A comprehensive 3D CT based classification of intertrochanteric fracture

INTRODUCTION

Despite advancements in surgical techniques complications like implant failure is very common after the fixation of intertrochanteric fractures. Classifying these complex fractures based on plain radiographs underestimates the complexity of these fractures which in turn leads to complications. We propose a comprehensive classification of the intertrochanteric fractures based on 3D Non Contrast Computed Tomography (3D NCCT) scan.

MATERIAL AND METHODS

A total of 102 patients (51 males and 51 females) with intertrochanteric fractures were included in this study conducted over a time period of 22 months in a Tertiary care center in North India. NCCT proximal femur of the intertrochanteric fracture patients was done to formulate a new CT classification system and classify all fractures. Intra and inter-observer reliability was tested using kappa variance.

RESULTS

New classification system was proposed which included 3 main and a total of 6 groups. All the fractures were classifiable into the new system. Kappa variance of the study showed a good intra and interobserver reliability (0.95 and 0.90) proving clinical agreement of the classification.

CONCLUSION

This new 3D-CT based classification has the advantages of being easy, comprehensible with high intra and inter-observer reliability. This 3DCT based classification can prove to be useful to detect occult intertrochanteric fractures undetectable in plain radiographs as well as choosing the optimum treatment plan.

Infection and utilization rates of bone allografts in a hospital-based musculoskeletal tissue bank in north India

BACKGROUND

The bone bank unit of interest in this article was established in January 2018, in a tertiary care teaching institute of north India. Aim of this article is to describe the sources of allografts obtained, discard rates of allografts and infection rates in the recipients after use.

MATERIAL AND METHODS

All the relevant details of donors and recipients were maintained, and donors were screened for standard inclusion and exclusion criteria before obtaining the grafts. Aerobic culture was performed before storage and just prior to use. Samples with incomplete documentation, incomplete donor screening or positive cultures were discarded. Data on surgical site infection in recipients was collected from hospital records retrospectively. Initially ELISA based serological tests were used for screening. Donor has to undergo these tests again after 6 months to account for the window period of proliferation of viruses. Nucleic acid amplification tests (NAAT) for these viral agents were introduced in the hospital in May 2018.

RESULTS

Allografts from a total of 196 donors were obtained in the bone bank over 2 years. Major source of bone was femoral heads harvested during total hip arthroplasty or hemi-arthroplasty. 44(22.4%) grafts had to be discarded. 95 allografts were used in 88 patients during this time. Most common indication for use was surgery for bone tumors (40%), followed by complex primary or revision arthroplasty (30.5%). Three (3.4%) recipients developed deep infection postoperatively.

CONCLUSION

Frozen allograft bone from hospital based bone banks is a reliable source of allografts. When meticulous precautions for sterility are followed, risk of infection is low. Monitoring of such bone banks should fall within a framework of the local legislature. Incomplete documentation is the major reason for wastage of the samples obtained. NAAT may be useful in screening of donors, as it reduces the wastage and the holding time of the allografts.

Results of ala carte Posteromedial Soft Tissue Release in Idiopathic Clubfoot

Introduction

The aim of this study is to assess the outcomes of ala carte posteromedial release in children over two years of age who were not responding to the Ponseti method of treatment of idiopathic clubfoot.

Material and Methods

A retrospective observational study from September 2013 to August 2015 was conducted at a tertiary level medical teaching institution. The clubfeet were classified according to the Harold and Walker classification. Radiographic parameters assessed were the talocalcaneal angle (AP, lateral), talus-first metatarsal angle (AP, lateral) and calcaneal-fifth metatarsal angle. The scar and the functional score, according to Laaveg and Ponseti, were evaluated as outcome measures at the final follow-up.

Results

Twenty-four children with a mean age of 43.7 ± 24.7 months were enrolled in the study. There was a total of 36 clubfeet: 21 (65.6%) with a poor functional outcome; 12 (37.4%) with excellent to good scar in both horizontal and vertical components. There was a statistical significance between the pre-operative and post-operative radiological parameters (p<0.05). None of the patients presented with any limitation of activities of daily living despite the poor functional outcome in many of the children. There was no significant association between the qualities of scar (horizontal, vertical) and the functional outcome with age at presentation, pre-operative Harold and Walker classification and pre-operative radiographic angles.

