Should all patients with a culture-negative periprosthetic joint infection be treated with antibiotics? : a multicentre observational study

AIMS

The aim of this study was to analyze the prevalence of culture-negative periprosthetic joint infections (PJIs) when adequate methods of culture are used, and to evaluate the outcome in patients who were treated with antibiotics for a culture-negative PJI compared with those in whom antibiotics were withheld.

METHODS

A multicentre observational study was undertaken: 1,553 acute and 1,556 chronic PJIs, diagnosed between 2013 and 2018, were retrospectively analyzed. Culture-negative PJIs were diagnosed according to the Muskuloskeletal Infection Society (MSIS), International Consensus Meeting (ICM), and European Bone and Joint Society (EBJIS) definitions. The primary outcome was recurrent infection, and the secondary outcome was removal of the prosthetic components for any indication, both during a follow-up period of two years.

RESULTS

None of the acute PJIs and 70 of the chronic PJIs (4.7%) were culture-negative; a total of 36 culture-negative PJIs (51%) were treated with antibiotics, particularly those with histological signs of infection. After two years of follow-up, no recurrent infections occurred in patients in whom antibiotics were withheld. The requirement for removal of the components for any indication during follow-up was not significantly different in those who received antibiotics compared with those in whom antibiotics were withheld (7.1% vs 2.9%; p = 0.431).

CONCLUSION

When adequate methods of culture are used, the incidence of culture-negative PJIs is low. In patients with culture-negative PJI, antibiotic treatment can probably be withheld if there are no histological signs of infection. In all other patients, diagnostic efforts should be made to identify the causative microorganism by means of serology or molecular techniques. Cite this article: Bone Joint J 2022;104-B(1):183-188.

Hereditary Haemorrhagic Telangiectasia of Nasal Mucosa- A Case Report

Hereditary Haemorrhagic Telangiectasia (HHT) is also known as Osler-Weber-Rendu syndrome is a development disorder of blood vessels. It is characterised by multiple telangiectases and Arteriovenous Malformations (AVMS) that cause direct connections between arteries and veins bypassing intermediate capillaries. The most prominent sites for telangiectasia are the lips, tongue, face, mucosa of the nose, oral cavity, and gastrointestinal tract. Telangiectases can rupture and bleed easily due to their thin walls, narrow tortuous courses, and proximity to the skin's surface or a mucous membrane. Depending on the organ affected, these symptoms include repeated persistent epistaxis, skin lesions, haemoptysis, gastrointestinal haemorrhage, and stroke. Complications of HHT include bleeding, anaemia, followed by stroke, pulmonary AVM, Transient Ischaemic Attack (TIA), hypovolemic shock due to severe intractable bleed, eventually leading to high output failure. Present case is of a 45-year-old female who presented with complaints of recurrent epistaxis. Diagnostic nasal endoscopy showed multiple telengiectasic spots which were cauterised with trichloroacetic acid. However recurrent episodes of bleed were encountered.

Non Indigenous Rhinoscleroma

Rhinoscleroma (RS) is a granulomatous illness of the upper respiratory tract caused by Klebsiella rhinoscleromatis. It is a rare, chronic, granulomatous disease. RS develops in the nasal mucosa subepithelium and can spread to the eustachian tube, maxillary antrum, oral cavity, larynx, orbit, trachea, and bronchi. The present case is of a 29-year-old female who came to the Ear Nose and Throat (ENT) outpatient department with chief complaints of bilateral nose block for six months. Examination by anterior rhinoscopy revealed pink nasal mucosa and a swelling arising from both sides of nasal septum, that was soft, non tender, did not bleed on touch. Diagnostic nasal endoscopy showed a midline septal mass which was present just posterior to mucocutaneous junction and a second septal mass was present posterior to first mass at level of posterior part of inferior turbinate. She underwent submucosal resection of septal mass and the same was sent for histopathological examination and it was diagnosed as features suggestive of RS. The patient was treated with a course of tablet ciprofloxacin, analgesics, antihistamines. There has been no recurrence during the one year follow-up period. Patient improved symptomatically and had no further complaints.

Anatomical changes in vertebra in dystrophic scoliosis due to neurofibromatosis and its implications on surgical safety

STUDY DESIGN

Detailed radiological analysis by multimodality imaging.

OBJECTIVE

To document anatomical changes jeopardizing instrumentation safety in Neurofibromatosis deformity correction surgeries.

MATERIALS AND METHODS

The apical and 3 adjacent vertebral segments above and below amounting to 70 segments in 10 NF scoliosis were studied by radiographs, CT and MRI. The changes in lamina, pedicle and vertebral body that could jeopardize pedicle screw and sublaminar wire placement were documented and changes were appropriately classified.

