Congenital talipes equinovarus is the commonest congenital anomaly with an incidence of one to two per 1000 live births. Over the centuries it has been treated by various modalities, but the dilemma facing the surgeon has been a strong tendency to relapse. With the use of the Ponseti technique, the number of patients who undergo soft tissue release has decreased. This technique probably represents a panacea for the treatment of this unsolved mystery.

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In osteonecrosis the success of interventions that forestall or prevent femoral head collapse and maintain hip function would represent a substantial achievement in the treatment of this disease. A review of recent literature regarding bisphosphonate, anticoagulant, and vasodilators and biophysical modalities have demonstrated efficacy in reducing pain and delaying disease progression in early stage osteonecrosis. Though it has been considered still insufficient, to support their routine use in the treatment or prevention of osteonecrosis of the hip. Core decompression with modification of technique is still one of the safest and most commonly employed procedures with evidence based success in the pre-collapse stage of AVN of femoral head. The additional use of bone morphogenic protein, and bone marrow stem cells may provide the opportunity to enhance the results of core decompression. At present, the use of large vascularised cortical grafts, the other surgical procedure with high success rate is still not common due to technical difficulty in surgery. Likewise osteotomies are also not getting common as arthroplasty is getting more acceptable, so is awaited without any intermediate big surgical interventions.

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Background: The outcome of treatment of hip fractures in different age groups in the elderly population is largely unknown. Hence, we stratified elderly patients with hip fracture into age groups and compared the prognosis in various age groups. Materials and Methods: Among 459 patients with hip fracture treated at our hospital from 1997, 430 patients aged 65 years or above at the time of injury were studied. The patients comprised 98 males and 332 females and the ages at injury ranged from 65 to 103 years (mean 83.4 years). There were 167 cases of femoral neck fracture and 263 cases of trochanteric fractures. Surgery was performed in 383 cases, while 47 cases were treated conservatively. The subjects were classified by age into young-old for those aged 65-74 years (group A, n = 55), middle-old for those aged 75-84 years (group B, n = 172), old-old for those aged 85-94 (group C, n = 180), and oldest-old for those aged 95 years or above (group D, n = 23). The functional and survival prognosis at discharge in each group was investigated. Results: Numbers of patients who were ambulatory at discharge among those ambulatory before injury were 43 of 49 (87.8%) in group A, 113 of 152 (74.3%) in group B, 86 of 138 (62.3%) in group C, and 5 of 14 (35.7%) in group D, showing worse recovery of walking ability as age advanced. Among those ambulatory before injury, 42 patients in group A, 139 patients in group B, 130 patients in group C, and 12 patients in group D underwent surgery and of these patients, 38 patients (90.5%) in group A, 109 patients (78.4%) in group B, 83 patients (63.8%) in group C, and 5 patients (41.7%) in group D were ambulatory at discharge. On the other hand, the numbers of patients who were ambulatory at discharge among those receiving conservative treatment were 5 of 7 (71.4%) in group A, 4 of 13 (30.8%) in group B, 3 of 8 (37.5%) in group C, and 0 of 2 (0%) in group D, showing better walking ability in surgical patients than in conservatively treated patients even in the elderly. There were two in-hospital deaths in group B, 11 in group C, and two in group D. Five of the 15 deaths were inoperable cases due to poor performance status at admission. Conclusion: Walking ability at discharge and survival prognosis worsened as age advanced. On the other hand, since surgical cases achieved better walking ability than conservatively treated cases, efforts should be made to achieve better functional prognosis even in the old-olds, including surgery together with early ambulation and rehabilitation.

