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   Table of Contents - Current issue
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July-August 2015
Volume 49 | Issue 4
Page Nos. 373-488

Online since Wednesday, July 01, 2015

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EDITORIAL  

Prophylactic antibiotics in orthopedic surgery Highly accessed article p. 373
Ish Kumar Dhammi, Rehan Ul Haq, Sudhir Kumar
DOI:10.4103/0019-5413.159556  
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REVIEW ARTICLE Top

Percutaneous vertebroplasty and percutaneous balloon kyphoplasty for osteoporotic vertebral compression fracture A metaanalysis Highly accessed article p. 377
Guo Shi-Ming, Luo Wen-Juan, Huang Yun-Mei, Wu Yin-Sheng, Huang Mei-Ya, Lin Yan-Ping
DOI:10.4103/0019-5413.154892  
Background: Osteoporotic vertebral compression fracture (OVCF) is the most common complication of osteoporosis, however, debate persists over which procedure of percutaneous vertebroplasty (PVP) or balloon kyphoplasty (BKP) is a better treatment. We performed a metaanalysis of prospective, randomized controlled and clinical controlled trials of PVP and BKP to determine the efficacy and safety for the treatment of OVCFs to reach a relatively conclusive answer. Materials and Methods: We searched computerized databases comparing efficacy and safety of PVP and BKP in osteoporotic vertebral compression fractures. These reports included pain relief, functional capacity (Oswestry disability index [ODI] score), anterior vertebral body height (AVBH), kyphotic angle and complications (i.e. cement leakage, incident fractures). Studies were assessed for methodological bias and potential reasons for heterogeneity were explored. Results: As of March 15, 2013, a PubMed search resulted in 761 articles, of which eleven studies encompassing 789 patients, met the inclusion criteria. The average length of followup is 17 months and 4.6% patients were lost to followup. Results of metaanalysis indicated that BKP is more effective for short term pain relief. In addition, BKP is more effective to restore the AVBH (anterior vertebral body height), ODI and kyphotic angle of OVCFs. Moreover, BKP need more polymethylmethacrylate amount. Conclusions: In terms of better effectiveness of BKP procedure, we believe BKP to be superior over PVP for the treatment of osteoporotic VCFs.
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ORIGINAL ARTICLES Top

Safe corridors for K-wiring in phalangeal fractures Highly accessed article p. 388
C Rex, R Vignesh, M Javed, Subba Chandra Balaji, C Premanand, Syed Ashfaque Zakki
DOI:10.4103/0019-5413.159591  
Background: Unstable phalangeal fractures are commonly treated with K-wire fixation. Operative fixation must be used judiciously and with the expectation that the ultimate outcome should be better than the outcome after nonoperative management. It is necessary to achieve a stable fracture fixation and early mobilization. In order to achieve this goal, one should closely understand the safe portals/corridors in hand for K-wire entry for fractures of the phalanges. Safe corridors were defined and tested using a pilot cadaveric and a clinical case study by assessing the outcome. Materials and Methods: In our prospective case series, 50 patients with 64 phalangeal fractures were treated with closed reduction and K-wires were inserted through safe portals identified by a pilot cadaveric study. On table active finger movement test was done and the results were analyed using radiology, disabilities of the arm, shoulder, and hand (DASH) score and total active motion (TAM). In our study, little finger (n = 28) was the most commonly involved digit. In fracture pattern, transverse (n = 20) and spiral (n = 20) types were common. Proximal phalanx (n = 38) was commonly involved and the common site being the base of the phalanx (n = 28). Results: 47 (95%) patients had excellent TAM and the mean postoperative DASH score was 58.05. All patients achieved excellent and good scores proving the importance of the safe corridor concept. Conclusion: K-wiring through the safe corridor has proved to yield the best clinical results because of least tethering of soft tissues as evidenced by performing "on-table active finger movement test" at the time of surgery. We strongly recommend K-wiring through safe portals in all phalangeal fractures.
