A new era in the surgical treatment of adolescent idiopathic scoliosis (AIS) opened with the introduction of pedicle screw instrumentation, which provides 3-column vertebral fixation and allows major deformity correction on the coronal, sagittal, and axial planes. A steep learning curve can be expected for spinal surgeons to become familiar with pedicle screw placement and correction techniques. Potential complications including injury to adjacent neural, vascular, and visceral structures can occur due to screw misplacement or pull-out during correction maneuvers. These major complications are better recognized as pedicle screw techniques become more popular and may result in serious morbidity and mortality. Extensive laboratory and clinical training is mandatory before pedicle screw techniques in scoliosis surgery are put to practice. Wider application, especially in developing countries, is limited by the high cost of implants. Refined correction techniques are currently developed and these utilize a lesser number of pedicle anchors which are strategically positioned to allow optimum deformity correction while reducing the neurological risk, surgical time, and blood loss, as well as instrumentation cost. Such techniques can be particularly attractive at a time when cost has major implications on provision of health care as they can make scoliosis treatment available to a wider population of patients. Pedicle screw techniques are currently considered the gold standard for scoliosis correction due to their documented superior biomechanical properties and ability to produce improved clinical outcomes as reflected by health-related quality-of-life questionnaires. Ongoing research promises further advances with the future of AIS treatment incorporating genetic counseling and possibly fusionless techniques.

Background: The osteoporotic vertebral compression fractures (OVCF) have attracted more and more attention due to increase in life span globally and aging population. Percutaneous vertebroplasty (PVP) and percutaneous kyphoplasty (PKP) have been popularized rapidly by virtue of their unique advantage in minimal invasiveness. We analysed our results in osteoporotic thoracolumbar fractures using percutaneous kyphoplasty and posterior screw rod system. To investigate the possibility of treatment of rupture of the posterior vertebral osteoporotic fractures by means of kyphoplasty combined with the posterior screw-rod system. Materials and Methods: Twenty six patients (65 years of age or older) with the single spine fractures included in study. The preoperative bone mineral density was measured by dual-energy X-ray. The PKP was done in all the cases. Decompression was done if neurological symptoms were present. Results: The results demonstrated osteoporosis with BMD T value ≤ −2.5; injured posterior vertebral body (3 cases) had shown the whole damage accompanied by neurological symptoms through X-ray or CT. After 2 days, the remaining patients of back pain symptoms were relieved or disappeared except for three cases of patients with decompression incision. VAS score and Cobb angle changed from preoperative 8.23 ± 0.17 and 28.7 ± 0.33° respectively to postoperative 3.77 ± 0.44 and 3.8 ± 0.2° respectively. Conclusion: Treatment of rupture of the posterior vertebral osteoporotic thoracolumbar fractures by means of kyphoplasty combined with posterior screw-rod system is a safe, effective procedure.

Background: Percutaneous vertebroplasty (PVP) is more commonly used for osteoporotic compression fractures (OCFs) and osteolytic vertebral body tumors. This study aimed to study the differences between OCFs and vertebral hemangiomas (VHs) treated with PVP. Materials and Methods: Between September 2007 and January 2010, we prospectively treated 28 consecutive patients of OCFs (43 recently symptomatic OCFs) and 24 cases of VHs (26 VHs). We used visual analogue scale (VAS) pain and Oswestry Disability Index (ODI) to evaluate the patients. The followup period in group 1 and 2 were 25.1 months (range 12 - 31 months) and 21.3 months (range 14 - 28 months), respectively. Comparison of means was carried out with the Chi Square Tests, t-test, and N Par-Test for multiple comparisons, whenever appropriate. The level of statistical significance was set at P < 0.05. Results: Following PVP the VAS score decreased to 4.57 and 4.17 in group 1 and 2, respectively. The ODI scores were 32.5% and 30%, respectively. This decrease in ODI scores lasted throughout the followup period. Conclusions: Although the preoperative scores were significantly different between group 1 and 2, there was no significant difference between two groups following the PVP.

