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   Table of Contents - Current issue
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July-August 2016
Volume 50 | Issue 4
Page Nos. 341-450

Online since Wednesday, July 06, 2016

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EDITORIAL  

Current state of orthopedic education in India p. 341
Anil Kumar Jain
DOI:10.4103/0019-5413.185586  
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REVIEW ARTICLE Top

Nonvascularized fibular grafting in nonunion of femoral neck fracture: A systematic review Highly accessed article p. 345
Sujit Kumar Tripathy, Ramesh Kumar Sen, Tarun Goyal
DOI:10.4103/0019-5413.185587  
Nonunion of femoral neck fractures following primary fixation and neglected femoral neck fracture in young adults is a challenging task. Every effort should be directed toward hip joint salvage in these patients. Among different available options of hip salvage, nonvascularized fibular graft (NVFG) osteosynthesis is simple, easy to perform, and a successful technique. In this review, the available literature on NVFG in neglected and nonunion femoral neck fractures has been analyzed. After review of 15 articles on NVFG, the average nonunion rate was estimated to be 7.86% (range 0-31%). Six articles that evaluated the preoperative and postoperative osteonecrosis reported improvement in 50% patients. The clinical and/or functional outcome was good to excellent in 56-96% patients following fibular osteosynthesis. Few complications such as coxa vara deformity, limb shortening, and intraarticular penetration of the graft or hardware have been reported. However, there are minimal donor site morbidities such as mild ankle pain, transient loss of toe flexors and extensors and transient lateral popliteal nerve palsy.
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ORIGINAL ARTICLES Top

Total enbloc spondylectomy for metastatic high grade spinal tumors: Early results Highly accessed article p. 352
Sanganagouda S Patil, Abhay M Nene
DOI:10.4103/0019-5413.185589  
Background: High grade metastatic spinal tumors are most common and are invasive. These patients can succumb to disease progression if not treated timely. Although considered as invasive and morbid, total enbloc spondylectomy (TES) in selected cases has better survival rates. The authors describe the results of TES for high grade metastatic spinal tumors. Materials and Methods: Five patients (four females and one male) underwent TES for solitary metastatic vertebral lesion between November 2012 and January 2014. These patients presented to us with spinal instability, unrelenting severe spinal pain and/or with severe progressive radiculopathy. Average age was 46.2 years (range 39-62 years). After complete investigations, computed tomography scan, magnetic resonance imaging scan and positron emission tomography (PET) scan, it was confirmed that these patients had high grade solitary vertebral metastatic tumor. Results: Average duration of followup was 18 months (range 16-20 months). The average preoperative visual analog scale score of 9.4 (range 9-10) improved to 2 (range 1-4) at last followup. Average blood loss was 1440 mL (range1000-2000 mL). Average duration of surgery was 198 min (range180-240 min). Significant pain relief was noticed in each patient in the immediate postoperative period and during followups. These patients attained complete functional activities of daily living with in a month. The imaging showed implants in situ, no recurrence of tumor, and no activity on PET scan at the final followup. Conclusion: The present series shows favorable short term results of TES for solitary, metastatic, high grade vertebral body tumors by a team approach.
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Management of osteonecrosis of the femoral head: A novel technique p. 359
Ahmed M Samy
DOI:10.4103/0019-5413.185590  
Background: Osteonecrosis of the femoral head (ONFH) is a debilitating disease in orthopedics, frequently progressing to femoral head collapse and osteoarthritis. It is thought to be a multifactorial disease. ONFH ultimately results in femoral head collapse in 75-85% of untreated patients. Total hip arthroplasty (THA) yields satisfactory results in the treatment of the end stage of the disease. However, disease typically affects males between the ages of 20 and 40 years and joint replacement is not the ideal option for younger patients. Recently, mesenchymal stem cells and platelet rich plasma (PRP) have been used as an adjunct to core decompression to improve clinical success in the treatment of precollapse hips. Materials and Methods: A prospective study of 40 hips in 30 patients was done. There were 19 males and 11 females with a mean age 36.7 ± 6.93 years. The indication for the operation was restricted primarily to modified Ficat stages IIb and III. 16 hips (40%) had stage IIb and 24 hips (60%) had stage III ONFH. The period of follow up ranged between 36-50 months with a mean 41.4 ± 3.53 months. All patients were assessed clinically during pre- and post-operative period according to the Harris Hip Score (HHS), Visual Analog Score (VAS) and radiologically by X-rays. Magnetic resonance imaging (MRI) was done preoperatively to confirm the diagnosis and every 6 months postoperatively for assessment of healing. The operative procedure include removal of necrotic area with drilling then the cavity was filled with a composite of bone graft mixed with PRP. Results: The mean HHS improved from 46.0 ± 7.8 preoperatively to 90.28 ± 19 at the end of followup ( P < 0.0001). The mean values of VAS were 78 ± 21 and 35 ± 19 at preoperatively period and final followup, respectively, with an average reduction of 43 points. Conclusion: We found that the use of PRP with collagen sheet can increase the reparable capacity after drilling of necrotic segment in stage IIb and III ONFH.