RESULTS

Extensive anatomical changes were noted. These changes were more severe at the apex and independent of the curve severity. Both laminae were normal in only 36 (Type 1), rest had either gross asymmetry in length and shape (Type 2; 21) or also in sloping (Type 3; 13). Of the 140 pedicles, normal pedicles were found only in 48 (Type 1); while they were divergent (Type 2; 4) or abnormally elongated with only thinning (Type 3a; 26); or with sclerosis (3b; 34); or very curved and wavy (3c; 23) and even fractured or indistinct (Type 4; 5). It was notable that 92 of the 140 pedicles were unsuitable for pedicle screws. A unique phenomenon of body drift was identified in 29 segments which could jeopardize screw placement and rib dislocation into the canal was found in 18 segments.

CONCLUSION

Gross anatomical changes jeopardizing both sublaminar wire strength and trajectory of pedicle screws were common in NF and independent of curve severity. Therefore, detailed preoperative assessment and planning by a 3D CT are essential.

Short-term outcomes of treatment in children presenting with DDH in walking age - An analysis of 84 hips

BACKGROUND

Developmental Dysplasia of Hip (DDH) presenting at walking age is not uncommon, particularly in developing countries. The available treatment modalities in this age group are closed reduction (CR), open reduction (OR), OR with additional femoral and/or pelvic osteotomy. This study was done in patients who presented between 12 and 36 months of age to assess the following: 1) Percentage of hips amenable for successful CR, 2) failure rate after CR and OR in walking age DDH and 3) the need for secondary procedures to address subluxation and residual dysplasia within first 2 years.

METHOD

ology: After IRB approval, the institutional database was searched for patients admitted with a diagnosis of DDH from January 2009 to January 2019. We identified 142 patients, of which 65 patients with 84 hips formed the study cohort after applying inclusion and exclusion criteria. Demographic details, details of the interventions, brace wear, revision procedures and radiological data were collected from Hospital Information System. We divided the patients in three groups: Group I - CR, Group II -OR, and Group III - OR with an additional bony procedure in the form of femoral and/or pelvic osteotomy.

RESULTS

The mean age at presentation was 20.1 months. We had 10 (11.9%) hips in group I, 39 (46.4%) hips in group II and 35 (41.6%) hips in group III. The mean follow-up was 44.8 months (24-132 months). In Group I, 5 (50%) had re-dislocation and 2 (20%) needed revision intervention for residual dysplasia. In Group II, 4 (10%) had re-dislocation and 4 (10%) needed revision intervention. In Group III, 5 (14.2%) hips needed revision intervention for residual dysplasia. The mean final AI was 24.6°in Group I, 28.2° in Group II and 26.3°in Group III. There was no significant difference in the final AI between the groups (p > 0.05).

CONCLUSIONS

An attempted closed reduction has a 50% failure rate, and we recommend a low threshold for open reduction. There is a 10% rate of re-dislocation following open reduction with or without additional bony procedure. About 50% of the dysplastic hips treated without pelvic osteotomy at the time of index procedure fail to remodel and have residual acetabular dysplasia.

Spinal Hypertrophic Pachymeningitis Causing Thoracic Myelopathy in a Patient of Takayasu Arteritis: A Case Report

CASE

A 52-year-old man presented with thoracic myelopathy, and his magnetic resonance imaging (MRI) was suggestive of T1-T4 hypertrophic-pachymeningitis. Incidentally, circumferential thickening of the infra-renal abdominal aorta and right common iliac artery was seen, which along with the findings in a contrast computed tomography was consistent with Takayasu arteritis (TA). The patient underwent T1-T4 laminectomy, thinning of dura, biopsy, and steroid therapy. At the 1-year follow-up, he was asymptomatic and MRI revealed resolution of the lesion.

CONCLUSION

This is the first report describing an association between TA and hypertrophic spinal pachymeningitis, emphasizing the unusual neurological manifestation of myelopathy and complete resolution of symptoms with timely and appropriate intervention.

Clinical efficacy of ultrasound guided bilateral erector spinae block for single-level lumbar fusion surgery: a prospective, randomized, case-control study

BACKGROUND CONTEXT

Postoperative experience plays a vital role in patient recovery and does not depend on the type and quality of the surgical procedure alone. Non-opioid therapies have become part of the multimodal analgesic regimen for better pain control and reduced opioid-related side effects. Most recently evolved among these are the regional anesthetic techniques, such as the thoracolumbar interfascial plane (TLIP) block and the erector spinae (ESP) block.

PURPOSE

To assess the efficacy of ultrasound-guided (US) ESP block for postoperative analgesia after a single level lumbar spine fusion surgery compared with conventional (opioid-based) multimodal postoperative analgesia.