Conclusion

Surgical intervention in terms of ala carte posteromedial soft tissue release could not produce a good outcome over four years in CTEV. The threshold for surgery in CTEV should be high, given the poor results.

A prospective study on transfer of pronator teres to extensor carpi radialis brevis for forearm and wrist deformity in children with cerebral palsy

We prospectively evaluated the clinical and functional outcomes of pronator teres to extensor carpi radialis brevis transfer in children with cerebral palsy. Patients were followed-up at 6 months postoperatively, and functionally assessed using the House classification, Manual Ability Classification System (MACS) and Upper Extremity Functional Index (UEFI). Fifteen children with a mean age of 8.1 years underwent tendon transfers. All patients were of Gschwind and Tonkin Grade 2 for pronation deformity; eight patients were of Zancolli's classification Group 1 and seven, Group 2 for wrist flexion deformity. The average gain in active supination was 67°, and wrist extension 15°. An increase of 7.0 in the UEFI score was recorded, although no significant improvement in MACS and House classification was observed. We conclude that the pronator teres to extensor carpi radialis brevis transfer improves upper limb function through effective correction of forearm pronation and wrist flexion deformities.Level of evidence: II.

Quality Comparison of 3 Tesla multiparametric MRI of the prostate using a flexible surface receiver coil versus conventional surface coil plus endorectal coil setup

PURPOSE

To subjectively and quantitatively compare the quality of 3 Tesla magnetic resonance imaging of the prostate acquired with a novel flexible surface coil (FSC) and with a conventional endorectal coil (ERC).

METHODS

Six radiologists independently reviewed 200 pairs of axial, high-resolution T2-weighted and diffusion-weighted image data sets, each containing one examination acquired with the FSC and one with the ERC, respectively. Readers selected their preferred examination from each pair and assessed every single examination using six quality criteria on 4-point scales. Signal-to-noise ratios were measured and compared.

RESULTS

Two readers preferred FSC acquisition (36.5-45%) over ERC acquisition (13.5-15%) for both sequences combined, and four readers preferred ERC acquisition (41-46%). Analysis of pooled responses for both sequences from all readers shows no significant preference for FSC or ERC. Analysis of the individual sequences revealed a pooled preference for the FSC in T2WI (38.7% vs 17.8%) and for the ERC in DWI (50.9% vs 19.6%). Patients' weight was the only weak predictor of a preference for the ERC acquisition (p = 0.04). SNR and CNR were significantly higher in the ERC acquisitions (p<0.001) except CNR differentiating tumor lesions from benign prostate (p=0.1).

CONCLUSION

Although readers have strong individual preferences, comparable subjective image quality can be obtained for prostate MRI with an ERC and the novel FSC. ERC imaging might be particularly valuable for sequences with inherently lower SNR as DWI and larger patients whereas the FSC is generally preferred in T2WI. FSC imaging generates a lower SNR than with an ERC.

Pyogenic Vertebral Body Osteomyelitis in a Child: A Case Report

Introduction:

Pyogenic vertebral body osteomyelitis is rarer in children in comparison to adults. A rare case of pyogenic vertebral body osteomyelitis in a 10-year-old male is presented which was managed conservatively with antibiotics on the basis of antibiogram of blood culture. With 6 weeks of antibiotic therapy and at 12-month follow-up, the patient has no symptoms with no affection of any activity. This should be considered as a differential diagnosis in pediatric patients presenting with atypical symptoms related to spine and hip.

Case Report:

A 10-year-old child presented with a 7-day history of progressively increasing insidious onset pain in the lower back radiating to the right hip, with an associated limp and restriction of floor level activities and activities of daily living. On examination, the child had tenderness at L3, L4, and L5 vertebral level and normal neurology in both lower limbs. A pseudoflexion deformity 20° was also noted in the right hip with normal range of motion in other planes. Keeping a differential of infective etiology of either hip or spine, routine blood investigations, blood culture, and radiological evaluation were done which included X-rays of lumbosacral spine and hip, ultrasound of bilateral hips and abdomen, and magnetic resonance imaging (MRI) of lumbosacral spine. The blood investigations showed an increase in white blood cell count, erythrocyte sedimentation rate, and high-sensitivity C-reactive protein, with the isolation of methicillin-sensitive Staphylococcus aureus in blood culture. Ultrasonography of hip showed mild effusion in the right hip and collections in the psoas; MRI confirmed the findings with an enhancement of L4 vertebral body.

