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Step-cut translation osteotomy and Y-plate fixation: A novel method for correction of cubitus varus and valgus deformity
Kumar Shashi Kant, Vikas Gupta
January-June 2017, 3(1):12-15
Introduction: Many types of osteotomy have been proposed for the treatment of cubitus varus and valgus deformity. All these osteotomies have their advantages and disadvantages; however, till date there is no uniform consensus as to which osteotomy is the best suited for correction of these deformities. Materials and Methods: We reviewed the results of step-cut translation osteotomy in the management of cubitus varus and cubitus valgus deformity. This study includes 27 cases of cubitus varus and five cases of cubitus valgus deformity that underwent supracondylar step-cut translation osteotomy with Y-plate fixation for correction of the deformity. Results: The results were evaluated according to the modified criteria of Oppenheim et al. There were 25 excellent, six good, and one poor result. Overall, complication rate in our series was 12.5% (4/32). There was no recurrence of deformity in the available follow-up. Conclusions: Step-cut translation osteotomy is a relatively simple procedure that corrects cubitus varus and valgus deformities without any prominence of the medial or lateral condyle. Moreover, a wide osteotomy surface and rigid fixation allows early mobilization of the joint with good clinical results.
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Safety, efficacy, and functional outcome of elastic stable intramedullary nailing in unstable fractures of both bones of forearm in children
Deeptiman James, Vrisha Madhuri
January-June 2017, 3(1):29-33
Aims: To determine the clinical profile and clinical, functional, and radiological outcomes and complications in children who underwent elastic stable intramedullary nailing (ESIN) for unstable fractures of both bones of forearm. Materials and Methods: A retrospective observational study was conducted in the Paediatric Orthopaedic Unit of the institution. Children with forearm fractures, who underwent ESIN of both the bones with titanium nails from January 2004 to June 2010, were included in the study. Clinical evaluation for deformity, range of motion at wrist and elbow, Daruwalla’s grading for forearm fractures, and radiological evaluation for bony union, malalignment, and radial bow were done. Paediatric Outcomes Data Collection Instrument (PODCI) questionnaire was used to assess functional outcome. Results: Twenty-six patients were followed up for a mean of 2.14 years. These included one primary internal fixation for unstable injury in a 15-year old, 10 open fractures, and 15 with malalignment after closed reduction. Age ranged from 5 to 15 years (mean of 11.39). Average time to bony union was 6 weeks. Twelve children had excellent, 12 good, and two fair outcomes according to Daruwalla’s grade. Average PODCI score was 50.78 (standardized range is minimum of −140 to maximum of 53). There were no major complications related to ESIN. Three patients had paraesthesia over superficial radial nerve distribution, three patients had hypertrophied scars, and one patient had superficial wound infection. One child had distal radial physeal arrest following inadvertent physeal injury during implant removal. Conclusion: ESIN is safe and effective for internal fixation of unstable forearm fractures.
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Isolation, in-vitro expansion, and characterization of human muscle satellite cells from the rectus abdominis muscle
David Livingstone, Albert A Kota, Sanjay K Chilbule, Karthikeyan Rajagopal, Sukria Nayak, Vrisha Madhuri
January-June 2017, 3(1):16-22
Introduction: Satellite cells are a resident population of stem cells beneath the basal lamina of mature skeletal muscle fibers. Their capacity to regenerate muscle makes them a potentially ideal source for human cell therapy with respect to muscle-related diseases such as urinary and fecal incontinence, and others. In this study, we describe a protocol to isolate, expand in-vitro, and characterize human muscle satellite cells from the rectus abdominis muscle. Materials and Methods: Muscle biopsies from human donors were harvested, digested using collagenase type II, and then plated on extracellular matrix-coated plates. Results: Immunocytochemistry revealed that satellite cells on day 8 were 70–80% Pax7 positive; in contrast, cells expanded until day 12 showed 50–75% positivity for Pax7. The real-time polymerase chain reaction for day 8 culture indicated four-fold increase in Pax3 and Pax7 gene expression, four-fold increase in MyoD gene expression, and five-fold increase in Myf5 gene expression. Conclusion: These findings suggest that satellite cells can be cultured until day 8 for translational purposes. The protocol described here is modest, operational, and reproducible and involves only basic cell culture equipment.
