabilised was operated in a stage-wise manner for all the fractures. This case report is about the unusual presentation of multiple fractures involving all the three ipsilateral major joints of the upper limb in an adult following a fall from a height and highlights the uniqueness of the fracture's presentation and effective surgical management for better outcomes and rehabilitation.

C-reactive protein (CRP) and Erythrocyte Sedimentation Rate (ESR) Trends following Total Hip and Knee Arthroplasties in an Indian Population - A Prospective Study

INTRODUCTION

To evaluate the trends of C-reactive protein (CRP) and Erythrocyte sedimentation rate (ESR) in the first three weeks after uncomplicated total hip (THR) and total knee (TKR) arthroplasty/replacement in the Indian population and to compare it with available literature.

MATERIALS AND METHODS

A total of 90 patients were enrolled for this prospective study, of which 30 were unilateral THR, 30 were unilateral TKR (U/L TKR) and 30 were simultaneous bilateral TKR (B/L TKR). Serum CRP and ESR were measured on the day before surgery and post-operatively on day 1st, 2nd, 3rd, 7th, 12th, and at the end of 3rd week.

RESULTS

CRP showed a peak at day 2nd with normalisation to pre-operative value by the end of 3rd week. While ESR showed a peak on day 3rd and continued to remain elevated even at end of 3rd week post-operatively. Both mean CRP and ESR values were higher in THR patients followed by in B/L TKR and then in U/L TKR patients.

CONCLUSION

CRP persists to be the best acute phase reactant in the early post-operative phase with a relatively typical pattern as compared to ESR. CRP values peak at post-operative day 2nd and then show a gradual decline. However, its normalisation to pre-operative baseline values may vary among different groups of population.

Full Thickness Tear of Quadriceps Tendon Associated with Closed Intra-Articular Distal Femur Fracture: A Case Report

Fractures of the supracondylar and intercondylar region of the distal femur usually result from high velocity injury that is uncommonly associated with violation of the integrity of the extensor mechanism. The consequences of missed quadriceps injury associated with a distal femur fracture are devastating. The present case report illustrates the importance of recognizing the rare association of quadriceps tear with distal femoral fractures, an appropriate surgical approach to repair the tear as well as fixation of fracture, and a protocol of postoperative rehabilitation to achieve a successful outcome.

Asperity level characterization of abrasive wear using atomic force microscopy

Using an atomic force microscope, a nanoscale wear characterization method has been applied to a commercial steel substrate AISI 52100, a common bearing material. Two wear mechanisms were observed by the presented method: atom attrition and elastoplastic ploughing. It is shown that not only friction can be used to classify the difference between these two mechanisms, but also the 'degree of wear'. Archard's Law of adhesion shows good conformity to experimental data at the nanoscale for the elastoplastic ploughing mechanism. However, there is a distinct discontinuity between the two identified mechanisms of wear and their relation to the load and the removed volume. The length-scale effect of the material's hardness property plays an integral role in the relationship between the 'degree of wear' and load. The transition between wear mechanisms is hardness-dependent, as below a load threshold limited plastic deformation in the form of pile up is exhibited. It is revealed that the presented method can be used as a rapid wear characterization technique, but additional work is necessary to project individual asperity interaction observations to macroscale contacts.

Non-subungual presentation of osteochondroma in toes-A case report with review of literature

A 23-year-old male presented with long-standing swelling in the middle of the third toe right side with difficulty in wearing footwear. Clinical examination revealed it as bony hard fixed swelling moving with interphalangeal joint movements. Clinical diagnosis of benign bony swelling was made and radiological investigation demonstrated features suggestive of osteochondroma. En-mass excision of the lesion was done, with histo-pathological confirmation of osteochondroma. Although the subungual presentation of osteochondroma or exostosis in toes is quite common, the astounding non-subungual presentation should also be kept in mind as a plausible differential diagnosis of benign bony swelling in toes.

Present and future scope of recombinant parathyroid hormone therapy in orthopaedics

Parathyroid Hormone (PTH) has a significant role in calcium metabolism. Its intermittent administration has an anabolic effect on bone mineralization. Teriparatide (PTH 1-34), a recombinant form of parathyroid hormone, is useful in the treatment of osteoporosis, fracture healing, non-union, stress fracture, augmentation of implant fixation with bone, and chondroprotection in osteoarthritis. The present review article will elaborate on the potential approved uses of recombinant PTH in orthopedics and its evolving role in the management of fracture osteosynthesis and other common challenging bone pathologies.

