Ashok Shyam

Mucormycosis is life threatening infection rarely affecting musculoskeletal system and spinal involvement is extremely rare with only two cases reported in English literature. We present this rare case of spondylodiscitis with lumbar vertebral osteomyelitis due to mucormycosis in a patient with chronic kidney disease on haemodialysis diagnosed by CT guided biopsy and highlight its clinico -radiological presentation and management principles. Thus, as the incidence of Mucorales infection increase due to increase in patients with predisposing factors, the unusual sites of affection increase. Treating clinician should have a high vigilance in patients with predisposing factors. Although there is dramatic improvement in the treatment modalities of mucormycosis, still the mortality is high. Early diagnosis is important to prevent dissemination and timely intervention in order to reduce morbidity and mortality. A well equipped multidisciplinary approach for clinico-radiological assessment...

Tendo-achillis tenotomy is required as last step of ponseti method of treatment of Congenital Talipes Equino Varus (CTEV). This technical note describes a simple method of doing a percutaneous tenotomy of tendo-achillis using a wide bore needle. This is a simple method and easy to learn and gives predictable results.

Editorial This is a digital world we live in. In last 20 years technology has changed the face of this world specially the way in which the data is shared and interaction is improved. This has accelerated things especially scientific inquiry and distribution of scientific concepts. In field of orthopaedics this has led to better implants and more literature. Increased numbers of journals and articles have led to increased awareness about the results of particular surgery and implant. Also it has improved the propagation of awareness about a new technique / implant and its results. In last century, a new technique would simply remain with a single surgeon or country for a long time [Ilizarov ring fixator for example], but now with advent of the online tools and websites, distribution of knowledge is simply amazing. One of the areas where technology can be successfully used is area of Training in surgical skills. We are currently having video websites like Vu-medi and many more videos on you tube etc, however I believe journals can play a very active part in this area. Surgical training of highest quality can reach each and every corner of the world simply by combining a format which will include text, pictures as well as videos. We all have basic surgical skill sets and to step up our training we would simply need to conceptualise and visualise different methods. This can easily be gained from the above format. Of course the learning curve for such training would be much longer and at times there will be unforeseen complications and difficulties. For this reason such articles should have a continued thread of comment and discussions which can be compiled over a period of time and better a list of frequently asked questions. This can provide answers to queries for a new trainee or even for an experienced surgeon. I believe the techniques should be open peer reviewed and not undergo a blinded peer review. The reviewers should be openly allowed to ask the surgeons questions and doubts that the reader will have. A post publication review of the technique is one of the most important part of this initiative where readers and peers can comment on the published technique. The goal of this entire exercise should be improvement of technique and to impart correct surgical principles to the trainees. Trauma International wants to pioneer in this area of surgical training by publishing and will be inviting