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A 28-year-old male had paraplegia as a result of fracture dislocation of T12/L1 six years ago. He was functioning independently until four weeks ago, when he started complaining of trunkal paraesthesia which later progressed to include the upper extremities. The initial diagnosis was that of posttraumatic syringomyelia (PTS). While awaiting the MRI scan he developed weakness of upper limbs. The weakness restricted his self-care activities including transfers. The MRI did not show any evidence of syringomyelia. Neurological consultation and assessment yielded provisional diagnosis of Guillain-Barre syndrome (GBS). The patient was treated with immunoglobulins and regained 90% of his previous neurological status. This case is reported to raise awareness among clinicians to include the possibility of the GBS in the differential diagnosis of progressive neurological loss on top of existing neurological deficiency in spinal cord injured patients.

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Giant cell tumor (GCT) of bone though one of the commonest bone tumors encountered by an orthopedic surgeon continues to intrigue treating surgeons. Usually benign, they are locally aggressive and may occasionally undergo malignant transformation. The surgeon needs to strike a balance during treatment between reducing the incidence of local recurrence while preserving maximal function. Differing opinions pertaining to the use of adjuvants for extension of curettage, the relative role of bone graft or cement to pack the defect and the management of recurrent lesions are some of the issues that offer topics for eternal debate. Current literature suggests that intralesional curettage strikes the best balance between controlling disease and preserving optimum function in the majority of the cases though there may be occasions where the extent of the disease mandates resection to ensure adequate disease clearance. An accompanying treatment algorithm helps outline the management strategy in GCT.

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Approximately 10% of the 7.9 million annual fracture patients in the United States experience nonunion and/or delayed unions, which have a substantial economic and quality of life impact. A variety of devices are being marketed under the name of "bone growth stimulators." This article provides an overview of electrical and electromagnetic stimulation, ultrasound, and extracorporeal shock waves. More research is needed for knowledge of appropriate device configurations, advancement in the field, and encouragement in the initiation of new trials, particularly large multicenter trials and randomized control trials that have standardized device and protocol methods.

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Background: Spasticity is a major problem related to spinal cord injuries. Use of intrathecal baclofen with an implanted pump seems a very useful mode of therapy in patients in whom oral antispasmodic agents are either not effective or produce intolerable side-effects. Materials and Methods: Twenty-four patients with mean age 50 years (range 32-72 years) had intrathecal baclofen pump implanted for the severe spasticity of spinal origin. One patient died following implantation of pump due to natural causes and was not included in the study. The patients were followed up for mean 22 months (range, one to five years). Results: All 24 patients showed improvement in their spasm following the procedure. Improvement was noted in pain (12), sleep disturbance (20) and sphincter control (14). Patients had improvement in activities of daily living such as feeding ability (10), self care (10), indoor and outdoor mobility (19), and driving (4). One patient had catheter leakage immediately after the surgery and required change of catheter. The radio telemetry allows very good adjustment of the dose according the individual patients needs. Conclusion: Intrathecal baclofen pump improves the symptoms of spasm and also the quality of life. It helps the patient to live more independently. It is not an irreversible surgery for the patient and hence it is very useful in the changing the dynamics in this group of patients.

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Background: Fingertip injuries are extremely common. Out of the various available reconstructive options, one needs to select an option which achieves a painless fingertip with durable and sensate skin cover. The present analysis was conducted to evaluate the management and outcome of fingertip injuries. Materials and Methods: This is a retrospective study of 150 cases of fingertip Injuries of patients aged six to 65 years managed over a period of two years. Various reconstructive options were considered for the fingertip lesions greater than or equal to 1 cm ² . The total duration of treatment varied from two to six weeks with follow-up from two months to one year. Results: The results showed preservation of finger length and contour, retention of sensation and healing without significant complication. Conclusion: The treatment needs to be individualized and all possible techniques of reconstruction must be known to achieve optimal recovery.

