Comparison between effects of instrument-assisted soft tissue mobilization and manual myofascial release on pain, range of motion and function in myofascial pain syndrome of upper trapezius - A randomized controlled trial

Background

Myofascial pain syndrome (MPS) is a muscle pain disorder characterized by the presence of Myofascial Trigger Point (MTrP) within a taut band, local tenderness, referral of pain to a distant site, restricted range of motion, and autonomic phenomena. The upper trapezius is the muscle most often affected by MTrPs. Manual myofascial release (MFR) and Instrument-Assisted Soft Tissue Mobilization (IASTM) are techniques of soft tissue release that are used to resolve MPS. Fifty six percent of physiotherapists complain of pain in multiple areas due to the massage and manual therapy that they have to perform.

Objective

The objective of this study is to find whether IASTM is better than manual MFR in treating patients with MPS in upper trapezius.

Methods

This study was a single-blinded randomized controlled trial that included 31 participants, both males and females between the age groups of 18-50 years. Participants were randomly divided into two groups. Three sessions were given over a period of one week for both groups. Group A received IASTM along with conventional treatment and Group B received Manual MFR along with the conventional treatment. The outcome measures evaluated were pain, cervical range of motion, pain pressure threshold (PPT) of trigger points, and the neck disability index. Pre- and post-measurements were taken and the analysis was done.

Results

Both the treatment methods significantly reduced pain, improved PPT, range of motion, and function. The effects between the groups showed that IASTM was significantly better than manual MFR to reduce pain. The improvement in PPT, range of motion and function were equal in both the groups.

Conclusion

IASTM and manual MFR both are effective individually as treatment procedures for pain, PPT, range of motion, and function. Neither of the treatment options can be considered better that the other. The clinician can decide based on the availability of the instrument, training, patient's preference, and his/her comfort whether which of the two treatment methods should be used.

Percutaneous pulsed radiofrequency ablation of articular nerves of the hip joint in patients with chronic hip pain refractory to conventional analgesics

OBJECTIVES

Total Hip Arthroplasty (THA) may be a risky proposition in patients with comorbidities, and they may require systemic analgesics for chronic hip pain (CHP). Since traditional pain medications may not provide complete pain relief or carry prohibitive adverse effects, pulsed radiofrequency (PRF) treatment of the hip articular nerves (HAN) has been proposed for effective clinical outcomes. We determined the efficacy of PRF-HAN in improvement in CHP compared to baseline pain on conventional systemic analgesics.

METHODS

Between August 2015 and December 2021, 31 adult patients with severe comorbid conditions and excruciating chronic hip pain were subjected to a PRF-HAN procedure following a diagnostic block. All 31 patients received PRF of the articular branches of the femoral and obturator nerves. Demographic parameters, numerical rating scale (NRS), Harris Hip Score (HHS), WOMAC scores, the change of these scores from baseline, and any adverse effects were recorded before treatment and on day 1, 1st week, 6 weeks, and 6 months after treatment.

RESULTS

All the patients who underwent the PRF-HAN reported a significant improvement in NRS, HHS, and WOMAC scores compared to the baseline values on day 1, at the end of the 1st week, and the 6th week (p<0.001). No adverse events were documented in the study post-procedure until the end of 6 months.

CONCLUSION

PRF-HAN is a strong alternative for chronic pain management and augments physical functioning and a return to daily activity in patients who would be deprived of arthroplasty considering associated comorbid conditions.

Radiofrequency Treatment of Genicular Nerves Using a Hybrid Technique

BACKGROUND

Radiofrequency ablation of genicular nerves is recommended to ameliorate the pain of osteoarthritis of the knee. However, long-term efficacy in patients with persistent pain following total knee arthroplasty remains elusive. The current study aimed to evaluate radiofrequency ablation of genicular nerves using a hybrid technique to manage severe incapacitating pain and quality of life following surgery.

METHODS

This prospective, observational study included patients suffering from intractable knee pain with scores > 4 on the Numeric rating scale after 6 months of total knee arthroplasty. Therapy included radiofrequency ablation of the superior medial, lateral, and inferior medial genicular nerves using a hybrid technique. The Numeric rating scale and Oxford Knee Score for quality of life were assessed before therapy and at 1-, 3- and 6 months following treatment.

RESULTS

Average pain scores reduced from 8.4 ± 1.3 (admission) to 3.3 ± 1.4 (1 month; p= <0.001) but subsequently started to increase to 4 ± 1.2 (3 months; p = 0.58), and 5.6 ± 0.9 (6 months; p= <0.001). Average Oxford Knee Score significantly improved from 14.2 ± 5.9 (admission) to 38 ± 8.6(1 month); p= <0.001, but these too subsequently reduced to 36.4 ± 7.9 (3 months); p= 1, and 22.5 ± 12.5(6 months); p= <0.001.

CONCLUSIONS

Ultrasound-guided radiofrequency ablation of genicular nerves diminishes intractable pain and disability in patients with chronic knee pain following total knee arthroplasty. Treatment is safe and effective, however, the benefit declined by 6 months. A repeat block would be necessary if the pain score worsens.

