Introduction: Magnetic resonance imaging (MRI) has become the choice of imaging modality for lumbar canal stenosis (LCS) due to limitations and radiation risks of computed tomography (CT) and spinal radiography. The radiological criteria for diagnosis of LCS are still ambiguous. Aim of this study is to find out the radiological dimensions on MRI of lumbar spinal canal in Indian patients and the critical dimensions at which the symptoms occur. Materials and Methods: A cross-sectional study was conducted in ESI Hospital, New Delhi from July 2011 to 2013. Two study groups were studied, the symptomatic LCS group, consisted of 30 individuals of either sex in age group of 45-65 years. The control group consisted of 30 asymptomatic age matched individuals. MRI scans were performed on 1.5 Tesla scanner. Dimensions of lumbar canal at all the levels (L1-L5) of lumbar vertebra of 60 patients were measured. Results: In our study, in symptomatic group, narrowest mid-sagittal diameter antero-posterior (mean 10.61) was at L5-S1 level. The interligamentous diameter (ILD) showed no significant difference between the two groups. Lateral recess depths showed a significant difference between the two groups at all levels except L1 on right side and L1 and L2 on left side. Critical canal dimension was found to be 11.13 mm. Conclusion: MRI can effectively evaluate the lumbar canal stenosis. The critical canal dimensions at which symptoms of stenosis appear were 11.13.

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Background: Open reduction of neglected dislocations of elbow often leads to less than optimal results. Extensive release during reduction and early mobilization may lead to instability. Post-surgical immobilization to recover the stability leads to loss of range of motion. Arafiles described a technique of creating a cruciate ligament like structure to provide stability while early mobilization is advocated. We have modified this technique in several aspects. We report a retrospective analysis of 26 such cases where we evaluated and compared the standard immobilization technique of K-wires with this new modified technique. Materials and Methods: Twenty-six consecutive cases of dislocated elbow with duration ranging from 4 to 56 months were included in this study. We performed standard open reduction and fixation with K-wire followed by immobilization for 3 weeks for the first 12 cases. In the next 14 cases after standard release and reduction we provided extra stability by adding a cruciate ligament like structure both on the medial and lateral side using autologous semitendinosus graft. Post-operative mobilization was advised the very next day. We evaluated the results of this technique and compared it with the previous one using MEPI scores, complication rate and radiological evaluation.Results: The average follow-up duration for the 26 patients is 4.5 years (2−7 years). All patients achieved full functional ROM in both planes. The mean increase in the MEPI score was significantly more for group II (53.5) than group I (36.6). Movement, activities and stability was better for this group II. Complication rates for both were similar.Conclusion: Providing stability at the time of operation with a mediolateral cruciate ligament provides the option of immediate mobilization post-operatively in open reduction of neglected dislocations of elbow. Thus, this technique provides excellent results disregarding the duration of dislocation with minimal morbidity for the patient.

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Injuries to pediatric athletes are becoming increasingly common as children compete in more physically demanding sports. These athletic injuries may be acute or as the result of chronic overuse. Acute trauma may lead to damage to tendons, ligaments, and muscles, as well as their bony attachment sites. Infections such as osteomyelitis must also be considered in the differential of pediatric patients presenting with hip or groin pain. This review will discuss the normal muscular attachments to hip physes and physeal equivalents, as well as common injuries and their management. These findings are important to help with the diagnosis and treatment of pediatric patients who present with hip pain.

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Clubfoot is the most common congenital deformity of lower limbs. Its etiology remains an enigma. The aim of the treatment is to obtain a plantigrate, painless and functional foot. Conservative treatment with Ponseti method of clubfoot is well-accepted and has been reported to result in good correction ranging from as low as 50% to as high as 90%. Surgical treatment is indicated only after failure of conservative methods, with limited release also known as " a la carte"release. This review looks at etiology, clinical assessment, scoring and provides an overview of operative and non-operative treatment options.

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The adductor longus has become recognized as one of the more commonly injured muscles in the medial compartment. Acute complete rupture injuries occurring at the proximal aspect of the muscle are less common. Limited data exist regarding management of the injuries in athletes required for return to play and functioning. The current data favors operative management; however, nonoperative treatment may be a viable option. Nonoperative management of avulsion injuries of the proximal adductor longus tendon may prove equal results to surgical repair in return to play and functioning. A semi-professional football player sustained a left groin injury while participating in the play. Due to continued pain, swelling, and suspicion of injury, a magnetic resonance imaging was performed diagnosing a complete tear of proximal adductor longus tendon. Physical examination, strength, and range of motion were recorded until the patient was able to function normally without strength deficit, the range of motion loss, and the return of speed. The player was treated nonoperatively and was eventually allowed to return to play. The time of return to play was 6 weeks. Strength deficit was not appreciated or loss of motion and player was able to return to baseline function. Nonoperative management of complete avulsion injuries of the proximal adductor longus tendon result in faster return to play than operative management even if significant retraction is present.

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Introduction: Stiffness following total knee replacement (TKR) is a debilitating complication. Manipulation under anesthesia (MUA), arthroscopy, and open arthrolysis are used to treat the stiffness. Objectives: The aim of the review was to answer the following questions. What is the gain in range of motion (ROM) after MUA for stiffness following TKR? Is the gain in ROM after MUA for stiffness following TKR retained at the last follow-up? What is the gender distribution amongst the patients presenting for MUA following TKR? What is the mean age of the patients presenting for MUA following TKR? What is the influence of timing of MUA following TKR on the ROM? The review was aimed towards establishing the current available evidence regarding MUA for stiffness. Materials and Methods: A systematic review of the current available literature was performed and the relevant studies were critically appraised. Results: Nine studies were identified to be relevant to the review (1-Level 2; 2-Level 3; 6-Level 4). It was found that there was a gain in the ROM after MUA and it was retained at the final follow-up. The patients presenting for MUA were younger and were predominantly females. Early MUA was found to be more effective, although late MUA was also beneficial. Conclusions: With limited and low quality of evidence, it is not possible to draw any conclusions.