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Osteosynthesis of ununited femoral neck fracture by internal fixation combined with iliac crest bone chips and muscle pedicle bone grafting p. 366
DD Baksi, AK Pal, DP Baksi
DOI:10.4103/0019-5413.185591  
Background: Ununited femoral neck fracture is seen commonly in developing countries due to delayed presentation or failure of primary internal fixation. Such fractures, commonly present with partial or total absorption of femoral neck, osteonecrosis of femoral head in 8-30% cases with upward migration of trochanter posing problem for osteosynthesis, especially in younger individuals. Several techniques for treatment of such conditions are described like osteotomies or nonvascularied cortical or cancellous bone grafting provided varying degrees of success in terms of fracture union but unsatisfactory long term results occurred due to varying incidence of avascular necrosis (AVN) of femoral head. Moreover, in presence of AVN of femoral head neither free fibular graft nor cancellous bone graft is satisfactory. The vascularied bone grafting by deep circumflex iliac artery based on iliac crest bone grafting, free vascularied fibular grafting and muscle pedicle periosteal grafting showed high incidence of success rate. Osteosynthesis is the preferred treatment of choice in ununited femoral neck fracture in younger individuals. Materials and Methods: Of the 293 patients operated during the period from June 1977 to June 2009, 42 were lost to followup. Seven patients with gluteus medius muscle pedicle bone grafting (MPBG) were excluded. Thus, out of 244 patients, 208 (85.3%) untreated nonunion and 36 (14.7%) following failure of primary internal fixation were available for studies. Time interval between the date of injury and operation in untreated nonunion cases was mean 6.5 months and in failed internal fixation cases was mean 11.2 months. Ages of the patients varied from 16 to 55 years. Seventy patients had partial and 174 had subtotal absorption of the femoral neck. Evidence of avascular necrosis (AVN) femoral head was found histologically in 135 (54.3%) and radiologically in 48 (19.7%) patients. The patients were operated by open reduction of fracture, cannulated hip screw fixation, iliac crest bone chips and quadratus femoris MPBG. Results: The mean followup is 12.5 years (range 3-35). The union of fractures occurred in 202 (82.8%), delayed union in 18 (7.3%), and established nonunion in 24 (9.8%) patients. Full weight bearing was permitted at 16-22 weeks after union of fractures. Mean Harris hip score at the longest followup was 85.5. Among the complications, superficial wound infection occurred in 20 (8.2%), deep infection in seven (2.9%), and coxa vara in 39 (16%) patients. Preoperative radiodensity of femoral head disappeared mostly after the union of fracture whereas fresh radiodensity of femoral head appeared in 20 (8%) patients; nine (45%) of them developed segmental collapse. Conclusion: Ununited femoral neck fractureis characterized by absorption of femoral neck, posterior cortical defect, smoothening and overriding of fracture surfaces with intervening fibrous tissues associated with or without AVN of femoral head. The above method of osteosynthesis rectified the above pathology and provided satisfactory results with union of fractures in 90.1% patients at long term followup.
