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   2013| November-December  | Volume 47 | Issue 6  
    Online since November 19, 2013

 
 
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ORIGINAL ARTICLES
Outcome and incidence of periprosthetic supracondylar femoral fractures in TKA
Somesh P Singh, Haresh P Bhalodiya
November-December 2013, 47(6):591-597
DOI:10.4103/0019-5413.121586  PMID:24379465
Background: Periprosthetic supracondylar femoral fractures following total knee arthroplasty (TKA) are infrequent, but is a devastating complication. The purpose of this study was to evaluate the incidence and outcomes of periprosthetic supracondylar femoral fractures following TKA using nonoperative as well as open reduction and internal fixation (ORIF) techniques. Materials and Methods: Between January 2004 and December 2010, we followed 3,920 operated patients of total knee arthroplasty (TKA) and identified 23 patients with periprosthetic supracondylar fractures. A retrospective analysis of the records of these patients was conducted. Details regarding pre fracture status, treatment offered and the present status were also recorded and analyzed. Time from index arthroplasty to periprosthetic fracture ranged from five days to six years. There were 17 women and 6 men and the average age was 68.26 years (range 52-83 years). Of the 23 patients, 20 patients were treated by operative method, whereas only three patients with relatively undisplaced fractures were treated nonoperatively. Results: The total incidence of periprosthetic fractures in operated cases of TKA was 0.58%. Three patients had infection after surgery. As per radiological assessment, two of three conservatively treated cases had malunion, whereas among 20 cases treated operatively, 16 had primary union with one malunion. Two patients had union after bone grafting, whereas two had nonunion. The average reduction in the knee score after fracture was 20.53%. Twenty one patients were able to achieve limited but independent activity. Conclusions: Desirable results for periprosthetic fractures can be obtained if proper and timely intervention is done, taking into account the other comorbid conditions. However, short duration of followup and small number of patients were major limiting factors in this study.
  6 2,682 134
Bone morphogenetic protein-7 accelerates fracture healing in osteoporotic rats
Ashish D Diwan, Anthony Leong, Richard Appleyard, Divya Bhargav, Zhi Ming Fang, Aiqun Wei
November-December 2013, 47(6):540-546
DOI:10.4103/0019-5413.121569  PMID:24379457
Background: Osteoporosis is characterized by low bone mass, bone fragility and increased susceptibility to fracture. Fracture healing in osteoporosis is delayed and rates of implant failure are high with few biological treatment options available. This study aimed to determine whether a single dose of bone morphogenetic protein-7 (BMP-7) in a collagen/carboxy-methyl cellulose (CMC) composite enhanced fracture healing in an osteoporotic rat model. Materials and Methods: An open femoral midshaft osteotomy was performed in female rats 3 months post-ovarectomy. Rats were randomized to receive either BMP-7 composite ( n = 30) or composite alone ( n = 30) at the fracture site during surgery. Thereafter calluses were collected on days 12, 20 and 31. Callus cross-sectional area, bone mineral density, biomechanical stiffness and maximum torque, radiographic bony union and histological callus maturity were evaluated at each time point. Results: There were statistically significant increases in bone mineral density and callus cross-section area at all time points in the BMP-7 group as compared to controls and biomechanical readings showed stronger bones at day 31 in the BMP-7 group. Histological and radiographic evaluation indicated significant acceleration of bony union in the BMP-7 group as compared to controls. Conclusion: This study demonstrated that BMP-7 accelerates fracture healing in an oestrogen-deficient environment in a rat femoral fracture healing model to scientific relevance level I. The use of BMP-7 composite could offer orthopedic surgeons an advantage over oestrogen therapy, enhancing osteoporotic fracture healing with a single, locally applied dose at the time of surgery, potentially overcoming delays in healing caused by the osteoporotic state.