ORTHO AI : World's First ARTIFICIAL INTELLIGENCE IN ORTHOPAEDICS

The landscape of AI (Artificial Intelligence) and specifically AI in healthcare is growing rapidly. Although most of these are focussed on complex issues of imaging and planning, we came up with the idea of impacting the very foundation of Clinical Decision Making by using the AI Technology. OrthoAI is a product of this thought process and was launched on 11th Dec 2023 at the hands of Dr Raghunath Mashelkar eminent scientist from India. It was an amazing event structured around the World’s First AI Focussed on Orthopaedics. OrthoAI, or OrthoGPT, is designed to transform clinical decision-making with its sophisticated database and advanced AI capabilities. OrthoAI: A Generative AI Revolution in Orthopaedics We believe OrthoAI is the foundation of the AI Revolution in Orthopaedics, and we would like to share some more insights about it. OrthoAI primarily is a Generative AI like chat GPT. You can even call it OrthoGPT (Ortho Generative Pre-trained Transformer), a type of artificial intelligence model designed for understanding and generating human-like text. OrthoAI, akin to a specialized version of Chat GPT, or ‘OrthoGPT’, stands on three foundational pillars: 1. The OrthoAI Database: The essence of OrthoAI lies in its meticulously curated vector database, developed over nine months by a team of expert orthopaedic surgeons. This database is the cornerstone of OrthoAI’s reliability and validation. 2. PubMed Access: OrthoAI’s integration with PubMed enriches its evidence base, ensuring that its responses are grounded in the latest orthopaedic literature. 3. OrthoTV Access: With over eleven thousand orthopaedic videos, OrthoTV provides a wealth of expert knowledge and experiences. OrthoAI’s access to this repository allows it to offer comprehensive answers, supplemented with relevant article links and video content At its core, AI involves creating computer systems that mimic human intelligence, enabling them to perform tasks that usually require human intellect. OrthoAI is equipped with following AI Core functions • Machine Learning (ML) is a subset of AI that allows computers to learn and improve from experience without being explicitly programmed • Deep Learning (DL) is a more complex subset of ML that mimics the neural networks of our brain. DL involves feeding a computer system a vast amount of data, which it uses to make decisions. This ability to process and analyse a significant amount of data makes DL particularly valuable for OrthoAI. • Natural Language Processing (NLP) can read and understand human language, enabling it to extract essential information from clinical notes or respond to patient queries in real-time. OrthoAI has NLP built in and will continue to learn from all its interactions. We believe the most important area of impact of OrthoAI will be Clinical Decision Making. OrthoAI as discussed above is built on a validated database, along with PubMed and OrthoTV access. This makes the answers most relevant and trustworthy. With a synthesised answer from all sources, it will be source of having a huge thinking knowledge bank at your fingertips. It will act as CO-PILOT or as EBM Assistant to Orthopaedic Surgeons, helping them in tricky situations. The queries can vary from clinical, academic, case based, surgical steps, drug interactions, rehabilitation, complications, and surgical planning too. This is the version 1, and more things would be added in coming versions. We will urge all readers to visit OrthoAI on www.orthoai.in webportal or scan the code to access the portal. Conclusion: OrthoAI is launched at the threshold of a new era in orthopaedics, bringing significant improvements in diagnosis, treatment planning, surgical execution, prosthetics, rehabilitation, and predictive analytics. As we start to incorporate AI more comprehensively into our practice, we need to conscientiously navigate the ethical and legal challenges it presents. Our enthusiasm as technologically inclined orthopaedic surgeons drives us to harness OrthoAI’s full potential, ushering in an era of precision, efficiency, and patient-centric care in orthopaedics.

A Case of Symmetrical Bilateral Bifocal Femur Fracture with Bilateral Patella Fracture - A Case Report!

Introduction

Bilateral bifocal femur fractures occur as a result of high-velocity trauma mainly road traffic accidents with dashboard injuries or fall from height. These fractures can result in high morbidity or mortality as they are usually presented with hypovolemic shock or fatal fat embolism syndrome.

Case Report

We present a 47-year-old male with a history of fall from 35 feet. He sustained a symmetrical intertrochanteric femur fracture with a diaphyseal femur fracture with a bilateral patella fracture. There was no evidence of any head injury or spinal fracture. The patient reached the emergency room in hypotension and was maintaining saturation on room air. The patient was admitted to the intensive care unit; hypotension was corrected overnight and was operated on after 24 h with bilateral intramedullary long proximal femoral nail and tension band wiring for the bilateral patella fractures. At 1-year follow-up, he was able to do his daily activities with minimal limitation.

Conclusion

Bilateral bifocal femur fractures result from a high-velocity trauma. In such injuries, careful evaluation of all the systems should be performed to find out concomitant injuries. Single-staged surgical intervention decreases the morbidities of the subsequent surgeries, helps in a rehabilitation hospital stay as well as financially suitable for the patient.

Labral Support Shelf Acetabuloplasty for Late Presenting Perthes Disease: Outcomes in Indian Patients

Introduction

The treatment of late-presenting Perthes disease with extrusion is controversial and debatable. One of the options available is the labral shelf acetabuloplasty (LSA).

Aim

The aim of the study was to evaluate the results of LSA in late-presenting Perthes disease in terms of clinic-radiological outcome measures.

Materials and Methods

A retrospective analysis of prospectively collected data of patients with late presenting Perthes disease (Elizabethtown stage 2B onwards) treated by LSA by 2 experienced paediatric orthopaedic surgeons was performed. Data was collected of clinical parameters such as hip range of motion(ROM) and Harris Hip score and radiological parameters such as acetabular height, width and volume, shelf width, Centre Edge angle(CEA) and the lateral extrusion.

Results

Thirty-five patients (28 males and 7 females) treated between 2012 to 2019 were analyzed. Majority were in Elizabethtown stage 3A (23) followed by 2B and 3B (12 each). At a mean follow up of 36 months, the hip ROM and the Harris Hip Score (from 65 ± 3.5 to 81.33 ± 7.12) improved significantly and there was a statistically significant improvement in terms of all radiological parameters. Majority of the hips were in Stulberg grade 3 (20) followed by grade 1 and 2 (7 each) and Stulberg 4 (1). There were no major complications in any of the patients of the series.

Conclusion

Labral support shelf acetabuloplasty is a valuable surgery for late presenting Perthes disease and helps in maintenance of good coverage and allows restoration of range of motion over time.

Learning curve across 2000 thoracolumbar pedicle screw placements using O-arm navigation: technical difficulties and their solutions

INTRODUCTION

Instrumentation using the intraoperative O-arm navigation technique appears safer than its predecessor techniques. However, only a handful of surgeons often used navigation during spinal surgeries. Too many operative glitches and unreliable navigation accuracy were the important reasons cited even by experienced surgeons for not using spinal navigation. We have studied the accuracy of pedicle screw placement during the learning curve and beyond it. We have also discussed in detail the intricacies of the technique and solutions to the difficulties encountered using spinal navigation.

MATERIALS AND METHODS

A total of 2000 thoracolumbar pedicle screws have been placed in the 324 spine surgeries meeting the inclusion and exclusion criteria included in this retrospective study. We have divided 2000 pedicle screw placements into consecutive groups of 200 each. We have compared these groups for the accuracy of screw placement with the surgeon's experience.

RESULTS

The accuracy of pedicle screw placement using the "in-versus-out" grading system in group 1 was 85.5% which significantly increased in group 2 to 93.5% (p-value: 0.0099), and thereafter, there was a nonsignificant increase in subsequent groups with the graph achieving the shape of a plateau.

CONCLUSION

Surgeons should learn the correct principles of the technique of O-arm navigation to prevent the loss of accuracy and place pedicle screws with high accuracy. There is a learning curve of around 30-35 surgeries or 200 pedicle screw placements to acclimatize with the technique of O-arm navigation and learn its principles.

The Paraneural Sciatic Sheaths in Longitudinal Axis at the Level of Greater Trochanter: An Ultrasound Cadaveric and Clinical Correlation Study

Background

Paraneural sheath engulfing the sciatic nerve (SN) between the ischial tuberosity and the greater trochanter is well known.

Methods

In order to explore the anatomical planes separating the paraneurium from the epineurium in SN, we conducted a cadaveric study (two patients and four specimens), followed by a clinical study in 10 patients.

Results

We demonstrated an elevation of 5-7 layers of paraneural tissues after an in-plane injection in the longitudinal axis of the proximal SN, which was possibly the last of the paraneural sheath. In the clinical study, the block provided low pain scores with no rescue analgesia postoperatively and no neurological deficit at the time of discharge.