Conclusion:

Pyogenic vertebral body osteomyelitis is a rare diagnosis in children that should be considered in patients with atypical symptoms. MRI is the investigation of choice with prompt antibiotic therapy instituted on time which leads to healing without any sequelae.

Short-term outcome of lamina-sparing decompression in thoracolumbar spinal tuberculosis

OBJECTIVE

The authors sought to assess the outcomes of lamina-sparing decompression using a posterior-only approach in patients with thoracolumbar spinal tuberculosis (TB). In patients with spinal TB with paraplegia, anterior decompression yields excellent results because it allows direct access to the diseased part of the vertebra, but the anterior approach has related morbidities. Posterior and posterolateral decompression mitigate approach-related morbidities; however, these approaches destabilize the already diseased segment. Lamina-sparing decompression through a posterior-only approach is a modification of posterolateral and anterolateral decompression that allows simultaneous decompression and instrumentation while preserving the posterior healthy bony structure as much as possible.

METHODS

Thirty-five patients with spinal TB underwent lamina-sparing decompression and instrumentation. Outcomes were determined by using a visual analog scale (VAS) and the Oswestry Disability Index (ODI) for functional assessment, the American Spinal Injury Association (ASIA) impairment grade for neurological assessment, blood loss and duration of surgery for surgical outcome assessment, and Cobb angles to measure kyphosis correction.

RESULTS

In total, 35 patients (12 men and 23 women) with an average age of 35.8 ± 18.7 (range 4-69) years underwent lamina-sparing decompression. Eight patients had dorsal, 7 had dorsolumbar, 7 had lumbar, 9 had multifocal contiguous, and 4 patients had multifocal noncontiguous spinal TB; 33 patients had paradiscal Pott's spine (tuberculous spondylodiscitis), and 2 had central-type disease. The average preoperative Cobb angle was 28.4° ± 14.9° (range 0°-60°) and the postoperative Cobb angle was 16.3° ± 11.3° (44° to -15°). There was loss of 1.6° ± 1.5° (0°-5°) during 16 months of follow-up. Average blood loss was 526 ± 316 (range 130-1200) ml. Duration of surgery was 228 ± 79.14 (range 60-320) minutes. Level of vertebral instrumentation on average was 0.97 ± 0.8 (range 0-4) vertebra proximal and 1.25 ± 0.75 (0-3) distal to the diseased segment. Neurological recovery during the immediate postoperative period occurred in 23 of 27 patients (85.1%). All patients had recovered at the final follow-up at 16 months. The preoperative ODI score improved from 76.4 ± 17.9 (range 32-100) to 6.74 ± 17.2 (0-60) at 16 months. The preoperative VAS score improved from 7.48 ± 1.16 (6-10) to 0.47 ± 1.94 (0-8). Surgical site infection occurred in 2 patients, and 1 patient had an intraoperative dural tear that was successfully repaired. One patient developed implant loosening at 3 months, which was managed by extended instrumentation.

CONCLUSIONS

To achieve stability, lamina-sparing decompression allows fixation of lower numbers of vertebrae proximal and distal to the diseased segment. This method has a fair outcome in terms of kyphosis correction, good functional and neurological recovery, shorter surgical duration than conventional methods, and less blood loss.

Spinal holocord epidural abscess evacuated with double thoracic interval laminectomy: a rare case report with literature review

Introduction

Holocord spinal cord epidural abscess is an uncommon condition that may result in serious neurological complications. Prompt diagnosis and early treatment is of paramount importance for an optimum clinical outcome. This case report describes a novel technique of interval laminectomy at two sites in the thoracic spine and surgical decompression with the help of infant feeding tubes in a case of holocord spinal epidural abscess (HSEA).