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Cervical spine trauma is a common problem with a wide range of severity from minor ligamentous injury to frank osteo-ligamentous instability with spinal cord injury. The emergent evaluation of patients at risk relies on standardized clinical and radiographic protocols to identify injuries; elucidate associated pathology; classify injuries; and predict instability, treatment and outcomes. The unique anatomy of each region of the cervical spine demands a review of each segment individually. This article examines both upper cervical spine injuries, as well as subaxial spine trauma. The purpose of this article is to provide a review of the broad topic of cervical spine trauma with reference to the classic literature, as well as to summarize all recently available literature on each topic. Identification of References for Inclusion: A Pubmed and Ovid search was performed for each topic in the review to identify recently published articles relevant to the review. In addition prior reviews and classic references were evaluated individually for inclusion of classic papers, classifications and previously unidentified references.

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Background: Ender and Simon Weidner popularized the concept of closed condylocephlic nailing for intertrochanteric fractures in 1970. The clinical experience of authors revealed that Ender nailing alone cannot provide secure fixation in elderly patients with osteoporosis. Hence we conducted a study to evaluate the efficacy of a combined fixation procedure using Ender nails and a cannulated compression screw for intertrochanteric fractures. Materials and Methods: 76 patients with intertrochanteric fractures were treated using intramedullary Ender nails and cannulated compression screw from January 2004 to December 2007. The mean age of the patients was 80 years (range 70-105 years).Using the Evan's system of classification 49 were stable and 27 unstable fractures. Inclusion criteria was high risk elderly patients (age > 70 years) with intertrochanteric fracture. The exclusion criteria included patients with pressure sores over the trochanteric region. Many patients had pre-existing co-morbidities like diabetes mellitus, hypertension, COPD, ischemic heart disease, CVA and coronary artery bypass surgery. The two Ender nails of 4.5mm each were passed across the fracture site into the proximal neck. This was reinforced with a 6.5 mm cannulated compression screw passed from the sub trochanteric region, across the fracture into the head. Results: The mean follow-up was 14 months (range 9-19 months) Average time to fracture union was 10 weeks (range 6-16 weeks). The mean knee ROM was 130^o (± 5^o). There was no case of nail penetration into hip joint. In five cases with advanced osteoporosis there was minimal migration of Ender nails distally. Conclusions: The Ender nailing combined with compression screw fixation in cases of intertrochanteric fractures in high risk elderly patients could achieve reliable fracture stability with minimal complications.

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Background: Gustilo's grade IIIB classification includes a wide spectrum of injuries and is limited by high inter and intra observer error rates. Methods: A trauma score for grade IIIB open tibial fractures was devised to assess injury to three components; the covering tissues, musculotendinous units and bone with the severity scale in each category from one to five. Seven co-morbid conditions known to influence the prognosis were each given a score of two and summed up. Results : Ninety six consecutive Grade IIIB open injuries of tibia were prospectively evaluated. At 3-5 year follow up, of the 88 available, final score was less than five in 6 patients (Group I), between six and ten in 48 (Group II), eleven to fifteen in 29 (Group III) and above 16 in five (Group IV). All patients in Group IV and one in Group III with score of fifteen underwent amputation. There was a significant difference (p less than 0.001) between the three groups in the requirement for flap (16.7,75&100 percent), time for union (16.3,24.9 & 46.9), incidence of deep infection (0,22.9 & 60.7 percent), number of surgical procedures (1.2,3.1 & 6.3) and inpatient days (12.5,22.6 & 59.4). A score of greater than three in any one component required special skills in management and interfered with healing of other structures. Conclusion: The scoring system was easy to apply and had a high degree of interobservor aggreement rate. This comprehensive score reliably prognosticates both limb salvage and outcome measures in severe open injuries of tibia.