Conclusion

This is probably the first series which has described the elevation of several layers of paraneural tissues after an in-plane injection in the longitudinal axis of the proximal SN.

Circumpsoas block ... an anterior myofascial plane block for lumbar plexus elements: case report

In an attempt to improvise the analgesia in patients with femoral fractures, we aimed at depositing local anesthetic deep to anterior psoas fascia (APf) under ultrasound (US) guidance to block lumbar plexus elements which emerge lateral, anterior, and medial to the psoas major muscle. We termed this as circumpsoas block (CPB). Clinical and computed tomography contrast studies revealed that a continuous CPB infusion with a catheter provided a reliable block of the lumbar plexus elements. No adverse were events noted. We conclude that US guided CPB is a reliable technique for managing postoperative pain after surgery of femur fractures.

Ultrasound-guided continuous costoclavicular block through retrograde stimulating catheter technique for postoperative analgesia in shoulder surgery: a case series

In five patient undergoing surgery for proximal humerus fracture we investigated into postoperative analgesia provided by continuous costoclavicular block using continuous stimulating catheter. The postoperative pain scores were less than 4 in all patients except in two patients who required intravenous tramadol 50 mg as a rescue analgesic. The radiocontrast dye study executed in two patients revealed contiguous contrast spread through the brachial plexus sheath with the catheter tip in the interscalene space. We propose that a continuous costoclavicular block with a retrograde stimulating catheter is a feasible alternative regional anesthesia technique for postoperative analgesia in shoulder surgery.

Intervertebral Foramen - A Gateway to Epidural Space in Severe Lumbar Scoliosis

We describe cases in which a preoperative computed tomography was used to guide the placement of an epidural catheter through the defect in the intervertebral foramina in patients with severe lumbar scoliosis. We demonstrate the adroitness with which epidural catheters were inserted through the intervertebral foramina. Computed tomography scan illustrates and plots the needle path creating a 3-dimensional image of the vertebral body rotation, needle trajectory, and the distance from the skin to the intervertebral foramina. Severe scoliosis is defined as a lateral curvature (Cobb's angle) of more than 50 degrees. It was proposed in severe idiopathic scoliosis that interventional pain management techniques are managed with fluoroscopic imaging or an alternative form. However, after a computed tomography evaluation of the scoliotic spine, we assumed that the intervertebral foraminal anatomy would facilitate a safe and efficient epidural needle and subsequent catheter positioning in severe scoliotic patients.

Comparative study lumbar plexus block and lumbar erector spinae plane block for postoperative pain relief after proximal femoral nail for proximal femoral fractures

Background

The clinical outcomes (time to ambulation, length of stay, and home discharge) after proximal femoral nail (PFN) for proximal femoral fractures (PFF) is dependent on successful pain management. Currently, the lumbar erector spinae plane block (LESPB) is in vogue and is associated with favorable outcomes in the postoperative period. Our study aimed to evaluate whether a LESPB provided equivalent analgesia and clinical outcomes as compared to LPB in PFN for PFF.

Material and Methods

We compared LPBs [L] with LESPBs [E], with 30 patients in each group, performed from June 2020 to June 2021 for PFN in PFF's. The primary outcome of this study was the average NRS pain scores over 24 hours postoperatively. Secondary outcomes included pain scores at different time points over 24 hours, opioid consumption between the groups at 24 hours postoperatively, time for request of first parenteral analgesia, quadriceps weakness and adverse events.

Results

The average pain scores over 24 hours were better in the LESPB group as compared to the LPB group (p = 0.02). Further, only n = 5 (30%) of patients in the LESPB group required opioids, while n = 13 (43.333%) of patients in the LPB group required opioids. Moreover, the median time for request of first parenteral analgesia was 615 (480-975) minutes, weakness of quadriceps function occurred in 2 patients in the L group, which recovered at 3rd and 5th month, respectively, with no incidences of hemodynamic instability and respiratory complications.

Conclusions

This trial demonstrated that single bolus LESPB is superior to LPB in terms of analgesic outcomes, has low adverse events, and is an agreeable substitute for patients with PFF undergoing a PFN.

Standalone cage versus anchored cage for anterior cervical discectomy and fusion: a comparative analysis of clinical and radiological outcomes

PURPOSE

The use of standalone cages (SAC) and anchored cages (AC) in anterior cervical discectomy and fusion surgery (ACDF) has shown advantage of reduced operative time and lower incidence of dysphagia. However, there is limited literature available comparing the clinical and radiological outcomes of SAC and AC.

METHODS

We conducted a prospective study for patients undergoing ACDF for cervical radiculopathy or myelopathy. Patient were classified based on the cage used into SAC group and the AC group. Clinical outcomes were assessed using the modified Japanese Orthopedic Association (mJOA) for myelopathy and Neck Disability Index (NDI) and Visual Analogue Scale (VAS) for radiculopathy. Dysphagia was graded as per Bazaz score. Radiologically, global cervical lordosis, segmental lordosis, cage subsidence, and migration were assessed.

RESULTS

We analyzed 31 patients in each group with a minimum two year follow-up. The mean VAS improved from 7.9 to 4.56, mean NDI score improved from 27.6 to 19.8, and mean mJOA improved from 10.8 to 11.7 which were statistically significant (p < 0.05); however, no significant difference was noted between the SAC and AC groups. Mean global lordosis improved from 14.4 to 20.3° and mean segmental lordosis improved from 6 to 10.1° at six months and plateaued to 6.9° at final follow up without any significant difference between the groups. The subsidence was statistically more in 12.9% (4/31) in SAC than 6.4% (2/31) in AC.

CONCLUSION

AC showed of lower rates of subsidence while both SAC and AC had comparable clinical outcomes and radiological alignment outcomes.

Utility of selected sequence MRI imaging of the axial skeleton in the diagnosis of axial spondyloarthritis

BACKGROUND

Whole body MRI has been used to evaluate inflammatory lesions associated with axial spondyloarthritis (SpA). These sequences are extensive, time consuming and add to the cost of the investigation. We aimed to determine the utility of selected sequence MRI imaging of the axial skeleton including spine, pelvis and sacroiliac (SI) joints to identify features of (SpA).

METHODS

A retrospective study was conducted on 76 patients diagnosed with SpA that underwent a selective sequence MRI imaging of the axial skeleton. The MRI were reported by two musculoskeletal trained radiologists were reviewed. The MRI sequences included whole spine sequences of sagittal STIR (short tau inversion recovery), T1 weighted and T2 weighted sequences. Coronal STIR and T1 weighted images were studied for SI joints and pelvis. The MRI were assessed based on the guidelines outlined by the Assessment of SpondyloArthritis International Society (ASAS) for features of spondylitis, spondylodiscitis, enthesitis, synovitis, capsulitis, bone marrow edema, fatty marrow replacement, erosions and bony ankylosis. Inflammatory lesions were documented in the spine, sacroiliac, facet, hip and costovertebral joints.