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Prophylactic corticosteroid injection in ulnar wrist pain in distal radius fracture p. 393
Alireza Saied, Afshin Heshmati, Amirreza Sadeghifar, Alia Ayatollahi Mousavi, Fateme Arabnejad, Alireza Pooladsanj
DOI:10.4103/0019-5413.159595  
Background: Ulnar sided wrist pain is one of the most common complications of distal radius fractures. The simplest method for decreasing pain for this affliction is corticosteroid injection. The present study was designed to assess the effect of corticosteroid injection in the prevention of ulnar sided wrist pain. Materials and Methods: In this clinical trial patients with distal radius fractures scheduled for closed reduction and percutaneous pin fixation were divided into control and corticosteroid groups. In the corticosteroid group, the patient received a single betamethasone injection in the dorsoulnar side of the wrist before reduction, while the control group received placebo. The patients were to be followed for at least 6 months. Results: 82 patients were followed for 6 months. At the end of the 3 months followup the difference between the two groups about the number of individuals without ulnar sided wrist pain was statistically significant ( P = 0.038), so that less patients in the control group were painless, while this was not the case in the 6 months followup ( P = 0.507), but in the both time frames the mean grip power, visual analog pain score and the disabilities of the arm, shoulder and hand (DASH) score showed statistically significant difference between the two groups, so that the corticosteroid groups demonstrated greater power grip and less scores in pain and DASH ( P < 0.05). Conclusion: Based on the findings of the present study it seems that prophylactic corticosteroid injection will be associated with a decrease in the severity of wrist pain in patients with acute distal radius fractures. With regard to the decrease in the number of painless individuals, it seems that the decrease is not persistent. Overall the need for a study with longer followup is obvious.
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Cast index in predicting outcome of proximal pediatric forearm fractures p. 398
Hassaan Qaiser Sheikh, Karan Malhotra, Phil Wright
DOI:10.4103/0019-5413.159609  
Background: Many pediatric forearm fractures can be treated in plaster following closed reduction. The cast index (CI, a ratio of anteroposterior to lateral internal diameters of the cast at the fracture site) is a simple, reliable marker of quality of molding and a CI of >0.8 correlates with increased risk of redisplacement. Previously, CI has been applied to all forearm fractures. We hypothesize that an acceptable CI is more difficult to achieve and does not predict outcome in fractures of the proximal forearm. Materials and Methods: Seventynine cases of pediatric forearm fractures initially treated by manipulation alone over a year were included in this retrospective radiographic analysis. The CI was calculated from the post manipulation radiographs. All fractures were divided as either proximal or distal half forearm based on the location of the radius fracture. Subsequent radiographs were reviewed to assess redisplacement and reoperation. Results: The mean CI was 0.77. Remanipulation was required in five cases (6%), all distal half fractures - mean CI 0.79. CI was higher in proximal half forearm fractures (0.83 vs. 0.76, P = 0.006), nonetheless these fractures did not re-displace more than distal fractures. Conclusion: Cast index is useful in predicting redisplacement of manipulated distal forearm fractures. We found that in proximal half forearm fractures it is difficult to achieve a CI of <0.8, but increased CI does not predict loss of position in these fractures. We therefore discourage the use of CI in proximal half forearm fractures.
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Subungual glomus tumors of the hand Treated by transungual excision p. 403
Harshad Jawalkar, Venkateshwar Reddy Maryada, Venkatramana Brahmajoshyula, Guruvardhan Kumar V Kotha
DOI:10.4103/0019-5413.159611  
Background: Glomus tumors are benign hamartomas arising from the glomus body, mostly occurring in the subungual region of the digits. A triad of excruciating pain, localized tenderness and cold sensitivity is the key to diagnosing these tumors. Two surgical approaches are described in the literature for excision of subungual glomus tumors-transungual and periungual. We reviewed retrospectively the results of subungual glomus tumors of the hand treated by transungual excision. Materials and Methods: Twelve patients (9 females and 3 males) with histopathologically confirmed subungual glomus tumors of the hand were treated by transungual excision at our institute. The mean age of the patients was 40.5 years (range 28-63 years). All patients presented with pain in the nail bed and cold sensitivity. A bluish-brown discoloration was present in 6 patients. Love's pin test was positive in all and Hildreth's test was positive in 8 patients. The mean duration of followup was 38 months (range 8-72 months). Results: All patients had complete pain relief. There was no new nail deformity and no recurrence till last followup. One patient had deformity of the nail preoperatively due to previous surgery, which persisted after excision of the tumor. All of them returned to their preoperative occupation and regained full function of the hand. Conclusions: The transungual approach provides good access to the entire lesion and facilitates complete excision. Contrary to reported literature, we did not find the development of any new nail deformity with this approach.