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Paediatric orthopaedics and global initiative for children's surgery
Vrisha Madhuri
January-June 2017, 3(1):1-2
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Comparison of two different medial reference points for measurements of the acetabular index
Sandeep Vijayan, Dhiren Ganjwala, Hitesh Shah
January-June 2017, 3(1):7-11
Introduction: Acetabular index (AI) is a commonly used quantitative measurement of acetabular inclination in plain radiographs. Repeated measurements of this index are used to determine dysplasia in children and for decision making about surgical management. Persistent acetabular dysplasia may be an indication for performing an acetabuloplasty. AI is commonly measured between the Hilgenreiner’s line (line that connects both triradiate cartilages) and the line joining lateral most ossified margin of the acetabulum and triradiate cartilage. Two different methods for measurement of AI with two different medial reference points at the triradiate cartilage have appeared in the literature. Aim: The specific aim of the study was to investigate the difference between AI measurements with two different methods and report on intraobserver and interobserver reliability of both the methods. Materials and Methods: Ninety-eight children with developmental dysplasia of the hip (DDH) (treated and untreated), younger than 9 years, were included in the study. Anteroposterior radiographs of the pelvis having acceptable pelvic rotation and pelvic tilt were included in the study. AI was measured using two different reference points for the affected and normal sides. AI was measured twice at 1-month interval by two investigators. The difference between the two measurement techniques was compared by the paired “t” test. Pearson’s correlation coefficient was calculated to test associations between the two measurement techniques. Results: The reproducibility of measurements of both the techniques was found satisfactory [intraclass correlation (ICC)-0.90 and 0.87]. Statistically significant difference (P value < 0.001) (5.7° for affected and 5.3° for normal side) between the indices measured by two techniques was noted. This difference was noted for all age groups. Significant positive correlations between both the techniques were noted in normal as well as dysplastic hips. Conclusion: Acetabular indices measured with two different medial points gave significantly different values. All subsequent assessment should be consistently carried out by the same method.
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Paediatric orthopaedics anaesthesia for surgeons
Serina Ruth Salins
January-June 2017, 3(1):3-6
Paediatric anaesthesia is a well-established subspecialty, which has allowed surgery to be safer, as the science advances in both the specialties. It is imperative for both surgeons and anesthesiologist to be aware of all the implications in children, especially syndromic, coming for surgery. This article gives a comprehensive overview of anaesthesia for orthopaedic surgery.
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Treatment of unstable hips in children with Ilizarov hip reconstruction: A retrospective analysis of six cases
Bipin Ghanghurde, Mandar Agashe, Tarush Rustagi, Chasanal Rathod, Rujuta Mehta, Dominic D'Silva, Alaric Aroojis
January-June 2017, 3(1):23-28
Introduction: Hip instability in older children and adolescents is mainly because of the loss of bone in the proximal femur or conditions that cause loss of the fulcrum. These may be related to infantile septic hip sequelae or neglected developmental dysplasia of the hip. Materials and Methods: We retrospectively analyzed six patients with hip instability treated by Ilizarov hip reconstruction from 2004 to 2007 at our institute. The mean age of the patients was 10 years (range 7–14 years). Results: The etiology was septic hip sequelae (Choi type IV) in four patients and neglected developmental dysplasia of hip in two patients. The fixator was kept for an average of 7 months (range 6–8 months). The average follow-up was 3 years. The visual analog score for pain improved from a preoperative mean of 8 to 2 postoperatively. The gait improved in all the patients and the leg length discrepancy improved from a preoperative mean of 5 to 1 cm postoperatively. All the limbs were aligned to a satisfactory level with the mean mechanical axis deviation of 3 mm (laterally) and pelvic mechanical axis of 90°. The Harris hip score improved from 41 preoperatively to 84 postoperatively (P < 0.0001). Conclusion: Ilizarov Hip Reconstruction is an excellent salvage procedure for adolescent patients with unstable hips, giving good results in the short-term.
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Common peroneal nerve entrapment during closed reduction and percutaneous pinning of paediatric distal femur fracture: Surgeons be aware!
Kiran Sasi, Binu P Thomas
January-June 2017, 3(1):38-40
Distal femoral metaphyseal fracture is a common injury faced by paediatric orthopaedic surgeons. This injury is usually managed with closed reduction and percutaneous Kirschner wire fixation. We present an unusual case wherein the common peroneal nerve was completely severed and entrapped in the fracture site following closed reduction and percutaneous Kirschner wire fixation of a distal femoral metaphyseal fracture.
