Avascular necrosis of femoral head [AVN] is almost invariably a painful condition. When diagnosed early before the collapse of the head of the femur, a core decompression is generally advocated. When the collapse is advanced or secondary arthritic changes occur an osteotomy or a total hip replacement is the treatment of choice. We report a series of cases AVN where, as part of a conservative regime when surgery was either not readily acceptable or was not feasible for some reason, we treated them with manipulation under general anaesthesia. In all 61 hips in 39 patients in Ficat-Arlet Stages I to IV underwent one or more manipulations. Follow-up ranged from 6 months to 6 years. Pain relief was excellent in 10.2%, good in 48.7%, fair in 25.6% and poor in 15.3% of cases. We found manipulation a useful non-operative modality of treatment, in AVN of hips.

In an effort to compare the effects of hyaluronic acid (HA) and cortisone on the healing of degenerative osteoarthrosis, a rabbit model was used in which a degenerative osteoarthrosis was created in the knee articular cartilage by the inoculation of Staphylococcus Aureus (SA). Thirty-two rabbits were used, and their knee articular cartilages of were inoculated with SA to create degeneration. At the 8th, 10th and 17th days of inoculation, three rabbits were sacrificed for each corresponding day. On the 20th, 23rd and 26th days, HA (group A) and cortisone (group B) were injected into the right knees (RN) of the rabbits. On the 25th and 35th days, six rabbit were sacrificed for each corresponding day (three of them injected with cortisone and the three with HA). On the 50th day, remaining 11 rabbits (six injected with cortisone and five with HA) were sacrificed. The biopsies obtained from eight different regions of the right knee joint were examined for both articular cartilage degeneration and inflammation of the soft tissue around the joint by light microscopy. The results showed that cortisone is effective in the treatment of cartilage degeneration and inflammation early in the course of the septic arthritis whereas the therapeutic effect of HA is higher late in the course of the disease. Further studies are required in order to understand the effectiveness of the combined or consecutive use of these drugs in degenerative osteoarthritis.

Intra-articular fractures lead to premature development of degenerative changes in the joint even after accurate reduction of the fracture, due to damage to the articular cartilage. The articular cartilage has extremely limited potential for regeneration. In fourteen patients with transverse fracture of patella, the fractures were internally fixed by A.O. tension band technique. After fixation of the fracture, the damaged articular cartilage was resurfaced by free periosteal grafts obtained from the adjoining area. The results were analysed at the time of hardware work removal. Free periosteal grafting leads to smooth articular cartilage formation.

Most patients in India present with advanced stages of degeneration of both knees requiring knee replacement surgery. Patients often keep hopping on the good leg when only one knee is initially involved and would reluctantly accept surgical intervention when the situation becomes hopeless and mobility comes to a grinding halt. Such patients predictably require more than one total replacement before on improved functional status occurs, and hence the question of multiple joint replacements under one anaesthetic (Head and Paradies 1977; Ritter and Randolph 1976). This study analyses the morbidity and coast analysis in sixty consecutive bilateral total knee replacements performed sequentially by one surgeon (SKSM).

The exact anatomical restoration of the disturbed anatomy in cases of ankle mal-union is often frustrating to the surgeon who uses the standard surgical approaches to the ankle joint. Between 1996 & 1998, we have operated upon five cases of ankle joint. After doing supra-syndesmotic osteotomy of fibula, we extraperiostially mobilize the fibular malleolus by dividing all the three syndesmotic ligaments. This facilitates pulling down of fibular malleolus to correct shortening & internal rotation of the same to exactly reconstruct the ankle mortise. The fibula is anatomically positioned into the incisura fibularis of the tibia under direct vision. The turning–down of fibular malleolus gives widest access to the posterior malleolus and the dome of talus – the two most inaccessible sites of the ankle joint. There was anatomic reduction of lateral malleolus-talus complex in four cases as per the AP and mortise radiographs while there was incomplete ankle reduction in one case due to inexact surgical technique. The operative technique is without any serious complication. There was no clinical deterioration nor radiological osteoarthrosis during the short follow-up period.

