Context: It has been well-established now that intravenous (IV) tranexamic acid (TXA) is a potent agent to control postoperative blood loss following total knee arthroplasty (TKA). Recently, intraarticular administration of this agent has also shown good efficacy for the same. Aims: Comparison of postoperative blood loss between IV and topical administration of TXA in TKAs. Materials and Design: Eighty-six TKAs on knees were included in this study. Randomization was done so that 40 TKA received 1 g of IV TXA, while 46 had intraarticular administration of 1 g TXA. Subjets and Methods: We compared the postoperative blood loss by calculating the difference in pre- and postop hemoglobin and need for blood transfusion. Functional assessment was done on basis of Western Ontario McMaster Osteo-Arthritis Index (WOMAC) scores and complications like postoperative infection, oozing from the wound site and thromboembolic manifestations. Results: Blood loss was significantly less in the intraarticular administration group as compared to the IV injection group. Total blood loss, blood transfusion group, and drain output was also less but the difference was not significant. The functional assessment (WOMAC) scores were equivocal and so were the complications including thromboembolic manifestations (two cases each of deep vein thrombosis (DVT) and no cases of pulmonary embolism (PE)). Conclusion: Intraarticular administration of TXA to prevent postoperative blood loss in TKA is a safe and effective alternative/adjunct to its IV administration.

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At one point or another in their lives, most people will experience some degree of shoulder pain. It may be secondary to a variety of underlying pathology. We report a case of shoulder pain caused by a granulocytic sarcoma (chloroma) in chronic myeloid leukemia (CML) patient misdiagnosed initially as synovitis. Although granulocytic sarcoma has many classic musculoskeletal manifestations, to our knowledge, a case of CML concurrent with chloroma of the shoulder joint has not been reported in the literature. We must not forget that the shoulder pain arising from granulocytic sarcoma may be the initial presenting feature of underlying hematological malignancy such as CML.

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INTRODUCTION: In the quest for better alternatives for open transforaminal lumbar interbody fusion (TLIF), minimally invasive surgery-TLIF (MIS-TLIF) has evolved, and feasibility studies of transforaminal endoscopic fusion are also getting reported in western literature. However, the cost of instrumented expandable cage may make it non-feasible for Indian setup whenever it will be commercially available. METHODS: This is a retrospective study of 13 patients of single-level percutaneous transforaminal endoscopic decompression and cageless percutaneous bone graft TLIF with percutaneous pedicle screw fixation under combined local with epidural anesthesia. The results of all patients as measured by validated tools of visual analogue score-Back and Leg, Oswestry Disability Index, patient satisfaction index, and fusion. The operating time, Estimated Blood Loss, Length of hospital stay and tolerance of patient for procedure was also scored. RESULTS: All the outcome measures were significant (P < 0.05) and fusion achieved in all with a mean follow-up period was 39 ± 6.36 months. Operating room time was 250.23 ± 52.90 min (187–327). Postoperative LOH hospital stay was 29.92 ± 4.94 h (24–39). The tolerance score was 2.30 ± 0.85 (1–3). One superficial bone graft site infection resolved with antibiotics. CONCLUSION: It not appealing to be recommendable to general population inspite of it being low cost and with negligible complications. Further research and engineered tools are needed to reduce the operating time.

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Objective: The purpose of this study was to correlate clinical, MRI, and arthroscopic findings in diagnosing ligament and meniscus tears in knee joint injuries. Materials and Methods: Our study included 20 patients in the age range of 11-60 years who were referred to radiology department for MRI of knee joint following injury to the knee. Prior to MRI, a detailed history, clinical, and local examination was done in all the subjects. MRI was carried out on 1.5 Tesla MR Machine and the standard protocol consisted of fat-suppressed PD (TE 45, TR 2800) in axial, sagittal, and coronal planes, T2W (TE 80, TR 4000) in sagittal plane and T1W (TE 11, TR 495) in sagittal plane. All the patients underwent arthroscopy by an orthopedic surgeon. Results: MR had 100% sensitivity and NPV of diagnosing ACL tears in this study. Clinical examination had sensitivity of 88% and NPV 75% in diagnosing ACL injuries. There was high NPV of MR examination (96%) in diagnosing meniscus tear while the PPV of MR examination was low (71%). These values were low in case of clinical examination. Conclusions: MRI is a useful non-invasive modality having high diagnostic accuracy, sensitivity, and negative predictive value making it a very reliable screening test for diagnosing internal derangements.