STUDY DESIGN

A prospective, randomized, controlled, and double-blinded clinical trial.

PATIENT SAMPLE

A 100 consecutive patients requiring single-level lumbar spinal fusion procedure were randomized into two groups- block (multimodal analgesia with US-ESP) and control (only multimodal analgesia) groups.

OUTCOME MEASURES

Demographic and surgical data, intra-operative blood loss, duration of surgery, total opioid consumption (TOC) and amount of muscle relaxants used were assessed. Postoperatively, the Numeric pain Rating Scale(NRS), Modified Observer's assessment of Alertness and/or Sedation Scale (MOASS) and Patient satisfaction scores were recorded every 2 hours for the first 6 hours followed by every 6 hours for 24 hours. Continuous variables were analyzed using Student's t-test, and categorical variables were analyzed using either the Chi-square test or Fisher's exact test. p-value < .05 was considered statistically significant.

METHODS

Patients in both groups underwent the identical protocol for pre-emptive analgesia and induction of anesthesia. Patients in the block group received the US-ESP block after induction and positioning, followed by the multimodal analgesia, while the control group received only the multimodal analgesia.

RESULTS

Both groups had identical demographic backgrounds and surgical profile. TOC for 24 hours following induction was significantly lower in the block group than the control group (105.0 ± 15.15 vs 158.00 ± 23.38mcg; p < .001). The total muscle relaxant consumption during surgery was also significantly less in the block group than the control group (51.90 ± 3.17 vs 57.70 ± 5.90; p < .001). The intra-operative blood loss was significantly less (p < .001) in the block group (303.00 ± 86.55 ml) than the control group (437.00 ± 116.85 ml). Compared to the block group, the control group's pain score (NRS) was significantly higher in the first 48 hours following surgery. The MOASS score was significantly lower in the control group (4.46 ± 0.50 vs 3.82 ± 0.82; p < .001) in the immediate postoperative period. The satisfaction score was significantly higher in the block group than the control group (9.52 ± 0.65 vs 8.22 ± 0.79; p < .001).

CONCLUSION

The employed US-ESP block for single-level lumbar fusion surgery is an effective component of multimodal analgesia for reducing blood loss, total opioid consumption, and related side effects with a significant reduction of postoperative pain and higher patient satisfaction.

Assessment of Effects on Prolonged Usage of Face Mask by ENT Professionals During Covid-19 Pandemic

The protection efficacy of face masks during this covid 19 pandemic has been well documented. The changes in human nasal functions after wearing facemask for prolonged period is not known. The aim of this study is to determine the effects of prolonged usage of facemask by ENT professionals during covid 19 pandemic. It is a cross sectional study conducted in department of ENT in Chettinad Hospital and Research Institute, Kelambakkam. A self-constructed questionnaire containing 21 queries regarding the effects of prolonged use of face mask, after being analysed by the experts of our institution were distributed to 124 ENT professionals all over India. People who are ENT by professionals can participate in this study. Participation is voluntary. Study period was from March 2020 to December 2020. All answered questionnaires were sent for statistical analysis. 63.71% experienced difficulty in breathing while wearing face mask, 37.10% experienced dry nose, 46.77% experienced dry mouth. The most common modality of prevention in an OPD setup was face mask with face shield (31.45%). About 80.65% people believed there are side effects due to wearing mask. Since facemasks are essential to protect us from COVID-19, certain strategies can be followed to reduce the discomfort due to its prolonged usage such as encouraging nasal breathing, taking short breaks from wearing mask in a safe environment and to maintain hydration.

Stability-indicating RP-UPLC Method for Determination of Vildagliptin in Drug Substance and Its Tablet Dosage Form

Aim: The foremost purpose of this research work is to diminish the analysis time and to establish cost effective method for estimation of Vildagliptin by RP-UPLC. Study Design: UPLC based Quantification studies. Place and Duration of Study: Department of Pharmacy, Bhagwant University, Ajmer, Rajasthan, Indiabetween June 2020 and August 2020. Methodology: A simple, responsive and precised RP-UPLC method with good robustness was developed and validated as per ICH for the analysis of Vildagliptin in drug substance and separation of degradants generated by different forced degradation conditions. Productive separation of Vildagliptin was attained by the use of Luna C18 column (100x2.6mm and 1.6µm) with a mobile phase composition of 0.1% v/v Trifluoroacetic acid and Acetonitrile in 80:20 v/v, which was pumped with 0.5 ml/min flow rate. The eluted substances were examined with PDA detector at 239nm. Stressed degradation studies were performed with proposed method to determine the percentage degradation of Vildagliptin. Results: The RT of Vildagliptin was observed at 1.56 min. The developed method was validated as per ICHQ2B and proved that the method was precise, sensitive, specific and accurate.The lowest concentration of limit of detection (0.05µg/ml) and limit of quantification(0.5µg/ml) of Vildagliptin make obvious about the sensitivity of the method. The correlation coefficient found to be 0.9997 for given range of linear concentrations. The calculated average percentage recoveries of Vildagliptin in spiked solutions were found to be in the range of 99.1-100.5. The calculated % RSD was determined to be less than 2. Determination of degradation of amount of Vildagliptin by forced degradation studies representing the stability indicating nature of the proposed method. Conclusion: The developed method said to be highly sensitive, accurate, specific and robust, therefore this method has high probability to adopt in pharmaceutical industry for regular analysis of Vildagliptin.