  5 2,908 123
Sciatic nerve repair with tissue engineered nerve: Olfactory ensheathing cells seeded poly(lactic-co-glygolic acid) conduit in an animal model
CW Tan, MH Ng, H Ohnmar, Y Lokanathan, H Nur-Hidayah, SA Roohi, BHI Ruszymah, MH Nor-Hazla, A Shalimar, AS Naicker
November-December 2013, 47(6):547-552
DOI:10.4103/0019-5413.121572  PMID:24379458
Background and Aim: Synthetic nerve conduits have been sought for repair of nerve defects as the autologous nerve grafts causes donor site morbidity and possess other drawbacks. Many strategies have been investigated to improve nerve regeneration through synthetic nerve guided conduits. Olfactory ensheathing cells (OECs) that share both Schwann cell and astrocytic characteristics have been shown to promote axonal regeneration after transplantation. The present study was driven by the hypothesis that tissue-engineered poly(lactic-co-glycolic acid) (PLGA) seeded with OECs would improve peripheral nerve regeneration in a long sciatic nerve defect. Materials and Methods: Sciatic nerve gap of 15 mm was created in six adult female Sprague-Dawley rats and implanted with PLGA seeded with OECs. The nerve regeneration was assessed electrophysiologically at 2, 4 and 6 weeks following implantation. Histopathological examination, scanning electron microscopic (SEM) examination and immunohistochemical analysis were performed at the end of the study. Results: Nerve conduction studies revealed a significant improvement of nerve conduction velocities whereby the mean nerve conduction velocity increases from 4.2 ΁ 0.4 m/s at week 2 to 27.3 ΁ 5.7 m/s at week 6 post-implantation ( P < 0.0001). Histological analysis revealed presence of spindle-shaped cells. Immunohistochemical analysis further demonstrated the expression of S100 protein in both cell nucleus and the cytoplasm in these cells, hence confirming their Schwann-cell-like property. Under SEM, these cells were found to be actively secreting extracellular matrix. Conclusion: Tissue-engineered PLGA conduit seeded with OECs provided a permissive environment to facilitate nerve regeneration in a small animal model.
  5 2,741 98
Management of complex long bone nonunions using limb reconstruction system
Hiranya Kumar Seenappa, Manoj Kumar Shukla, Muralidhar Narasimhaiah
November-December 2013, 47(6):602-607
DOI:10.4103/0019-5413.121590  PMID:24379467
Background: Management of complex nonunions is difficult due to the presence of infection, deformities, shortening and multiple surgeries in the past. Complex nonunions are traditionally managed by Ilizarov fixation. The disadvantages of Ilizarov are poor patient compliance, inconvenience of the frame and difficult frame construction. We conducted a study on 30 long bone complex nonunions treated by the limb reconstruction system (LRS). Materials and Methods: Between April 2009 and September 2012, we treated 30 cases of complex nonunion of long bone with the LRS. 28 were male and 2 females. Average shortening was 5.06 cm and 14 cases presented with infected implants. Initially we managed with implant removal, radical debridement followed by fixation with the LRS. In 16 cases, corticotomy and lengthening was done. The average duration of treatment was 9.68 months. We compressed the fracture site at the rate of 0.25 mm per day for 1-2 weeks and distracted the corticotomy at the rate of 1 mm/day till lengthening was achieved. Result: The union occurred in 89.28% cases and eradication of infection in 91.66% cases. Average lengthening done was 4.57 cm. We had 79% excellent, 11% good and 10% poor bony result and fnctional result was excellent in 40% cases, good in 50% and failure in 10% cases using ASAMI scoring system. Conclusion: LRS is an alternative to the Ilizarov fixation in their management of complex nonunion of long bones. It is less cumbersome to the patient and more surgeon and patient friendly.