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Outcome of humeral shaft fractures treated by functional cast brace p. 408
Jitendra Nath Pal, Prahas Biswas, Avik Roy, Sunit Hazra, Somnath Mahato
DOI:10.4103/0019-5413.159619  
Background: Functional brace application for isolated humeral shaft fracture persistently yields good results. Nonunion though uncommon involves usually the proximal third shaft fractures. Instead of polyethylene bivalve functional brace four plaster sleeves wrapped and molded with little more proximal extension expected to prevent nonunion of proximal third fractures. Periodic compressibility of the cast is likely to yield a better result. This can be applied on the 1 st day of the presentation as an outpatient basis. Comprehensive objective scoring system befitting for fracture humeral shaft is a need. Materials and Methods: Sixty six (male = 40, female = 26) unilateral humeral shaft fractures of mean age 34.4 years (range 11-75 years) involving 38 left and 28 right hands were included in this study during April 2008 to December 2012. Fractures involved proximal (n = 18), mid (n = 35) and distal (n = 13) of humerus. Transverse, oblique, comminuted and spiral orientations in 18, 35 and 13 patients respectively. One had segmental fracture and three had a pathological fracture with cystic bone lesion. Mechanisms of injuries as identified in this study were road traffic accidents 57.6% (n = 38), fall 37.9% (n = 25). 12.1% (n = 8) had radial nerve palsy 7.6% (n = 5) had Type I open fracture. Four plaster strips of 12 layers and 5-7.5 cm broad depending on the girth of arm were prepared. Arm was then wrapped with single layer compressed cotton. Lateral and medial strips were applied and then after molding anterior and posterior strips were applied in such a way that permits full elbow range of motion and partial abduction of the shoulder. Care was taken to prevent adherence of one strip with other except in the proximal end. Limb was then put in loose collar and cuff sling intermittently allowing active motion of the elbow ROM and pendular movement of the shoulder. Weekly tightening of the cast by fresh layers of bandage over the existing cast brace continued. Results: The results were assessed using 100 point scoring system where union allotted 30 points and 60 points allotted for angulations (10), elbow motion (10), shoulder abduction (10), shortening (5), rotation (5), absence of infection (10), absence of nerve palsy during treatment (10). Remaining 10 points were allotted for five items with two points each. They were the absence of skin sore, absence of vascular problem, absence of reflex sympathetic dystrophy (RSD), recovery of paralyzed nerve during injury and recovery of paralyzed nerve during treatment. Results were considered excellent with 90 and above, good with 80-89, fair with 70-79 and poor below 70 point. Results at 6 months were excellent in 43.94% ( n = 29), good in 42.42% ( n = 28), fair in 9.1% ( n = 6), poor in 4.55% ( n = 3). Union took place in 98.48% ( n = 65) with an average of 10.3 weeks (range 6-16 weeks). 87.5% ( n = 7) paralyzed radial nerve recovered. All wounds healed. Four patients had transient skin problem. One patient with mid shaft fracture had nonunion due to the muscle interposition. Conclusion: Modified functional cast brace is one of the options in treatment for humeral shaft fractures as it can be applied on the 1 st day of the presentation in most of the situations. Simple objective scoring system was useful particularly in uneducated patients.