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Ganglion cysts are found in locations which are under constant stress. Although somewhat controversial, one common explanation for the formation of ganglion cysts is that they are the result of mucoid cystic degeneration in collagenous structures. Most commonly, they are found along the tendons or joints of wrist or hand. The common locations of ganglion cysts are the wrist, knee, and anterolateral aspect of the ankle. Intra-articular ganglion cysts of the knee are rare, and most originate from the cruciate ligaments. The symptoms and signs of intra-articular ganglion cysts of the knee are pain, effusion, limitation of motion, and a clicking sensation. Increased size may lead to increased symptoms. Their location can sometimes interfere with joint movement. We present a case of ganglion cyst arising over medial collateral ligament which was presented as a swelling and investigated using sonography, magnetic resonance imaging and arthroscopy, surgically resected and confirmed on histopathology. Thus awareness of the symptoms and locations is necessary.

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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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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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A 48-year-old woman sustained simultaneous isolated bilateral greater trochanteric fracture, following a road traffic accident. The patient presented to us 1 month after the injury. She presented with complaints of pain in the left hip and inability to walk. Roentgenograms revealed displaced comminuted bilateral greater trochanter fractures. The fracture of the left greater trochanter was reduced and fixed internally using the tension band wiring technique. The greater trochanter fracture on the right side was asymptomatic and was managed conservatively. The patient regained full range of motion and use of her hips after a postoperative follow-up of 6 months. Isolated fractures of the greater trochanter are unusual injuries. Because of their relative rarity and the unsettled controversy regarding their etiology and pathogenesis, several methods of treatment have been advocated. Furthermore, the reports of this particular type of injury are not plentiful and the average textbook coverage afforded to this entity is limited. In our study we discuss the mechanism of injury and the various treatment options available.

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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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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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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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Total knee Arthroplasty is the most common and successful surgery world wide. Foundation of TKA is based on three pillars soft tissue balancing, bone cuts and cementing. All these factors are equally important and mistake at any level will lead to failure. We here would like to add the fourth pillar 'Joint line Restoration' for successful TKA.

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Isolated fracture of the trapezoid bone is due to axial loading on the outstretched palm and extended wrist, transmitted through the second metacarpal bone. Traumatic lesions of trapezoid bone are rare because of its well-protected position in the wrist and hence missed in the past. The modern diagnostic modalities have made its diagnosis more frequent. The ability of wrist to place the hand in 3-dimensional space is essential for normal daily function of the upper extremity. Some wrist injuries remain a diagnostic enigma, while others remain frustrating to treat either conservatively or with operative intervention. Isolated fractures of the trapezoid bone are rarely reported in the literature. We report a case of an isolated, non-displaced trapezoid bone fracture, which sustained injury by direct trauma and treated conservatively by a cast with return of normal functions.

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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: Idiopathic clubfoot surgery is known for a number of complications, that is, skin slough and wound dehiscence medially, infection and limitation of full correction at the time of surgery which leads to excessive scar hypertrophy, recurrence of deformity, and a poor functional outcome. Many procedures done in the past have reported complications ranging from 3 to 30%. We are doing surgical correction of congenital idiopathic clubfoot by two incisions avoiding dissection of the medial skin to overcome these problems and are reporting our results. Materials and Methods: We used two incisions (a medial and a posterior incision) in cases with moderate to severe congenital idiopathic clubfoot. These were those cases who did not want to continue with Ponseti's technique so as to avoid repeated follow-ups. Assessment of results was done by comparing preoperative and postoperative Pirani scores. Results: Our results were excellent in 7.9% (6 feet), good in 72.3% (55 feet), and fair in 15.8% (12 feet) cases. All of our cases had primary wound healing and no delayed scar related complication. Conclusions: Two incisions avoid stress on the medial skin. They permit release of all contracted structures posteromedially. We are describing this technique for its simplicity.

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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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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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Intraosseous ganglion is a benign bony cyst that mainly involves the epiphysis and metaphysis of long bones. Intraosseous ganglions are rare in talus, and in all the cases reported in literature, the patients had symptoms pertaining to the ankle joint. No case has been reported where the lesion in the talus has caused symptoms specific to the subtalar joint. A 20-year-old female presented to our hospital with pain in the right foot from last 6 months. Ankle joint movements were within normal limits, but the subtalar movement were significantly reduced. Plain radiographs of the foot and ankle were normal. Computed tomography (CT) scan of the foot and ankle showed a cystic lesion (0.5 × 0.5 cm) involving the base of the talar body which communicated with the subtalar joint. The patient was treated by curettage of the lesion through a curvilinear incision over the medial aspect of the subtalar joint. The clinical results after 3 months were excellent. The patient returned to her regular and light recreational activities with full, painless range of motion. There was no recurrence of symptoms at 6 months. Intraosseous ganglion is of talus is a rare entity. Symptomatic patient should be treated surgically.

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There are reports of spontaneous regression of large extruded disc; however, the exact underlying mechanism and management of such cases remains controversial. We report a 40-year-old female who opted for conservative management for a large extruded lumbar disc. Follow-up magnetic resonance imaging (MRI) showed complete disappearance of the disc fragment; however, there were degenerative changes in the upper and lower adjacent margins of the vertebral body. Spine surgeons should be aware of spontaneous regression of the disc phenomenon as a patient with a large extruded disc who opted for the conservative management initially can have persistence pain, but there may not be an underlying protruded disc.

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