  4 2,377 384
Primary total elbow arthroplasty
Suresh Kumar, Sunayan Mahanta
November-December 2013, 47(6):608-614
DOI:10.4103/0019-5413.121592  PMID:24379468
Background: Primary total elbow arthroplasty (TEA) is a challenging procedure for orthopedic surgeons. It is not performed as frequently as compared to hip or knee arthroplasty. The elbow is a nonweight-bearing joint; however, static loading can create forces up to three times the body weight and dynamic loading up to six times. For elderly patients with deformity and ankylosis of the elbow due to posttraumatic arthritis or rheumatoid arthritis or comminuted fracture distal humerus, arthroplasty is one of the option. The aim of this study is to analyze the role of primary total elbow arthroplasty in cases of crippling deformity of elbow. Materials and Methods: We analyzed 11 cases of TEA, between December 2002 and September 2012. There were 8 females and 3 males. The average age was 40 years (range 30-69 years). The indications for TEA were rheumatoid arthritis, comminuted fracture distal humerus with intraarticular extension, and posttraumatic bony ankylosis of elbow joint. The Baksi sloppy (semi constrained) hinge elbow prosthesis was used. Clinico-radiological followup was done at 1 month, 3 months, 6 months, 1 year, and then yearly basis. Results: In the present study, average supination was 70° (range 60-80°) and average pronation was 70° (range 60-80°). Average flexion was 135° (range 130-135°). However, in 5 cases, there was loss of 15 to 35° (average 25°) of extension (45°) out of 11 cases. The mean Mayo elbow performance score was 95.4 points (range 70-100). Arm length discrepancy was only in four patients which was 36% out of 11 cases. Clinico-radiologically all the elbows were stable except in one case and no immediate postoperative complication was noted. Radiolucency or loosening of ulnar stem was seen in 2 cases (18%) out of 11 cases, in 1 case it was noted after 5 years and in another after 10 years. In second case, revision arthroplasty was done, in which only ulnar hinge section, hinge screw and lock screw with hexagonal head were replaced. Conclusion: Elbow arthroplasty remains a valuable option for deformed and ankylosed elbows especially in the demanding patients with crippling deformity of the elbow.
  4 3,920 226
Biomechanical comparison of dynamic condylar screw and locking compression plate fixation in unstable distal femoral fractures: An in vitro study
Ashutosh Kumar Singh, Amit Rastogi, Vakil Singh
November-December 2013, 47(6):615-620
DOI:10.4103/0019-5413.121594  PMID:24379469
Background: Distal femur fractures are difficult to manage and the selection of implant for internal fixation remains controversial. The objective of this study is to establish the relative strength of fixation of a distal femoral locking plate (DFLP) compared with the dynamic condylar screw (DCS) in the distal femur fractures. Materials and Methods: Study was conducted on 16 freshly harvested cadaveric distal femoral specimens, eight implanted with DCS and other eight with DFLP. The construct was made unstable by removing a standard sized medial wedge of 1 cm base (gap-osteotomy) beginning 6 cm proximal to the lateral joint line in distal metaphyseal region with the loss of medial buttress. Fatigue test was conducted under load control mode at the frequency of I Hz. Specimens were subjected to cyclic loading of 2 kN, under observation for 50,000 cycles or until failure/cutout, which ever occurred earlier. Results: In DFLP group, there was no implant failure and the average number of cycles sustained was 50,000. Six out of eight specimens completed 50,000 cycles and two failed in DCS group. The average number of cycles sustained by DCS was 46150. Though the bone quality as assessed by dual energy X-ray absorptiometry DEXA was comparable in both DFLP and DCS group ( P = 0.06), none failed in DFLP group and subsidence was 1.02 ± 0.34 mm (range: 0.60-1.32 mm), which was significantly 43% lower ( P = 0.006) than subsidence in DCS group (1.82 ± 0.58; range: 1.20-3.08 mm). The average stiffness of DCS group was 52.8 ± 4.2 N/mm, which was significantly lower than average stiffness of locked condylar plate group (71.2 ± 5.1 N/mm) ( P = 0.02). Conclusions: DFLP fixation of the distal femur fractures resulted in stronger construct than the DCS fixation in both cyclic loading and ultimate strength in biomechanical testing of a simulated A3 distal femur fracture.