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Fat embolism syndrome (FES) is a life-threatening situation, which warrants greater emphasis than it receives in the literature. FE occurs following various medical and surgical conditions leading to a cascade of systemic inflammatory process affecting multiple organs of the body, which may lead to end-organ failure. It has high mortality and morbidity. Despite advancement in science and technology, diagnosis of this fatal syndrome is mainly based on clinical symptoms and signs and no major definitive diagnostic tool and treatment method is available. At present, treatment of this disastrous medical condition is only supportive. In this review, we summarize the incidence, etiology, pathophysiology, and management of FES.

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Spondylodiscitis is on rise due to increasing elderly population and immunocompromised people and now gets early detected due to early imaging. Percutaneous Transforaminal Endoscopic Discectomy and Drainage (PTELDD), is simple procedure that yields high culture wihich helps in specific targeted antimicrobial bombardment. Dr. Satishchandra Gore has been pioneer in introducing transforaminal endoscopy in India way back in 1999. His persistent efforts has made inroads into traditional spine care treatments and endoscopy bandwagon is flying high and many surgeons are able to give results with the technique all over India. The available english literature of transforaminal endoscopy in spondylodiscitis is reviewed here with technical note of this simplistic procedure. The reported outcome in literature is excellent in majority of cases. Authors unpublished report of 16 cases is also comparable with literature. PTELDD is a simplistic most minimalist minimally invasive procedure that gives very positive outcome in early cases of spondylodiscitis.

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Background: The wound management is a huge complex problem consuming billions of dollars. The standard treatment includes advance therapeutics with drugs (such as antibiotics), intense local dressings (such as negative pressure/antimicrobial) and multiple surgical interventions/reconstructions. Such intervention and modalities requires experts and large resources. Still the outcomes are unpredictable and associated with morbidities at donor (otherwise normal) sites. Materials and Methods: The "Sandeep's Technique's for Assisted Regeneration of Skin" (STARS) is therapy for complete healing of wounds with Autologous self activated Platelet Rich Plasma (PRP), imparted as local subcutaneous infiltrate in the wound margin, on every 4 ^th day, till complete repair takes place and local skin regenerates. The wounds are dressed daily/alternate day with only moist saline. It is a Pilot study of patients treated with STARS Therapy treated at Acharya Vinobha Bhave Rural Hospital, J.N.Medical College, Wardha, INDIA. The different types of wounds were acute wounds with exposed deep tissues such tendons and bones; compound fractures; infected wounds; necrotising post surgical flaps and chronic non healing ulcers including diabetic and pressure ulcers. Result: All the wounds healed aby PRP infiltration not requiring any further drugs, complex dressings and surgical reconstruction. Conclusion: It is safe, effective, efficient, and easily reproducible technique with predictable results for even complex wounds in which surgical reconstructions are not possible. This method of treatment is a huge step forward in preservation of resources and prevention of morbidity.

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Introduction: Rheumatoid arthritis (RA) affects 0.5-1% of population all over the world. As the duration of treatment is more in RA, patient's adherence to treatment is less. Controlling the number of patients lost to follow-up is essential for the successful completion of randomized clinical trials. Also, patient adherence is critical in clinical trial setting as it has impact on validity of clinical data and also it remains an issue of utmost importance to pharmaceutical manufacturers as well as scientific and regulatory community. The studies which show reasons for withdrawal from clinical trials are done for diseases like tuberculosis (TB). None of the study is available to find reasons for withdrawal from clinical trials in RA. Hence, this study is planned. Aims and Objectives: Find reasons and effect of age, sex, duration of therapy, and distance from home on withdrawal from clinical trial. Materials and Methods: This study is a retrospective observational data analysis. Primary outcome are to find reasons for withdrawal from trial. Results: Withdrawal from clinical trial in patients of RA is more in female. In this study, reasons for withdrawal from study are change in location, loss to follow-up, failure of therapy, concomitant illness, patient withdrew consent, and adverse effects is the common reason for withdrawal from clinical trial in both patient and investigator-related reason for withdrawal.