Cervical spine TB - Current concepts in management

OBJECTIVE

Cervical tubercular disease (CTB) is a rare pathology and constitutes 3-5% of all spinal TB. It includes atlantoaxial TB and sub-axial TB. As the literature evidence on this subject is scarce, majority of issues concerning CTB are still controversial. The current narrative review comprehensively discusses the various aspects related to CTB. Literature search: An elaborate search was made using keywords cervical tuberculosis, atlantoaxial tuberculosis, sub-axial tuberculosis, and cervico-thoracic tuberculosis, on pubmed and google (scholar.google.com) databases on 2 December 2020. We identified crucial questions regarding CTB and included relevant articles pertaining to them.

RESULTS

The initial search using keywords cervical tuberculosis, atlantoaxial tuberculosis, sub-axial tuberculosis, and cervico-thoracic tuberculosis yielded 4128, 76, 3 and 9 articles on 'pubmed' database, respectively. A similar search using the aforementioned keywords yielded 1,96,000, 2130, 117 and 728 articles on 'google scholar' database. The initial screening resulted in the identification of 178 articles. Full manuscripts were obtained for these articles and thoroughly scrutinised at the second stage. Review articles, randomised controlled trials and level 1 studies were given preference. Overall, 41 articles were included.

CONCLUSION

AATB and SACTB constitute 0.3 to 1% and 3% of spinal TB, respectively. The incidence of neuro-deficit in CTB is significantly more than other spinal TB. The general principles of management of CTB are similar to spinal TB elsewhere and medical therapy remains the cornerstone. Surgery is advocated in specific scenarios involving gross neuro-deficit, later stages of disease with significant bony/ligamentous disruptions, altered sagittal balance, drug resistance, and poor response to medications. The surgical approaches for AATB include anterior-alone, posterior-alone and combined approaches, although posterior access is the most preferred. Most of the studies on SACTB have supported the role of anterior approach. Additionally, posterior stabilisation may be necessary in specific scenarios. The overall long-term outcome in CTB is favourable.

An unusual case of gluteal pain - Case report and review of literature

Numerous pathologies of the spine, pelvis and hips can present with gluteal pain and pose a challenge to orthopaedic surgeons. We report a unique Case of tuberculous osteomyelitis of the ischium in a young immunocompetent individual presenting as gluteal pain. A high index of suspicion, early diagnosis and prompt management is mandatory to promote early and complete healing and prevent complications.

Intravenous bisphosphonate therapy does not delay fracture healing in inter-trochanteric femur fractures - A randomised controlled study

Hip fractures in elderly are commonly associated with osteoporosis and surgical outcome is influenced by its concurrent management. The purpose of our study is to determine the association between timing of bisphosphonate administration in inter-trochanteric (IT) fractures and fracture healing. Patients with IT fractures (aged≥50 years) and T-score ≤ -1.5 [WHO defines osteopenia as T-score between -1 and -2.5, and osteoporosis as T-score ≤ -2.5 on DEXA scan (which was obtained post-operatively in our cohort)], who underwent proximal femoral nailing were included. Patients were divided into three groups: group 1a-intravenous bisphosphonate {ivBP [zoledronic acid (ZA)]} given within one week, group 1b-ZA at six weeks and group 2-control group. Post-operative radiographs were assessed for reduction parameters [neck-shaft angle, tip-apex distance, reduction variance]. Radiological union was determined using RUSH score and functional outcome (at one year) with Modified Harris Hip Scores. 41 (23 males), 40 (15 males) and 42 (15 males) patients were included in groups 1a, 1b and 2, respectively (no statistical difference in sex distribution among the groups; p = 0.12). Mean age in groups 1a, 1b and 2 was 71.8 ± 8.1, 75.9 ± 8.5 and 72.3 ± 10.6 years (p = 0.09). There was no significant difference in the pattern of injuries (AO classification) among the groups (p = 0.72). Mean time to union in groups 1a, 1b and 2 was 13.7,13.7 and 14.2 weeks, respectively (p = 0.69). Mean time to union in AO types A1, A2 and A3 fractures was 13.2 ± 2.1, 13.7 ± 2.8 and 16.1 ± 4.9 weeks (p = 0.01). We did not observe any association between T-scores and fracture union (hip:p = 0.52, spine:p = 0.93).The functional outcome was similar among groups (p = 0.96). Early administration of ZA did not negatively influence fracture healing in patients undergoing fixation of IT fractures. Among the various other factors analyzed, there was a statistically significant association between the fracture type (AO type A3) and longer time to fracture union.