  3 4,145 322
CASE REPORTS
Reconstruction of bilateral tendoachilles with fascia lata graft
Vikas Saxena, Pavan Pradhan, Ashok Yadav, Neeraj Nathani
November-December 2013, 47(6):634-638
DOI:10.4103/0019-5413.121600  PMID:24379473
A 19 year old male presented with progressive enlargement of both tendoachilles for 2 years and difficulty in walking for 3 months. The neurological history and examination revealed progressive mental deterioration and ataxia. The blood investigation revealed hypercholesterolemia. We report this rare case of cerebrotendinous xanthomatosis with bilateral tendoachilles enlargement, which was treated by excision of bilateral tendoachilles and reconstruction with fascia lata. The American Orthopedic Foot and Ankle Society hindfoot score was 93/100 bilaterally and the subjective evaluation of the patient showed very good results.
  2 1,735 149
ORIGINAL ARTICLES
Navicular stress fractures treated with minimally invasive fixation
Korula Mani Jacob, Roger S Paterson
November-December 2013, 47(6):598-601
DOI:10.4103/0019-5413.121589  PMID:24379466
Background: Stress fractures of the naviculum bone are uncommon injuries occurring predominantly in athletes. These fractures are usually treated nonoperatively with a nonweight bearing cast for a minimum of 6 weeks followed by rehabilitation. Further, there is a paucity of literature on the long term clinical followup of these patients. These fractures do not heal predictably with conservative management, which does not inspire great compliance and their clinical outcome is variable. We report on the outcome of these fractures following early operative intervention by minimally invasive fixation and early weight bearing and rehabilitation. We propose that this is reliable and a successful treatment regimen and its role as the definitive management of this clinical problem should be explored. Early intervention with minimally invasive surgery has significantly less morbidity and a reliable early return to active sports and is therefore the best option in high-performance athletes. Materials and Methods: Nine athletes with ten stress fractures of the navicular treated at our institution between April 1991 and October 2000. The mean age of the patients was 22.8 years (range 18-50 years). All patients were treated by minimally invasive screw fixation and early weight bearing mobilization without a cast. The average followup was 7 years (range 2-11 years). Results: Seven of the nine patients returned to their pre-fracture level of sporting activity at an average of 5 months (range 3-9 months). One patient returned to full sporting activity following a delay of 2 years due to an associated tibial stress fracture and one patient had an unsatisfactory result. Long term review at an average of 7 years showed that six of these eight patients who returned to sports remained symptom free with two patients experiencing minimal intermittent discomfort after prolonged activity. Conclusions: We recommend percutaneous screw fixation as a reliable, low morbidity procedure allowing early return to full sporting activity without long term complications or recurrences.
  2 3,018 128
Accuracy and safety of free-hand pedicle screw fixation in age less than 10 years
Hyoung Yeon Seo, Ji Hyeon Yim, Jung Pil Heo, Abhishek S Patil, Seung Min Na, Sung Kyu Kim, Jae Yoon Chung
November-December 2013, 47(6):559-564
DOI:10.4103/0019-5413.121577  PMID:24379460
Background: Pedicle screws are being used commonly in the treatment of various spinal disorders. However, use of pedicle screws in the pediatric population is not routinely recommended because of the risk of complications. The present study was to evaluate the safety of pedicle screws placed in children aged less than 10 years with spinal deformities and to determine the accuracy and complication (early and late) of pedicle screw placement using the postoperative computed tomography (CT) scans. Materials and Methods: Thirty one patients (11 males and 20 females) who underwent 261 pedicle screw fixations (177 in thoracic vertebrae and 84 in lumbar vertebrae) for a variety of pediatric spinal deformities at a single institution were included in the study. The average age of patients was 7 years and 10 months. These patients underwent postoperative CT scan which was assessed by two independent observers (spine surgeons) not involved in the treatment. Results: Breach rate was 5.4% (14/261 screws) for all pedicles. Of the 177 screws placed in the thoracic spine, 13 (7.3%) had breached the pedicle, that is 92.7% of the screws were accurately placed within pedicles. Seven screws (4%) had breached the medial pedicle wall, 4 screws (2.3%) had breached the lateral pedicle wall and 2 screws (1.1%) had breached the superior or inferior pedicle wall respectively. Of the 84 screws placed in the lumbar spine, 83 (98.8%) screws were accurately placed within the pedicle. Only 1 screw (1.2%) was found to be laterally displaced. In addition, the breach rate was found to be 4.2% (11/261 screws) with respect to the vertebral bodies. No neurological, vascular or visceral complications were encountered. Conclusions: The accuracy of pedicle screw placement in pedicles and vertebral bodies were 94.6% and 95.8% respectively and there was no complication related to screw placement noted until the last followup. These results suggest that free-hand pedicle screw fixation can be safely used in patients younger than 10 years to treat a variety of spinal disorders.