Case presentation

An 18-year-old male presented to the emergency department with high-grade fever and low back ache of 2 weeks duration and loss of bowel and bladder control for 4 days. Neurological examination revealed intact motor power and sensation in all four limbs at presentation; however, there was a rapid deterioration to complete quadriplegia within 24 h. A diagnosis of holocord epidural abscess was made. Emergent decompression via interval thoracic laminectomy was done and appropriate antimicrobial therapy was instituted. At 10 months of follow-up, the individual showed complete neurological recovery.

Discussion

The technique used in this case is unique with respect to the level of laminectomy and the manoeuvre employed for pus evacuation. Complete neurological and functional recovery was achieved despite complete paralysis pre-operatively. The outcome indicates that there may be good prognosis for individuals with HSEA accompanied with neurological deficit and emergent surgical decompression.

Hand function outcome in closed small bone fractures treated by open reduction and internal fixation by mini plate or closed crossed pinning: a randomized controlled trail

PURPOSE

No study in literature clearly gives advantage of one method of surgical fixation of fracture over the other in metacarpal and phalangeal bones of hand comparing wider outcome measures.

MATERIALS AND METHODS

A randomized controlled trial between closed reduction and percutaneous Kirschner wire fixation or open reduction and internal fixation with mini fragment plates was conducted. A total of 32 patients with 16 in each group were taken in tertiary-level teaching hospital from 2014 to 2016. Four patients lost to follow-up apart from 32 studied. Inclusion criteria were age group 16-60 years, fresh (3 days) closed shaft fractures of metacarpal and phalanges. Outcome evaluated were time to union of fracture, degree of strength achieved measured with dynamometer, DASH scoring, range of motion of hand and each digit.

RESULTS

Both groups were comparable in terms of return to full hand function, union and total range of motion. K wire fixation results were slightly better than plating group in terms of early DASH score and grip strength after fixation.

CONCLUSION

No modality was found to be superior for fixation of small bone fractures of hand. But K wire being cheaper and without inherent complication of plating like scar and tendon irritation, K wire fixation is preferred over plating in shaft fractures of metacarpal and phalanges.

LEVEL OF EVIDENCE

Level I Therapeutic study.

Biological modalities for treatment of acute spinal cord injury: a pilot study and review of the literature

OBJECTIVE

Paraplegia due to traumatic spinal cord injuries is one of the devastating effects of dorsolumbar vertebral fractures. Treatment modalities for such fractures, such as stabilization, have no effect on the neurological recovery. Thus, various pharmacological and biological treatment modalities have been used. The more recent trend of using autologous stem cells from the iliac crest has been used in some clinical trials with varying success. Thus, more clinical studies are required to study the effect of this novel approach

METHODS

This is a prospective hospital-based cohort study (level IV). The study was conducted in the Dept. of Orthopaedics, University College of Medical Sciences and GTB Hospital, Delhi from November 2010 to March 2012. Ten patients who had sustained traumatic dorsolumbar vertebral fractures with complete paraplegia were recruited for this study. Under suitable anaesthesia, at the beginning of surgery, 100 ml of bone marrow was aspirated. This was centrifuged and buffy coat isolated and then transferred into a sterile tube and sent to the operating room on ice packs. After surgical decompression and stabilization, the buffy coat isolate was injected into the dural sleeve at the site of the injury using a 21G needle. All the patients were evaluated for neurological improvement using the American Spinal Injury Association (ASIA) score and Frankel grade at 6 weeks and 3 months postoperatively.

RESULTS

The evaluation at 6 weeks showed some improvement in terms of the ASIA scores in 2 patients but no improvements in their Frankel Grade. The other 8 patients showed no improvements in their ASIA scores or their Frankel Grades. The current pilot study has shown that there has been no improvement in most of the recipients of the transplant (n=8). Some patients (n=2) who did show some improvement in their sensory scores proved to be of no significant functional value as depicted by no change in their Frankel Grades.

CONCLUSION

The outcome of current study shows that although this modality of treatment is safe for the patients, it provides no additional benefits on improvement of quality of life among these patients.