As Evident in earlier Editorials [1,2,3], we at JOCR are striving for a better understanding at Clinical Decision Making and better Patient Care. Human A deliberations and Single observations have been highlighted as important concepts in building a comprehensive paradigm for individual patient management [2,3]. A review of the quality and direction of current body of 'Selective' literature, which is highly biased towards Evidence Based Medicine (EBM), is needed. EBM has its own role and important place in literature but it might be suffering from a 'Central Control' phenomenon in terms of few 'Chosen' groups of experts who are dig the Evidence and instruct others on how to interpret and utilize 'Evidence'. Here I will like to introduce a concept from Cybernetics called 'Variety' which represents possible alternatives or possible bits of information. The concept of variety is embodied by Ashby's Law which is stated (and also applicable) in many forms. The most useful form for us is as stated by Steve Hickey and Hillary Roberts: " Ashby's Law stipulates that the minimum amount of information needed to give an accurate answer is exactly the amount needed to specify the problem " [4]. This is interpreted as; if the question has lot of variety the answer too will have same amount of variety. A complicated question will not have a simple answer. Management of a complex fracture in patient with multiple co-morbidites in a resourcefully challenged situation cannot be resolved by 'Cookbook' approach that EBM will like us to believe. Thus if we need an answer to a complex situation, more information will be needed and on a large scale 'Wisdom of Crowds' will be more effective than a controlled guideline. Every one of us holds a part of knowledge about management of these cases and when put together will be much more helpful than the group statistics of large clinical trials. Again as surgeons we need to predict the individual patient outcome and not what will be the outcome in group of such patients. Here if we have had a patient with similar profile, we can model the current patient according to him and apply it to subsequent similar group of patients. However can we get enough information from group statistics to treat Individual patients? This reverse is not found to be true [5] and thus all our Literature which is based on group studies has to be carefully reviewed and interpreted. Again the Best Evidence as defined by a 'central control' will go against the Ashby's law as a group of experts will surely have less variety than an entire profession and their patients. Representation of this individual variety in patient presentation and management is currently lacking in Literature and the main reason is the group statistical process of approximation and 'rounding off ' at all levels of information, practiced in current evidence based literature. We believe that this variety is extremely important in clinical decision making and should be provided a platform for presentation. We should be able to make informed decisions based on wisdom of the crowds and in principle should be able to publish and use all the available information. The concept of 'Wisdom of Crowds' has been introduced and detailed by James Surowiecki in his book 'The Wisdom of Crowds' and finds wide applicability in business world and is also a model for popular online portals like Wikipedia [Crowd Computing] [6]. EBM will definitely be a part of this Information network; not the most important part but just as important as other parts namely human deliberations, collective individual opinions, patient's perspective and socioeconomic aspects. I see no other way in which we will be ever able to build a comprehensive paradigm enabling us to make informed and practical decisions for our patients. Of course there will be a lot of 'Noise' which will be associated with this process but I believe most of us will be very able to detect 'Noise' from 'Value' unlike the same in EBM scenario where we find ourselves so prohibitively unable to sort out the 'Noise' from useful information. Another problem with this paradigm is that EBM is the only front that has been developed and given importance while others are criticized and looked upon negatively. It's high time that we should stop equating Level V

The anatomical and morphological differences and high-flexion daily activities in the Asian population have since ever prompted for development of customized knee replacement systems. INDUS knee system has advantages both of high-flex designs and is developed by keeping the anatomical variations of the native population in mind. The purpose of this study is to analyze the 2-year follow-up results using the INDUS prosthesis. Two hundred and ninety-seven knees in 276 patients were prospectively analyzed. There were 65 men (72 knees) and 211 (225 knees) women with a mean age of 64.56 years. Two hundred and forty-five knees had primary osteoarthritis, 48 knees had rheumatoid arthritis, and four knees had post-traumatic arthritis. Clinical parameters, including the Knee Society scores (knee score and function score), range of motion, post-operative anterior knee pain, and complications were recorded. Pre- and post-operative serial radiographs were analyzed for limb alignment, component positioning, and evidence of loosening. The patients were followed-up for an average of 2.59 years (range, 2-3.3 years). The mean knee score and the mean function score were significantly improved from a pre-operative value of 39.4 points and 46.7 points to a post-operative value of 87 points and 86 points, respectively (P value <0.05). Two hundred and thirty four knees had no anterior knee pain while 63 knees had mild to moderate pain, but none of the patients requested any intervention for the same. Of the 276 patients (297 knees), 79 knees had flexion above 140 degrees , 167 had a flexion range of 130-140 degrees , 27 had a flexion range of 100-130 degrees , and 24 knees had a flexion < 100 degrees , with the mean range of movement being 132.9 degrees . Improvements in the range of movement were retained over time and a total of 205 patients (224 knees, 75.7%) could squat or sit cross-legged at the final follow-up. The mean tibiofemoral angle was 8.5 degrees +/-6.9 degrees of varus pre-operatively and 5.4 degrees +/-2.2 degrees of valgus (3-7 degrees of valgus) at the final follow-up, with no loss of alignment noted in any case. One knee underwent revision for late infection while another knee had periprosthetic supracondylar fracture treated with plate fixation. Use of the INDUS knee prosthesis has a favorable short-term outcome, with a mean range of 135 degrees flexion and excellent knee scores.