  2 2,290 119
CASE REPORTS
Traumatic posterior atlantoaxial dislocation without related fractures of C1-C2
Maruti Kambali, HS Vijay Anand, H Priyamargavi, Ram Bhupal Varma
November-December 2013, 47(6):624-629
DOI:10.4103/0019-5413.121597  PMID:24379471
Posterior dislocation without any associated fracture of odontoid is exceedingly rare and only 11 cases have been reported so far. A 32 year old male presented with pain, stiffness in neck, difficulty in breathing, associated lacerations on face and deformity of mandible and inability to open mouth. His plain radiographs, CT scan, MRI demonstrated a posterior dislocation of the atlas with respect of axis and a flake of bone from odontoid process on CT scan. He was successfully managed by closed reduction, C1C2 lateral mars pedicular screw stabilization and inter facetal fusion with synthetic bone graft substitute. At 10 months followup he had lost only 30° cervical rotation. The case is reported in view of rarity and to discuss the treatment rationale.
  1 1,722 96
CASE REPORTS
Treatment of habitual dislocation of patella in an adult arthritic knee
Raghuveer K Reddy, Vamsi Kondreddi
November-December 2013, 47(6):630-633
DOI:10.4103/0019-5413.121599  PMID:24379472
Habitual dislocation of the patella (HDP) is a common presentation in pediatric age unlike adults. Many surgical procedures using proximal realignment and distal realignment have been reported to treat HDP in children with satisfactory results. However, late presentation of habitual patellar dislocation with osteoarthritis is rare and treatment plan has not yet been established. We present a case of neglected iatrogenic habitual patellar dislocation with osteoarthritis in a 50-year-old woman. Two-staged procedure was planned, first with patellar realignment and later with definitive total knee arthroplasty. Quadricepsplasty, medial patello-femoral ligament reconstruction, lateral release and tibial tuberosity transfer was done as primary procedure and total knee arthroplasty, which was planned as secondary procedure, was deferred as the patient improved functionally.
  1 4,143 192
LETTERS TO EDITOR
Tru-cut biopsy as the initial method of tissue diagnosis in bone tumors with soft tissue extension
Ashish Gulia
November-December 2013, 47(6):643-644
DOI:10.4103/0019-5413.121606  PMID:24379476
  1 709 60
Curettage of benign bone tumors and tumor like lesions: A retrospective analysis
Ajay Puri, Ashish Gulia
November-December 2013, 47(6):645-646
DOI:10.4103/0019-5413.121610  PMID:24379478
  1 762 70
ORIGINAL ARTICLES
Osteogenic potentials of osteophytes in the cervical spine compared with patient matched bone marrow stromal cells
Pei Zhao, Weidong Ni, Dianming Jiang, Wei Xiong, Feng Li, Wei Luo
November-December 2013, 47(6):565-571
DOI:10.4103/0019-5413.121579  PMID:24379461
Background: Osteophytes that form adjacent to degenerated disc have osteogeic potential. Studies suggest that their formation is associated with mesenchymal precursors arising from the chondrosynovial junction. This study is aimed to determine the cellular aging and osteogenic differentiation potential of osteophyte-derived mesenchymal cells (oMSCs) when compared to patient-matched bone marrow stromal cells (bMSCs). Materials and Methods: oMSCs and bMSCs were isolated from tissue samples during anterior cervical discectomy and fusion surgery. Extensive expansion of cell cultures was performed and early and late passage cells (P 4 and P 9 , respectively) were used to study cell senescence and telomerase activity. Furthermore, osteogenic differentiation was applied to detect their osteogenic capacity. Results: The proliferation capacity of oMSCs in culture was superior to that of bMSCs and these cells readily underwent osteogenic differentiation. Our results showed that oMSCs had higher telomerase activity in late passages compared with bMSCs, although there was no significant difference in the telomerase activity in the early passages in either cell types. The telomerase activity was detectable only in early passage oMSCs and not in bMSCs. Conclusions: Our results indicate that oMSCs retain a level of telomerase activity in vitro, which may account for the relatively greater longevity of these cells, compared to bMSCs. Furthermore, when compared to bMSCs, oMSCs maintained a higher proliferative capacity and the same osteogenic capacity, which may offer new insights of tissue formation.