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Reverse distal femoral locking compression plate a salvage option in nonunion of proximal femoral fractures p. 374
Sampat S Dumbre Patil, Sachin S Karkamkar, Vaishali S Dumbre Patil, Shailesh S Patil, Abhijeet S Ranaware
DOI:10.4103/0019-5413.185598  
Background: When primary fixation of proximal femoral fractures with implants fails, revision osteosynthesis may be challenging. Tracts of previous implants and remaining insufficient bone stock in the proximal femur pose unique problems for the treatment. Intramedullary implants like proximal femoral nail (PFN) or surface implants like Dynamic Condylar Screw (DCS) are few of the described implants for revision surgery. There is no evidence in the literature to choose one implant over the other. We used the reverse distal femur locking compression plate (LCP) of the contralateral side in such cases undergoing revision surgery. This implant has multiple options of fixation in proximal femur and its curvature along the length matches the anterior bow of the femur. We aimed to evaluate the efficacy of this implant in salvage situations. Materials and Methods: Twenty patients of failed primary proximal femoral fractures who underwent revision surgery with reverse distal femoral locking plate from February 2009 to November 2012 were included in this retrospective study. There were 18 subtrochanteric fractures and two ipsilateral femoral neck and shaft fractures, which exhibited delayed union or nonunion. The study included 14 males and six females. The mean patient age was 43.6 years (range 22-65 years) and mean followup period was 52.1 months (range 27-72 months). Delayed union was considered when clinical and radiological signs of union failed to progress at the end of four months from initial surgery. Results: All fractures exhibited union without any complications. Union was assessed clinically and radiologically. One case of ipsilateral femoral neck and shaft fracture required bone grafting at the second stage for delayed union of the femoral shaft fracture. Conclusions: Reverse distal femoral LCP of the contralateral side can be used as a salvage option for failed fixation of proximal femoral fractures exhibiting nonunion.
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Arthroscopic resection of the distal clavicle in osteoarthritis of the acromioclavicular joint p. 379
Tae-Soo Park, Kwang-Won Lee
DOI:10.4103/0019-5413.185601  
Background: Symptomatic acromioclavicular joint (ACJ) lesions are a common cause of shoulder complaints that can be treated successfully with both conservative and surgical methods. There are several operative techniques, including both open and arthroscopic surgery, for excising the distal end of the clavicle. Here, we present a new modified arthroscopic technique for painful osteoarthritis of the ACJ and evaluate its clinical outcomes. Our hypothesis was that 4- to 7-mm resection of the distal clavicle in an en bloc fashion would have several advantages, including no bony remnants, maintenance of stability of the ACJ, and reduced prevalence of heterotopic ossification, in addition to elimination of the pathologic portion of the distal clavicle. Materials and Methods: 20 shoulders of 20 consecutive patients with painful and isolated osteoarthritis of the ACJ who were treated by arthroscopic en bloc resection of the distal clavicle were included in the study. There were 10 males and 10 females with an average age of 56 years (range 42-70 years). The mean duration of followup was 6 years and 2 months (range 4-8 years 10 months). The results were evaluated using the University of California Los Angeles (UCLA) shoulder rating score. Results: The overall UCLA score was 13.7 preoperatively, which improved to 33.4 postoperatively. All subscores were improved significantly ( P < 0.001). There were no specific complications at the latest followup. Conclusion: It is critical in this procedure to resect the distal clavicle evenly from superior to inferior in an en bloc fashion without any small bony remnants and to preserve the capsule and acromioclavicular ligament superoposteriorly. This arthroscopic procedure is a reliable and reproducible technique for painful osteoarthritis of the ACJ lesions in active patients engaged in overhead throwing sports and heavy labor.
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Assessment of survival rates compared according to the Tamai and Yamano classifications in fingertip replantations p. 384
Mehmet Dadaci, Bilsev Ince, Zeynep Altuntas, Ozan Bitik, Haldun Onuralp Kamburoglu, Hakan Uzun
DOI:10.4103/0019-5413.185602  
Background: The fingertip is the most frequently injured and amputated segment of the hand. There are controversies about defining clear indications for microsurgical replantation. Many classification systems have been proposed to solve this problem. No previous study has simultaneously correlated different classification systems with replant survival rate. The aim of the study is to compare the outcomes of fingertip replantations according to Tamai and Yamano classifications. Materials and Methods: 34 consecutive patients who underwent fingertip replantation between 2007 and 2014 were retrospectively reviewed with respect to the Tamai and Yamano classifications. The medical charts from record room were reviewed. The mean age of the patients was 36.2 years. There were 30 men and 4 women. All the injuries were complete amputations. Of the 34 fingertip amputations, 19 were in Tamai zone 2 and 15 were in Tamai zone 1. When all the amputations were grouped in reference to the Yamano classification, 6 were type 1 guillotine, 8 were type 2 crush and 20 were type 3 crush avulsions. Results: Of the 34 fingertips, 26 (76.4%) survived. Ten (66.6%) of 15 digits replanted in Tamai zone 1 and 16 (84.2%) of 19 digits replanted in Tamai zone 2 survived. There were no replantation failures in Yamano type 1 injuries (100%) and only two failed in Yamano type 2 (75%). Replantation was successful in 14 of 20 Yamano type 3 injuries, but six failed (70%). The percentage of success rates was the least in the hybridized groups of Tamai zone 1-Yamano type 2 and Tamai zone 1-Yamano type 3. Although clinically distinct, the survival rates between the groups were not statistically significantly different. Conclusions: The level and mechanism of injury play a decisive role in the success of fingertip replantation. Success rate increases in proximal fingertip amputations without crush injury.