Macrodystrophia Lipomatosa of Thoracic Spine Causing Progressive Neurodeficit: A Case Report and Review of Literature

CASE

We report the first case of a 21-year-old male patient with macrodystrophia lipomatosa (MDL), with local gigantism involving the thoracic spine and progressively worsening neurodeficit. Imaging studies revealed fatty infiltration and hypertrophied intercostal nerves, dextroscoliosis, osseous hypertrophy between C4 and T2, and severe canal stenosis at the T4 to T5 level secondary to lamino-facetal hypertrophy. He underwent debulking of the lesion and posterior instrumented decompression in a staged manner. His neurodeficit improved postoperatively and was ambulant without support at the end of the 2-year follow-up.

CONCLUSION

Surgery in patients with MDL is technically challenging and fraught with complications such as neurological deficit and significant blood loss.

Subclinical infection can be an initiator of inflammaging leading to degenerative disk disease: evidence from host-defense response mechanisms

PURPOSE

There is considerable controversy on the role of genetics, mechanical and environmental factors, and, recently, on subclinical infection in triggering inflammaging leading to disk degeneration. The present study investigated sequential molecular events in the host, analyzing proteome level changes that will reveal triggering factors of inflammaging and degeneration.

METHODS

Ten MRI normal disks (ND) from braindead organ donors and 17 degenerated disks (DD) from surgery were subjected to in-gel-based label-free ESI-LC-MS/MS analysis. Bacterial-responsive host-defense response proteins/pathways leading to Inflammaging were identified and compared between ND and DD.

RESULTS

Out of the 263 well-established host-defense response proteins (HDRPs), 243 proteins were identified, and 64 abundantly expressed HDRPs were analyzed further. Among the 21 HDRPs common to both ND and DD, complement factor 3 (C3) and heparan sulfate proteoglycan 2 (HSPG2) were significantly upregulated, and lysozyme (LYZ), superoxide dismutase 3 (SOD3), phospholipase-A2 (PLA2G2A), and tissue inhibitor of metalloproteinases 3 (TIMP-3) were downregulated in DD. Forty-two specific HDRPs mainly, complement proteins, apolipoproteins, and antimicrobial proteins involved in the complement cascade, neutrophil degranulation, and oxidative-stress regulation pathways representing an ongoing host response to subclinical infection and uncontrolled inflammation were identified in DD. Protein-Protein interaction analysis revealed cross talk between most of the expressed HDRPs, adding evidence to bacterial presence and stimulation of these defense pathways.

CONCLUSIONS

The predominance of HDRPs involved in complement cascades, neutrophil degranulation, and oxidative-stress regulation indicated an ongoing infection mediated inflammatory process in DD. Our study has documented increasing evidence for bacteria's role in triggering the innate immune system leading to chronic inflammation and degenerative disk disease.

Ender's nailing of displaced tibia shaft fractures in children - A nine-year experience

BACKGROUND

Displaced fractures of the tibial shaft in children can be effectively treated with minimal complications with flexible nails. Our aim is to evaluate the outcome of displaced paediatric tibia shaft fractures treated with Ender's nails.

MATERIALS

We retrospectively reviewed the records of all unstable tibial fractures treated between 2010 and 2018, in our institution. Only children with a minimum of six months follow-up and complete clinical data were considered for the study.

RESULTS

Of the 72 patients who fulfilled the inclusion-exclusion criteria, 8 were lost for follow-up and hence we had 64 patients included for the study. There were 54 boys and 10 girls, with an average age of 10.9 years(4 to 17 years). The average follow-up was 16.9 months (6 to 47 months). There were nine open fractures. Two nails were used in 52(81.25%) patients while a single nail was used in 6(9.37%) patients and three nails were used in 6(9.37%) patients. The union rate was 100% with an average union time of 10.6 weeks. There were 17 (26.5%) patients with delayed union but none required intervention. One (1.56%) child had a malunion >10° (recurvatum of 11.9° and varus of 8.1°). Radiographs at the final review demonstrated >5° of coronal plane malalignment in eight patients (12.5%) and >5° sagittal plane malalignment (recurvatum) in six patients (9.37%). There was an associated fibular fracture in 50 children and there was no significant association between the presence of fibular fracture and malalignment (p>0.05). All children who presented for implant removal had full range of movement at the knee and ankle joint and no limb length discrepancy.

