D. K. Patro

Serum Procalcitonin is a sensitive and specific marker in the diagnosis of septic arthritis and acute osteomyelitis.

BackgroundEarly diagnosis of Acute Osteomyelitis (OM) and Septic Arthritis (SA) is of vital importance to avoid devastating complications. There is no single laboratory marker which is sensitive and specific in diagnosing these infections accurately. Total Count, ESR and CRP are not specific as they can also be elevated in non pyogenic causes of inflammation. Pus Culture and sensitivity is not a true gold standard due to its varied positivity rates (40 – 70%). Serum Procalcitonin (PCT), at 0.5 ng/ml is found to be an accurate marker for pyogenic infections. The objectives of this study were to show that PCT is an accurate marker in differentiating Acute Osteomyelitis and Septic Arthritis from viral and non infective inflammatory bone and joint conditions.MethodsPatients of all age groups (n = 82) with suspected Acute Osteomyelitis and Septic Arthritis were prospectively included in this study. All patients were subjected to TC, CRP, PCT, IgM Dengue, IgM Chikungunya, pus and blood culture and sensitivity. At the end of the study, patients were classified into 3 groups: Group 1 = Confirmed Pyogenic (n = 27); Group 2 = Presumed Pyogenic (n = 21); Group 3 = Non – infective inflammatory (n = 34).ResultsGroup 1 has higher mean PCT levels than Group 2 and 3 (p < 0.05). PCT, at 0.4 ng/ml, was 85.2% sensitive and 87.3% specific in diagnosing Septic Arthritis and Acute Osteomyelitis. In comparison, PCT at conventional cut – off of 0.5 ng/ml is 66.7% sensitive and 91% specific.ConclusionSerum Procalcitonin, at a cut – off of 0.4 ng/ml, is a sensitive and specific marker in the diagnosis of Septic Arthritis and Acute Osteomyelitis.

Calcium Sulfate as Bone Graft Substitute in the Treatment of Osseous Bone Defects, A Prospective Study

BACKGROUND Calcium sulfate belongs to synthetic ceramic group of bone graft substitutes having an osteoconductive property. Calcium sulfate is an easily available, economic bone graft substitute. It is a bio-inert material which over a period of weeks get resorbed and fibrovascular tissue takes its place which eventually allows neovascularisation and bone formation within the area. Use of calcium sulfate as a bone graft substitutes avoids the complications and morbidity associated with autograft like infection, second surgery, and finite amount of graft. MATERIAL AND METHODS A total of 15 patients with benign bone lesions and chronic osteomyelitis were operated and the osseous defects were filled with calcium sulfate which was comprehensively sterilized. Patients were followed with serial radiographs at six week intervals. Calcium sulfate resorption and new bone formation was studied. RESULTS Thirteen cases out of 15 showed calcium sulphate resorption and new bone incorporation. Calcaium sulphate resorption occurred at an average of 14.5 weeks (range,13-18weeks) whereas new bone incorporation occurred at an average of 6months ( range,5-7months). Thirteen patients out of these 15 cases returned to full activities of daily living. One patient had pathological fracture at the osseous defect postoperatively. One patient with GCT of distal end of tibia had recurrence of tumor and had to undergo second surgery. CONCLUSION Although autogenous bone graft is the gold standard for bone grafting, it has limitations like finite amount, additional surgery and donor site morbidity. Calcium sulphate is safe, efficient and easily available bone graft substitute in the treatment of osseous defects. Most common complication encountered was aseptic serous discharge. Functional results were favorable in most of the cases.

Undergraduate orthopedic education: Is it adequate?

Background: Basic musculoskeletal knowledge is essential to the practice of medicine. The purpose of this study was to assess the adequacy of musculoskeletal knowledge of medical students. Materials and Methods: The validated basic competency examination in musculoskeletal medicine devised by Freidman and Bernstein was administered to final year medical students just prior to their final professional examination. Participants were also required to assess their confidence at making a musculoskeletal physical examination and diagnosis as well as comment on the adequacy of time in the curriculum devoted to Orthopedics. Results: The response rate was 83% (40/48). The average cognitive examination score was 48.3%. Two participants (5%) obtained a score of ≥ 73.1%, the recommended mean passing score. Seventeen students (42.5%) felt orthopedic clinical cases were the most difficult to perform a physical examination and diagnose. Thirteen students (32.5%) felt that the time devoted to orthopedics in the medical curriculum was inadequate. Conclusions: Ninety-five percent of the students failed to show basic musculoskeletal competency. A change in medical curriculum and teaching methods is required to address this problem.