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Anterior cervical discectomy and fusion for noncontiguous cervical spondylotic myelopathy p. 390
Sun Qizhi, Li Peijia, Sun Lei, Chen Junsheng, Li Jianmin
DOI:10.4103/0019-5413.185603  
Background: Noncontiguous cervical spondylotic myelopathy (CSM) is a special degenerative disease because of the intermediate normal level or levels between supra and infraabnormal levels. Some controversy exists over the optimal procedure for two noncontiguous levels of CSM. The study was to evaluate the outcomes of the anterior cervical discectomy and fusion (ACDF) with zero-profile devices for two noncontiguous levels of CSM. Materials and Methods: 17 consecutive patients with two noncontiguous levels of CSM operated between December 2009 and August 2012 were included in the study. There were 12 men and 5 women with a mean age of 60.7 years (range 45-75 years). Involved disc levels were C3/4 and C5/6 in 11 patients and C4/5 and C6/7 in six patients. Preoperative plain radiographs, computed tomography (CT) with 3-D reconstruction and magnetic resonance imaging (MRI) of the cervical spine were taken in all patients. All radiographs were independently evaluated by 2 spine surgeons and 1 radiologist. The outcomes were assessed by the average operative time, blood loss, Japanese Orthopedic Association (JOA) score, improvement rate, neck dysfunction index (NDI), swallowing quality of life (SWAL-QOL) score, the cervical lordosis and complications. Results: The mean followup was 48.59 months (range 24-56 months). The average operative time and blood loss was 105.29 min and 136.47 ml, respectively. The preoperative JOA score was 8.35, which significantly increased to 13.7 at the final followup ( P < 0.01). The NDI score was significantly decreased from preoperative 13.06 to postoperative 3.35 ( P < 0.01). The operation also provided a significant increase in the cervical lordosis ( P < 0.01) from preoperative 10.17° to postoperative 17.06°. The fusion rate was 94.1% at 6 months postoperatively, and 100% at 12 months after surgery. The mean SWAL-QOL score decreased from preoperative 68.06 to immediate postoperatively 65.65 and then increased to 67.65 at final followup. There was a statistically significant difference between preoperative and immediate postoperatively values ( P < 0.05), but none between preoperative and at final followup ( P > 0.05). Cerebrospinal fluid leak, dysphagia and radiological adjacent segment degeneration occurred in one patient, respectively. Conclusion: The ACDF with zero-profile devices is generally effective and safe in treating two noncontiguous levels of CSM.
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Limb lengthening in achondroplasia p. 397
Sanjay K Chilbule, Vivek Dutt, Vrisha Madhuri
DOI:10.4103/0019-5413.185604  
Background: Stature lengthening in skeletal dysplasia is a contentious issue. Specific guidelines regarding the age and sequence of surgery, methods and extent of lengthening at each stage are not uniform around the world. Despite the need for multiple surgeries, with their attendant complications, parents demanding stature lengthening are not rare, due to the social bias and psychological effects experienced by these patients. This study describes the outcome and complications of extensive stature lengthening performed at our center. Materials and Methods: Eight achondroplasic and one hypochondroplasic patient underwent bilateral transverse lengthening for tibiae, humeri and femora. Tibia lengthening was carried out using a ring fixator and bifocal corticotomy, while a monolateral pediatric limb reconstruction system with unifocal corticotomy was used for the femur and humerus. Lengthening of each bone segment, height gain, healing index and complications were assessed. Subgroup analysis was carried out to assess the effect of age and bone segment on the healing index. Results: Nine patients aged five to 25 years (mean age 10.2 years) underwent limb lengthening procedures for 18 tibiae, 10 femora and 8 humeri. Four patients underwent bilateral lengthening of all three segments. The mean length gain for the tibia, femur and humerus was 15.4 cm (100.7%), 9.9 cm (52.8%) and 9.6 cm (77.9%), respectively. Healing index was 25.7, 25.6 and 20.6 days/cm, respectively, for the tibia, femur and humerus. An average of 33.3% height gain was attained. Lengthening of both tibia and femur added to projected height achieved as the 3 rd percentile of standard height in three out of four patients. In all, 33 complications were encountered (0.9 complications per segment). Healing index was not affected by age or bone segment. Conclusion: Extensive limb lengthening (more than 50% over initial length) carries significant risk and should be undertaken only after due consideration.