  1 1,751 67
Hip arthroplasty in failed intertrochanteric fractures in elderly
Javahir A Pachore, Vikram I Shah, Ashish N Sheth, Kalpesh P Shah, Dhiraj P Marothi, Rahul Puri
November-December 2013, 47(6):572-577
DOI:10.4103/0019-5413.121581  PMID:24379462
Background: Failed intertrochanteric fractures in elderly patients are surgical challenge with limited options. Hip arthroplasty is a good salvage procedure even though it involves technical issues such as implant removal, bone loss, poor bone quality, trochanteric nonunion and difficulty of surgical exposure. Materials and Methods: 30 patients of failed intertrochanteric fractures where hip arthroplasty was done between May 2008 and December 2011 were included in study. 13 were males and 17 were females with average age of 67.3 years. There were 2 cemented bipolar arthroplasties, 19 uncemented bipolar, 4 cemented total hip arthroplasty and 5 uncemented total hip arthroplasties. 16 patients had a trochanteric nonunion, which was treated by tension band principles. Total hip was considered where there was acetabular damage due to the penetration of implant. Results: The average followup was 20 months (range 6-48 months). Patients were followed up from 6 to 48 months with average followup of 20 months. None of the patients were lost to followup. There was no dislocation. All patients were ambulatory at the final followup. Conclusion: A predictable functional outcome can be achieved by hip arthroplasty in elderly patients with failed intertrochanteric fractures. Though technically demanding, properly performed hip arthroplasty can be a good salvage option for this patient group.
  1 3,393 410
Management of developmental dysplasia of the hip in less than 24 months old children
Mehmet Bulut, Murat Gürger, Oktay Belhan, Omer Cihan Batur, Suat Celik, Lokman Karakurt
November-December 2013, 47(6):578-584
DOI:10.4103/0019-5413.121584  PMID:24379463
Background: There is no consensus on the treatment of developmental dysplasia of the hip in children less than 24 months of age. The aim of this study was to present the results of open reduction and concomitant primary soft-tissue intervention in patients with developmental dysplasia of the hip in children less than 24 months of age. Materials and Methods: Sixty hips of 50 patients (4 male, 46 female) with mean age of 14.62 ± 5.88 (range 5-24 months) months with a mean followup of 40.00 ± 6.22 (range 24-58 months) months were included. Twenty five right and 35 left hips (10 bilaterally involved) were operated. Open reduction was performed using the medial approach in patients aged < 20 months (with Tönnis type II-III and IV hip dysplasias) and for those aged 20-24 months with Tönnis type II and III hip dysplasias ( n = 47). However for 13 patients aged 20-24 months with Tönnis type IV hip dysplasias, anterior bikini incision was used. Results: Mean acetabular index was 41.03 ± 3.78° (range 34°-50°) in the preoperative period and 22.98 ± 3.01° (range 15°-32°) at the final visits. Mean center-edge angle at the final visits was 22.85 ± 3.35° (18°-32°). Based on Severin radiological classification, 29 (48.3%) were type I (very good), 25 (41.7%) were type II (good) and 6 (10%) were type III (fair) hips. According to the McKay clinical classification, postoperatively the hips were evaluated as excellent ( n = 42; 70%), good ( n = 14; 23.3%) and fair ( n = 4; 6.7%). Reduction of all hip dislocations was achieved. Additional pelvic osteotomies were performed in 14 (23.3%) hips for continued acetabular dysplasia and recurrent subluxation. (Salter [ n = 12]/Pemberton [ n = 2] osteotomy was performed). Avascular necrosis (AVN) developed in 7 (11.7%) hips. Conclusion: In DDH only soft-tissue procedures are not enough, because of the high rate of the secondary surgery and AVN for all cases aged less than 24 months. Bone procedures may be necessary in the walking age group with high acetabular index.