Abstract Introduction: Compound distal tibia fractures have high incidence of nonunions and have varied presentation as far as status of fibula is concerned. If fibula is sufficiently healthy we can use it for bridging the nonunion of tibia. Case Report: We present a case of 20 year old female with compound and segmental tibia fracture. Primary stablisation by external fixation and later cast brace application achieved union at the proximal end of the segmental fragment with non union at the distal end. This was then treated with bridge grafting of fibula and screw fixation of fibula to the tibia. Five years follow shows good clinical and functional outcome without any complications. Conclusion: Its infrequent to find fibula spanning across the tibia nonunion, however when available this can be used as bridge graft to promote healing. Keywords: Fibula Bridge Grafting, Tibia Nonunion, bone grafting.

Medical and other scientific literature follow a peculiar repetitive pattern in their (r)evolution. They begin with an a concept (or a case) which forces us to think and deliberate on it. Be it the famous ‘Apple fall’ leading to proposal of gravity or unexpected growth of mould leading to discovery of Penicillin. Such happenings occur and define a turning point, which further ramify into organized studies and data accumulation. As argued by Thomas S Khun in his book “The Structure of Scientific Revolution” the ‘development-by-accumulation’ model of science is interrupted by episodic accelerations which are sparked by individual observations or thought process [1]. Such observations and deliberations (or anomalies) are, what we can define as the ‘Epitome of Case Reports’. Case reports in medicine are conventionally assumed to be something of rare occurrence of disease or medical observations. This definition needs to be expanded to include observations and deliberations that can pote...

Journal of Orthopaedic Case Reports (JOCR) has completed Its First Anniversary and this is the fifth issue of the Journal. In last one year we had a memorable journey and in coming one year we have planned incredible routes for JOCR. The idea of JOCR was proposed for the first time in late 2010. The scenario of Research in Orthopaedics was undergoing rapid change. Evidence based Medicine was been highlighted and the principles been spread and widely accepted. EBM movement had its effect on Orthopaedic Journals too, which started publishing less number of Case reports. In this backdrop when JOCR was proposed, it was not an idea which had many supporters. We were trying to create a journal which will publish Case Reports when all other journals are refusing to take them. Where will such a journal stand in EBM landscape? Where are the funds, who will sponsor, what is the need for the journal? And the greatest threat ‘What if we Fail?’ The Indian Orthopaedic Research group was in its in...

ABSTRACT Numerous factors contribute to success of a total knee replacement (TKR); including surgical instruments, operational methods, positioning of prosthesis, cementing techniques, surgical experience and limb alignment. Limb alignment of±30 has been rationally thought to be an acceptable alignment and clinical studies have to certain extent validated these assumptions. However these alignment boundaries still remain a hypothesis, as±30 is an arbitrary value; therefore need validation. In this work, the main objective was to analyze the pattern of relative stress distribution in TKR if the axial alignment is gradually increased or decreased including the range of±3°. This work shows an application of digital modeling of limbs and implants, where CAD has been applied to design and assembly of femur, tibia and knee implants. The analysis was carried out at different alignment positions in Ansys workbench 14.0. It was found that within±4° the rise in stress across the model surfaces is not much, however beyond±5° there is dramatic increase in pressure and pressure imbalance with every degree of change. This investigation will be useful for surgeons in TKR surgeries and possibly underlines the importance of use of computer assisted surgeries to obtain more accurate alignment and more ever to avoid the outliers outside±5° which might cause grater imbalance and early failure of implants.

Nous décrivons l'observation d'un homme de 27 ans originaire d'Asie du sud qui a consulté pour des masses juxta-articulaires volumineuses mais indolores aux deux coudes et à la hanche droite, accompagnées d'une neuropathie cubitale et de signes généraux. L'imagerie, les ...