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Relation between the development of osteoporosis and osteonecrosis following glucocorticoid in a rabbit model p. 406
Tao Lin, Junbin Liu, Shuhua Yang, Xianzhe Liu, Xiaobo Feng, Dehao Fu
DOI:10.4103/0019-5413.185606  
Background: There has been a recent increase in the number of patients suffering from bone and joint diseases, as a consequence of corticosteroids administration. There are more patients treated with low dose of GCs under long-term conditions in clinical, such as effect of GCs on Rheumatoid arthritis, Crohn's disease and Asthma patients. Hence, it was difficult for doctor to determine which problem occur first - OP or ON; however, there was no clinical report previously in the literature, and there was no effective animal model of OP and ON about low dose GCs. This study was conducted to develop rabbit models of glucocorticoid (GC)-induced femoral head ON and OP and to investigate the temporal relationship between the occurrence of the two events following administration of glucocorticoids. Materials and Methods: Fifty six, 6 months old female rabbits were randomly divided into the GC group and control group (C). Rabbits received gluteal injections of methylprednisolone sodium succinate once a day for 4 weeks, while normal saline solution in the control group. Rabbits were sacrificed at 0, 2, 4, and 8 weeks. Hip magnetic resonance imaging was performed before the rabbits were sacrificed. Serum calcium (Ca), phosphorus (P), total cholesterol, and triglyceride levels were also measured. The bone mineral density (BMD) of femoral head and the femoral shaft were measured by dual-energy X-ray absorptiometry. The trabecular parameters of the femur and the 4 th lumbar vertebrae (L4) were measured with a micro-computed tomography (μ-CT). Also, the femoral head was stained with hematoxylin-eosin staining. Results: At 4 weeks in the GC group, the BMD of the femur reduced 33% and 22% in the femoral head and shaft; there was irregular intermediate to high T2-weighted images signals; μ-CT showed microfractures and cystic changes in the femoral head and L4 at 4 weeks. At 8 weeks in the GC group, the classical "line-like sign" indicating ON of the femoral head was observed in 64.3% of the rabbits. Conclusion: A rabbit model of GC-induced OP and ON was developed by repetitive injection with small doses of GCs in the gluteal region. OP was observed at 4 weeks while ON developed at 8 weeks and followed a clear temporal pattern.
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Effect of insulin-like growth factor-1 and hyaluronic acid in experimentally produced osteochondral defects in rats p. 414
Celil Alemdar, İstemi Yücel, Barış Erbil, Havva Erdem, Ramazan Atiç, Emin Özkul
DOI:10.4103/0019-5413.185607  
Background: The common purpose of almost all methods used to treat the osteochondral injuries is to produce a normal cartilage matrix. However current methods are not sufficient to provide a normal cartilage matrix. For that reason, researchers have studied to increase the effectiveness of this methods using chondrogenic and chondroprotective molecules in recent experimental studies. Insulin-like growth factor-1 (IGF-1) and hyaluronic acid (HA) are two important agents used in this field. This study compared the effects of IGF-1 and HA in an experimental osteochondral defect in rat femora. Materials and Methods: The rats were divided into three groups ( n = 15 per group) as follows: The IGF-1 group, HA group, and control group. An osteochondral defect of a diameter of 1.5 mm and a depth of 2 mm was created on the patellar joint side of femoral condyles. The IGF-1 group received an absorbable gelatin sponge soaked with 15 μg/15 μl of IGF-1, and the HA group received an absorbable gelatin sponge soaked with 80 μg HA. The control group received only an absorbable gelatin sponge. Rats were sacrificed at the 6 th week, and the femur condyles were evaluated histologically. Results: According to the total Mankin scale, there was a statistically significant difference between IGF-1 and HA groups and between IGF-1 and control groups. There was also a significant statistical difference between HA and control groups. Conclusion: It was shown histopathologically that IGF-1 is an effective molecule for osteochondral lesions. Although it is weaker than IGF-1, HA also strengthened the repair tissue.