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An eight year old girl presented with a progressively increasing deformity of the left proximal tibia since last 2 years. She had no history of trauma, fever and swelling of left knee. There were no obvious signs of rickets/muscular dystrophy. She had 25 degrees of tibia vara clinically with lateral thrust and a prominent fibular head. The radiograph of left knee revealed tibia vara with medial beaking and a significant depression of the medial tibial epiphysis and metaphysis. A computed tomography (CT)scan revealed significant depression of the medial tibial epiphysis but no bony bar in the physis or fusion of the medical tibial epiphysis. There was a posterior slope in addition to the medial one. She was treated with elevation of the medial tibial hemiplateau with subtuberosity valgus derotation dome osteotomy. She also underwent a lateral proximal tibial hemiphysiodesis (temporary stapling). A prophylactic subcutaneons anterolateral compartment fasciotomy was also performed. All osteotomies united in 2 months. All deformities were corrected and she regained a knee range of 0 to 130 degrees. At final followup (4 years), there was no recurrence of varus deformity, knee was stable, with 1cm of leg length discrepancy. In Langenskiold stage IV tibia vara, elevation of medial tibial plateau, a subtuberosity valgus derotation osteotomy and a concomitant lateral hemiephiphysiodesis has given good results.

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Femoral neck fractures in young adults are uncommon and often the result of high-energy trauma. They are associated with higher incidences of femoral head osteonecrosis and nonunion. Multiple factors can play a significant role in preventing these devastating complications and contribute to a good outcome. While achieving an anatomic reduction and stable internal fixation are imperative, other treatment variables, such as time to surgery, the role of capsulotomy and the fixation methods remain debatable. Open reduction and internal fixation through a Watson-Jones exposure is the recommended approach. Definitive fixation can be accomplished with three cannulated or noncannulated cancellous screws. Capsulotomy in femoral neck fractures remains a controversial issue and the practice varies by trauma program, region and country. Until there is conclusive data (i.e. prospective and controlled) we recommend performing a capsulotomy. The data available is inconclusive on whether this fracture should be operated emergently, urgently or can wait until the next day. Until there is conclusive data available, we recommend that surgery should be done on an urgent basis. The key factors in treating femoral neck fractures should include early diagnosis, early surgery, anatomic reduction, capsular decompression and stable internal fixation.

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Background: Most patients of symptomatic osteoarthrosis of knee are associated with varus malalignment that is causative or contributory to painful arthrosis. It is rational to correct the malalignment to transfer the functional load to the unaffected or less affected compartment of the knee to relieve symptoms. We report the outcome of a simple technique of high tibial osteotomy in the medial compartment osteoarthrosis of the knee. Materials and Methods: Between 1996 and 2004 we performed closing wedge osteotomy in 78 knees in 65 patients. The patients selected for osteotomy were symptomatic essentially due to medial compartment osteoarthrosis associated with moderate genu varum. Of the 19 patients who had bilateral symptomatic disease 11 opted for high tibial osteotomy of their second knee 1-3 years after the first operation. Preoperative grading of osteoarthrosis and postoperative function was assessed using Japanese Orthopaedic Association (JOA) rating scale. Results: At a minimum follow-up of 2 years (range 2-9 years) 6-10° of valgus correction at the site of osteotomy was maintained, there was significant relief of pain while walking, negotiating stairs, squatting and sitting cross-legged. Walking distance in all patients improved by two to four times their preoperative distance of 200-400 m. No patient lost any preoperative knee function. The mean JOA scoring improved from preoperative 54 (40-65) to 77 (55-85) at final follow-up. Conclusion: Closing wedge high tibial osteotomy performed by our technique can be undertaken in any setup with moderate facilities. Operation related complications are minimal and avoidable. Kirschner wire fixation is least likely to interfere with replacement surgery if it becomes necessary.