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Mid term results of Pemberton pericapsular osteotomy p. 418
Mehmet Bülent Balioglu, Ali Öner, Ümit Selçuk Aykut, Mehmet Akif Kaygusuz
DOI:10.4103/0019-5413.159627  
Background: Treatment for developmental dysplasia of the hip (DDH) varies according to the age of the patient. For children under 3 months, the preferred treatment is Pavlik bandaging and/or dynamic hip orthosis;for children of 3-18 months (with/without arthrography), closed and open reductions (ORs) are most common; and for children 18 months and older, pelvic osteotomies are used. Radiological and functional outcomes of patients between 16 months and 7 years of age who underwent Pemberton pericapsular osteotomy (PPO) were evaluated. Materials and Methods: Twelve patients with developmental dysplasia of the hip (DDH) received treatment on 14 hips between 2001 and 2006. All patients with DDH had PPO as pelvic osteotomy. PPO was done solely in 3 hips, PPO and open reduction (OR) in and OR + PPO + femoral shortening in 6. The average age was 39.85 months (range 16-83 months). All had 1-stage surgery. Acetabular index (AI) and the grade of displacement were determined according to Tönnis'. Center-edge (CE) angle was evaluated. Clinical evaluations were made as described by McKay, radiological assessments by Severin's criteria and femoral head avascular necrosis measurements by Kalamchi-MacEwen's criteria. Average followup periods were 83.35 months (range 48-115 months). Results: Preoperative and postoperative average AI levels were 41.92° (range 30-50°) and 19,5° (range 5-34°), respectively ( P < 0.001). According to Severin's classification, 11 (78.57%) patients were Ia, 1 (7.14%) was Ib, 1 (7.14%) was II and 1 (7.14%) was III. According to Kalamchi-McEven criteria, 12 (85.71%) patients were type I, 2 (14.28%) patients were type II. CE postoperatively was measured as 24.24° (range 12-41°). Clinically (McKay), the functional results in 13 (92.85%) patients were very good (I) and in 1 (7.14%) was good (II). Conclusions: Functional and radiological mid term outcomes were found to be comparable in most of the patients with DDH undergoing PPO between the ages of 16 months and 7 years.
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Vertical pelvic ring displacement in pelvic ring injury Measurements in pelvic outlet radiograph and in cadavers p. 425
Krit Boontanapibul, Thos Harnroongroj, Narumol Sudjai, Thossart Harnroongroj
DOI:10.4103/0019-5413.159634  
Background: Vertical pelvic ring displacement (VPRD) is a serious injury and needs assessment. Pelvic outlet radiographs are routinely taken. However, relationship of radiographic and actual VPRD is still in question. Thus, measurement of VPRD from pelvic radiographs was studied. Materials and Methods: 2 dry pelvic bones and 1 sacrum from same cadaver was reconstructed to be the pelvic ring. Five specimens were enrolled. 10, 20 and 30 mm vertical displacement of right pelvic bone was performed at levels of sacroiliac joint and pubic symphysis for representing right VPRD. Then, the pelvis was set sacral inclination at 60° from X-ray table for outlet and anteroposterior pelvic radiographs. Right VPRD was measured by referring to superior most pelvic articular surface of both sacroiliac joints and sacral long axis. Radiographic VPRD and actual displacement were analyzed by Pearson correlation coefficient at more than 0.90 for the strong correlation and strongly significant simple regression analysis was set at P < 0.01. Results: Radiographic VPRD from outlet and anteroposterior pelvic views at 10 mm actual displacement were 20.12 ± 1.98 and 4.08 ± 3.76 mm, at 20 mm were 40.31 ± 1.97 and 9.94 ± 7.27 mm and at 30 mm were 58.56 ± 2.53 and 11.29 ± 2.89 mm. Statistical analyses showed that radiographic VPRD from pelvic outlet view is 1.95 times of actual displacement with strong correlation at 0.992 coefficient and strongly significant regression analysis (P < 0.001) with 0.984 of R[2] value. Whereas, the measurement from anteroposterior pelvic radiograph was not strongly significant. Conclusion: Pelvic outlet radiograph provides efficient measurement of VPRD with 2 times of actual displacement.