Background: The objective of this cadaveric study was to analyze the effects of iatrogenic pedicle perforations from screw misplacement on the mean pullout strength of lower thoracic and lumbar pedicle screws. We also investigated the effect of bone mineral density (BMD), diameter of pedicle screws, and the region of spine on the pullout strength of pedicle screws. Materials and Methods: Sixty fresh human cadaveric vertebrae (D10-L2) were harvested. Dual-energy X-ray absorptiometry (DEXA) scan of vertebrae was done for BMD. Titanium pedicle screws of different diameters (5.2 and 6.2 mm) were inserted in the thoracic and lumbar segments after dividing the specimens into three groups: a) standard pedicle screw (no cortical perforation); b) screw with medial cortical perforation; and c) screw with lateral cortical perforation. Finally, pullout load of pedicle screws was recorded using INSTRON Universal Testing Machine. Results: Compared with standard placement, medially misplaced screws had 9.4% greater mean pullout strength and laterally misplaced screws had 47.3% lesser mean pullout strength. The pullout strength of the 6.2 mm pedicle screws was 33% greater than that of the 5.2 mm pedicle screws. The pullout load of pedicle screws in lumbar vertebra was 13.9% greater than that in the thoracic vertebra ( P = 0.105), but it was not statistically significant. There was no significant difference between pullout loads of vertebra with different BMD ( P = 0.901). Conclusion: The mean pullout strength was less with lateral misplaced pedicle screws while medial misplaced pedicle screw had more pullout strength. The pullout load of 6.2 mm screws was greater than that of 5.2 mm pedicle screws. No significant correlation was found between bone mineral densities and the pullout strength of vertebra. Similarly, the pullout load of screw placed in thoracic and lumbar vertebrae was not significantly different.

Background: Large lumbar disc herniation (LDH) has been reported to have a greater tendency to resolve in clinical and pathomorphological evolutions. However, various definitions of large LDH have been used without validation, and the clinical symptoms of large LDH have not been fully elucidated. We conducted a retrospective analysis to determine the clinical characteristics and treatment outcome of massive LDH with complete dural sac stenosis Materials and Methods: We retrospectively reviewed 33 cases of LDH with complete dural sac stenosis on magnetic resonance imaging. Complete dural sac stenosis was defined as no recognizable rootlet and cerebrospinal fluid signal on T2-weighed axial MR images. The clinical outcome parameters included back pain, leg pain, Oswestry disability index (ODI), and neurological dysfunction. The paired t-test and Wilcoxon's signed rank test were used to compare serial changes in back pain, leg pain and neurological dysfunction. Results: Mean duration of followup was 66 months (range 24 - 108 months). There were 24 male and 9 female. The mean age was 37 years (range 20 - 53 years). At presentation, mean visual analogue scales for back pain and leg pain were 75.3 ± 19.1 (range 12 - 100) and 80.2 ± 14.6 (range 0 -100), respectively. Mean ODI was 67.1 ± 18.8 (range 26 - 88). Neurological dysfunction was found in 9 patients (27.3%), and the bowel/bladder dysfunction was found in 2 patients (3.1%). Conservative treatment was performed in 21 patients (63.6%) with satisfactory results. Seven patients underwent decompressive surgery, and 5 underwent posterolateral fusion. Conclusions: A massive LDH with complete dural sac stenosis was found to be associated with severe back and leg pain at presentation, however surgical treatment can be deferred unless significant neurological symptoms occur.