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Background: Dislocation is one of the most common complications of total hip arthroplasty with a reported dislocation rate of 3.2%. Despite increased experience with hip replacement, the overall rate has not yet changed. The aim of this paper is to review the most recent literature published on this topic and indexed in Medline, in order to clarify the main risk factors, and to standardize a treatment protocol of such an important complication of prosthetic surgery. Materials and Methods: Medline database was searched using key words: "hip dislocation", "hip instability" from 1980-2007. Studies were eligible for review and included if they met the following criteria: (1) publication in English, (2) clinical trials (3) review papers. Results: The risk of first-time dislocation as a function of time after the surgery is not well understood. Most, but not all, series have demonstrated that the risk of dislocation is highest during the first few months after hip arthroplasty; however, first-time late dislocation can also occur many years after the procedure. Several risk factors were described, including the surgical approach, the diameter of the head, impingement, component malposition, insufficient abductor musculature. In addition, there are also many treatment options, such as long-term bracing after closed reduction, component reorientation, capsulorraphy, trochanteric advancement, increasing offset, exchange of the modular head and the polyethylene liner, insertion of constrained liner. Conclusion: Preventing hip dislocation is obviously the best strategy. Surgeons must take into account patient and surgical risk factors. For patients at high risk for dislocation the surgeon should accurately restore leg length and femoral offset; the use of larger femoral heads, posterior transosseous repair of the capsulotendinous envelope if posterior approach is chosen or the use of a lateral approach should be considered. Proper patient education and postoperative care are very important.

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Injury that occurs to a finger wearing a ring though rare can have grave consequences. It is a preventable injury which has a peculiar mode of trauma that is usually occupational. Injury ranges from simple contusion to degloving of soft tissues to traumatic amputation. We hereby report our experience of four cases of finger avulsion injuries due to a ring and discuss their variable clinical presentation and individualized management.

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Background: Bone marrow edema (BME) is a common cause of hip pain. The aim of the study was to assess the efficacy of the vasoactive drug iloprost in the treatment of BME of femoral head. Materials and Methods: We reviewed 27 patients (19 male, 8 female) with BME of the femoral head. Their mean age was 53.7 ± 10.8 years. All patients were treated with iloprost, a vasoactive drug that dilates arterioles and venules, reduces capillary permeability and suppresses platelet aggregation. The therapy comprised a series of five infusions with 20 to 50 μg iloprost over 6 h on 5 consecutive days each. Weight bearing was reduced for up to 3 weeks, depending on the severity of symptoms. Pain at rest as well as under stress was assessed with a semi quantitative scale from before and 4 months after therapy. MRI investigations were done before and repeated 4 months after therapy. Results: At the clinical follow up of four months after therapy, the pain level at rest had diminished by a mean of 58.3% ( P < 0.0001). Pain under stress decreased by a mean of 41.9% ( P < 0.0001). On MRI, 20 patients had a significant reduction of BME size or complete normalization and 4 showed no change. Worsening of the MRI pattern was found in 3 patients. Conclusion: The authors conclude that the use of parenteral iloprost might be a viable method in the treatment of BME of femoral head.

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Subchondral fracture of the femoral head is an uncommon entity and usually occurs as an insufficiency fracture associated with poor bone quality or as a fatigue fracture in young military recruits. This condition should be considered in the differential diagnosis of acute hip pain in young patients along with transient osteoporosis and avascular necrosis of the hip. We report a case of acute onset hip pain in an asymptomatic healthy adult in which the diagnosis was made by magnetic resonance imaging and the patient responded well to conservative treatment.