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Neurogenic fibrolipomatous hamartoma (FLH) is a benign lesion that can affect any of the peripheral nerves, causing significant enlargement. Though the pathology is a rare one, median nerve is the most common nerve in the body to be affected. The most common segment of the nerve to be affected is that around the wrist. We present a case of carpal tunnel syndrome caused by FLH of the median nerve associated with macrodactyly.

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A rare case of primary intraosseous meningioma of the calvarial bones presenting as solitary osteolytic lesion on the skull radiograph and correctly diagnosed pre-operatively on computed tomography (CT) and magnetic resonance imaging (MRI) by correlating the clinical and imaging findings is reported in this communication. The clinical, radiographic, CT and MR imaging features of the case and the difficulties in making a correct clinico –radiological diagnosis are highlighted in this communication.

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While operating on the hip joint, breaking of guide wire became a challenge for treating orthopedic surgeon. Here we report a simple method of removal, which requires limited resources and does not need sophisticated instrumentation. By using this method, we remove broken guide wire in a patient of sub-trochantric fracture of femur managed by close reduction and internal fixation by proximal femoral nail. During the removal of the guide wire, after placing distal screw in the neck the guide wire comes out with some difficulty in the final view on image intensifier - the guide wire broken and transfixes the hip joint but does not enter the pelvis. After removal of the distal screw, its cannulated drill bit was connected to a T-handle and introduced into the track of distal screw up to the broken distal end of guide wire and slow manual reaming done under C-arm image intensifier to prevent damage to the articular cartilage. This process was repeated three times after cleaning drill bit each time to clear the base of guide wire for grasping its distal end. With the help of Kerryson rounger/grasper, the distal end of the guide wire was grasped and easily removed. The distal screw was placed in its original track and the procedure was completed.

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We report a case of transient osteoporosis of the hip (TOH) in a 50-year-old man including the clinical presentation, diagnostic studies, management, and clinical progress. TOH is a rare self-limiting condition that typically affects middle-aged men or, less frequently, women in the third trimester of pregnancy. Affected individuals present clinically with acute hip pain, limping gait, and limited ranges of hip motion. TOH may begin spontaneously or after a minor trauma. Radiographs are typically unremarkable but magnetic resonance (MR) imaging studies yield findings consistent with bone marrow edema. TOH is referred to as regional migratory osteoporosis (RMO) if it travels to other joints or the contralateral hip. TOH often resembles osteonecrosis but the two conditions must be differentiated due to different prognoses and management approaches. The term TOH is often used interchangeably and synonymously with transient bone marrow edema (TBME).

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Cysts are very common lesions around the knee although they seldom cause complications. Peripheral neuropathy caused by these structures most commonly occurs by compression of the common peroneal nerve and its branches, at the level of the fibular neck. We report a case of a 44-year-old male admitted to the emergency department with complaints of right foot drop and numbness on the lateral side of the right leg caused by an extraneural synovial cyst compressing the peroneal nerve. Ultrasonography and magnetic resonance aided on the diagnosis. The cyst was removed surgically. Three months after the procedure, the patient was without complaints, with full motor and sensory function.

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Tarsal tunnel syndrome is generally a subacute condition that gradually develops and worsens with time. Urgent tarsal tunnel release to treat an acute onset of symptomatic neurocompression within the tarsal tunnel following a fracture repair has not been previously reported. We present a case of a pregnant woman who developed an acute tarsal tunnel syndrome following an open reduction internal fixation of an ankle fracture. The urgent release of the tarsal tunnel resulted in resolution of her symptoms.

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Diabetic muscle infarction is an underdiagnosed and underreported complication of long-standing diabetes mellitus occurring in a middle-aged person with symptoms simulating infective or inflammatory condition most commonly involving the thigh muscles, legs, and arms, in decreasing order of frequency. Magnetic resonance imaging is the diagnostic modality of choice showing diffuse hyperintense signal involving the muscles and deep fascia on T2 images. It is a self-limiting condition which resolves simply by rest and analgesic; therefore, being aware of this condition is necessary to avoid unnecessary interventions.