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Grievous injuries in children due to tractor-related accidents
Kala Ebenezer, Rimi Manners, Sampath Karl, Vrisha Madhuri
January-June 2017, 3(1):34-37
Introduction: Tractor-related accidents are common among the agricultural injuries. Children are prone to such incidents as farmers live in the vicinity of the farmland. Materials and Methods: From the Paediatric Intensive Care unit (PICU) database we extracted the details of children with unintentional injuries and poisonings during the period January 2008 to June 2009. Those with tractor-related injuries were further analyzed using outpatient and inpatient charts, computerized hospital records were accessed to obtain laboratory and radiological investigations details. The clinical characteristics, injuries, and outcome of these children are presented. Results: In the 18 months period, there were 107 children with trauma, envenomations and poisoning constituting 6.5% of all PICU admissions. Of the 31 (29%) with polytrauma, four (12.9%) children, three of them boys had sustained tractor-related injuries. The injuries included three with multiple limb fractures, two each of head, chest, musculoskeletal and perineal injury and one each of abdominal and major vascular injury. All had reached the hospital in life-threatening shock and were resuscitated. Multidisciplinary surgical intervention including craniectomy, liver resection and femoral vessels anastomosis were required along with blood transfusions, ventilatory support and inotropes. Three of them survived the injuries after a mean PICU stay of 34 days. Conclusion: Tractor-related incidents among rural children are associated with major injuries and fatalities in children. The findings call for interventions to prevent such injuries and education of the farming community involved with tractors and other agricultural machineries.
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Early Surgical Intervention in Children with a Suspected Diagnosis of Acute Septic Arthritis or Osteomyelitis: Is it Justified?
Petnikota Harish
July-December 2017, 3(2):43-50
Context: Early surgical intervention is the key for good outcome in children with acute haematogenous osteomyelitis (AHO) or septic arthritis. Often there is an impasse to observe or intervene early when the diagnosis is inconclusive due to blunted clinical findings and equivocal investigations. Aim: This study is aimed at justifying early surgical intervention in these doubtful/suspected cases. Settings and Design: This study was a retrospective review of AHO/septic arthritis treated by the author between August 2010 and January 2015. A new scoring system, haematogenous osteomyelitis and septic arthritis (HOMSA) score was developed to aid in classifying and decision-making. With a maximum score of 8, a score >6 in the absence of infection elsewhere or a score <6 with radiological evidence makes the diagnosis of AHO/septic arthritis definite. A score ≤6 without radiological evidence makes the diagnosis suspected/doubtful. Outcome was measured by a new discrete criterion for the upper and lower limbs. Materials and Methods: The protocol was early surgical intervention in both the groups. In septic arthritis, open arthrotomy along with joint lavage and debridement was performed. In AHO, bone decompression with abscess drainage was performed. Initial parenteral administration of antibiotics was followed by oral antibiotic administration. Necessary adjuvant treatment was given. Results: Thirty-four children with 40 sites of infection were identified. Among them, 50% were neonates. Only 4/40 children were treated conservatively. Following surgery, outcome was excellent-to-good in 92.8% of the children with doubtful/suspected diagnosis and 96.6% with definite infection. One child in each group who were treated surgically, and two children in the group with definite infection treated non-operatively had fair-to-poor outcomes. Conclusion: Early surgical intervention is justified even in children with a doubtful/suspected diagnosis of AHO or Septic Arthritis. The new scoring system, HOMSA Score, is a better tool to diagnose Acute septic arthritis or osteomyelitis, even with limited resources.
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Amputation Following Meningococcal Septicaemia in Children: the Surgical Management of the Residual Limb
Brigid M Aherne, Fergal P Monsell
July-December 2017, 3(2):60-66
Background: Meningococcal septicaemia is a potentially life-threatening disease and remains the most common infective cause of mortality in the UK. Improvements in healthcare have led to early recognition and treatment, and a decrease in mortality. As more children now survive the initial acute illness, the long-term musculoskeletal consequences have become more prevalent. These include growth plate injury, tissue loss and amputation. Patients with limb loss present specific difficulties due to the effect of remaining longitudinal growth on the function of the residual limb, and often require surgical treatment that continues throughout childhood. Patients and Methods: This case series reviews the histories of 13 children who underwent amputation as a complication of meningococcal septicaemia. All patients attend a specialist clinic and our experience in the management of the residual limb is described. Results: Thirteen patients, with a mean age of 16 months at the onset of meningococcal septicaemia, required amputation in the management of the skeletal consequences of the infection. Revision surgery was necessary for all 13 patients and involved management of bone overgrowth, growth arrest, scar and soft tissue contracture, neuroma development, and infection. The details of our approach to each of these complications is described. Conclusion: Due to improvements in diagnosis and initial management, a significant proportion of patients are surviving infantile meningococcal septicaemia. Many develop musculoskeletal consequences including amputation, and this case series serves to increase knowledge in the complex managements of the residual limb in these patients.