Aneurysmal bone cyst of maxilla existing concurrently with a giant cell granuloma of mandible: a case report of an unusual presentation

Aneurysmal bone cysts (ABCs) are relatively rare but well-described expansile, osteolytic psuedocysts are most commonly seen in the long bones, pelvis, and vertebra. Although a well-described lesion, much confusion exists in its pathogenesis especially of the associations of this lesion with other lesions. Approximately, one-third of patients with ABC present simultaneously with another bone pathology. The aim of this paper is to describe a rare case of simultaneously occurring ABC of the maxilla and mandible with the mandibular lesion occurring predominantly as a giant cell granuloma. The paper discusses the various histopathological variations of ABC as well as different lesions associated with ABC and tries to provide a review of different pathogenesis theories of this interesting lesion.

Radiography and sonography of clubfoot: A comparative study

BACKGROUND

Congenital talipes equinovarus is a common foot deformity afflicting children with reported incidence varying from 0.9/1000 to 7/1000 in various populations. The success reported with Ponseti method when started at an early age requires an imaging modality to quantitate the deformity. Sonography being a radiation free, easily available non-invasive imaging has been investigated for this purpose. Various studies have described the sonographic anatomy of normal neonatal foot and clubfoot and correlated the degree of severity with trends in sonographic measurements. However, none of these studies have correlated clinical, radiographic and sonographic parameters of all the component deformities in clubfoot. The present study aims to compare the radiographic and sonographic parameters in various grades of clubfoot.

MATERIALS AND METHODS

Thirty-one children with unilateral clubfoot were examined clinically and graded according to the Demeglio system of classification of clubfoot severity. Antero-posterior (AP) and lateral radiographs of both normal and affected feet were obtained in maximum correction and AP talo-calcaneal (T-C), AP talo-first metatarsal (TMT) and lateral T-C angles were measured. Sonographic examination was done in medial, lateral, dorsal and posterior projections of both feet in static neutral position and after Ponseti manouever in the position of maximum correctability in dynamic sonography. Normal foot was taken as control in all cases. The sonographic parameters measured were as follows : Medial malleolar- navicular distance (MMN) and medial soft tissue thickness (STT) on medial projection, calcaneo-cuboid (C-C) distance, calcaneo-cuboid (C-C) angle and maximum length of calcaneus on lateral projection, length of talus on dorsal projection; and tibiocalcaneal (T-C) distance, posterior soft tissue thickness and length of tendoachilles on posterior projection. Also, medial displacement of navicular relative to talus, mobility of talonavicular joint (medial view); reducibility of C-C mal alignment (lateral view); talonavicular relation with respect to dorsal/ ventral displacement of navicular (dorsal view) and reduction of talus within the ankle mortise (posterior view) were subjectively assessed while performing dynamic sonography. Various radiographic and sonographic parameters were correlated with clinical grades.

RESULTS

MMN distance and STT measured on medial view, C-C distance and C-C angle measured on lateral view and tibiocalcaneal distance measured on posterior view showed statistically significant difference between cases and controls. A significant correlation was evident between sonographic parameters and clinical grades of relevant components of clubfoot. All radiographic angles except AP T-C angle were significantly different between cases and controls. However, they did not show correlation with clinical degree of severity.

CONCLUSION

All radiographic angles except AP T-C angle and sonographic parameters varied significantly between cases and controls. However, radiographic parameters did not correlate well with clubfoot severity. In contrast, sonography not only assessed all components of clubfoot comprehensively but also the sonographic parameters correlated well with the severity of these components. Thus, we conclude that sonography is a superior, radiation free imaging modality for clubfoot.

Adult presentation of PHACES syndrome

A significant percentage of children with hemangiomas may have PHACES syndrome which refers to the association of posterior fossa malformations, facial hemangiomas, arterial cerebrovascular abnormalities, cardiovascular anomalies, eye abnormalities and ventral defects like sternal clefting or supraumbilical raphe. A variety of factors have led to under diagnosis of PHACES syndrome in the past including lack of awareness and limited imaging modalities. Also, patients with PHACES syndrome with arterial cerebrovascular abnormalities can present with acute ischemic stroke. However, these patients usually present before one year of age. We describe a 29-year-old woman with no history of cerebrovascular disease who initially presented with symptoms of a stroke and was subsequently diagnosed to have PHACES syndrome exhibiting an array of multiple unusual imaging findings. We also discuss the current literature and recommendations about PHACES syndrome.

