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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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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INTRODUCTION: Managing and treating infected nonunion is one of the most challenging clinical scenarios despite numerous advances in the fixation methods, soft-tissue management, and antibiotic therapy. The infection of the fracture site causes internal fixation to become unstable and it slows down fracture healing. AIMS AND OBJECTIVES: To assess role of antibiotic-impregnated bone cement rod in control of bone infection and assessing its role in union in cases of infective nonunion of long bones. MATERIALS AND METHODS: This was a prospective study comprising of 30 cases of established infected nonunion of long bones carried out in a tertiary care center in Western Maharashtra. Patients of nonunion of long bone diaphysis with established clinical and laboratory evidence of infection were included in the study. RESULTS: Twenty-one cases showed complete union at 6 months or earlier. Two more cases showed significant callus formation. In three cases, there was no callus formation at fracture site till 6 months. DISCUSSION: Various authors in their studies confirmed that gentamicin and vancomycin are antibiotics which maintain activity even after being exposed to the high temperatures resulting from poly (methyl methacrylate) hardening. CONCLUSION: From our study, we confirm that the use of antibiotic-impregnated bone cement rod has a significant role in control of bone infection and also assists in union in cases of infective nonunion of long bones.

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BACKGROUND: Studies have shown that tranexamic acid reduces blood loss and transfusion need in patients undergoing total hip arthroplasty. However, till date, no study has been large enough to determine definitively whether the drug is safe and effective in total hip arthroplasty. We examined whether intravenous tranexamic acid, when compared with placebo, is safe and effective in total hip arthroplasty. MATERIALS AND METHODS: A prospective, randomized, double blinded study was conducted in a group of 142 patients undergoing total hip arthroplasty divided equally into tranexamic acid group and control group. Our protocol included administration of one dose of 15 mg/kg of TXA (given as infusion over 15 min ) in 100 ml NS just 15 min before incision and the subsequent 8 hourly in TXA group. In control group we have given 100 ml normal saline infusion just before operation and 100 ml NS infusion 8 hourly for 2 days postoperatively. Postoperative blood parameters were recorded. RESULTS: The total postoperative drain output and transfusion requirement was found to be lower in patients who received TXA (352-412 ml) as compared to control group (804-878 ml). We have observed 3 and 4 cases of DVT in TXA and control group respectively. Coagulation profile is least affected in both the groups. CONCLUSION: We conclude that tranexamic acid significantly reduces postoperative blood loss and transfusion requirements during total hip arthroplasty.

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BACKGROUND: Vitamin D deficiency has been implicated in the pathogenesis of autoimmune diseases. Reduced Vitamin D intake has been linked to increased susceptibility to the development of rheumatoid arthritis (RA). The objective was to evaluate 25-hydroxy (25-OH) Vitamin D status in patients with RA and to assess the relationship between Vitamin D level and RA disease activity. MATERIALS AND METHODS: The study consists of 50 RA patients as cases and 50 age- and body mass index matched healthy individuals as controls. All study participants (both controls and cases) underwent biochemical profile such as RA factor, serum uric acid (UA), calcium, phosphorous, alkaline phosphatase, and 25-OH Vitamin D levels. Disease activity was evaluated by calculating the 28-joint count as disease activity score. All the results were expressed as mean and standard deviation (SD). RESULTS: Mean and SD values of serum UA (mg/dl), calcium (mg/dl), and phosphorous levels (mg/dl) in RA cases are as follows 7.2 ± 1.3, 7.5 ± 0.5, and 6.9 ± 1.5, respectively. Serum UA, calcium, and phosphorous levels in RA cases were found to be elevated when compared to controls (P < 0.0001). Mean erythrocyte sedimentation rate was 58.4 ± 14.7 mm/h in the group of patients with RA. Levels of 25-OH Vitamin D were found to be negatively correlated to the DAS28, the correlation coefficient being r = −0.51 (P < 0.05). Levels of 25-OH Vitamin D were found to be positively correlated to serum calcium levels, the correlation coefficient being r = 0.82 (P < 0.01). CONCLUSION: RA patients had lower Vitamin D values than healthy controls. There was a negative correlation between serum Vitamin D and RA disease activity.