RESULTS

The mean scan duration was 28 min. SI joint involvement was noted in 74 (97.3%) of patients. The other most prevalent findings were spondylitis in 44 (57.8%) patients, costovertebral joint involvement in 31 (40.7%), facet joint lesions in 32 (42.1%), spondylodiscitis in 21 (27.6%), enthesitis in 13 (17.1%), hip lesions in 16 (21%) and ankylosis in 10 (13.1%).

CONCLUSIONS

This selective sequence imaging of the pelvis and spine was able to identify typical lesions of SpA in a shorter time period. Fifty-five percent patients had lesions in the posterior elements including facet joints and costovertbral joints that would be missed on traditional SI joint imaging.

A Single Approach for Management of Fractures Involving Both Columns of the Acetabulum: A Case Series of 23 Patients

Aim and objective

To study the radiological and functional outcomes as well as complications in the management of fractures involving both columns of the acetabulum using a single surgical approach.

Design

Type IV, prospective clinical study.

Setting

Level I trauma centre.

Materials and methods

Inclusion criteria were as follows: (a) patients over 20 year of age and (b) patients suffering from acetabular fractures involving both columns as per Letournel and Judet classification, namely transverse, transverse + posterior wall, T type, anterior column posterior hemi-transverse (ACPHT) and associated both columns. Exclusion criteria were as follows: (a) patient suffering from isolated anterior column, posterior column, anterior wall, posterior wall and posterior wall + column fractures; (b) patient who have undergone surgical procedures of the hip prior to trauma; and (c) compound acetabular fractures. A total of 23 patients having both column acetabulum fractures were included prospectively from June 2016 to December 2018 and followed up till 1 year postoperatively. Open reduction and internal fixation were performed through one of three described approaches, i.e., iliofemoral, Kocher-Langenbeck, and anterior intrapelvic or ilioinguinal.

Results

Our study population consisted of 30.4% transverse, 39.1% associated both columns, 21.7% T type and 8.7% anterior column + posterior hemi-transverse. Of these, 65.2% were operated using the Kocher-Langenbeck approach, while 30.4% of patients required the anterior intrapelvic approach. The remaining 4.3% of patients were operated by the iliofemoral approach. Anatomic reduction was achieved in 100% of our study population with remaining displacement less than or equal to 1°mm. At 1-year follow-up, all fractures showed a satisfactory union with an excellent Matta index in 100% study subjects. Complications at 1 year included one case of foot drop, which was present preoperatively but failed to improve and one case of post-traumatic arthritis. Average Harris Hip score (HHS) and mean Merle D'Aubigne (MDA) scores suggested good clinical outcomes in the study population.

Conclusions

A single approach can be used to achieve good functional and radiological outcomes in carefully selected bicolumnar fractures of the acetabulum, with less approach-related morbidity.

Clinical significance

Traditionally, multiple approaches are used for acetabulum fractures involving both columns, but with proper patient selection, single approach can be used with good functional and surgical outcomes.

How to cite this article

Patil A, Attarde DS, Haphiz A, et al. A Single Approach for Management of Fractures Involving Both Columns of the Acetabulum: A Case Series of 23 Patients. Strategies Trauma Limb Reconstr 2021;16(3):152–160.

Emergently Managed Rare Case of Extraosseous Hemorrhagic Spinal Epidural Cavernous Hemangioma: A Case Report

Introduction: Commonly spinal cavernous hemangioma (CH) is found in vertebral body at thoracic level. Purely extraosseous epidural CH contributes only 4% of all CH. In addition, these patients usually present in their 3rd–6th decade of life. Here, we report emergently treated rare case of hemorrhagic extraosseous epidural thoracic CH in a 26-year-old male Case Report: A 26-year-old male presented with inability to walk without support with acute onset paraparesis and hypoesthesia below D7 with positive myelopathy signs. Magnetic resonance imaging showed posterior epidural well-defined homogenous mass from D6-8 region. PET scan ruled out other primary lesions in body. Intraoperative after D6-8 laminectomy extradural vascular mass was found which was bleeding on touch. With adequate hemostasis complete mass was excised and sent for sampling which revealed CH. The patient showed gradual clinical recovery with complete neurological recovery after 3 months with no signs of clinical and radiological recurrence on 2 years of follow-up. Conclusion: Extraosseous epidural CH is very rare presentation; hence, the differentials of schwannoma, lymphoma, tubercular/pyogenic epidural abscess, metastasis, and others must always be ruled out. They can present a decade earlier in a case of hemorrhagic CH with rapid progressive neurological deficit which warrants early surgical decompression like in our case and the foraminal or paravertebral extension needs foraminotomy or thoracotomy for complete excision.

Intricacies of ultrasound-guided lumbar plexus block in octogenarians: A retrospective case series

Background:

Ultrasound (US)-guided lumbar plexus block (LPB) could be technically challenging in elderly patients. The lumbar paravertebral sonoanatomy is undescribed in the elderly. In an attempt to understand the relevant sonoanatomy, identify the lumbar plexus elements, and understand the difficulties that encountered while performing LPB in elderly patients, we retrospectively analyzed US of 23 elderly patients who were administered US-guided LPBs.

Methods:

After institutional ethics committee approval, we retrospectively reviewed stored US images of lumbar paravertebral sonoanatomy in 23 elderly patients and analyzed psoas major muscle, lumbar vertebral body, lumbar nerve, and lumbar artery.

Results:

On US examination, features of psoas major muscle, lumbar vertebral body, lumbar nerve, and lumbar artery were noted and analyzed.

Conclusion:

US-guided visualization of the components of the lumbar paravertebral area is difficult and inconsistent in the elderly. Therefore, we suggest performing a scout scan, identify the structures, and use neurostimulation all the time for performing LPB in these patients.

Osteosclerotic Multiple Myeloma without POEMS Syndrome - A Rare Case Report

Introduction

Multiple myeloma is a plasma cell neoplasm that is commonly associated with lytic bone lesions; however, osteosclerotic multiple myeloma is a rare entity. Osteosclerotic multiple myeloma has been reported in association with POEMS syndrome.

Case Presentation

A 60-year-old female patient presented to us with low back pain for 2 months. The investigations revealed that the patient had multiple osteosclerotic lesions in the axial skeleton with a L4 ivory vertebra. The serum immunoelectrophoresis was negative. Positron emission tomography scan was done which showed multiple skeletal lesions in the right iliac bone, left femoral neck, thoracic vertebrae T1, T6, T12, and lumbar vertebra L4. Biopsy and immunohistochemistry of the lesion showed plasma cell proliferation; producing lambda light chains. However, there were no features of POEMS syndrome including polyneuropathy, organomegaly, endocrinopathy, and skin changes. The patient was started on chemoradiation and achieved clinical remission and was asymptomatic at 12 months follow-up.