Predicting cubitus varus in supracondylar fractures of the humerus by Baumann's angles in post reduction X-rays

OBJECTIVES

The present study presents the technique to predict cubitus varus by post reduction Affected Side and Normal Side Baumann's angle difference (ASBA and NSBA) respectively. It intends to correlate the Baumann's angle to the final carrying angle of the injured elbow and presents the relevant mathematical clinical rule along with its prediction test characteristics.

MATERIAL AND METHODS

Total 57 patients of 6.5+/-1.67 yrs, 22 were males and 8 females with 19/30 having left side injury. Isolated closed supracondylar fractures of humerus up to 5 days duration included and previous trauma, pathological fracture, other injury, elbow disease were excluded .30/57 completed >1 year follow-up.

RESULTS

The Mean NSBA was 74.4+/-4.14 masculine. The mean normal side carrying angles (NSCA) were 9.56 +/- 2.2 masculine. The NSCA IQR (Inter Quartile Range) was 8.8-10 masculine. The ASBA was 79.9+/-9.1 masculine and affected side carrying angles (ASCA) was 0.20+/-8.7 masculine. The ASCA was best predicted by the difference between ASBA-NSBA (ASCA=3.87-0.65(ASBA- NSBA; F=15.91). At a cut off of 8.8 masculine (the lower limit of IQR for NSCA), a value >0 masculine for ASBA- NSBA was 80% predictive of cubitus varus. With pre test probability of varus at 70%, sensitivity was 0.94 and specificity 0.42.

DISCUSSION

A prediction rule to predict the final carrying angle from ASBA NSBA difference is presented with a positive predictive value 0.80, specificity of 0.42, and sensitivity of 0.94 at a pre test probability of 0.70.When the diagnosis of cubitus varus is ASCA<8.8 masculine (Lower limit of the IQR for NSCA).

CONCLUSION

If affected side Baumann's Angle - Normal Side Baumann's Angle is equal to or greater than 0 then there was 80% probability of having cubitus varus.

Prediction of walking possibility in crawling children in poliomyelitis

Crawling is one of the most common modes of ambulating in children with severe paralysis and deformities in poliomyelitis. Restoring upright posture and bipedal gait, although desirable, has its own limitations due to various factors. Fifty-three children below the age of 12 years (29 boys and 24 girls) crawling due to post-poliomyelitis residual paralysis were assessed for the genesis of crawling as a mode of ambulating. The patterns of crawling were classified according to Cross's classification. Paralyzed muscles and deformities in definite combinations were found responsible for each type of crawling. Trunk muscles, gluteus maximus, quadriceps, hamstrings, tibialis anterior, and triceps surae were identified as muscles crucial for walking in order of priority. At least antigravity power in these muscles was necessary for an upright posture and walking with support. Various combinations of treatment modalities were used to correct the deformities before fitting an orthosis and instituting gait training. Thirty-four children became outdoor walkers, 14 indoor walkers, and five remained nonwalkers. The most favorable patterns of crawling for restoration of upright posture were true quadruped progression (30 cases) and infant-like crawl (14 cases). Average follow-up was 17 months (range, 6 months to 5 years).

An assessment of continuous fetal heart rate monitoring in labor. A randomized trial

Intrapartum continuous fetal heart rate monitoring has been routinely performed at the Jessop Hospital for Women for some years. However, no controlled trials had ever been performed to show its advantages over intermittent auscultation in low-risk patients. A prospective randomized study of 504 patients compared continuous fetal heart rate monitoring with intermittent auscultation. There was no significant difference between the two groups in neonatal deaths, Apgar scores, maternal and neonatal morbidity, and cord blood gases. The cesarean section rate was significantly increased (p less than 0.05) in the monitored patients but this did not seem attributable to fetal monitoring. No beneficial or deleterious effects of continuous fetal heart rate monitoring in labor were shown.

A flexible approach for on-line computerised quantification of intra-uterine pressure data

Utilising simple mathematical techniques of differential calculus, a computer program has been developed for real time, on-line processing of uterine contractions with a small computer. The area under the intra-uterine pressure--time curve is calculated and two distinctive values of this area are printed on-line every 512 sec. The 'active area', which is the area above the resting tone, is calculated in addition to the 'total area'--that is, the area above 0 mmHg. This allows an objective and efficient assessment of uterine activity which may be used as a basis of comparison between individual patients and groups of patients.