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BACKGROUND: India bears the highest burden of tuberculosis (TB), i.e., about one-fourth of the total burden. Of the musculoskeletal TB, spinal TB affects half of the patients. Pharmacological treatment in the form of AKT is the mainstay of treatment of spinal TB, but surgery has its own role to play as an adjunct to AKT in selected cases. Various surgical methods and approaches are mentioned in literature. We studied the efficacy and safety of posterior only approach for decompression and internal fixation in treating thoracic and lumbar spinal TB in adults. MATERIALS AND METHODS: In this prospective randomized control study, we treated twenty patients with thoracic-lumbar TB with single-stage posterior only debridement, decompression, and transpedicular screw fixation. Preoperative and postoperative C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), kyphosis angle, visual analog scale (VAS) score and Frankel neurological grading, intraoperative blood loss, and duration of surgery were compared. Correction in kyphosis angle and loss of kyphosis angle at final follow-up was assessed. RESULTS: Sixteen male and four female patients with mean age 37.9 years were treated. Average follow-up was 14.95 months. Thirteen patients had two level involved; seven had single level. The average duration of surgery was 155 min (standard deviation [SD] 23.951). Preoperative average increase in ESR was 39.4 mm/h (SD 9.046) and 24.15 mm/h (SD 3.787) at 3 weeks. Average preoperative CRP was 15.7 mg/L (SD 5.398) and 9.05 mg/L (SD 3.456) at 3 weeks. Average preoperative kyphosis angle was 24.7° (SD 6.822) corrected to an average of 10.1° (SD 3.932) postoperative. At final follow-up, there was a mean loss of 1.4° of kyphosis angle. The average blood loss was 722.75 ml; the average duration of surgery was 228.5 min. The pain VAS dropped significantly from 7.05 (SD 1.468) to 3.9 (SD 1.209). At final follow-up, VAS was 1.7 (SD 0.864). All the patients had good neurological recovery except one. CONCLUSIONS: Single-stage posterior-only procedure is safe and effective for management of thoracolumbar spinal TB.

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BACKGROUND: Transforaminal endoscopic discectomy has become popular due to its advantages over open discectomy. However, transforaminal endoscopic surgery may be difficult to perform at L5-S1 level in some cases due to anatomic variations such as high iliac crest. Endoscopic transiliac approach is an option for patients with high iliac crest or narrow foramen. The aim of this retrospective study was to describe the technique, analyse the results and complications. MATERIALS AND METHODS: 10 patients with variety of L5-S1 disc pathology who were treated with endoscopic transiliac surgery under local anaesthesia from June 2015 to December 2016 were included in the study. Clinical follow up was done at one month, three months, six months, one year. Outcome was assessed using modified Macnab's criteria. RESULTS: All patients had immediate relief from symptoms. Excellent outcome was noted in eight patients, Good outcome in one patient, and fair result in one patient. No patient had any complications. No patient required conversion to open or alternative procedure. Mean hospital stay was 1 day. CONCLUSIONS: Endoscopic transiliac approach is safe and effective in lumbosacral disc pathologies. Transiliac approach removes the limitations of transforaminal approach for L5-S1 disc space. Transiliac approach is the only versatile minimally invasive approach to lumbosacral junction which can tackle variety of clinical conditions.

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OBJECTIVE: The objective of the study is to generate reference values of bone mineral density (BMD) in north Indian population using phantomless quantitative computed tomography (QCT). MATERIALS AND METHODS: Bone mineral densities were generated from the computed tomography (CT) scans of 691 patients (390 males and 301 females, ages 11–85 years) who underwent CT of the abdomen or thorax for indications unrelated to bone diseases. The individuals were divided according to age groups from 11–15 to 80–85 years. BMD was calculated by phantomless QCT software by assessing L1 and L2 vertebrae. RESULTS: For females, the maximum BMD was observed for the age group of 21–25 years (144.67 mg/cc). The overall bone loss per year from 26 to 85 years was 1.62 mg/cc. Greater bone loss was seen from ages of 36–55 years which was 2.18 mg/cc. With bone loss per year being 0.99 mg/cc in ages from 26 to 35 years and 1.41 mg/cc from 56 to 85 years. Regression analysis gave a better fit using third order polynomial of age than did a linear regression line. For males, the maximum BMD was observed for the age group of 21–25 years (147.67 mg/cc). The overall bone loss per year from 26 to 85 years was 1.2 mg/cc. Regression analysis gave the best fit using linear regression. CONCLUSION: In the study population, the males show a linear relationship between age and BMD with continuous bone loss after the age of 25 years while females demonstrate a more complex relationship between age and BMD with accelerated bone loss in perimenopausal age group.