Conclusion

Osteosclerotic myeloma without the features of POEMS syndrome is an extremely rare entity. This case reports documents a unique clinical scenario of osteosclerotic non-secretory light chain myeloma without POEMS syndrome.

Prophylaxis for preventing venous thromboembolism in knee arthroscopy and soft tissue reconstruction: consensus statements from an international panel of experts

PURPOSE

There is a lack of consensus regarding need for Venous Thrombo Embolism (VTE) prophylaxis following arthroscopic knee surgery and open soft tissue knee reconstruction. Clear cut guidelines like ones for trauma surgery and arthroplasty do not exist and the published literature is limited to case reports with a few society guidelines. Given this lack of consensus, we conducted a modified Delphi questionnaire of international experts to provide recommendations on this topic.

METHODS

The consensus statements were generated using an anonymised 3 round modified Delphi questionnaire, sent to an international panel of 38 knee surgeons, with an 80% agreement being set as the limit for consensus. The responses were analysed using descriptive statistics with measures like mode, median and box plots. Feedback was provided to all panelists based on responses from the previous rounds to help generate the consensus.

RESULTS

Six consensus statements were generated after the three rounds of Delphi. Patient factors, prolonged surgery duration and family history of thrombogenic events emerged as the main points to be taken into consideration for prophylaxis.

CONCLUSION

It was established through this study, that there exists a select group of patients undergoing arthroscopic surgery that justify the usage of VTE prophylaxis. The expert responses to most of the questions in different scenarios favoured usage of VTE prophylaxis based on patient factors like advanced age, past history of VTE, smoking, oral contraceptive use etc. LEVEL OF EVIDENCE: Level V.

Tuberculosis of the Cuboid in a 16-Month-Old Child: A Case Report

CASE

A 16-month-old male child presented with swelling over the dorsolateral aspect of the right foot associated with limp and no other constitutional symptoms. Tenderness and swelling were noted over the dorsolateral aspect, and radiographs revealed an eccentric lytic expansile lesion in the right cuboid. Biopsy of the lesion revealed necrotizing granulomas, and molecular testing later documented tuberculosis. The child received antitubercular medications and was relieved of symptoms in 6 weeks. Complete healing was observed after 12 months.

CONCLUSION

In developing countries, a high index of suspicion helps in the early diagnosis and appropriate management of tubercular osteomyelitis in children.

Undescribed Vascular Signatures: A Contraindication to Ultrasound-guided Parasagittal Infraclavicular Block! A Retrospective Observational Study

Background:

The ultrasound-infraclavicular block (US-ICB) is a popular and efficient block for below-elbow surgeries. However, the vascular anatomy of infraclavicular area close to the brachial plexus has remained unresearched. We aimed to explore the presence of aberrant vasculature in the infraclavicular area that could pose a contraindication to US-ICB.

Methods:

In this retrospective observational study, we reviewed the US images of patients undergoing below-elbow surgery under US-ICB. Before performing the block, a scout scan of parasagittal infraclavicular areas was performed and the scan images were saved. The primary objective was to find the prevalence of aberrant vasculature due to which the US–ICB was abandoned. The secondary objective was to understand the pattern and position of the aberrant vessels.

Results:

Out of 912 patients, 793 patients underwent surgery under US–ICB and in 119 patients (13.05%), the USG-ICB was abandoned due to aberrant vasculature close to the brachial cords and intended position of the needle tip. The anomalous vessels were identified in the lower inner, lower outer, and upper outer quadrants around the axillary artery (AA). Some of these vascular structures also had classical patterns which we described as “satellites,” “clamping,” or “hugging” of the AA.

Conclusion:

Anomalous vascular structures in the infraclavicular area were seen in 13.05% of patients planned for US–ICB. We, therefore, recommend, that a thorough scout US scan should be mandatorily performed ICB and in the presence of aberrant vascular structures, an alternative approach to brachial plexus block may be adopted.

Orthopaedic surgeons and covid- 19, the fear quotient "What are we really worried about?"

INTRODUCTION

The COVID-19 pandemic swiftly affected the world in a very short duration, and the orthopaedic surgery practice is no exception. Unprecedented lockdown was enforced in many countries including India as a first response to contain virus and its spread. That lead to a lot of confusion, fear, anxiety among general population as well as orthopaedic surgeons. We have studied the impact of this pandemic with fear as a denominator and how it affected the practice and health of orthopaedic surgeons.

METHODS

Cross-sectional web-based national survey distributed to orthopaedic surgeons by social media platform over period of one month from July 25, 2020 to August 25, 2020.

RESULTS

Among 1065 responders, 731 completed the survey. Among 1065 responders, 27.22% had orthopaedic practice experience ranging from 10 to 20 years while 21.48% had orthopaedic experience more than 20 years. Scientific literature as well as social media and news media contributed significantly to Covid-19 knowledge and fear. 98.88% were worried about contracting disease by themselves or by family members. 89.47% were worried due to financial loss due to pandemic. 37 (5.06%) surgeons had a FCV- 19 scale (Fear for Covid-19 scale) score more than 60 (8.2%) while 291 (39.8%) had 41-60 and score was <40 in 403 (55.12%) surgeons. According to survey vaccine availability and emergence of effective drug and treatment protocol will alleviate most of the concerns. 70.81% felt mildly depressed during pandemic times while 65.33% surgeons expressed interest in joining discussion groups and meetings encouraging positive thoughts.

CONCLUSION

Financial liabilities and well-being of self and family are important factors which induced fear of Covid-19 among orthopaedic surgeons. Positive discussions and timely information from credible sources regarding prevention, diagnosis and management and will reduce psychological burden due to Covid-19, also this will help to form policies for future pandemics.

A Polyostotic Paget’s Disease Involving Lumbar Spine Presenting with Cauda Equina Syndrome: An Unusual Entity

Introduction:

Paget’s disease of bone (PDB) is a metabolic bone disease presenting as polyostotic or monostotic lesions of the spine. Although common in the Anglo-Saxon population, it is rare on the Indian subcontinent. Neurological complications though infrequent can be severe in pagetic spine.

Case Report:

We report a case of a polyostotic variant of PDB involving lumbar spine (L2 vertebrae), iliac bones, and femur presenting as chronic low back pain and neurological deficit, i.e., cauda equina syndrome. On initial workup, a diagnosis of PDB was made and given cauda equina compression with neurological deficit, posterior spinal decompression, and biopsy was performed. The histopathological evaluation confirmed the diagnosis and the patient was treated with bisphosphonates for 6 months, along with serial monitoring of alkaline phosphatase levels.

Conclusion:

Through this case report, we hope to emphasize that PDB should be considered as a possible cause of neurological symptoms at presentation, especially in elderly patients. Also furthermore, early surgical intervention followed by bisphosphonates therapy can lead to favorable outcomes in such patients.