Disinfectant and antibacterial properties of ozone are utilized in the treatment of nonhealing or ischemic wounds. We present here a case of 59 years old woman with compartment syndrome following surgical treatment of stress fracture of proximal tibia with extensively infected wound and exposed tibia to about 4/5 of its extent. The knee joint was also infected with active pus draining from a medial wound. At presentation the patient had already taken treatment for 15 days in the form of repeated wound debridements and parenteral antibiotics, which failed to heal the wound and she was advised amputation. Topical ozone therapy twice daily and ozone autohemotherapy once daily were given to the patient along with daily dressings and parenteral antibiotics. Within 5 days, the wound was healthy enough for spilt thickness skin graft to provide biological dressing to the exposed tibia bone. Topical ozone therapy was continued for further 5 days till the knee wound healed. On the 15(th) day, implant removal, intramedullary nailing, and latissimus dorsi pedicle flap were performed. Both the bone and the soft tissue healed without further complications and at 20 months follow-up, the patient was walking independently with minimal disability.

Thromboangiitis obliterans (TAO), also known as Buerger disease, is characterized by thrombosis in medium-sized arteries and veins along with a marked inflammatory response. TAO can be managed by using the principle of distraction osteogenesis to induce neoangiogenesis. We report thirty patients of TAO in the age-group of 20-50 years were treated with the Ilizarov method. Patients with severe rest pain (n=30), absent distal pulsation (n=30) and ulcer (n=6) and/or gangrene of the toes (n=4), who had failed the conservative pharmacological modalities of treatment were included. A lateral tibial corticotomy was performed and distraction applied by use of olive wire. A two-ring frame was used for all cases. Of the 30 cases, 25 patients became pain free while 1 had partial relief of pain. The four patients worsened on treatment and developed frank infection were amputed. The average distraction was 1.8±0.3 mm (range: 1.5-2.2 cm). The mean consolidation period was 98±11 days, after which the fixator was removed. The total duration of treatment was 122±23 days. There were two cases of osteomyelitis in our series; both healed after debridement and both patients had good result, with relief of pain. The ulcers started healing by 4-6 weeks. The principle of the distraction osteogenesis including neoangiogenesis can be used for treatment of TAO and has an acceptable complication rate.

Sixty feet in 38 patients, 22 with bilateral and 16 with unilateral clubfeet in children less than two years of age and without any prior manipulation or surgical treatment were randomly allocated to the Ponseti (30 feet) and Kite (30 feet) methods of manipulation. This process resulted ...

Brachial plexus injury leading to flail upper limb is one of the most disabling injuries. Neglect of the injury and delay in surgeries may preclude reinnervation of the paralysed muscles. Currently for such injuries nerve transfers are the preferred procedures. We here present a series of 93 cases of global brachial plexus palsy treated with nerve transfers. Ninety-three cases of global palsies out of 384 cases of brachial plexus injury operated by the senior surgeon (AB) were selected. Age varied from 4 to 51 years with 63 patients in 20 to 40 age group and all patients having a minimum follow up of at least 1 year post surgery ranging up to 130 months. The delay before surgery ranged from 15 days to 16 months (mean 3.2 months). The aim of the surgery was to restore the elbow flexion, shoulder abduction, triceps function and wrist and finger flexion in that order of priority. The major nerve transfers used were spinal accessory to suprascapular nerve, intercostal to musculocutaneous nerve and pectoral nerves, contralateral C7 to median and radial nerves. Nerve stumps were used whenever available (30 patients). Recovery of ≥ grade 3 power was noted in biceps in 73% (68/93) of patients, shoulder abduction in 89% (43/49), pectoralis major in 100% (8/8). Recovery of grade 2 triceps power was seen in 80% (12/16) patients with nerve transfer to radial nerve. Derotation osteotomies of humerus (n=13) and wrist fusion (n=14) were the most common secondary procedures performed to facilitate alignment and movements of the affected limb. Better results were noted in 59 cases where direct nerve transfers were done (without nerve graft). Acceptable function (restoration of biceps power ≥3) can be obtained in more than two thirds (73%) of these global brachial plexus injuries by using the principles of early exploration and nerve transfer with rehabilitation.