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Introduction: Sacroiliac screw placement is one standard treatment option for stabilization of posterior pelvic ring injuries encountering high intra- and inter-individual variations of bone stock quality as well as a vast variety and prevalence of sacral dysmorphism. An individual, easy-to-use preoperative bone stock quality estimation would be of high value for the surgeon. Materials and Methods: We analyzed 36 standard computed tomography datasets with the uninjured pelvic ring. Using a two-plane cross-referencing technique, we assessed the Hounsfield unit (HU) mean values as well as standard deviation and minimum/maximum values within selected region of interests (ROIs) at five key areas: os ilium left and right, massa lateralis of os sacrum left and right, and central vertebral body on levels S1 and S2. Results: Results showed no difference in mean HU at any ROI when comparing male and female data. For all ROIs set on S1 and S2, there was an age-related decline of HU with a calculated slope significantly different from zero. There was no statistical difference of slopes when comparing S1- and S2-level with respect to any distinct ROI. Comparison of levels S1 and S2 revealed differences at the vertebral body and at the right os ilium. The right and left massa lateralis of os sacrum had lower bone density than the center of the vertebral body, the right, or left os ilium on S1; right and left massa lateralis density did not differ significantly. On level S2, results were comparable with no difference of massa lateralis density. Conclusion: With our easy-to-use preoperative assessment of bone density of five key areas of sacroiliac screw anchoring we were able to find the lowest bone density in both the left and right massa lateralis on levels S1 and S2 with high inter- and intra-individual variations. Significantly lower bone density was found in the center of the vertebral bodies S2 in comparison to S1, which both are crucial for iliosacral screw placement. We thus recommend priority use of level S1 in screw placement and careful consideration of sole massa lateralis short-screw anchoring.

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Introduction: Intertrochanteric femur fracture incidence has increased due to increased life expectancy and osteoporosis. Management of these fractures in elderly is challenging due to difficult anatomical reduction, poor bone quality and osteoporosis. Internal fixation in these cases usually involves prolonged bed rest to prevent implant failure which leads higher complication such as deep vein thrombosis, pneumonia pulmonary embolism, bed sores, increased morbidity. Materials and Methods: We have done a prospective study in 18 cases of unstable intertrochanteric fracture where 12 (not associated hip arthritis) patients are operated by bipolar hemiarthroplasty and 6 (associated hip arthritis) patients operated by total hip arthroplasty (THA). Results: Patients were followed for an average of 12 months duration (9-15 months). Patients treated by bipolar hemiarthroplasty group (Group 1) have an average surgery duration of 95 min and blood loss of 315 ml. While patients treated with THA (Group 2) has average surgery duration of 152 min, blood loss of 565 ml. About 91% of 1 ^st group and 100% of 2 ^nd group has an excellent to fair outcome. Conclusion: Bipolar hemiarthroplasty for unstable intertrochanteric fracture femur without hip arthritis, and THA for intertrochanteric fracture with hip arthritis in elderly patient results in early ambulation and good functional outcome. However, as our study group is small, so further large randomized trail required before reaching conclusion.