Background: Anterior fixation using two 3.5 mm screws is typically recommended for type II odontoid fractures. However, it is unsuitable in patients with an odontoid diameter of <9.0 mm. There is no data regarding the morphology of odontoid process in the Indian population. The aim of our study was to: a) Measure the external diameters of odontoid process in the Indian population using CT scan and thus determine the feasibility of two 3.5 mm screw fixation in them. b) Determine if any correlation exists between body height (Ht) and weight (Wt) and external odontoid diameters. Materials and Methods: CT images of odontoid process of 100 consecutive patients were analyzed. Antero- posterior (AP) and transverse (TD), outer diameters of the odontoid process were measured from the base and at 1 mm interval upwards on axial CT images. Results: The mean AP and mean TD were 11.52 mm and 9.85 mm, respectively. Fifty-five (55%) of the patients had at least one TD <9.0 mm. Five (5%) patients had at least one TD <7.4 mm. None of the patients had any diameter <5.5 mm. Body Ht correlated significantly with mean AP and mean TD of the odontoid process (AP: r = 0.276, P = 0.013; TD: r = 0.359, P = 0.001), whereas body Wt correlated significantly only with mean TD (AP: r = 0.162, P = 0.15; TD: r = 0.297, P = 0.007). Conclusion: More than half of the study population (55%) was unsuitable for two 3.5 mm screw fixation for type II odontoid fracture. Two 2.7 mm screws can be safely used in 95% of the population. A 4.5 mm Herbert screw can be safely used in the entire population. We recommend two 2.7 mm screws or a 4.5 mm Herbert screw for fixation of these fractures in the Indian population. Body height showed a significant correlation with external odontoid diameters, whereas weight showed significant correlation only with TD of the odontoid process.

Background: Transforaminal lumbar interbody fusion (TLIF) has been preferred to posterior lumbar interbody fusion (PLIF) for different spinal disorders but there had been no study comparing their outcome in lumbar instability. A comparative retrospective analysis of the early results of TLIF and PLIF in symptomatic lumbar instability was conducted between 2005 and 2011. Materials and Methods: Review of the records of 102 operated cases of lumbar instability with minimum 1 year followup was done. A total of 52 cases (11 men and 41 women, mean age 46 years SD 05.88, range 40-59 years) underwent PLIF and 50 cases (14 men and 36 women, mean age 49 years SD 06.88, range 40-59 years) underwent TLIF. The surgical time, duration of hospital stay, intraoperative blood loss were compared. Self-evaluated low back pain and leg pain status (using Visual Analog Score), disability outcome (using Oswestry disability questionnaire) was analyzed. Radiological structural restoration (e.g., disc height, foraminal height, lordotic angle, and slip reduction), stability (using Posner criteria), fusion (using Hackenberg criteria), and overall functional outcome (using MacNab's criteria) were compared. Results: Pain, disability, neurology, and overall functional status were significantly improved in both groups but PLIF required more operative time and caused more blood loss. Postoperative hospital stay, structural restoration, stability, and fusion had no significant difference but neural complications were relatively more with PLIF. Conclusions: Both methods were effective in relieving symptoms, achieving structural restoration, stability, and fusion, but TLIF had been associated with shorter operative time, less blood loss, and lesser complication rates for which it can be preferred for symptomatic lumbar instability.