Evaluation of Acetabular Development Following Open Reduction of Developmental Dysplasia of Hip in Children After Walking Age

BACKGROUND AND PURPOSE

The growth and development of the acetabulum in children with developmental dysplasia of hip (DDH) depends upon the extent of concentric reduction. Children in walking age often need open reduction with or without additional osteotomies to obtain congruous, stable reduction. The purpose of this study was to evaluate acetabular development in late diagnosed DDH treated by open reduction with or without femoral osteotomy.

METHODS

This is a retrospective study of 29 children (40 hips) with idiopathic DDH, previously untreated managed by open reduction with or without femoral osteotomy. We analyzed preoperative and yearly postoperative radiographs up to 6 years of age for acetabular development by measuring acetabular index. Acetabular remodeling was assessed with a graphical plot of serial mean acetabular index. Those with AI < 30° at outcome measure point of 6 years of patient age were considered to have satisfactory acetabular remodeling.

RESULTS

Mean age of surgery was 26.8 months. Open reduction alone was done in 14 hips and open reduction with concurrent femoral osteotomy done in 26 hips. The mean acetabular index pre operatively was 36.6° ± 5.9° which reduced to 29.7° ± 6° at 1-year follow-up and to 26.6° ± 5.9° at 2-year follow-up. 28 out of 40 hips were available for evaluation at outcome measure point of 6 years of age, which showed satisfactory remodeling in 24 hips with mean AI of 22.7° ± 5.7°. Maximum acetabular development was seen at 2 years post-surgery and better remodeling was seen in children operated at less than 2 years of age. 5 hips had changes of avascular necrosis of femoral head. There was no incidence of redislocation/subluxation at latest follow-up.

CONCLUSION

Open reduction in late-diagnosed developmental dysplasia of hip has potential for favourable acetabular development. Femoral osteotomy when required along with open reduction may suffice to address acetabular dysplasia found in the initial years of management of DDH.

Achondroplasia with seronegative spondyloarthropathy resulting in recurrent spinal stenosis : A case report

Background:

Achondroplasia is an autosomal dominant condition caused by the G380 mutation of the gene encoding fibroblast growth factor receptor 3 on chromosome 4P. The classical findings include rhizomelic extremities, short stature, and spinal stenosis involving the upper cervical and distal lumbar spine. Rarely, achondroplasia coexisting with seronegative spondyloarthropathy can result in recurrent canal stenosis. Here, we report a 36-year-old male with symptomatic recurrent L3-L4 spinal stenosis 9 years following an original L2-S1 lumbar decompression for stenosis.

Case Description:

A 36-year-old male with achondroplasia (height of 113 cm and weight 43 kg [BMI-33.7]) presented with low back and right lower extremity sciatica (ODI 39). He had achondroplasia with a short stature. Nine years ago, he had an L2-S1 laminectomy for decompression of stenosis. When the new MRI revealed recurrent severe L3-4 stenosis, he underwent a repeated L3-L4 decompression with fusion. One year later, the patient was neurologically intact with radiographic confirmation of adequate L3-L4 arthrodesis.

Conclusion:

A 36-year-old male with achondroplasia and a history 9 years ago of an L2-S1 laminectomy for stenosis, presented with symptoms and signs of recurrent L3-L4 stenosis that responded to repeated decompression and fusion.

Recurrent solitary bone plasmacytoma: A case report

BACKGROUND

Plasmacytoma is an hematological malignancy that originates in bone. It may involve a single skeletal location. Notably, these lesions can progress to involve multiple segments in 50% of cases, at which point they are classified as having multiple myeloma (MM).

CASE DESCRIPTION

One year ago, this patient had undergone a D6 laminectomy and biopsy for plasmacytoma. Now at age 73, she newly presented with the onset of a progressive paraparesis of 4 weeks' duration. On examination, she had 3/5 strength in both lower extremities accompanied by diffuse hyperreflexia, and bilateral Babinski signs. She underwent a D5-D7 decompression, D6 corpectomy with anterior mesh cage reconstruction, and a D3-D9 posterior fusion.

CONCLUSION

Patients originally treated for plasmacytoma present 50% of the time with the new onset of neurological symptoms and signs due to the subsequent evolution of MM. As these lesions may be refractory to radiation and/or chemotherapy, surgery is often warranted.

Anterior proximal humerus fracture dislocation with concomitant glenoid fracture: An operative challenge! A case report

Introduction

Combined proximal humerus fracture dislocation and glenoid fracture is a rare combination of injuries which presents technical operative challenges. There is little evidence to guide surgical management.

Case Report

We report a case of a proximal humerus fracture with anterior dislocation and glenoid fracture treated in the same sitting with open reduction and internal fixation with angular stability locking plate and cannulated screw. The surgical technique involved standard deltopectoral approach with coracoid osteotomy.

Conclusion

By addressing both fractures operatively at the same time, we reported a satisfactory clinical and functional outcome with bony union of the fracture sites without instability at end of 1 year. Coracoid osteotomy may open an alternative pathway to treat complex proximal humerus injuries with ipsilateral glenoid fracture.

Ponseti Cast Removal: Video Technique

Introduction:

Ponseti casting method is the gold standard for the management of congenital talipes equinovarus in neonates, which consists of weekly manipulation and serial casting. Using oscillatory saw for cast removal is user-dependant and has been fraught with complications consisting of saw burns, thermal abrasions, anxiety, and fear of the saw (especially in children). The aim of this article is to describe our technique of cast removal using visual media format.

Technique:

This video describes an easy method of cast soakage with lukewarm water. Once the cast is soaked in water, the knob is identified, and the loosened outer layer of the cast is unwrapped in layers. Complete procedure can be done at home by parents. Since no equipment is utilized, the technique eliminates all complications associated with an oscillating saw.

Conclusion:

Cast soakage with lukewarm water followed by unwrapping is a simple and cost-effective method of Ponseti cast removal which can be done by parents at home improving the overall satisfaction of the family.

Management Guidelines for Infection After ACL Reconstruction: Expert Opinion Statement Based on the Modified Delphi Survey of Indian Arthroscopy Surgeons

AIM

Infection after anterior cruciate ligament (ACL) reconstruction, though rare, is a potentially devastating complication and the evidence-based recommendation on the various topics in its management is limited. The purpose of this study was to develop recommendations for the prevention and management of infections in ACL reconstruction surgery by performing a structured expert consensus survey using Delphi methodology.

MATERIALS AND METHODS

22 topics of relevance in the prevention and management of infection following ACL reconstruction were chosen from an extensive literature review. 30 panelists were requested to respond to a three-round survey, with feedback, to develop a consensus statement on the topics.

RESULTS

Consensus statements could be prepared in eleven out of twenty-two topics including: the graft is retained at the first arthroscopic debridement, the graft is removed when repeated debridement are needed, and revision ACL reconstruction is needed only if the patient develops instability. Concurrence could be obtained in the topics including: longer duration of antibiotics is needed in immunocompromised patients, soaking graft in antibiotic solution reduces infection risk, and knee swelling without warmth does not suggest infection.