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Outcome of limb reconstruction system in open tibial diaphyseal fractures p. 429
Anand Ajmera, Ankit Verma, Mukul Agrawal, Saurabh Jain, Arunangshu Mukherjee
DOI:10.4103/0019-5413.159638  
Background: Management of open tibial diaphyseal fractures with bone loss is a matter of debate. The treatment options range from external fixators, nailing, ring fixators or grafting with or without plastic reconstruction. All the procedures have their own set of complications, like acute docking problems, shortening, difficulty in soft tissue management, chronic infection, increased morbidity, multiple surgeries, longer hospital stay, mal union, nonunion and higher patient dissatisfaction. We evaluated the outcome of the limb reconstruction system (LRS) in the treatment of open fractures of tibial diaphysis with bone loss as a definative mode of treatment to achieve union, as well as limb lengthening, simultaneously. Materials and Methods: Thirty open fractures of tibial diaphysis with bone loss of at least 4 cm or more with a mean age 32.5 years were treated by using the LRS after debridement. Distraction osteogenesis at rate of 1 mm/day was done away from the fracture site to maintain the limb length. On the approximation of fracture ends, the dynamized LRS was left for further 15-20 weeks and patient was mobilized with weight bearing to achieve union. Functional assessment was done by Association for the Study and Application of the Methods of Illizarov (ASAMI) criteria. Results: Mean followup period was 15 months. The mean bone loss was 5.5 cm (range 4-9 cm). The mean duration of bone transport was 13 weeks (range 8-30 weeks) with a mean time for LRS in place was 44 weeks (range 24-51 weeks). The mean implant index was 56.4 days/cm. Mean union time was 52 weeks (range 31-60 weeks) with mean union index of 74.5 days/cm. Bony results as per the ASAMI scoring were excellent in 76% (19/25), good in 12% (3/25) and fair in 4% (1/25) with union in all except 2 patients, which showed poor results (8%) with only 2 patients having leg length discrepancy more than 2.5 cm. Functional results were excellent in 84% (21/25), good in 8% (2/25), fair in 8% (2/25). Pin tract infection was seen in 5 cases, out of which 4 being superficial, which healed to dressings and antibiotics. One patient had a deep infection which required frame removal. Conclusion: Limb reconstruction system proved to be an effective modality of treatment in cases of open fractures of the tibia with bone loss as definite modality of treatment for damage control as well as for achieving union and lengthening, simultaneously, with the advantage of early union with attainment of limb length, simple surgical technique, minimal invasive, high patient compliance, easy wound management, lesser hospitalization and the lower rate of complications like infection, deformity or shortening.
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Outcome of intertrochanteric fractures treated by intramedullary nail with two integrated lag screws A study in Asian population p. 436
Jong-Won Kim, Tae-Young Kim, Yong-Chan Ha, Young-Kyun Lee, Kyung-Hoi Koo
DOI:10.4103/0019-5413.159647  
Background: The incidence of intertrochanteric fracture has increased during recent years as life expectancy has also increased. Currently, orthopedic surgeons use various fixation methods for intertrochanteric fractures like, intramedullary (IM) nailing or dynamic hip screws and plates. The intramedullary (IM) nail with two integrated lag screws has been used recently in intertrochanteric fractures to overcome Z-affect phenomenon. However, no study is available in an Asian population. This prospective study was undertaken to document the clinical and radiologic outcomes of the IM nail with two integrated lag screws and its limitations in Asian patients. Materials and Methods: Osteosynthesis was performed using InterTAN nail in 100 patients with an intertrochanteric fractures followed up for at least 1 year after surgery. We evaluated the recovery rates to prefracture status, time to bony union and the incidence of complications. Results: Seventy four patients were available for at least 1 year followup examinations. Forty-five patients (60.8%) recovered prefracture status. Mean time to bony union was 18.3 ± 8.6 weeks. Intraoperative technical problems related to an unavoidable superior positioning of the lag screw occurred in five cases. Postoperative complications requiring reoperation occurred in three patients; two cases of varus collapse with cut out and one case of periprosthetic fracture. Conclusions: The IM nail with two integrated lag screws showed favorable outcomes in Asian patients with an intertrochanteric fracture even though several complications that were not previously reported with this nail were found. The proper selection of patients and careful insertion of two lag screws should be mandatory in Asian patients.
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Cementless arthroplasty with a distal femoral shortening for the treatment of Crowe type IV developmental hip dysplasia p. 442
Chang-Yong Guo, Bo-Wei Liang, Mo Sha, Liang-Qi Kang, Jiang-Ze Wang, Zhen-Qi Ding
DOI:10.4103/0019-5413.159652  
Background: Severe developmental dysplasia of the hip is a surgical challenge. The purpose of this study is to describe the cementless arthroplasty with a distal femoral shortening osteotomy for Crowe type IV developmental hip dysplasia and to report the results of this technique. Materials and Methods: 12 patients (2 male and 10 female) of Crowe type IV developmental hip dysplasia operated between January 2005 and December 2010 were included in the study. All had undergone cementless arthroplasty with a distal femoral shortening osteotomy. Acetabular cup was placed at the level of the anatomical position in all the hips. The clinical outcomes were assessed and radiographs were reviewed to evaluate treatment effects. Results: The mean followup for the 12 hips was 52 months (range 36-82 months). The mean Harris hip score improved from 41 points (range 28-54) preoperatively to 85 points (range 79-92) at the final followup. The mean length of bone removed was 30 mm (range 25-40 mm). All the osteotomies healed in a mean time of 13 weeks (range 10-16 weeks). There were no neurovascular injuries, pulmonary embolism or no infections. Conclusion: Our study suggests that cementless arthroplasty with a distal femoral shortening is a safe and effective procedure for severe developmental dysplasia of the hip.