  1 3,378 222
Morphological character of cervical spine for anterior transpedicular screw fixation
Rong-Ping Zhou, Jian Jiang, Zi-Chun Zhan, Yang Zhou, Zhi-Li Liu, Qing-Shui Yin
November-December 2013, 47(6):553-558
DOI:10.4103/0019-5413.121575  PMID:24379459
Background: Anterior cervical interbody grafts/cages combined with a plate were frequently used in multilevel discectomies/corpectomies. In order to avoid additional posterior stabilization in patients who undergo anterior reconstructive surgery, an anterior cervical transpedicular screw fixation, which offers higher stability is desirable. We investigated in this study the anatomical (morphologic) characters for cervical anterior transpedicular screw fixation. Materials and Methods: Left pedicle parameters were measured on computed tomography (CT) images based on 36 cervical spine CT scans from healthy subjects. The parameters included outer pedicle width (Distance from lateral to medial pedicle surface in the coronal plane), outer pedicle height (OPH) (Distance from upper to lower pedicle surface in the sagittal plane), maximal pedicle axis length (MPAL), distance transverse insertion point (DIP), distance of the insertion point to the upper end plate (DIUP), pedicle sagittal transverse angle (PSTA) and pedicle transverse angle (PTA) at C3 to C7. Results: The values of outer pedicle width and MPAL in males were larger than in females from C3 to C7. The OPH in males was larger than in females at C3 to C6, but there was no difference at C7. The DIP and PTA were significantly greater in males than in females at C3, but there was no difference in the angle at C4-7. The PSTA was not statistically different between genders at C3, 4, 7, but this value in males was larger than females at C5, 6. The DIUP was significantly greater in males at C3, 4, 6, 7 but was non significant at C5. Conclusions: The placement of cervical anterior transpedicular screws should be individualized for each patient and based on a detailed preoperative planning.
  1 1,882 116
CASE REPORTS
Disseminated histoplasmosis
CA Mansoor, PV Bhargavan, R Rajanish, Lekha R Nair
November-December 2013, 47(6):639-642
DOI:10.4103/0019-5413.121601  PMID:24379474
Disseminated histoplasmosis is a relentlessly progressive granulomatous disease which can mimic many other granulomatous diseases including tuberculosis. A 48-year-old male was referred to us with 11 months history of multiple subcutaneous swellings and ulcerations over the upper and lower limbs and fever for 2 months. He was evaluated outside for several months and received anti tubercular drugs for about 2 years in the past for a granulomatous infection of bone and soft tissue identified by various biopsies, without any improvement. When he was evaluated and fresh biopsies were taken, they were stained for fungus and disseminated histoplasmosis was detected. This case confirms the importance of considering fungal infections as a possibility while treating disseminated granulomatous infections, even in immune-competent patients, especially if response to treatment is inadequate.