Extensor Mechanism Reconstruction Using Allograft Following Total Knee Arthroplasty: A Review of Current Practice

The disruption of the extensor mechanism/apparatus of the knee is a dreaded complication following Total Knee Arthroplasty (TKA). Fresh frozen allograft containing the patella, and peripatellar musculotendinous attachments has emerged as an ideal alternative or salvageable option for the efficient reconstruction of extensor mechanism disrupted following TKA, where repair is almost impossible. However, any allograft implantation is associated with certain complications and extensor apparatus allograft is not the exception. Despite being allogenic, reconstruction of the extensor mechanism of the knee using allograft has given promising results. This narrative review aims to elaborate on the current application of allograft in the reconstruction of the disrupted extensor mechanism following TKA.

Amid COVID-19 pandemic-an innovative use of local resources to substitute the need for specialized operation theatre tables for orthopaedic and trauma surgery

Pelvic-acetabulum and spine surgery are two important constituents of complex trauma surgery and require a gamut of resources for fracture management. In the pandemic crisis of COVID-19 where existing health care resources are scarce and a major section of health care infrastructure has been assigned to fight against it, the compromised and less equipped health care facility is left to tackle the ongoing presentation of complex trauma surgery. One major challenge faced to manage these complex procedures is the availability of specialized radiolucent operation tables as even the apex level health care setups generally have one or two such kinds of table. Therefore, in this state of pandemic crisis, innovations utilizing the available local resources need to be developed to avoid deferring these complex operations.

Osteoporotic Distal Fibula Fractures in the Elderly: How To Fix Them

Osteoporotic fractures of the distal fibula in elderly patients is a challenge to manage. Non-operative management has a poor outcome so operative management is preferred. There are a variety of options for operative management such as locked plate systems, anti-glide plate construct, dual plating constructs, fibula nail, plate with tibial pro-fibular screws, and injectable bone cement (polymethylmethacrylate (PMMA), calcium phosphate). However, no clear guidelines exist for the operative management of osteoporotic distal fibula fractures. The surgeon should detect osteoporotic fractures early to make the best use of resources and avoid complications such as implant failure.

Radial Nerve Palsy After Intercondylar Distal Humerus Fracture: A Case Report

CASE

A 30-year-old man sustained an injury to the right elbow after a fall from a bike. On clinical examination, he had preoperative radial nerve palsy with radiological diagnosis of the intercondylar distal humerus fracture. Intraoperatively, the patient had the radial nerve entrapped between the proximal metaphyseal fragment and distal lateral condyle of the humerus.

CONCLUSION

Preoperative radial nerve palsy associated with the intercondylar distal humerus fracture is very rare. Fractures with the significant anterolateral displacement of the proximal metaphyseal fracture segment may entrap the course of the radial nerve in the anterior compartment of the distal humerus and thus manifest as radial nerve palsy.

Epidemiological assessment of acetabular fractures in a level one trauma centre: A 7-Year observational study

PURPOSE

The present study was conducted to evaluate the epidemiological characteristics of the Acetabular fractures treated in a level one trauma centre of India. This study is one of the largest to provide first-hand information regarding the demography, fracture patterns, other associated injuries, and the hospital stay of acetabular fractures in India.

METHOD

Patients admitted with the diagnosis of acetabular fractures between January 2013 and November 2019 were retrospectively analyzed in terms of demographic data such as age and sex, mechanism of injury, other associated injuries, and the duration of hospital stay.

RESULTS

A total of 305 patients with 313 fractures of the acetabulum were included in the study. Among the 305 patients, 268 (87.8%) were male and 37 (12.1%) were female, with a declining male to female ratio over the years. The mean age was 37.1 ± 13.2 years (range 14-84 years). During the seven years, the mean age of presentation progressively increased. Linear regression showed an increase from 33 to 40 years from 2013 to 2019 (R2 = 0.027). Road traffic injuries were the most common mechanism of injury, contributing to about 77.4% of all cases. Associated injuries were seen in 62% of total cases with multiple system involvement in 26.6% of patients. The most frequent pattern in this epidemiological study was an isolated posterior wall fracture (21.4%) while the isolated anterior wall was the least frequent (0.95%).

CONCLUSION

Acetabular fractures are increasing in numbers and with increasing knowledge so is their surgical management in our country. It shall be prudent to establish an integrated electronic national trauma registry to maintain complete documentation in all institutions dealing with trauma management to ascertain the changing trends of acetabular fracture patterns in the country over time.