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Short term results of cementless total hip arthroplasty in sicklers p. 447
Yash Gulati, Mrinal Sharma, Bhupendra Bharti, Vibhu Bahl, Ishwar Bohra, Amit Goswani
DOI:10.4103/0019-5413.159659  
Background: Sickle cell (SC) disease leading to endarteritis induces skeletal changes in the form of osteitis, sclerosis of femoral canal and osteonecrosis of the femoral head. All these make total hip arthroplasty (THA) difficult and prolonged. There is increased risk of infection, SC crisis and increased complication rate. Our paper aims to highlight preoperative, intraoperative and postoperative hurdles encountered in performing THA in sicklers and the short term outcome using cementless implants. Materials and Methods: Thirty-nine patients with SC disease, who had osteonecrosis of the femoral head, were operated between 2007 and 2011. The mean age of patients was 22 years (range 13-49 years). There were twenty eight females and 11 males. Bilateral cementless total hip replacement (THR) was performed in 11 patients (22 hips) and in the rest unilateral (28 hips). Preoperative and postoperative modified Harris hip score was evaluated. The average followup was 3.8 years (range 2-6 years). Results: The average operating time was 96 min (range 88-148 min). The average blood loss was 880 ml (range 650-1200 ml). The average intraoperative blood transfused was 2.3 units (range 2-5 units). All patients showed an improvement in Harris hip score from 42 points preoperatively to 92 points at latest followup. Intraoperatively, one patient had a periprosthetic fracture. Six patients developed acute SC crisis and were managed in intensive care unit. Three patients developed wound hematoma. Three patients developed limb length discrepancy less than 1 cm. None had early or late dislocations, infection, heterotopic ossification, sciatic nerve palsy and aseptic loosening. Conclusion: THA in sicklers involves considerable challenge for the orthopedic surgeon. Management requires a multidisciplinary approach involving the anesthetist, hematologist and the orthopedic surgeon. Contrary to previous reports, THA in sicklers now has a predictable outcome especially with the use of cementless implants.
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Robot assisted navigated drilling for percutaneous pedicle screw placement: A preliminary animal study p. 452
Hongwei Wang, Yue Zhou, Jun Liu, Jianda Han, Liangbi Xiang
DOI:10.4103/0019-5413.159670  
Background: There is much more radiation exposure to the surgeons during minimally invasive pedicle screws placement. In order to ease the surgeon's hand-eye coordination and to reduce the iatrogenic radiation injury to the surgeons, a robot assisted percutaneous pedicle screw placement is useful. This study assesses the feasibility and clinical value of robot assisted navigated drilling for pedicle screw placement and the results thus achieved formed the basis for the development of a new robot for pedicle screw fixation surgery. Materials and Methods: Preoperative computed tomography (CT) of eight bovine lumbar spines (L1-L5) in axial plane were captured for each vertebra, the entry points and trajectories of the screws were preoperatively planned. On the basis of preoperative CT scans and intraoperative fluoroscopy, we aligned the robot drill to the desired entry point and trajectory, as dictated by the surgeon's preoperative plan. Eight bovine lumbar spines were inserted 80 K-wires using the spine robot system. The time for system registration and pedicle drilling, fluoroscopy times were measured and recorded. Postoperative CT scans were used to assess the position of the K-wires. Results: Assisted by spine robot system, the average time for system registration was (343.4 ± 18.4) s, the average time for procedure of drilling one pedicle screw trajectory was (89.5 ± 6.1) s, times of fluoroscopy for drilling one pedicle screw were (2.9 ± 0.8) times. Overall, 12 (15.0%) of the 80 K-wires violated the pedicle wall. Four screws (5.0%) were medial to the pedicle and 8 (10.5%) were lateral. The number of K-wires wholly within the pedicle were 68 (85%). Conclusions: The preliminary study supports the view that computer assisted pedicle screw fixation using spinal robot is feasible and the robot can decrease the intraoperative fluoroscopy time during the minimally invasive pedicle screw fixation surgery. As spine robotic surgery is still in its infancy, further research in this field is worthwhile especially the accuracy of spine robot system should be improved.