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N-terminal telopeptides of type I collagen and bone mineral density for early diagnosis of nonunion: An experimental study in rabbits p. 421
Jian-Ping Lin, Zhan-Jun Shi, Ning-Jiang Shen, Jian Wang, Zao-Min Li, Jun Xiao
DOI:10.4103/0019-5413.185608  
Background: The diagnosis and treatment of bone nonunion have been studied extensively. Diagnosis and treatment of nonunion are mainly performed based on the interpretation of clinico-radiographic findings, which depend on the clinician's experience and the degree of bone callus formation during the fracture-healing process. However, resolution may be compromised when the bone mineral content is <25%. A feasible method of monitoring bone-healing is therefore needed. We monitored a rabbit model of bone nonunion by regular radiographic examinations, QCT detection, and biomarker concentrations. Materials and Methods: Twenty purebred New Zealand rabbits (10 male and 10 female, 5-6 months of age, 2.5-3.0 kg) were divided into bone defect Group (I) that 10 left radius bones underwent resection of 1.5 cm of mid-radius bone and bone fracture Group (II) that another 10 left radius bones underwent only mid-radius fracture. Quantitative computed tomography detection of bone mineral density (BMD) and serum markers of bone formation (osteocalcin [OC], bone-specific alkaline phosphatase) and bone resorption (C- and N-terminal telopeptides of type I collagen (NTX) and tartrate-resistant acid phosphatase 5b) were assayed. There are twenty rabbits (10 male and 10 females). The age was 5-6 months weighing 2.5-3.0 kg). The defect was created in middle 1/3 radius in 10 rabbits and fracture was created in middle 1/3 radius of 10 rabbits. Results: BMD and NTX concentrations were significantly lower at 5 weeks postoperatively compared to the preoperative values and were significantly different between the two groups. OC showed no significant difference before and after surgery. Conclusions: BMD and NTX concentrations may be useful for early detection of bone nonunion in rabbits.
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Decalcified allograft in repair of lytic lesions of bone: A study to evolve bone bank in developing countries p. 427
Anil Kumar Gupta, Kumar Keshav, Praganesh Kumar
DOI:10.4103/0019-5413.185609  
Background: The quest for ideal bone graft substitutes still haunts orthopedic researchers. The impetus for this search of newer bone substitutes is provided by mismatch between the demand and supply of autogenous bone grafts. Bone banking facilities such as deep frozen and freeze-dried allografts are not so widely available in most of the developing countries. To overcome the problem, we have used partially decalcified, ethanol preserved, and domestic refrigerator stored allografts which are economical and needs simple technology for procurement, preparation, and preservation. The aim of the study was to assess the radiological and functional outcome of the partially decalcified allograft (by weak hydrochloric acid) in patients of benign lytic lesions of bone. Through this study, we have also tried to evolve, establish, and disseminate the concept of the bone bank. Materials and Methods: 42 cases of lytic lesions of bone who were treated by decalcified (by weak hydrochloric acid), ethanol preserved, allografts were included in this prospective study. The allograft was obtained from freshly amputated limbs or excised femoral heads during hip arthroplasties under strict aseptic conditions. The causes of lytic lesions were unicameral bone cyst ( n = 3), aneurysmal bone cyst ( n = 3), giant cell tumor ( n = 9), fibrous dysplasia ( n = 12), chondromyxoid fibroma, chondroma, nonossifying fibroma ( n = 1 each), tubercular osteomyelitis ( n = 7), and chronic pyogenic osteomyelitis ( n = 5). The cavity of the lesion was thoroughly curetted and compactly filled with matchstick sized allografts. Results: Quantitative assessment based on the criteria of Sethi et al. (1993) was done. There was complete assimilation in 27 cases, partial healing in 12 cases, and failure in 3 cases. Functional assessment was also done according to which there were 29 excellent results, 6 good, and 7 cases of failure (infection, recurrence, and nonunion of pathological fracture). We observed that after biological incorporation, the graft participates in bone physiology and morphology. We did not observe any adverse host graft antigenic reaction. Conclusions: We conclude that decalcified allograft is suitable alloimplant for use in benign lesions of bone, is easy to prepare and store, and is thus well suited for use in developing countries.