From 1974 to 1999. 35 patients with intractable pyogenic and tuberculosis infection of bone and joint were treated by combining local instillation of Cyclophosphamide (CPM) to standard conventional treatment. Topical CPM was first used in 1974 in a 22 year old male to treat tuberculosis of hip which became secondarily infected with Staph aureus following an arthrotomy. With instillation of CPM through a sinus lead to stoppage of discharge within a week and satisfactory progress of healing. Such serendipitous favourable result prompted us to use topical CPM in 34 other patients with intractable bone and joint infection. Healing occurred in 28 (80%) patients. Amongst the 7 patients who did not respond fully, one patient required disarticulation of the shoulder and another patient required removal of a total knee prosthesis. Remaining 5 patients are still under treatment.

The isoprenoid pathway produces three key metabolites digoxin (membrane sodium-potassium ATPase inhibitor which can regulate intracellular calcium/magnesium ratios), dolichol (regulates Nglycoylation of proteins) and ubiquinone (free radical scavenger). The pathway was assessed in senile osteoporosis. Spondylosis and osteoarthritis. The pathway was upregulated with increased digoxin synthesis in patients with spondylosis and osteoarthritis. In this group of patients the glycoconjugate levels and dolichol levels were increased and lysosomal stability reduced. The ubiquinone levels were low and free radicals increased in spondylosis and osteoarthritis. On the other hand in senile osteoporosis the isoprenoid pathway was down regulated and digoxin synthesis reduced. The glycocnjugate and dolichol levels were low and lysosmal stability increased. The ubiquinone levels were increased and free radical production increased in senile osteoporosis. The significance of these changes in the pathogenesis is discussed. The hyperdigosinemic state is seen in osteoarthritis and spondylosis and in right hemispheric dominance. The hypodigoxincmic state is seen in left hemispheric dominance and senile osteoporosis. The role of hemispheric dominance in deciding the predisposition to these disease states is discussed.

To study the CT appearances in tuberculous spondylitis and stage the disease by correlating the findings, CT scans of 58 patients in whom tuberculous spondylitis was proved histopathologically were evaluated. The dorsal spine was the most commonly involved region (55.1%). Osteolytic lesions were the most common pattern of bone destruction, accounting for 36.2% and another 31% in combination with fragmentary lesions. CT well depicted the paravertebral soft tissue shadow, the spinal canal and the involvement of posterior elements. The stages of osteoporosis, osteolysis, fragmentation and deformity could also be differentiated. CT imaging was useful in tuberculous spondylitis in isolated involvement of posterior elements, to visualize difficult sites like craniovertebral and cervicodorsal regions, and to visualize the level, extent and cause of cord compression. A staging of the disease was suggested based on a type of bone destruction and the presence of deformity.

Conventional bone scan, using Technetium-99m MDP, has proven sensitivity in the diagnosis of Pott’s spine but bone scanning and radiological investigations cannot objectively define the treatment endpoint. Our previous experience with Tc-99m citrate indicated that it may be suitable for the purpose. In a group of 45 patients (Group A-12 fresh cases, Group B-22 cases on antitubercular treatment for 2-26 months, and Group C-11 healed cases of pott’s spine), Tc-99mm citrate and conventional bone scanning was done within a week of each other. Tc-99m citrate scan was positive in 12 of 12 Group A, 16 of 22 Group B, A, 22 of 22 Group B, and 7 of 10 Group C cases respectively. We conclude that Tc-99mm citrate scan is a better of treatment response and may be helpful in objectively defining treatment end-point.