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Stop Maligning the Asymptomatic Child’s Flatfoot
Benjamin Joseph
July-December 2017, 3(2):41-42
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The Role of Pirani Scoring in Predicting the Frequency of Casting and the Need for Percutaneous Achilles Tenotomy in the Treatment of Idiopathic Clubfoot Using the Ponseti Method
Chukwuemeka O Anisi, Joseph E Asuquo, Innocent E Abang, Michael E Eyong, Onyebuchi G Osakwe, Ngim E Ngim
July-December 2017, 3(2):55-59
Background: The Pirani scoring system is a simple tool widely used for grading the severity of clubfoot. This study was designed to objectively assess its value in predicting the total number of casts required, and the need for percutaneous Achilles tenotomy to achieve correction of the idiopathic clubfoot treated by the Ponseti method. Patients and Methods: All patients with idiopathic clubfoot, who attended our clubfoot clinic between January, 2013 and December, 2015, were prospectively studied. Each clubfoot was scored at presentation and at each visit by the first and second authors, using the Pirani scoring system. All patients were treated by the first and second authors by weekly stretching and cast application following the Ponseti treatment protocol until correction was achieved (with or without percutaneous Achilles tenotomy). Chi-square tests were applied to establish any existing relationship between the Pirani scores and the need for percutaneous tenotomy as well as the number of casts required to achieve correction. Results: A total of 69 patients with 108 idiopathic clubfeet were recruited into the study. In that, 14 patients defaulted, leaving the study with 81 clubfeet belonging to 55 patients. The median total Pirani score (TPS), midfoot contracture score and hindfoot contracture score at presentation were 4.0, 2.0 and 2.0, respectively. A total of 57 (70.4%) feet required percutaneous Achilles tenotomy to achieve correction. The average number of casts (including casts after tenotomy) required to achieve correction was 4.9 (2–10). The average number of casts required to achieve correction was 4.1 (2–10) for the no tenotomy group and 5.4 (3–10) for the tenotomy group. Statistically significant relationship was established between the TPS and number of casts required to achieve correction for both the tenotomy group (P = 0.039) and no tenotomy group (P = 0.05). Conclusion: High Pirani scores were associated with increased number of casts and percutaneous Achilles tenotomy for the correction of idiopathic clubfoot using the Ponseti method.
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Predicting the Need for Tenotomy in the Management of Idiopathic Clubfoot by the Ponseti Method
Ranjit V Deshmukh, Aditi A Kulkarni
July-December 2017, 3(2):51-54
Purpose: The aim of this study was to determine the role of Pirani scoring system for predicting the treatment of idiopathic clubfoot with the Ponseti technique. Materials and Methods: A retrospective study was conducted. The records of 132 idiopathic clubfeet of patients treated by the Ponseti method and scored by the Pirani system between May 2007 and September 2015 were analyzed. Result: Of the 132 feet, 101 (76.5%) feet of the patients required tenotomy. The mean number of casts required was significantly higher (P = 0.033) for the group that required tenotomy (5.53 ± 1.6 casts) than the group that did not require tenotomy (4.87 ± 0.9 casts). Conclusion: The initial Pirani score is predictive of the number of casts that may be required and the need for a tenotomy of the Achilles tendon.
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10-Year Radiological Follow-Up of Multifocal Recurrent Eosinophilic Granuloma With Vertebra Plana: A Case Report and Review of Literature
Amit Kumar, Shivam Sinha, Shyam Kumar Saraf, Vineeta Gupta, Deepa Rani, Jyoti Kumari
July-December 2017, 3(2):72-76
Eosinophilic granuloma (EG) is the benign localized form of histiocytosis. Owing to the relative rarity of the condition, diagnosis is often delayed or missed, and many questions remain unanswered, ranging from cause and pathogenesis to therapy. Observation and immobilization are adequate for improvement of the condition in most patients. However, treatment other than simple observation is recommended in patients with symptomatic EG. This article presents a 10-year follow-up study of a 15-year-old girl with a symptomatic multifocal EG treated effectively by monitored chemotherapy and orthosis.
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The Role of Imaging in Diagnosis and Management of Congenital High Scapula (Sprengel’s Deformity): Case Report and Review
Nada Garrouche, Saida Jerbi, Nedra Chouchane, Wassia Kessomtini, Hssine Hamza
July-December 2017, 3(2):67-71
Sprengel’s deformity is the congenital failure of descent of the scapula. The diagnosis is based on a clinical examination and radiological procedures. Volume rendering three-dimensional computed tomography reconstructions analyze the precise topography and spatial proportions of examined bone structures. It enables an optional rotation of visualized bone structures to clarify the anatomical abnormalities. Ultrasound and magnetic resonance are useful in prenatal management and for the diagnosis of concomitant abnormalities. In this paper, we report our imaging experience from one child with Sprengel’s deformity and discuss the importance of imaging techniques with a particular focus on the role of three-dimensional reconstructions.
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