Congenital Insensitivity to Pain and Anhydrosis: A Report of Two Cases

We report on 2 patients with congenital insensitivity to pain and anhydrosis. The first one was a 7-month-old boy who presented with non-traumatic, haematogenous septic dislocation of the right elbow with physeal separation of the distal humerus. The second one was a 3-year-old girl suspected to have Job syndrome with an altered immunological profile.

Evaluation of static and dynamic MRI for assessing response of bone sarcomas to preoperative chemotherapy: Correlation with histological necrosis

Objectives: Preoperative chemotherapy plays a key role in management of bone sarcomas. Postoperative evaluation of histological necrosis has been the gold standard method of assessing response to preoperative chemotherapy. This study was done to evaluate the efficacy of static and dynamic magnetic resonance imaging (MRI) for assessing response preoperatively. Materials and Methods: Our study included 14 patients (12 osteosarcomas and 2 malignant fibrous histiocytomas) with mean age of 21.8 years, treated with preoperative chemotherapy followed by surgery. They were evaluated with static and dynamic MRI twice, before starting chemotherapy and again prior to surgery. Change in tumor volume and slope of signal intensity - time curve were calculated and correlated with percentage of histological necrosis using Pearson correlation test. Results: The change in dynamic MRI slope was significant (P = 0.001). Also, ≥60% reduction in slope of the curve proved to be an indicator of good histological response [positive predictive value (PPV) =80%]. Change in tumor volume failed to show significant correlation (P = 0.071). Although it showed high negative predictive value (NPV = 85.7%), PPV was too low (PPV = 57.14%). Conclusions: Dynamic MRI correctly predicts histological necrosis after administration of preoperative chemotherapy to bone sarcomas. Hence, it can be used as a preoperative indicator of response to neoadjuvant chemotherapy. On the other hand, volumetric assessment by static MRI is not an effective predictor of histological necrosis. This study proves the superiority of dynamic contrast-enhanced study over volumetric study by MRI.

Unusual inferior dislocation of shoulder: reduction by two-step maneuver: a case report

Dislocation of the shoulder is the commonest of all large joint dislocations. Inferior dislocation constitutes 0.5% of all shoulder dislocations. It characteristically presents with overhead abduction of the arm, the humerus being parallel to the spine of scapula. We present an unusual case of recurrent luxatio erecta in which the arm transformed later into an adducted position resembling the more common anterior shoulder dislocation. Such a case has not been described before in English literature. Closed reduction by the two-step maneuver was successful with a single attempt. MRI revealed posterior labral tear and a Hill-Sachs variant lesion on the superolateral aspect of humeral head. Immobilisation in a chest-arm bandage followed by physiotherapy yielded excellent results. The case is first of its kind; the unusual mechanism, unique radiological findings and alternate method of treatment are discussed.

Management of unstable spinal fractures with segmental spinal instrumentation (VSP System) : Results at 5 year follow up

Background: Pedicle screw instrumentation has been widely used for spinal stabilisation following spinal injury with variable results. The controversial points associated with spinal injury are effects of canal compromise and decompression on neurological status. Methods: Thirty four patients of unstable thoraco-lumbar fracture with or without neuro-deficit were treated by decompression and stabilisation with VSP system and followed up for 22 - 39 months (mean 29 months). The results were evaluated by neurological recovery (ASIA score), pain relief, loss of surgical correction and functional rehabilitation (FIM score). Results: We achieved a mean post-operative correction of the kyphotic deformity by 14 degrees and an average gain of 30.2% in the canal diameter by decompression. However no correlation was established between degree of canal compromise before or after the surgery with the final neurological outcome. Conclusion: Although the infrastructure for spinal injury management in developing countries is inadequate in many aspects, we find that it is still possible to achieve results, which are comparable with standard literature by adequate decompression and stabilisation followed by appropriate rehabilitation according to the social and cultural demands of the patients.