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Background: Fracture of the distal end radius constitutes one of the most common skeletal injuries treated by the orthopedic surgeon. Wide arrays of techniques have been described including closed reduction, percutaneous fixation and open methods of reduction, and stabilization. Displaced extra- or intra-articular distal radius fractures require accurate reduction to allow a good outcome. We assessed the outcome of volar plate osteosynthesis and compared its outcome with other methods of treatment to confirm satisfactory reduction and functional outcomes. Materials and Methods: Prospective study conducted in our medical institution between 2012 and 2013. Inclusion criteria included skeletally mature patients who presented to casualty with fractures of the distal radius. Closed reduction cast application/K-wire fixation/open reduction and internal fixation with a volar plate was done under general anesthesia in 60 patients (20 cases each). During the follow-up, radiological and functional parameters were assessed and Gartland and Werley scoring was done. Results: Patients with volar plate fixation had a better outcome than the K-wire fixation and cast application. Radiological parameters were well-maintained, and functional parameters showed a significant improvement during the follow-up period. The complication rate was less and insignificant. 
Conclusion: Primary volar plate fixation of unstable distal radius fracture provides a stable construct that helps in early mobilization, thereby better functional outcomes and minimizes chances of delayed/malunion and, thereby is an upcoming method of choice for fracture distal end of radius. The present study comprised of 60 patients of distal radius fractures in 20 patients treated by plating, 20 by cast application and 20 by K-wire application. The minimum follow-up was 8 weeks, and the maximum was 36 weeks. This study was undertaken to assess the functional outcome of operative management of distal radial fractures and the following conclusions were drawn - male patients predominated female patients (36 males to 24 females) and average age of patients is 46.01 years. Left sided fractures were more common (61.6%). Road traffic accident was the commonest cause of the trauma (73.3%). AO 23 A-2 was the most common type of fracture, accounting for (26.6%) with Associated injuries seen in 4 patients (6.6%). Functional outcome as per Gartland and Werley was 3.75 for plating, 8.6 for cast application, and 7.55 for K-wire fixation. About 90% excellent to good results were observed in plating group as compared to 55% in cast and 65% in K-wire fixation in demerit score. Complication such as irregular articular surface, wrist pain, finger stiffness, K-wire loosening was observed. Thus, based on this study, we conclude that volar plating has relatively better outcome for distal end fractures of radius particularly volar Barton fractures, with minimum chance of loosening of implant even in highly comminuted cases and cases having osteoporosis.

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Management of unstable proximal humeral fractures has remained controversial since ages. Open reduction and internal fixation have resulted in devastating complications like stiffness of shoulder joint, avascular necrosis, infection, etc., We are presenting a novel method of percutaneous pinning of unstable proximal humeral fractures. All cases (32) were done closely without soft tissue stripping. All cases were followed-up for a period of 3 years; and results were assessed according to 100 point constant score. A total of 75% cases showed excellent to good results. To minimize the complications like pin site infection, loosening, neurovascular damage we used fixed pin site insertion technique, and threaded pins in osteoporotic patients. So percutaneous pinning is a safe and novel method of management of unstable proximal humeral fractures if certain principles are borne in mind before using it.

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Objective Unstable intertrochanteric fractures continue to be a challenge for orthopedic surgeons due to the functional limitations it results in the postoperative period. Anatomical reconstruction of the posteromedial fragment becomes difficult through conventional lateral approach, leading to excessive fracture collapse and limping. Materials and Methods: prospective, nonrandomized study was done with 40 patients. They were operated in prone position through posterior approach. Cancellous screws or SS-wires were used to fix the greater or lesser trochanteric fragments and dynamic hip screw (DHS) or dynamic condylar screw (DCS) for the main two fragments. Bone grafts were used to pack cavities at the posterior trochanteric regions. Results: Fracture healing occurred earlier compared to conventional lateral approach without excessive fracture collapse in majority of cases (average time to achieve union was 13.8 weeks; range: 10–18 weeks). Good functional recovery was noted with 75% 'Good' or 'Excellent' Harris Hip Scores at 24 weeks. Conclusion: Anatomical reconstruction of unstable trochanteric fractures becomes easier through posterior approach with earlier and better functional recovery.

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Bone regeneration, reparative and restorative techniques of bone length discrepancies, correction of posttraumatic and congenital defects and deformities can be induced mesenchymal stem cells (MSCs) which is taken from the bone marrow. In this review article, we aimed to have a look at MSCs for bone and tissue regeneration. MEDLINE ^® , Embase™, the Science Citation Index, and Google™ Scholar were used to look for relevant articles which published in English since January 2000. Studies on bone regeneration using MSCs in the field of clinical orthopedics were retrieved. The bone graft can create a self-reliant mechanism to induce bone cellular environment that adapts to the whole skeletal nature. There are several factors contributory to deciding which approach to take. These include the type of bone deformities, defects, the biological setting of the patient, the nature of the reparative process desired, and surgical or orthopedic possibility of conducting all these processes. All these factors and several others should be taken into consideration and careful medical consultation. Orthopedics along with osteology made much headway in restoring bone and tissue in uniquely medical approach that is MSCs through the autologous cancellous bone taken from the bone marrow.

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