CONCLUSIONS

A proper skin preparation, a longer course of antibiotics in immunocompromised patients, and soaking the graft in antibiotics reduces the risk of infection. In case of infection, a healthy-looking graft must be retained at the first debridement and if the graft must be removed, revision ACL reconstruction is advised only if the patient develops instability.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s43465-021-00363-z.

Triggering of Thumb by a Ganglion Cyst of the Flexor Tendon Sheath at A1 Pulley: A Case Report

Introduction:

Ganglions of the wrist and hand are commonly seen but the most common sites are in the dorsum of the wrist followed by the volar side in the distal forearm at the wrist crease. The Ganglion cysts arising from the flexor tendon sheath are rare and only a few are reported in the literature.

Case Report:

We report a rare case of a ganglion cyst of the flexor tendon sheath at A1 pulley of thumb in a 35-year-old male who came with the complaint of chronic triggering of the left thumb. The histopathological examination confirmed the ganglion which was removed from the A1 pulley area.

Conclusion:

A1 pulley ganglion causing trigger thumb is uncommon entity. Although, traditional treatment for this is conservative or aspiration. High recurrence is observed. When it comes to preservation of fine movements such as thumb, aggressive approach involving exploration and excision of cyst gives good functional outcome and reduces chance of recurrence.

Actinomycotic Infection of Spine - A Rare Disease with Diagnostic Challenge, an Update on Spinal Infection

INTRODUCTION

We are reporting a rare case of lumbar spinal actinomycosis with superficial discharging sinuses in an elderly female.

CASE REPORT

A 56-year-old female came in outpatient with chief complaints of low back pain radiating to both buttocks, burning sensations to both lower limbs. Magnetic resonance imaging (MRI) re-vealed signal intensity changes suggestive of patchy marrow edema present over the L2 to S1 vertebra. Surgery was performed in the form of laminectomy and decompression by posterior approach and tissue was collected from right sacral ala. Contrast MRI showed patchy areas of marrow signal ab-normality L1, L2, L4, and L5 vertebra and adjoining end plates of L5, S1, and S2 segments. Ring en-hancing lesions at L2 and L3 levels. The patient underwent revision surgery. Histopathology revealed clumps of basophilic filamentous bacteria in a vaguely rosette-like configuration surrounded by acute inflammatory cells, characteristic of actinomycosis.

CONCLUSION

Actinomycotic infections of spine are a rare cause of spinal infections but should be kept in mind once the tubercular infection is ruled out. The definitive diagnosis of actinomycosis can be made by finding actinomycetes in the pus from affected tissue.

Does subepineural injection damage the nerve integrity? A technical report from four amputated limbs

Local anesthetic (LA) injection outside the sheath in epineural or paraneural connective tissue is considered safe practice among regional anesthesiologists. There is limited evidence as to whether neurological complications occur if LA is injected inside the sheath (subepineural - intraneural). We performed ultrasound guided injections at the level of undivided sciatic nerve in four amputated lower limbs. In two specimens, LA was injected in epineural connective tissue (paraneural tissue) and in another two specimens by penetrating the outer nerve sheath (hyperechoic epineurium). Ultrasonography demonstrated an increase in the size of nerve and macroscopic findings revealed fascicular tracings with sub-epineural injections. Limbs were sent for histological analysis in formalin containers. Pathologist performed the analysis which demonstrated an intact perineurium and a breach in the epineurium. We conclude that sub-epineural injections are unsafe and injection should be done in paraneural tissue to ensure safety and avoid unwanted neurological sequelae after the block.

Flow dynamics of ultrasound-guided lumbar plexus block in adults

Background and Aims:

The outcomes of plexus and peripheral nerve blocks depend on needle-nerve contact and the spread of local anesthetic (LA) around the plexus or nerve. Needle-nerve distance and spread of LA could be visualized during US-guided lumbar plexus block (LPB).

Material and Methods:

After Institutional Ethics Committee approval and after obtaining informed consent, 24 American Society of Anesthesiologists’-physical status I–III patients who underwent surgical fixation of fractures of proximal femur were enrolled. Spinal anesthesia was a primary anesthetic in all patients. At the end of the surgery, all patients received US and neurostimulation-aided LPB at the third lumbar nerve root (LNr). The primary aim was to determine the spread of LA in the lumbar plexus area with the relation of the needle tip and LNr contact. The secondary aim was to understand block efficacy in terms of pain scores monitored at regular intervals and 100 mg intravenous tramadol was administered as a rescue analgesic if VAS >4.

Results:

In all 24 patients, we observed an oval and antegrade LA spread after lumbar plexus was identified with neurostimulation at L3. With the needle closer to intervertebral foramina (IVF), a retrograde spread was visualized. Only 2/24 patients received rescue analgesia in the first 24 h.

Conclusion:

The type of spread after the US-guided LPB could predict block success of block and a possible epidural spread.

Comparison between neurodynamic therapy and foam rolling in cool-down sessions for delayed onset muscle soreness in healthy individuals

BACKGROUND

Delayed onset of muscle soreness (DOMS) is a common finding in trained and untrained individuals post high intensity exercises which can lead to injuries. Foam rolling (FR) and neurodynamic therapy (NDT) are types of active cool-down which provides effective for treatment of DOMS. But their role in reduction of intensity of the same in cool down is not established.

STUDY DESIGN

Crossover study.

METHODOLOGY

Total 60 healthy individuals participated in the study. Pre intervention readings were taken of strength and tightness by Range of motion. Subjects performed both the types of cool-down separated by 4 weeks interval with random allocation. Post intervention readings of hamstring and quadriceps tightness, grade of tenderness and stand to sit VAS score was taken post 24 h and 48 h and strength post 48 h.

RESULTS

Analysis was done for using repeated measures ANOVA and Friedman's test. The difference of values for Straight Leg Raise and Prone knee Flexion between NDT and FR post 24 h were statistically significant (p < 0.05) while that of NDT post 24 h being similar to FR post 48 h (p > 0.05). There was a significant difference between strength, tenderness and VAS in NDT and FR (p < 0.05). With the mean of post 24 h as well as post 48 h being less in the FR intervention.

CONCLUSION

Foam rolling is a better option than Neurodynamic therapy for reduction of intensity of DOMS.