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Caveats of bisphosphonate abuse p. 434
Sanjay Agarwala, Vikas M Agashe, Vivek Shetty, Ganesh Mohrir, Pradeep Moonot
DOI:10.4103/0019-5413.185612  
Background: Bisphosphonates (BPs) are the common drugs used for the treatment of postmenopausal osteoporosis. Short term benefits of the BPs are well known. However, there are concerns regarding their long term use. The aim of the study was to analyze the association between atypical femoral fractures and BP misuse/abuse as well as study the outcome of management of these fractures. Materials and Methods: A retrospective study of a prospectively studied patients who presented with atypical femoral fractures between January 2010 and August 2012 and were followed up upto June 2014. The cohort consisted of nine female patients (12 fractures) with an average age of 71 years (range 58-85 years). Analysis was done for the indications, duration of BP use, configuration of associated fractures and method of treatment. Results: The mean duration of BP use was 6.6 years (range 4-10 years). BP treatment was initiated without sufficient indication and continued without proper review and followup in most cases. Most patients did not followup and continued to consume BPs without any review by the doctors. All patients had prodromal thigh pain of various duration, which was inadequately investigated and managed before the presentation. Two cases with an incomplete fracture and no thigh pain were managed successfully with conservative treatment. The rest were treated by surgery with intramedullary nailing. The average union time was longer and two fractures went into nonunion which required further surgical intervention. Conclusion: Atypical femoral fractures appear to be strongly related to abuse of BPs. Great care is to be exercised at initiation as well as the continuation of BP therapy, and regular review is required. There is a need for improved awareness among physicians about the possibility of such fractures, and interpretation of thigh pain and radiological findings, especially if the patient has been on BPs therapy. Internal fixation for complete fractures and for incomplete fractures with thigh pain is needed. Delayed union is common.
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CASE REPORTS Top

Lumbar epidural varices: An unusual cause of lumbar claudication p. 440
Meenakshisundaram Subbiah, Krishnan Yegumuthu
DOI:10.4103/0019-5413.185613  
Lumbar epidural varices can also present with radiculopathy similar to acute intervertebral disc prolapse (IVDP). However as the magnetic resonance imaging (MRI) in these patients are usually normal without significant compressive lesions of the nerve roots, the diagnosis is commonly missed or delayed leading to persistent symptoms. We present a rare case of acute severe unilateral claudication with a normal MRI unresponsive to conservative management who was treated surgically. The nerve root on the symptomatic side was found to be compressed by large anterior epidural varices secondary to an abnormal cranial attachment of ligamentum flavum. Decompression of the root and coagulation of the varices resulted in complete pain relief. To conclude, lumbar epidural varices should be considered in the differential diagnosis of acute onset radiculopathy and claudication in the absence of significant MRI findings.
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Complete dorsal dislocation of the carpal scaphoid with perilunate dorsal dislocation p. 444
Jong Woo Kang, Jong Hoon Park, Dong Hun Suh, Jong Woong Park
DOI:10.4103/0019-5413.185615  
Complete dorsal dislocation of the carpal scaphoid combined with dorsal perilunate dislocation is an extremely rare carpal injury. We describe the case of a 23-year-old man who presented with a complete dorsal dislocation of the carpal scaphoid, combined with a perilunate dislocation. Surgical treatment was performed with open reduction and interosseus ligament repair. At 4 years follow up, the patient's wrist pain had completely resolved without limitations of wrist joint motion and without evidence of avascular necrosis of the carpal scaphoid.
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LETTERS TO EDITOR Top

Early results of displaced supracondylar fractures of humerus in children treated by closed reduction and percutaneous pinning p. 447
Mehraj Din Tantray
DOI:10.4103/0019-5413.185621  
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Author's reply p. 448
Jaswinder PS Walia, Bhupinder S Brar, Anmol Sharma, Sudhir Sethi
DOI:10.4103/0019-5413.185624  
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BOOK REVIEW Top

Practical orthopedics - Biological options and simpler techniques for common disorders p. 449
Satish C Goel
DOI:10.4103/0019-5413.185626  
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ERRATUM Top

Erratum: Surgical hip dislocation for treatment of cam femoroacetabular impingement p. 450

DOI:10.4103/0019-5413.185627  
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