Bone allografting: an Indian experience

Freeze-drying is considered to be the best technique for allograft preparation and storage. This method is, however, unsuitable for use in developing countries due to high costs. Ethylene oxide sterilization is still controversial because of its effect on osteoinductive capacity. This study involved setting up a bone bank for the first time. Cancellous bone collected from 40 patients was cleaned thoroughly, chemically processed, and sterilized with ethylene oxide gas and stored doubly packed. The grafts were implanted in 11 patients with 14 nonunions. Patients were followed up clinically and radiologically. Thirteen sites were united at the end of 12 months, taking an average of 44.8 weeks to unite. Allograft was also used in 8 benign bone lesions, which showed incorporation of the graft by 29 weeks. This study shows cancellous allograft is suitable for packing cavities in the treatment of benign bone lesions and in treatment of nonunion. There was one deep infection. The low infection rate confirms the efficacy of ethylene oxide as a reliable option for sterilization of bone allograft, and it is also cost effective.RésuméLa congélation sèche est considéré comme la meilleure technique pour la préparation et le stockage des allogreffes. Cependant cette méthode est inapte pour les pays en voie de développement en raison des coûts élevés. La stérilisation à l’oxyde d’éthylène est encore controversée à cause de son effet sur l’osteoinductivité. De l’os spongieux de 40 patients a été collecté, nettoyé entièrement, traité chimiquement et stérilisé avec de l’oxyde d’éthylène gazeux puis entreposé sous double emballage. Les implantations ont été faites à 11 malades avec 14 non-consolidations. Les malades ont été suivis d’une manière clinique et radiologique. Treize sites étaient consolidés à 12 mois avec une moyenne de délai de 44,8 semaines. Ces allogreffes a aussi été utilisées dans 8 lésions osseuses bénignes qui ont montré une incorporation de la greffe à 29 semaines. Cette étude montre que les allogreffes spongieuses sont convenable pour combler des cavités dans le traitement de lésions bénignes aussi bien que dans le traitement des non-consolidations. Il y avait une infection profonde. Le faible taux de l’infection confirme l’efficacité de l’oxyde d’éthylène pour la stérilisation des allogreffes osseuses ce qui a, de plus, a un coût assez bas.

Radiolunate coalition: a case report and literature review

Radiolunate coalition is a very rare entity and was never reported before. we herein describe a case of congenital non-syndromic radiolunate coalition in a 30 year old male with a brief review of literature. we have also suggested a modification to Minaars classification for carpal coalition.

Radiologic assessment of femoral and tibial tunnel placement based on anatomic landmarks in arthroscopic single bundle anterior cruciate ligament reconstruction

Background: Accurate tibial and femoral tunnel placement has a significant effect on outcomes after anterior cruciate ligament reconstruction (ACLR). Postoperative radiographs provide a reliable and valid way for the assessment of anatomical tunnel placement after ACLR. The aim of this study was to examine the radiographic location of tibial and femoral tunnels in patients who underwent arthroscopic ACLR using anatomic landmarks. Patients who underwent arthroscopic ACLR from January 2014 to March 2016 were included in this retrospective cohort study. Materials and Methods: 45 patients who underwent arthroscopic ACLR, postoperative radiographs were studied. Femoral and tibial tunnel positions on sagittal and coronal radiographic views, graft impingement, and femoral roof angle were measured. Radiological parameters were summarized as mean ± standard deviation and proportions as applicable. Interobserver agreement was measured using intraclass correlation coefficient. Results: The position of the tibial tunnel was found to be at an average of 35.1% ± 7.4% posterior from the anterior edge of the tibia. The femoral tunnel was found at an average of 30% ± 1% anterior to the posterior femoral cortex along the Blumensaats line. Radiographic impingement was found in 34% of the patients. The roof angle averaged 34.3° ± 4.3°. The position of the tibial tunnel was found at an average of 44.16% ± 3.98% from the medial edge of the tibial plateau. The coronal tibial tunnel angle averaged 67.5° ± 8.9°. The coronal angle of the femoral tunnel averaged 41.9° ± 8.5°. Conclusions: The femoral and tibial tunnel placements correlated well with anatomic landmarks except for radiographic impingement which was present in 34% of the patients.