Effects of the intramyocardial implantation of stromal vascular fraction in patients with chronic ischemic cardiomyopathy

Background

Stromal vascular fraction (SVF) can easily be obtained from a mini-lipoaspirate procedure of fat tissue. The SVF contains a mixture of cells including ADSCs and growth factors and has been depleted of the adipocyte (fat cell) population. We evaluated the safety and efficacy of administering SVF intra-myocardially into patients with chronic ischemic cardiomyopathy.

Methods

A total of 28 patients underwent a local tumescent liposuction procedure to remove approximately 60 ml of fat tissue. The fat was separated to isolate the SVF and the cells were delivered into the akinetic myocardial scar region using a transendocardial delivery system (MyoCath^®) in patients who had experienced a previous myocardial infarct. The subjects were then monitored for adverse events, ejection fraction via echocardiogram and six-minute walk test (6MWT) over a period of 6 months.

Results

The average EF was 29 % at baseline and significantly increased to 35 % at both 3 and 6 months. Patients walked an average of 349 m at baseline and demonstrated a statistically significant improvement at 3 and 6 months’ post treatment of more than 80 m.

Conclusions

Overall, patients were pleased with the treatment results. More importantly, the procedure demonstrated a strong safety profile with no severe adverse events or complications linked to the therapy.

Trial registration NCT01502514

Name of registry: http://www.clinicaltrials.gov

URL: https://www.clinicaltrials.gov/ct2/show/NCT01502514?term=adipose+cells+heart&rank=4

Date of registration: December 27, 2011

Date of enrollment: January 2012

An improvised two in one syringe suction drain for surgeries of extremities

Use of an improvised two in one syringe suction drain is being presented for a case with two adjacent non-communicating surgical wounds following release of Duputryn′s contracture primarily involving the longitudinal band of the palmar fascia of the hand, in line with the middle and ring finger. Instead of using two separate closed suction drainage system we modified our method by using a 3 way cannula which could accept 2 draining tubes to be connected to one 50cc syringe with negative suction pressure.

Modulation of macrophage structure and function by low level He-Ne laser irradiation

Studies have shown that He-Ne laser irradiation can affect the biological functions of macrophages. The aim of the present study was to investigate the effect of He-Ne laser irradiation on the various functional parameters of macrophages and look for possible correlations in the effects to understand the mechanisms involved. Mice peritoneal macrophages were irradiated with a He-Ne laser (632.8 nm, approximately 10 W m(-2)) at energy densities ranging from 100 to 600 J m(-2) and the activities of lysozyme and cathepsin, phagocytosis, and cell spreading (markers of cell activation), as well as changes in NAD(P)H autofluorescence, were monitored. He-Ne laser irradiation was observed to lead to significant changes in all the parameters investigated. While lysozyme activity and spreading of the peripheral membrane were found to increase with the irradiation dose over the dose range investigated, the phagocytotic activity of macrophages, the activity of cathepsin, the observed decease in cell membrane fluidity and the observed increase in NAD(P)H level showed a peak at 200 J m(-2). Possible reasons for and the significance of the observed correlations are discussed.

A solid liquid extraction and preconcentration method for the atomic absorption spectrometric determination of trace cobalt in various alloys and biological samples

Cobalt is quantitatively retained as cobalt-2-nitroso-4-sulfonic acid (nitros-S)-tetradecyldimethylbenzylammonium (TDBA+) ion-pair complex on microcrystalline naphthalene in the pH range 6.2-9.0 from a large volume of its aqueous solution of various complex samples. After filtration, the solid mass consisting of cobalt complex and naphthalene is dissolved in 5 ml of dimethylformamide (DMF) and the metal is determined by flame atomic absorption spectrometry (FAAS). Cobalt complex can alternatively be quantitatively adsorbed on tetradecyldimethylbenzylammonium chloride-naphthalene adsorbent packed in a column and determined similarly. The calibration curve is linear over the concentration range 0.2-11.5 micrograms of cobalt in 5 ml of the final DMF solution. In this case, 0.2 microgram of cobalt may be concentrated in a column from 250 ml of aqueous sample where its concentration is as low as 0.8 ng/ml. Eight replicate determinations of 3.0 micrograms of cobalt in the final DMF solution give a mean absorbance of 0.045 with a relative standard deviation of 1.8%. The sensitivity for 1% absorption is 59 ng/ml. The interference of a large number of anions and cations on the determination of cobalt has been studied and the optimum conditions developed utilized for its trace determination in various alloys and biological samples. The method may also be used for the determination of cobalt in some environmental samples.