Background: Slipped upper femoral epiphysis (SUFE) is the gradually acquired malalignment of the upper femoral epiphysis (capital) and the proximal femoral metaphysis. SUFE is uncommon in India, and there are no previous studies on outcome and clinical characteristics of patients with SUFE from India. This study evaluates the presentation, disease associations and outcome of SUFE from a tertiary care centre in India. Materials and Methods: Twenty six consecutive children with SUFE seen over a period of 4 years were reviewed. The clinical presentations, severity of the slip, surgical interventions (n=30) were assessed. Twenty one boys and five girls with a mean age 13.1 years (range 10-16 years) were included in the study. Four children had bilateral involvement. There were 4 rural and 22 urban children from the eastern and southern states of the country. The presentation was acute in 7, acute on chronic in 5, and chronic in 14, with a mean duration of symptoms of 51 days (range 3-120 days). Slips were stable in 16 and unstable in 10 children. Two children had adiposogenital syndrome. Body mass index was high in 12 out of 23 children. Vitamin D levels were low in 20 out of 21 children, with a mean vitamin D level of 12.61 ± 5 ng/ml. Eighteen children underwent in situ pinning. Eight children underwent capital realignment. Results: Clinical outcome as assessed by Merle d' Aubigne score was excellent in 6, good in 10, fair in 6 and poor in 1. Half of the in situ fixation patients underwent osteoplasty procedure for femoroacetabular impingement and 5 more were symptomatic. The head neck offset and α angle after in situ pinning were -1.12 ± 3 mm and 66.05 ± 9.7°, respectively and this improved to 8.7 mm and 49°, respectively, after osteoplasty. One child in the pinning group had chondrolysis. Eight patients with severe slip underwent capital realignment. Mean followup was 20.15 months. The anterior head neck offset and α angle were corrected to 6.8 ± 1.72 mm and 44.6 ± 7.0° mm, respectively. Two children with unstable slip in the capital realignment group had avascular necrosis which was diagnosed at presentation by bone scan. Conclusion: High BMI, vitamin D deficiency and endocrine disorders are associated with SUFE in India and should be evaluated as some of these are amenable to prevention and treatment. Most patients treated with in situ pinning developed femoroacetabular impingement. The early results after capital realignment procedure are encouraging and help to avoid a second procedure which is needed in a majority of patients who underwent in situ pinning.

Background: Ipsilateral fractures of the proximal femur and femoral shaft are extremely uncommon injuries which occur in young adults who sustain a high energy trauma. A variety of management modalities have been tried to treat this complex fracture pattern ranging from conservative approach to recently introduced reconstruction nails. All these approaches have their own difficulties. We studied the outcome of long proximal femoral nail (LPFN) in the management of concomitant ipsilateral fracture of the proximal femur and femoral shaft. Materials and Methods: We analysed the prospective data of 36 consecutive patients who had sustained a high energy trauma (30 closed fractures and 6 open shaft fractures) who had concomitant ipsilateral fractures of the femoral shaft associated with proximal femur fractures treated with LPFN between December 2005 and December 2011. The mean age was 39 years (range 28-64 years). Twenty nine males and seven females were enrolled for this study. Results: The patients were followed up at three, six, twelve, and eighteen months. The mean healing time for the neck fractures was 4.8 months and for the shaft fractures was 6.2 months. The greater trochanter was splintered and widened in two cases which eventually consolidated. Two patients had superficial infection, two patients had lateral migration of the screws with coxa vara which was due to severe osteoporosis detected during the followup. We had two cases of nonunion of shaft fracture and one case of nonunion of neck fracture. Two cases of avascular necrosis of femoral head were detected after 2 years of followup. No cases of implant failure were noted. Limb shortening of less than 2 cms was noted in four of our patients. The functional assessment system of Friedman and Wyman was used for evaluating the results. In our series 59.9% ( n = 23) were rated as good, 30.6% ( n = 11) as fair, and 5.5% ( n = 2) as poor. Conclusion : Long PFN is a reliable option for concomitant ipsilateral diaphyseal and proximal femur fractures.

Background: There is medium correlation between the current anthropometric method and the radiography in the angle of hallux valgus (AoH) measurement, so this study aimed at designing a reliable and more accurate approach to measure the AoH (AoH). Materials and Methods: Fifteen age, body weight, and height matched male students were included and those with foot disorders, deformities, or injuries were excluded from the study. The dorsal protrusions of the first metatarsal and the hallux were marked by palpating from three experienced observers; then their barefoot model in standing was collected by a three dimensional laser scanning system. The AoH was defined in the X-Y plane by the angle between the line joining the marks of centre of head and centre of base of metatarsal shaft and the one connecting the marks of the centre of metatarsal head and the hallux. The same procedure was repeated a week later. Besides, other measures based on the footprint, outline, and the radiography were also available for comparisons. Paired t-test, linear regression, and reliability analysis were applied for statistical analysis with significant level of 0.05 and 95% confidence interval. Results: There were no significant differences recorded between the new method and the radiographic method ( P = 0.069). The AoH was superior to the methods of footprint and outline and it displayed a relative higher correlation with the radiographic method (r = 0.94, r² = 0.89). Moreover both the inter and intraobserver reliabilities of this method were proved to be good. Conclusion: This new method can be used for hallux valgus inspection and evaluation.