Successful sterilization and immediate reimplantation of extruded femoral diaphyseal segment: A case report and review of literature

Extrusion of bone is a rare situation in open fractures due to high energy trauma. There are few studies, reporting successful reimplantation of the extruded bone segment using various sterilization and fixation protocols. However, there are no definitive treatment strategies for this challenging situation. We report a case of 30-year-old male patient with grade IIIB compound right distal femur fracture with an extruded long bone segment, who was treated with successful sterilization and immediate reimplantation of an extruded long diaphyseal segment of distal femur following extensive cleaning with sterile normal saline, removal of debris with scrubbing by sterile brush, soakage in the broad-spectrum antimicrobial solution for 30 min, sterilization by autoclaving at 121°C for 45 min, and reimplantation during stable internal fixation with lateral distal femur locking plate using Arbeitsgemeinschaft für Osteosynthesefragen techniques. At 3 months, iliac crest bone grafting, osteoperiosteal flaps, and augmented fixation with a medial locking plate were performed through a subvastus approach for a void in the medial supracondylar femur region. Intraoperatively, punctate bleeding was observed from the reimplanted fragment. Infection was ruled out with normal leukocyte count, C-reactive protein marker, no evidence of unhealthy granulation tissue, and a sterile culture report from the fracture site. The fracture healed in 12 months and the patient had good functional outcome with a lower extremity functional score of 80% and knee range of motion of 110° at short-term follow up of 2 years without any complication. Decision of reimplantation is individualized depending on the time of presentation, contamination, and comminution of extruded fragment with scarce literature on standard treatment strategies. In our case, early presentation, meticulous debridement, unique sterilization technique, immediate reimplantation, and augmented dual distal femur plating with bone grafting aided in achieving successful union with good functional outcome and knee range of motion, avoiding any complications.

Tubercular compound palmar ganglion presenting as a severe carpal tunnel syndrome- A case report

Atypical presentation of tuberculosis is not uncommon in developing countries. Among extra-pulmonary sites, tendons are very rarely involved. Compound palmar ganglion associated with tuberculosis is an uncommon condition in which a swelling is present across the wrist joint on either side of the flexor retinaculum. Very rarely such lesion can compress over neural structures and may present as Carpal Tunnel Syndrome. A therapeutic challenge consists of treating disease and its associated presentation. Treatment of choice for such conditions include complete excision of the mass along with the radical synovectomy of the wrist joint and associated flexor tendon sheaths followed by anti-tubercular medications. With early diagnosis and treatment good recovery can be achieved. We present a Case of a large compound tubercular palmar ganglion who presented to us with symptoms of carpal tunnel syndrome which was treated surgically with excision and carpal tunnel release.

Clinical and radiological factors associated with postoperative shoulder imbalance and correlation with patient-reported outcomes following scoliosis surgery

Background

Shoulder balance (SB) is an important cosmetic concern and is a determinant to assess outcomes following scoliosis surgery. Shoulder imbalance (SI) has been studied predominantly in idiopathic scoliosis with limited literature on other etiologies.

Purpose

To assess SB following scoliosis surgery and correlate SRS-30 self-image scores with radiological shoulder imbalance SI.

Methods

A retrospective analysis was performed for 43 patients undergoing scoliosis surgery with a minimum 2-year follow-up. Radiological SI was assessed by the coracoid height difference on whole spine standing radiographs at preoperative, 12-weeks postoperative and 2-year follow-up. The preoperative Cobb angle, postoperative Cobb angle and mean correction were recorded. The upper and lower end vertebrae (UEV/LEV), and instrumented vertebrae (UIV/LIV) were documented. The aetiology of scoliosis and functional outcomes based on the SRS-30 questionnaire were noted.

Results

There were 19 males and 24 females with a mean age of 14.5 ± 4.7 years. The 12-week postoperative radiographs showed SI in 15 patients and residual SI in 7 patients at 2-year follow-up. SI was seen in four congenital scoliosis with segmentation or mixed anomalies in the proximal thoracic spine. Two idiopathic scoliosis (Lenke type 1 and type 3) showed SI where the UIV was T3 and T2 respectively. The mean preoperative SRS-30 score for patients with SB (N = 9) was 2.5 ± 0.72 and for SI (N = 34) was 3 ± 0.42 without significant difference (p > 0.5). The final mean SRS-30 self-image score for patients with SB was 3.7 ± 0.54 and for patients with SI was 3.7 ± 0.53 without significant difference (p > 0.05).

Conclusion

Radiological SI assessed by coracoid height difference was not associated with a significant difference in SRS 30 scores preoperatively and at 2 year follow up. SI was seen with congenital scoliosis associated with segmentation and mixed anomalies of the proximal thoracic spine.

Romosozumab in Skeletally Mature Adults with a Fresh Unilateral Tibial Diaphyseal Fracture: A Randomized Phase-2 Study

BACKGROUND

Romosozumab is an antibody that binds and inhibits sclerostin, thereby increasing bone formation and decreasing bone resorption. A double-blinded, randomized, phase-2, dose-finding trial was performed to evaluate the effect of romosozumab on the radiographic and clinical outcomes of surgical fixation of tibial diaphyseal fractures.

METHODS

Patients (18 to 82 years old) were randomized 3:1:1:1:1:1:1:1:1:1 to a placebo or 1 of 9 romosozumab treatment groups. Patients received subcutaneous injections of romosozumab or the placebo postoperatively on day 1 and weeks 2, 6, and 12. The primary outcome was the time to radiographic evidence of healing ("radiographic healing") analyzed after the week-24 assessments had been completed for all patients.

RESULTS

A total of 402 patients were randomized: 299 to the romosozumab group and 103 to the placebo group. The median time to radiographic healing (the primary outcome) ranged from 14.4 to 18.6 weeks in the romosozumab groups and was 16.4 weeks (95% confidence interval [CI]: 14.6 to 18.0 weeks) in the placebo group, which was not a significant difference. There was also no significant difference in the median time to clinical healing, no relationship between romosozumab dose/frequency and unplanned revision surgery, and no apparent treatment benefit in terms of physical function. The safety and tolerability profile of romosozumab was comparable with that of the placebo.

CONCLUSIONS

Romosozumab did not accelerate tibial fracture-healing in this patient population. Additional studies of patients at higher risk for delayed healing are needed to explore the potential of romosozumab to accelerate tibial fracture-healing.

LEVEL OF EVIDENCE

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

Subcoracoid tunnel block as an alternative infraclavicular brachial plexus approach -a case series

BACKGRUOND

Magnetic resonance neurography shows the brachial plexus cords in the subcoracoid tunnel beneath the pectoralis minor. With an ultrasound scan along the brachial line, the brachial plexus cords in the subcoracoid tunnel can be targeted using an in-plane needle approach. We describe this new approach to the infraclavicular block called the "subcoracoid tunnel block."

CASE

Twenty patients were administered with the ultrasound-guided subcoracoid tunnel block for the below-elbow surgery. The contact of the needle tip with cords was visible in all 20 patients. With neurostimulation, the posterior cord was identified in 11 (55%) and medial cord in 9 (45%) patients on the first needle pass. The subcoracoid tunnel block was successful in 16 patients (80%).

CONCLUSIONS

Our case series shows that the subcoracoid tunnel block is an excellent alternative technique for the infraclavicular block. Its advantages include better needle-cord visibility and easy identification of the brachial plexus cords.