  - 1,623 135
Transient long thoracic nerve injury during posterior spinal fusion for adolescent idiopathic scoliosis: A report of two cases
Athanasios I Tsirikos, Khalid Al-Hourani
November-December 2013, 47(6):621-623
DOI:10.4103/0019-5413.121595  PMID:24379470
We present the transient long thoracic nerve (LTN) injury during instrumented posterior spinal arthrodesis for idiopathic scoliosis. The suspected mechanism of injury, postoperative course and final outcome is discussed. The LTN is susceptible to injury due to its long and relatively superficial course across the thoracic wall through direct trauma or tension. Radical mastectomies with resection of axillary lymph nodes, first rib resection to treat thoracic outlet syndrome and cardiac surgery can be complicated with LTN injury. LTN injury producing scapular winging has not been reported in association with spinal deformity surgery. We reviewed the medical notes and spinal radiographs of two adolescent patients with idiopathic scoliosis who underwent posterior spinal arthrodesis and developed LTN neuropraxia. Scoliosis surgery was uneventful and intraoperative spinal cord monitoring was stable throughout the procedure. Postoperative neurological examination was otherwise normal, but both patients developed winging of the scapula at 4 and 6 days after spinal arthrodesis, which did not affect shoulder function. Both patients made a good recovery and the scapular winging resolved spontaneously 8 and 11 months following surgery with no residual morbidity. We believe that this LTN was due to positioning of our patients with their head flexed, tilted and rotated toward the contralateral side while the arm was abducted and extended. The use of heavy retractors may have also applied compression or tension to the nerve in one of our patients contributing to the development of neuropraxia. This is an important consideration during spinal deformity surgery to prevent potentially permanent injury to the nerve, which can produce severe shoulder dysfunction and persistent pain.
  - 2,427 54
EDITORIAL
Process of peer review continues
Ish Kumar Dhammi, Sudhir Kumar
November-December 2013, 47(6):537-539
DOI:10.4103/0019-5413.121568  PMID:24379456
  - 1,530 109
LETTERS TO EDITOR
Author's reply
Zile Singh Kundu, Vinay Gupta, Sukhbir Singh Sangwan, Parveen Rana
November-December 2013, 47(6):646-646
DOI:10.4103/0019-5413.121611  
  - 885 60
Author's reply
Amit Joshi, Sushil Rana Magar, Pankaj Chand, Rajesh Panth, Bachchu Ram KC
November-December 2013, 47(6):644-645
DOI:10.4103/0019-5413.121608  
  - 704 42
Internal fixation of fractures of both bones forearm: Comparison of locked compression and limited contact dynamic compression plate
Shailesh Pai, M Shantharam Shetty, M Ajith Kumar
November-December 2013, 47(6):643-643
DOI:10.4103/0019-5413.121604  PMID:24379475
  - 1,011 139
ORIGINAL ARTICLES
Computer navigation experience in hip resurfacing improves femoral component alignment using a conventional jig
Zachary Morison, Akshay Mehra, Michael Olsen, Michael Donnelly, Emil Schemitsch
November-December 2013, 47(6):585-590
DOI:10.4103/0019-5413.121585  PMID:24379464
Background:The use of computer navigation has been shown to improve the accuracy of femoral component placement compared to conventional instrumentation in hip resurfacing. Whether exposure to computer navigation improves accuracy when the procedure is subsequently performed with conventional instrumentation without navigation has not been explored. We examined whether femoral component alignment utilizing a conventional jig improves following experience with the use of imageless computer navigation for hip resurfacing. Materials and Methods:Between December 2004 and December 2008, 213 consecutive hip resurfacings were performed by a single surgeon. The first 17 (Cohort 1) and the last 9 (Cohort 2) hip resurfacings were performed using a conventional guidewire alignment jig. In 187 cases, the femoral component was implanted using the imageless computer navigation. Cohorts 1 and 2 were compared for femoral component alignment accuracy. Results:All components in Cohort 2 achieved the position determined by the preoperative plan. The mean deviation of the stem-shaft angle (SSA) from the preoperatively planned target position was 2.2° in Cohort 2 and 5.6° in Cohort 1 ( P = 0.01). Four implants in Cohort 1 were positioned at least 10° varus compared to the target SSA position and another four were retroverted. Conclusions: Femoral component placement utilizing conventional instrumentation may be more accurate following experience using imageless computer navigation.
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