Background: Treatment of elbow dislocation with irreparable radial head fracture needs replacement of radial head to achieve stability of elbow. An alternate method in cases of elbow dislocation with radial head fracture can be resection of radial head with repair of medial collateral ligament. We report a retrospective analysis of cases of elbow dislocation with irreparable radial head treated by excision head of radius and repair of MCL. Materials and Methods: Nine patients of elbow dislocation with associated irreparable fractures of the head of the radius were included in this analysis (6 F:3 M, Age: 35-47 years). Radial head excision was done through the lateral approach and MCL was sutured using no 3 Ethibond using medial approach. Above elbow plaster was given for 6 weeks and gradual mobilization was done thereafter. All patients were assessed at final followup using Mayo elbow performance score (MEPS). Results: Mean followup was 19.55 ± 7.12 months (range 14-36 months). There was no extension deficit when compared to opposite side with mean range of flexion of 138.8° ± 6.97° (range 130 -145°). Mean pronation was 87.7° ± 4.4° (range 80-90°) and mean supination was 87.7 ± 4.62° (range 80-90°). The mean MEPS was 98.8 ± 3.33 (range 90-100). No patient had pain, sensory complaints, subluxation or redislocation. All were able to carry out their daily activities without disability. Conclusion: Radial head excision with MCL repair is an acceptable option for treatment of patients with elbow dislocation and irreparable radial head fracture.

Background: Many studies in literature have supported the role of wrist arthroscopy as an adjunct to the stable fixation of unstable intraarticular distal radial fractures. This article focuses on the surgical technique, indications, advantages, and results using wrist arthroscopy to assess articular reduction and evaluates the treatment of carpal ligament injuries and triangular fibrocartilage complex (TFCC) injuries in conjunction with the stable fixation of distal radial fractures. Materials and Methods: We retrospectively evaluated 27 patients (16 males and 11 females), who underwent stable fixation of intraarticular distal radial fractures with arthroscopic evaluation of the articular reduction and repair of associated carpal injuries. As per the AO classification, they were 9 C 1, 12 C2, 2 C3, 3 B 1, and 1 B2 fractures. The final results were evaluated by modified Mayo wrist scoring system. The average age was 41 years (range: 18-68 years). The average followup was of 26 months (range 24-52 months). Results: Five patients needed modification of the reduction and fixation after arthroscopic joint evaluation. Associated ligament lesions found during the wrist arthroscopy were TFCC tears (n=17), scapholunate ligament injury (n=8), and luno-triquetral ligament injury (n=1). Five patients had combined injuries i.e. included TFCC tear, scapholunate and/or lunotriquetral ligament tear. There were 20 excellent, 3 good, and 4 fair results using this score. Conclusion: The radiocarpal and mid carpal arthroscopy is a useful adjunct to stable fixation of distal radial fractures.