The object of present study is to assess the validity of lumbar interbody fusion after disc excision. Seventeen consecutive patients (13 male and 4 females) of age group 22-65 year having low backache with radiculitis, were diagnosed to have lumbar disc prolapse by clinical, neurological and radiological parameters. Conventional discectomy was done along with posterior lumbar interbody fusion using allogenic and or autologous grafts of cortical and corticancelous variety. Follow-up was between 6 weeks to 23 months with a mean follow-up of 9 months and 16 patients were available for the last followup, among them thirteen patients 18.25% revealed good results and three patients (18.75%) had poor results. There were eight patients who completed a follow-up period of 1 year of whom 75% had excellent results, good and fair results were in 12.5% cases respectively, with an uneventful post-operative and rehabilitative period. We found PLIF a technically demanding, yet satisfactory procedure to relieve backache after disc excision in properly selected patients.

We report a series of twenty-four cases of tuberculosis of lumbosarcral [L5-S1] region, seen during February 1992 to January 1999. The diagnosis of tuberculosis was missed initially in fifteen cases by us or others. This was because low back pain, stiffness, sciatica and, in some patients, a positive neurology were common features. Lumbosacral junction is not always clearly seen on X-rays, especially in the obese patients and this probably contributed to the missed diagnosis of tuberculosis of lumbosarcral junction is a high index of suspicion. Prognosis is good at this level.

Transpedicular screw fixation is perhaps the most common spinal instrumentation today, with advances in intra-operative imaging techniques. Pedicle is the strongest part of the vertebra and the pull out strength of the screw and stability of the fixation depends on the integrity of the pedicle. A good knowledge of the pedicle size is therefore essential for proper instrumentation. The vertical diameter, maximum and minimum transverse diameters of the pedicle were measured from 250 pedicles off 125 lumbar vertebrae taken from 25 cadavers. They were compared with the radiological values obtained from the X-rays of the specimens. The mean vertical diameter of the pedicle varied from 13.80mm at L1 to 14.7 mm at L5. The mean maximum transverse diameter varied from 7.25-7.3mm at L1 to 7.5.7.6mm at L5. The mean minimum transverse diameter of pedicle ranged from 4.80-4.95mm at L1 to 7.90.7.95mm at L5. The minimum transverse diameter could not be measured radiologically. All parameters showed a low value at L2 suggesting that L2 vertebrae had the smallest pedicle.

Due to the improved techniques of obstetrical practice and the expanding indications of cesarean section, the incidence of birth injury to Brachial plexus has become very low. Still, few patients present with residual deformity secondary to muscle imbalance despite varying degrees of recovery. Patients with internal rotation contracture and loss of abduction in the shoulder are benefited from tendon transfers as advised by L’Episcopo. From the year 1987 to 1998, 29 children with birth palsy with internal rotation contracture and adduction contracture of shoulder were treated by L’Episcopo procedure. Twenty-two patients were followed up and the results discussed. Patients with only upper arm type of birth palsy showed good functional results compared to fair functional results in patients with whole arm type of injury. But both groups showed excellent cosmetic improvement.

External fixation ligamentotaxis is one of the most effective methods for maintaining the distal radius fracture fragments in accurate alignment after reduction, especially in unstable intraarticular distal radius fractures. We have devised an extremely inexpensive and simple external fixator clamp with ordinary chrome plated bolts and nuts, by drilling two holes at right angles to each other in the bolt to hold connecting rod and Schanz screw. Nuts screwed on top of connecting rod and Schanz screw hold them securely. Twenty cases of distal radius fractures all of whom were dorsally displaced Colle’s type were managed by closed reduction and application of “Gulbarga fixator�. Average period of immobilization in external fixator was 8 weeks. Functional results were excellent in 10 cases, good in 4 cases, fair in 4 cases and poor in 2 cases. Radial length was restored back to normal in 18 cases and palmar angle to 50 average.