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Outcome of percutaneous balloon kyphoplasty in vertebral compression fractures p. 458
B Praveen Saxena, B Viral Shah, S Prateek Joshi
DOI:10.4103/0019-5413.159673  
Background: Incidence of vertebral compression fractures (VCFs) is increasing due to increase in human life expectancy and prevalence of osteoporosis. Vertebroplasty had been traditional treatment for pain, but it neither attempts to restore vertebral body height nor eliminates spinal deformity and is associated with a high rate of cement leakage. Balloon kyphoplasty involves introduction of inflatable balloon into the fractured body of vertebra for elevation of the end-plates prior to fixation of the fracture with bone cement. This study evaluates short term functional and radiological outcomes of balloon kyphoplasty. The secondary aim is to explore short-term complications of the procedure. Materials and Methods: A retrospective study of 199 kyphoplasty procedures in 135 patients from March 2009 to March 2012 were evaluated with short form-36 (SF-36) score, visual analogue scale (VAS), detailed neurological and radiological evaluations. The mean followup was 18 months (range 12-20 months). Statistical analysis including paired sample t-test was done with statistical package for social sciences. Results: Statistically significant improvements in SF-36 (from 34.29 to 48.53, an improvement of 14.24, standard deviation (SD) - 20.08 P < 0.0001), VAS (drop of 4.49, from 6.74 to 2.24, SD - 1.44, P < 0.0001), percentage restoration of lost vertebral height (from 30.62% to 16.19%, improvement of 14.43%, SD - 15.37, P < 0.0001) and kyphotic angle correction (from 17.41° to 10.59°, improvement of 6.82, SD - 7.26°, P < 0.0001) were noted postoperatively. Six patients had cement embolism, 65 had cement leak and three had adjacent level fracture which required repeat kyphoplasty later. One patient with history of ischemic heart disease had cardiac arrest during the procedure. No patients had neurological deterioration in the followup period. Conclusions: Kyphoplasty is a safe and effective treatment for VCFs. It improves physical function, reduces pain and corrects kyphotic deformity.
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Cervical pedicle screw fixation at C6 and C7 A cadaveric study p. 465
Ye Li, Jingchen Liu, Yulong Liu, Yuntao Wu, Qingsan Zhu
DOI:10.4103/0019-5413.159678  
Background: Cervical pedicle screw fixation is an effective method for treating traumatic and non traumatic injuries. But many studies have reported higher incidence of cervical pedicle penetration, so many research efforts have aimed at improving the accuracy of cervical screw fixation.Most of the anatomical studies on cervical pedicle screw placement previously published focused on the measurements of anatomical parameters, the entry point of pedicle screw is vague. We preliminarily designed a C3, C4 and C5 pedicle screw fixation method that had clear entry point and clinical cases confirmed that this method is feasible and safe. So we did this study of cervical pedicle screw fixation for C6 and C7 vertebrae. Materials and Methods: Fifteen cervical vertebrae specimens were prepared and bilateral pedicle screws were manually inserted into C6 and C7. The intersection of the horizontal line through the midpoint of the transverse process root and the vertical line through the intersection of the posterolateral and posterior planes of the isthmus was the entry point. The screws were inserted along the axis of the pedicle, with the screw axis coinciding with the pedicle. The pedicle was truncated axially and sagittally along the trajectory and the narrowest pedicular height (PH), pedicular width (PW), overall length of the screw channel (LSC), transverse angle (E) and vertical angle (F) were measured. Results: In C6, the PW and PH were 6.12 ± 0.78 and 7.48 ± 0.81 mm, respectively. In C7, the PW and PH were 6.85 ± 0.73 and 8.03 ± 0.38 mm, respectively. The LSC was 30.83 ± 0.91 mm. Two E angles were identified, namely E1 and E2 and their values were 89.61 ± 1.24 and 59.71 ± 1.10°, respectively. Meanwhile, F averaged 75.86 ± 1.12°. Conclusion: The intersection of the horizontal line through the midpoint of the transverse process root and vertical line through the intersection of the posterolateral and posterior planes of the isthmus can be used as an entry point for C6 and C7 pedicle screw fixation. The screws should be inserted at 60 or 90° with the posterolateral isthmus in the horizontal plane and at 75° with the posterior isthmus in the sagittal plane. The LSC should not exceed 30 mm.