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Background: Complex deformity correction and fracture treatment with the Ilizarov method needs extensive preoperative analysis and laborious postoperative fixator alterations, which are error-prone. We report our initial experience in treating the first 22 patients having fractures and complex deformities and shortening with software-controlled Taylor spatial frame (TSF) external fixator, for its ease of use and accuracy in achieving fracture reduction and complex deformity correction. Settings and Design: The struts of the TSF fixator have multiplane hinges at both ends and the six struts allow correction in all six axes. Hence the same struts act to correct either angulation or translation or rotation. With a single construct assembled during surgery all the desired axis corrections can be performed without a change of the montage as is needed with the Ilizarov fixator. Materials and Methods: Twenty-seven limb segments were operated with the TSF fixator. There were 23 tibiae, two femora, one knee joint and one ankle joint. Seven patients had comminuted fractures. Ten patients who had 13 deformed segments achieved full correction. Eight patients had lengthening in 10 tibiae. (Five of these also had simultaneous correction of deformities). One patient each had correction of knee and ankle deformities. Accurate reduction of fractures and correction of deformities and length could be achieved in all of our patients with minimum postoperative fixator alterations as compared to the Ilizarov system. The X-ray visualization of the osteotomy or lengthening site due to the six crossing struts and added bulk of the fixator rings which made positioning in bed and walking slightly more difficult as compared to the Ilizarov fixator. Conclusions: The TSF external fixator allows accurate fracture reduction and deformity correction without tedious analysis and postoperative frame alterations. The high cost of the fixator is a deterrent. The need for an internet connection and special X-rays to operate the fixator add to its complexity.

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Background: Anterior decompression with posterior instrumentation when indicated in thoracolumbar spinal lesions if performed simultaneously in single-stage expedites rehabilitation and recovery. Transthoracic, transdiaphragmatic approach to access the thoracolumbar junction is associated with significant morbidity, as it violates thoracic cavity; requires cutting of diaphragm and a separate approach, for posterior instrumentation. We evaluated the clinical outcome morbidity and feasibility of extrapleural retroperitoneal approach to perform anterior decompression and posterior instrumentation simultaneously by single "T" incision outcome in thoracolumbar spinal trauma and tuberculosis. Patients and Methods: Forty-eight cases of tubercular spine (n = 25) and fracture of the spine (n = 23) were included in the study of which 29 were male and 19 female. The mean age of patients was 29.1 years. All patients underwent single-stage anterior decompression, fusion, and posterior instrumentation (except two old traumatic cases) via extrapleural retroperitoneal approach by single "T" incision. Tuberculosis cases were operated in lateral position as they were stabilized with Hartshill instrumentation. For traumatic spine initially posterior pedicle screw fixation was performed in prone position and then turned to right lateral position for anterior decompression by same incision and approach. They were evaluated for blood loss, duration of surgery, superficial and deep infection of incision site, flap necrosis, correction of the kyphotic deformity, and restoration of anterior and posterior vertebral body height. Results: In traumatic spine group the mean duration of surgery was 269 minutes (range 215-315 minutes) including the change over time from prone to lateral position. The mean intraoperative blood loss was 918 ml (range 550-1100 ml). The preoperative mean ASIA motor, pin prick and light touch score improved from 63.3 to 74.4, 86 to 94.4 and 86 to 96 at 6 month of follow-up respectively. The mean preoperative loss of the anterior vertebral height improved from 44.7% to 18.4% immediate postoperatively and was 17.5% at final follow-up at 1 year. The means preoperative kyphus angle also improved from 23.3° to 9.3° immediately after surgery, which deteriorated to 11.5° at final follow-up. One patient developed deep wound infection at the operative site as well as flap necrosis, which needed debridement and removal of hardware. Five patients had bed sore in the sacral region, which healed uneventfully. In tubercular spine (n=25) group, mean operating time was approximately 45 minutes less than traumatic group. The mean intraoperative blood loss was 1100 ml (750-2200 ml). The mean preoperative kyphosis was corrected from 55° to 23°. Wound healing occurred uneventful in 23 cases and wound dehiscence occurred in only 2 cases. Nine out of 11 cases with paraplegia showed excellent neural recovery while 2 with panvertebral disease showed partial neural recovery. None of the patients in both groups required intensive unit care. Conclusions: Simultaneous exposure of both posterior and anterior column of the spine for posterior instrumentation and anterior decompression and fusion in single stage by extra pleural retroperitoneal approach by "T" incision in thoracolumbar spinal lesions is safe, an easy alternative with reduced morbidity as chest and abdominal cavities are not violated, ICU care is not required and diaphragm is not cut.

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