CONCLUSION

We report the largest series of paediatric tibial shaft fractures treated with Ender's nails. Ender's nail is a simple and cost-effective option for treating these fractures with excellent union rates and minimal complications.

The catastrophization effects of an MRI report on the patient and surgeon and the benefits of 'clinical reporting': results from an RCT and blinded trials

PURPOSE

Inappropriate use of MRI leads to increasing interventions and surgeries for low back pain (LBP). We probed the potential effects of a routine MRI report on the patient's perception of his spine and functional outcome of treatment. An alternate 'clinical reporting' was developed and tested for benefits on LBP perception.

METHODS

In Phase-I, 44 LBP patients were randomized to Group A who had a factual explanation of their MRI report or Group B, who were reassured that the MRI findings showed normal changes. The outcome was compared at 6 weeks by VAS, PSEQ-2, and SF-12. In Phase-II, clinical reporting was developed, avoiding potential catastrophizing terminologies. In Phase-III, 20 MRIs were reported by both routine and clinical methods. The effects of the two methods were tested on four categories of health care professionals (HCP) who read them blinded on their assessment of severity of disease, possible treatment required, and the probability of surgery.

RESULTS

Both groups were comparable initial by demographics and pain. After 6 weeks of treatment, Group A had a more negative perception of their spinal condition, increased catastrophization, decreased pain improvement, and poorer functional status(p = significant for all). The alternate method of clinical reporting had significant benefits in assessment of lesser severity of the disease, shift to lesser severity of intervention and surgery in three groups of HCPs.

CONCLUSION

Routine MRI reports produce a negative perception and poor functional outcomes in LBP. Focussed clinical reporting had significant benefits, which calls for the need for 'clinical reporting' rather than 'Image reporting'.

A Simple Modified Technique for In-Situ Screw Fixation in Slipped Capital Femoral Epiphysis

BACKGROUND

In-situ pinning has a definite role in the management of slipped capital femoral epiphysis (SCFE). We describe a modified technique for in-situ screw fixation on a regular radiolucent operating table which avoids certain complications innate with the existing techniques.

MATERIALS

Sixty consecutive hips which underwent either in-situ fixation for SCFE (28 hips) or prophylactic fixation of the contralateral hip (32 hips) by the modified technique were analysed. The femoral head was divided into three zones (A-central, B-middle, C-peripheral) of equal circles. The zone of the screw was noted in both AP and lateral views. The angle between the physeal line and the screw in AP(S_AP) and lateral (S_lat) view, and the distance from screw tip to articular surface in both views were measured.

RESULTS

In AP view, 55/60 (91.6%) screws were in zone-A, and five were in zone-B. In the lateral view, 56/60 (93.3%) screws were in zone-A, and four were in zone-B. There was no screw placed in zone-C in either of the views. The average deviation was < 15° in AP view and < 7° in lateral view from the ideal placement. The mean distance from the screw tip to the articular margin in AP was 5.15 mm and that in lateral was 6.15 mm. The interobserver agreement rate was found to be 0.8. No patient had intraoperative breakage of a drill bit or joint penetration, avascular necrosis, chondrolysis or screw-related complications at a minimum follow-up of one year.

CONCLUSION

In-situ pinning on the radiolucent table is safe and has distinct advantages. The modified technique of in-situ screw fixation adds to the safety and accuracy of the procedure.

LEVEL OF EVIDENCE

Level IV.

Displaced Femoral Neck Fracture in a Child Mimicking the Retinacular Flap Technique for Capital Realignment: A Case Report

CASE

Pediatric femoral neck fractures are rare injuries usually associated with high-energy trauma. We present a grossly displaced femoral neck fracture in a 7-year-old girl due to a high violence road traffic accident, in which the femoral neck had buttonholed medially into the adductors. The management and clinical and radiological outcomes are discussed with relevant literature.

CONCLUSION

This case is reported for its atypical presentation, in which the metaphysis of the proximal femur completely separated from the capital epiphysis and the greater trochanteric apophysis leaving the posterior periosteal flap intact mimicking the retinacular flap technique for capital realignment procedure.

Boxing Match Gone Awry- A Punch over the Head Leading to Eccentric Proptosis in a Child

The most common ocular pathologic conditions in amateur boxing are sub conjunctival haemorrhage, lid injuries, cataract, pupil deformation, angle abnormalities and retinal tear. Proptosis due to frontoethmoidal mucocele in young is one of the least common complications seen in boxers. Here, we discuss a rare case of unilateral eccentric proptosis of right eye in a child after he was punched over the right side of the head during a boxing match. He came with complaints of swelling of upper eyelid. Examination revealed right sided eccentric proptosis with restricted ocular movements and defective vision. Computed Tomography (CT) of orbit showed a well-defined isodense lesion with smooth margins arising from the frontal sinus, extending inferiorly to anterior ethmoidal sinus which caused mass effect over right eye and ocular muscles which resulted in displacement of the eye ball. Otolaryngologist’s opinion was obtained. Functional Endoscopic Sinus Surgery (FESS) was done. Postoperatively vision improved with no proptosis and eyeball returned to its normal position.