Background: Curettage is one of the most common treatment options for benign lytic bone tumors and tumor like lesions. The resultant defect is usually filled. We report our outcome curettage of benign bone tumors and tumor like lesions without filling the cavity. Materials and Methods: We retrospectively studied 42 patients (28 males and 14 females) with benign bone tumors who had undergone curettage without grafting or filling of the defect by any other bone graft substitute. The age of the patients ranged from 14 to 66 years. The most common histological diagnosis was that of giant cell tumor followed by simple bone cyst, aneurysamal bone cyst, enchondroma, fibrous dysplasia, chondromyxoid fibroma, and chondroblastoma and giant cell reparative granuloma. Of the 15 giant cell tumors, 4 were radiographic grade 1 lesions, 8 were grade 2 and 3 grade 3. The mean maximum diameter of the cysts was 5.1 (range 1.1-9 cm) cm and the mean volume of the lesions was 34.89 cm ³ (range 0.94-194.52 cm ³ ). The plain radiographs of the part before and after curettage were reviewed to establish the size of the initial defect and the rate of reconstitution, filling and remodeling of the bone defect. Patients were reviewed every 3 monthly for a minimum period of 2 years. Results: Most of the bone defects completely reconstituted to a normal appearance while the rest filled partially. Two patients had preoperative and three had postoperative fractures. All the fractures healed uneventfully. Local recurrence occurred in three patients with giant cell tumor who were then reoperated. All other patients had unrestricted activities of daily living after surgery. The rate of bone reconstitution, risk of subsequent fracture or the incidence of complications was related to the size of the cyst/tumor at diagnosis. The benign cystic bone lesions with volume greater than approximately 70 cm ³ were found to have higher incidence of complications. Conclusion: This study demonstrates the natural healing ability of bone without filling with bone grafts or bone graft substitutes. In selected sizes and locations of the benign lytic tumors and tumor like lesions extended curettage alone can be sufficient.

Conjoint bicondylar Hoffa fracture is an extremely rare injury. Only one case has been reported previously in the pediatric age group. We describe this injury in a 17-year-old male who presented following a fall with direct impact on his semiflexed right knee. Plain radiographs were inadequate to define the exact pattern of injury. Computed tomographic (CT) scans demonstrated the coronal fracture involving both the femoral condyles which were joined by a bridge of intact bone. The patient was treated with open reduction and internal fixation using swashbuckler (modified anterior) approach. Union occurred within 3 months and at final followup (at 18 months) the patient had a good clinical outcome. The possible mechanism of injury is discussed.

Extruded middle segment of radius with open segmental fracture both bone forearm and dislocation of ipsilateral elbow is a rare injury. A 12-year-old child presented to us within 4 hours following fall from tree. The child's mother was carrying a 12-cm-long extruded soiled segment of radius. The extruded bone was thoroughly washed. The medullary cavity was properly syringed with antiseptic solution. The bone was autoclaved and put in the muscle plane of the distal forearm after debridement of the wound. After 5 days, a 2.5-mm K-wire was introduced by retrograde method into the proximal radius by passing through the extruded segment. Another 2.5-mm K-wire was passed in ulna. The limb was evaluated clinicoradiologically every 2 weeks. The wound was healed by primary intention. At 4 months, the reposed bone appeared less dense radiologically and K-wire seemed to be out of the bone. In the subsequent months, the roentgenograms show remodeling of the extruded fragment. After 20 weeks, the K-wires were removed (first ulnar and then radial). Complete union was achieved with full range of movement except loss of few degrees of extension of elbow and thumb. This case is reported to show a good outcome following successful incorporation of an extruded segment of radius in an open fracture.

Nutcracker fractures of the cuboid (compressed) are rare and often missed at an initial visit. We report a 21-year-old patient presented with a 9 months old cuboid fracture. He presented with a localized pain around his left foot. Radiograph revealed the shortening of the lateral column with old cuboid fracture. The lateral column of foot was reconstructed. The patient remained symptom-free and no radiographic evidence of recurrence was observed 1 year postsurgery.

We report a case of localized nodular synovitis of the infrapatellar fat pad impinging on the patellofemoral joint causing limitation of extension. Arthroscopy involved use of a superolateral portal because location of lesion hindered access via a conventional anterior portal. The infrapatellar mass impinged in the patellofemoral joint upon knee extension and retracted upon flexion. Superior-superior triangulation allowed for complete excision of the mass.