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Anterior D-rod and titanium mesh fixation for acute mid-lumbar burst fracture with incomplete neurologic deficits A prospective study of 56 consecutive patients p. 471
Zhe-yuan Huang, Zhen-qi Ding, Hao-yuan Liu, Jun Fang, Hui Liu, Mo Sha
DOI:10.4103/0019-5413.159680  
Background: Anterior decompression and reconstruction have gained wide acceptance as viable alternatives for unstable mid-lumbar burst fracture, but there are no mid and long term prospective studies regarding clinical and radiologic results of mid-lumbar burst fractures. Materials and Methods: An Institutional Review Board-approved prospective study of 56 consecutive patients of mid-lumbar burst fractures with a load-sharing score of 7 or more treated with anterior plating was carried out. All patients were evaluated for radiologic and clinical outcomes. The fusion status, spinal canal compromise, segmental kyphotic angle (SKA), vertebral body height loss (VBHL), and adjacent segment degeneration was examined for radiologic outcome, whereas the American Spinal Injury Association scale, the visual analog scale (VAS), and the employment status were used for clinical evaluation. Results: The patients underwent clinical and radiologic followup for at least 5 years after the surgery. At the last followup, there was no case of internal fixation failure, adjacent segment degeneration, and other complications. Interbody fusion was achieved in all cases. The average fusion time was 4.5 months. No patient suffered neurological deterioration and the average neurologic recovery was 1.3 grades on final observation. Based on VAS pain scores, canal compromise, percentage of VBHL and SKA, the difference was statistically significant between the preoperative period and postoperative or final followup ( P < 0.05). Results at postoperative and final followup were better than the preoperative period. However, the difference was not significant between postoperative and final followup ( P > 0.05). Thirty-four patients who were employed before the injury returned to work after the operation, 15 had changed to less strenuous work. Conclusion: Good mid term clinicoradiological results of anterior decompression with D-rod and titanium mesh fixation for suitable patients with mid-lumbar burst fractures with incomplete neurologic deficits can be achieved. The incident rate of complications was low. D-rod is a reliable implant and has some potential advantages in L4 vertebral fractures.
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CASE REPORTS Top

Nine toes; Mirror Foot Deformity p. 478
Aleksandar M Vlahovic, Boris S Pistignjat, Natasa S Vlahovic
DOI:10.4103/0019-5413.159681  
Mirror foot is a very rare congenital anomaly, with only a few papers presenting definitive treatment for this entity. There are limited management recommendations. Most cases are treated before walking age. In our case, there were no associated developmental defects of the leg. The child underwent complex rays resection with medial foot reconstruction. After 7.5 years of followup, definitive surgical treatment was performed with satisfactory cosmetic and functional outcome.
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Multifocal bilateral xanthogranulomatous osteomyelitis p. 482
Rahul Sapra, Pankaj Jain, Shubha Gupta, Rakesh Kumar
DOI:10.4103/0019-5413.159682  
Xanthogranulomatous osteomyelitis is a rare chronic inflammatory disorder which clinically resembles bone tumor. It is characterized histologically by the presence of a large number of foamy histiocytes admixed with lymphocytes and plasma cells. Xanthogranulomatous inflammation can involve any organ, with kidneys and gall bladder being the worst affected. Only anecdotal cases of osteomyelitis have been reported in the past with scant medical literature. However, all the earlier reported cases, except one, were unifocal lesions. The authors present a case of multifocal xanthogranulomatous osteomyelitis involving the left medial malleoli, left talus and the right cuboid bones.
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LETTERS TO EDITOR Top

Stem cell therapy in spinal trauma: Does it have scientific validity? p. 485
Sandeep Singh
DOI:10.4103/0019-5413.159683  
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Author's reply p. 485
Harvinder S Chhabra, Kanchan Sarda
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ERRATUM Top

Bipolar hip arthroplasty for avascular necrosis of femoral head in young adults: Erratum p. 487

DOI:10.4103/0019-5413.159685  
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Results of reconstruction of massive irreparable rotator cuff tears using a fascia lata allograft: Erratum p. 488

DOI:10.4103/0019-5413.159686  
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