Timing of intervention for spinal injury in patients with polytrauma

OBJECTIVE

The optimal timing of surgical intervention of spinal fractures in patients with polytrauma is still controversial. In the setting of trauma to multiple organ systems, an inappropriately timed definitive spine surgery can lead to increased incidence of pulmonary complications, hemodynamic instability and potentially death, while delayed surgical stabilisation has its attendant problems of prolonged recumbency including deep vein thrombosis, organ-sp ecific infection and pressure sores.

METHODS

A narrative review focussed at the epidemiology, demographics and principles of surgery for spinal trauma in poly-traumatised patients was performed. Pubmed search (1995-2020) based on the keywords - polytrauma OR multiple trauma AND spine fracture AND timing, present in "All the fields" of the search tab, was performed. Among 48 articles retrieved, 23 articles specific to the management of spinal fracture in polytrauma patients were reviewed.

RESULTS

Spine trauma is noted in up to 30% of polytrauma patients. Unstable spinal fractures with or without spinal cord injury in polytrauma require surgical intervention and are treated based on the following principles - stabilizing the injured spine during resuscitation, acute management of life-and limb-threatening organ injuries, "damage control" internal stabilisation of unstable spinal injuries during the early acute phase and, definitive surgery at an appropriate window of opportunity. Early spine fracture fixation, especially in the setting of chest injury, reduces morbidity of pulmonary complications and duration of hospital stay.

CONCLUSION

Recognition and stabilisation of spinal fractures during resuscitation of polytrauma is important. Early posterior spinal fixation of unstable fractures, described as damage control spine surgery, is preferred while a delayed definitive 360° decompression is performed once the systemic milieu is optimal, if mandated for biomechanical and neurological indications.

Thyroglossal Duct Cyst with Multiple Tracts- A Case Report

A thyroglossal duct cyst is an embryological remnant which persists due to failure in the closure of thyroglossal duct. Worldwide the prevalence of thyroglossal cysts is about 7%. There is no sexual predominance seen. Normally at about 10th week of gestation the thyroglossal duct involutes, if there is any persistent duct remnant then this can lead to thyroglossal duct cyst formation. There is 1% chance of malignant transformation (papillary carcinoma). A 21-year-old female presented to the Ear, Nose and Throat Department with the complaint of swelling in front of the neck for the past one month. A 2×1.5 cm2 swelling was observed in the anterior aspect of neck-infrahyoid region extending till thyroid notch. The swelling moved upwards with protrusion of the tongue and deglutition. Ultrasound neck revealed a complex cystic lesion in midline of neck of size 2×1×2.2 cm3 suggestive of thyroglossal cyst. Fine Needle Aspiration Cytology (FNAC) showed features suggestive of thyroglossal duct cyst. Patient was prepared for Sistrunk procedure. Intraoperatively multiple tracts of thyroglossal duct cyst were seen and the same were removed in toto. Patient was on regular follow-up postoperatively for a period of one year and no evidence of any recurrence was seen.

Papillary Carcinoma of Thyroid in Thyroglossal Cyst- A Case Report

Thyroglossal duct cysts are most commonly occurring congentinal midline swellling of the neck. Usually carcinomas in thyroglossal duct cysts is extremely rare, commonly known as papillary carcinomas. However, the diagnosis is only made postoperatively after excision of the cyst. Although the Sistrunk procedure is often regarded as adequate but controversies exist, the need for thyroidectomy is based on histopathological findings. This is a case report of 43-year-old male presenting with swelling in the midline of the neck for one year. On examination, a cystic swelling was present in the midline of the anterior aspect of the neck. Ultrasonography (USG) neck revealed heteroechoic cystic lesion with solid component and microcalcifications present within the cyst suggestive of thyroglossal duct cyst probably neoplastic. The mass was surgically excised and sent for histopathological examination and reported as thyroglossal duct cyst with papillary carcinoma of thyroid. Appropriate history, clinical examination and investigation leads to the correct diagnosis and treatment. Incomplete removal of the mass leads to recurrence. Histopathological examination is a must postoperatively. The patient is still on follow-up and no recurrence have been noted.