Fifty children with displaced supracondylar fracture of the humerus who were treated by close reduction and above elbow posterior plaster splint followed by modified shoulder spica were observed. We analysed the role of modified shoulder spica in the prevention of the secondary displacement in plaster slab leading to cubitus varus. At final follw-up, 5(10%) children had cubitus varus, compared to most series reporting up to 30% cases.

Open reduction and internal fixation of 42 cases of paediatric supracondylar fracture is discussed. All grade III supra condylar fractures were reduced using lateral and/or medial supracondylar approach and fixed with Criss cross K wires from medial and lateral epicondyles. The result were excellent in 36 cases (85%) and poor in 6 cases (15%). The poor results were due to technical errors in surgery. Supracondylar fracture is classified as grade I (undisplaced) and grade-II (displaced) because differentiating grade II from III (Gartlands 1959) is difficult radiologically. The lateral exposure for open reduction of supracondylar fracture has not been described earlier. The posterior approach routinely used for open reduction and internal fixation of fractures around the elbow, when compared with lateral approach is very traumatic and is often associated with stiffness of the elbow.

Seventeen patients with Scaphoid nonunion (SNU) of the Lichtman Stage II type were treated by interpositional bone grafting: the Fisk-Fernandez technique. Internal fixation was with K-Wires in 16 wrists and Herbert screw in1. union was complete in 16 SNU(94.1%) at a mean duration of 10.5 weeks. There was clinical improvement in grip and pinch strength and radiological improvement in the dorsal intercalated segment instability (DISI) and the intercarpal segment instability (DISI) and the intercarpal angles in the fractures that united. At follow-up (mean 4.5 year) there was no localized radioscaphoid or generalized radiocarpal joint arthrosis. In the SNU’s without arthrosis the Fisk-Fernandez technique gives predictable results with no further deterioration of wrist function.

The posterior horn of the medical meniscus in very vital to the knee joint in stability, shock absorption, load distribution and to avoid extremes of flexion. When the posterior horn is avulsed due to injury, the intensity of pain is extremely severe, restricting the mobility of the patient to a great extent. In a study of 154 patients, from 1990 to 1997 with a follow up of 18 months of 24 months, the arthroscopic patterns of these avulsions are identified, classified and analysed with respect to the mode of injury, the time lapse after injury and the type of tear. The prognosis of these lesions, with the pattern of the tear and the associated lesions is discussed. The purpose of this presentation is to bring about awareness of this entity, and outline the mode of management and treatment.

In this single blind, randomized, comparative evaluation of nimesulide transudermal gel (Nimesulide Trans gel) versus diclofenac and piroxicam gel in acute musculoskeletal conditions, two hundred and seventy-six patients were analysed for assessing the efficacy and safety of these gels. More number of patients got better relief in pain and inflammation parameters with nimesulide transdermal gel than the other two groups. The drug related side effects were low and not significant.

Trochanteric neck femur is very common in geriatric patients all over world. Various implants are evolved in the treatment. Dynamic Hip Screw (D. H. S) is considered a gold standard in their treatment by many surgeons. But D. H. S. does also fail. The author carried out Bone Model study to understand cause of failure of D. H. S. cases, and found out a fault in the design of D. H. S. as a possible cause- i.e. rotational instability of proximal fragment in operated D. H. S. New facts regarding biomechanics and anatomy of proximal femur were noticed. Based on these facts, biomechanical evaluation of various implants was done, especially to understand causes of implant failures in troachanteric fractures. The problem was studied from various angles, and a thesis was evolved to arrive at certain principles. If thesis principles are observed then we may be able to reduce the implant failure rate in trochanteric fractures.

Author tried to find forces applied on the femur and to express them mathematically. This paper includes: (a) Mathematical division of human anatomical configuration by Fibonacci’s number and Schooling’s concept. (b) Insertion of head of femur by the use centre of gravity into the hip-bone (c) Weight distribution through the neck of the femur to the shaft. (d) Capacity of absorbing stress & strain by the shaft of the femur due to its Spiralic Helical formation of bone-grains.