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AIMS: The aim of this prospective study was to evaluate the effectiveness of intramedullary nailing and fixation by locking plates in displaced midclavicular fracture and to compare the functional outcome of intramedullary nailing versus plating. MATERIALS AND METHODS: This prospective comparative study was conducted at the tertiary center between October 2013 and September 2015 after being approved by the local Ethical Committee. A total of 66 patients ranging between 18 and 60 years of age were included in this study. They were randomized into two groups to be treated either by an intramedullary nail or by locking plate. Clinical and radiological assessments were performed at the 3^rd week and 6^th week and 3^rd, 6^th, and 12^th month postoperatively. Outcomes and complications were compared to the 1-year follow-up in both groups. RESULTS: There was no significant difference found between two groups with regard to functional outcome after fracture union. Although lesser operative time, lower blood loss, less duration of hospital stay, easier implant removal, and better cosmetic appearance were noted in the nailing group. Constant shoulder scores were significantly higher in plating groups when compared to nailing group for the 1^st 12 weeks of follow-up. However, this difference becomes insignificant between the two groups after 6 months of follow-up. Infection and revision surgery rates were more in plating group, but this difference is not significant. CONCLUSIONS: Functional outcome and complications remain same in intramedullary nailing and plating group. However, intramedullary nailing is advantageous concerning faster healing, secure implant removal, and better cosmetically appeared scars.

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Winging of scapula is comprehensively known for the serratus anterior palsy and its dynamic presentation. However, on the contrary, pseudo winging may occur due to nonneuromuscular cause like osteochondroma. It is a rare case of pseudo winging of scapula due to osteochondroma in a pubescent girl. This article is for knowledge to share the experience of static scapula alata due to osteochondroma. It was managed by excision and confirmed by histopathological study. Patient relieved completely from her complaints.

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AIMS: The current orthopedic treatment of geriatric hip fracture is inadequate as per the British Orthopaedic Association guidelines and hence to know whether there is a need of orthogeriatric unit in the tertiary hospital setups in India for the management of hip fracture. METHODOLOGY: This is a retrospective cross-sectional study, held in tertiary care teaching hospital. The data of patients with age >60 years admitted with hip fracture of 2016–2017 were recorded from medical record section. Age, sex, type of fracture, total duration of admission, delay in surgery, and associated comorbidities were recorded. Patients who had undergone hip surgery electively for other hip or acetabular fracture were excluded from the study. OBSERVATION: There were a total of 81 cases of hip fracture, of which there were 39 males and 42 females. Seventy-one percent of patients were from the age group of 60–70 years. Maximum number of (54.3%), 44 Patients were having intertrochanteric fracture, followed by fracture of the neck of the femur (35 patients) and subtrochanteric fracture (7 patients). These patients were treated with bipolar hemiarthroplasty, total hip replacement, or with proximal femoral nail fixation or with dynamic hip screw fixation. Hypertension, diabetes mellitus, asthma, and hemiparesis were associated diseases. The maximum stay was 65 days, the minimum stay was 8 days, and the average stay was 13 days.The average delay between admission to surgery was 7 days, maximum of 24 days. We could not analyze the exact cause for delay due to lack of proper data in most of the cases. CONCLUSION (IMPACT OF STUDY): Hip fractures in the elderly in India are increasing and not getting the quality of care required. There is an urgent need to the implementation of orthogeriatric unit, and team approach is required to curtail the delay in treatment. This may lead to decrease in the cost of treatment, reduced postfracture morbidity, and mortality. Formation of hip fracture registry would also help us to analyze the present status of care for hip fractures in the elderly.

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Ralstonia pickettii remains a rare cause of periprosthetic joint infections, may therefore elude diagnosis, and causes a delay in optimal management. We describe our experience with a case of R. pickettii prosthetic knee joint infection to highlight key features in clinical presentation, isolation, identification, and optimal management.

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We report the case of a 66-year-old female who sustained a closed ankle fracture dislocation of her right ankle (Weber B; AO 44-B3.2). She underwent an open reduction with internal fixation, complicated with a small, superficial wound dehiscence during the initial follow-up. One month after surgery, she developed inflammatory signs on her right ankle, but disregarded them. One week later, she was admitted into the emergency department with infection of her ankle's osteosynthesis, and a necrotizing fasciitis of her left upper limb, neck, and thorax. The patient underwent multiple surgical interventions for the removal of osteosynthesis hardware, fasciotomies, consecutive debridements, and finally a below-the-knee amputation. Streptococcus pyogenes was identified in several cultures as the responsible agent, and directed antibiotic treatment was performed. However, despite all treatments, the patient's clinical status progressively worsened until she eventually deceased, 1 month after admission.

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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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