Epley’s Maneuver versus Semont’s Maneuver in the Treatment of Posterior Semicircular Canal Benign Paroxysmal Positional Vertigo: A Cohort Study

Introduction: Benign Paroxysmal Positional Vertigo (BPPV) is the most common cause of vertigo in otorhinolaryngological practice. Canalolithiasis and cupulolithiasis are the main theories which describe the pathophysiology of BPPV. Particle repositioning maneuvers are non invasive, simple, bedside procedure that are better tolerated by patients and give symptomatic relief. Aim: To compare the effectiveness of Epley’s vs Semont’s maneuver in the treatment of Posterior Semicircular Canal (PSC) BPPV. Materials and Methods: A cohort study was conducted in Otorhinolaryngology Department of Chettinad Hospital and Research Institute from October 2020-March 2021. A total of 108 patients who reported to the outpatient department and were diagnosed with PSC BPPV were included in this study. A detailed clinical history was recorded audio vestibular examination was conducted and Dix-Hallpike maneuver were performed to confirm the diagnosis. Following which, patients were subjected to treatment with either Epley’s maneuver or Semont’s maneuver. A total of 54 patients were treated with Epley’s maneuver and 54 patients were treated with Semont’s maneuver. Patients were followed-up one week after performing the maneuver. In case of presence of persistent symptoms, the maneuver was repeated upto a maximum of three times. Successful treatment was assessed based upon the patient’s symptomatic improvement of vertigo and a negative Dix-Hallpike test which was performed at the follow-up. Data was presented in proportion (descriptive statistics) and chi-square test was used. The p-value <0.05 was considered as statistically significant. Results: In a total of 108 cases, the most common age group affected by BPPV was that of 21-40 years. Left side BPPV was noted in 50 (46.3%) patients, right side BPPV in 48 (44.4%) patients and 10 (9.3%) patients were found to have bilateral BPPV. Fifty two patients responded well for Epley’s maneuver and had complete resolution of symptoms on first follow-up and 46 patients responded to Semont’s maneuver and improved symptomatically. Conclusion: Greater number of patients improved symptomatically in the first visit itself with Epley’s maneuver compared to Semont’s maneuver. Hence, Epley’s maneuver is the preferred initial treatment and effective modality for PSC BPPV.

Recurrent Multinodular Pleomorphic Adenoma of Parotid Gland- A Case Report

Pleomorphic adenoma or benign salivary gland tumours predominantly affects the superficial lobe of parotid gland. It is a slow growing swelling with or without facial nerve involvement with female predilection in third and fifth decade of life. The origin of the tumour is both epithelial and connective tissue and hence it is of pleomorphic nature. After surgery, its recurrence rate varies considerably and seems to depend more on the surgical technique used. A 49-year-old male patient, presented with complaints of swelling in front of right ear and right parotid region for past eight years. He gave previous history of similar swelling in the right parotid region and history of previous surgery done elsewhere in 2009. Right superficial parotidectomy was done following which he was asymptomatic for two years. On examination of right parotid- a multilobulated irregular swelling was present in right parotid region and the swelling extended till the right ear lobule. The swelling hid previous surgical scar. Facial nerve was clinically intact. Fine Needle Aspiration Cytology (FNAC) was suggestive of Pleomorphic Adenoma. Magnetic Resonance Imaging (MRI) with contrast revealed that the lesions were arising from superficial lobe of the parotid gland. Right superficial parotidectomy was planned. Mass was excised and sent for histopathological examination and was reported to be Pleomorphic Adenoma. Patient is still on follow-up and no recurrence has been noted. The rate of recurrence depends on tumour spillage, intra-surgical rupture, or any histopathological feature. There is significant risk for local recurrence if the microscopic finger like formation (pseudopodia) of tumour tissue extends beyond the main mass.

Current updates in management of extremity injuries in polytrauma

Injury-related morbidity and mortality have been one of the most common causes of loss in productivity across all geographic distributions. It remains to be a global concern despite a continual improvement in regional and national safety policies. The establishment of trauma care systems and advancements in diagnostics and management have improved the overall survival of severely injured. A better understanding of the physiopathological and immunological responses to injury led to a significant shift in trauma care from "Early Total Care" to "Damage Control Orthopedics." While most of these algorithms were tailored to the philosophy of "life before limb," the impact of improper fracture management on disability and societal loss is increasingly being recognized. Recently, "Early Appropriate Care" of extremities has gained importance; however, its implementation is influenced by regional health care policies, available resources, and expertise and varies between low and high-income countries. A review of the literature was performed using PubMed, Embase, Web of Science, and Scopus databases on articles published from 1990 to 2020 using the Mesh terms "Polytrauma," "Multiple Trauma," and "Fractures." This review aims to consolidate on guidelines and available evidence in the management of extremity injuries in a polytraumatized patient to achieve better clinical outcomes of these severely injured.