Measurement of maximum inspiratory pressure is the most prevalent method used in clinical practice to assess the strength of the inspiratory muscles. Although there are many devices available for the assessment of inspiratory muscle strength, there is a dearth of literature describing the reliability of devices that can be used in clinical patient assessment. The capsule-sensing pressure gauge (CSPG-V) is a new tool that measures the strength of inspiratory muscles; it is easy to use, noninvasive, inexpensive and lightweight. To test the intra- and inter-rater reliability of a CSPG-V device in healthy adults. A cross-sectional study involving 80 adult subjects with a mean (± SD) age of 22±3 years was performed. Using simple randomization, 40 individuals (20 male, 20 female) were used for intrarater and 40 (20 male, 20 female) were used for inter-rater reliability testing of the CSPG-V device. The subjects performed three inspiratory efforts, which were sustained for at least 3 s; th...

Background: Respiratory muscles like all other skeletal muscles improve their function in response to training. The principles of progressive overload and specificity of training apply to respiratory muscles also. Inspite so many studies on effect of RMT (respiratory muscle training) on athletes and other respiratory conditions, there is lack of literature on RMT in healthy individuals. Methods: 50 subjects were divided in 2 groups (25 each): training and control group. The training group was given 4-week inspiratory muscle training program while the control group did not participate in any form of training. IMT was given with an elastic resistant band tied around the thorax at the xiphisternal level. 30 breaths twice a day, 6 days a week for 4 weeks was given. Outcome measures: shuttle run test (SRT) and estimated . Conclusion: Specific inspiratory muscle training shows significant improvement in aerobic capacity. Keywords: Inspiratory muscle training, aerobic capacity. Thesis Ques...

Purpose of Study: Physiotherapy plays a major role in rehabilitating a patient. The role of a Physiotherapist is to deal with application of physiotherapy skills & knowledge to the assessment, design, delivery & evaluation of physiotherapeutic treatments in the management of the various conditions of acute or chronic sickness, disability or handicap. The history of physiotherapy, in India, was laid back in 1952 following an epidemic of poliomyelitis. Slowly and steadily physiotherapy did establish a firm base in India with lot of new developments, but still by large, physiotherapy remains a secondary referral profession not only in our country, but in other countries too. Further development of physiotherapy would be dependent on the awareness of referring physicians. It has been seen in the literature that there is a lack of awareness among the general practitioners and physician students. Hence this study was conducted to look at the Physicians (Doctors) Perspective as to how much...

Background: Core stability of trunk is a basic function of both the local and global muscles. But there is insufficient research based data to determine the cause or ascertain how low back pain might be related to any of the particular features of pregnancy especially the core muscle strength. Objective: To study correlation between low back pain and core muscle strength amongst the pregnant females. Materials and Methods: 148 primigravida females (mean age 21.36 ± 1.54) in their 2nd trimester with complaints of backache were given VAS and Roland Morris Questionnaire to fill in. The core strength was assessed using pressure biofeedback unit while performing ‘drawing in’ maneuver in supine crook lying. Results: Study showed negative correlation between core muscle strength and intensity of low back pain [r = - 0.489, p < 0.05] and negative correlation between core muscle strength and disability related to low back pain [r = - 0.536, p < 0.05] Conclusion: Core muscle strength is...

Background: Treatment of the anterior acetabular fractures is known to have worse results than other fracture types. The operative results of the anterior acetabular fracture, however, have not been well documented and the literature concerning them is sparse. To determine the results of operative treatment for anterior column acetabular fractures, we did a prospective cohort study of 17 cases of anterior column fractures. Methods: A total of 17 patients had anterior column fractures, with an average follow-up period of 24 months; 1 anterior wall, 3 anterior column, 8 anterior fracture with posterior hemitransverse and 5 anterior wall with anterior column fractures. There were 15 men and 2 women, with a mean age of 36.6 years. The surgical approaches used were ilioinguinal approach used in 14 cases and extended iliofemoral approach used in 3 patients with delayed presentation. Postoperative radiographic results were evaluated by Matta’s criteria. Final clinical results were evaluate...

Background: The main purpose of this study was to assess the results of surgical treatment of severe and stiff adolescent idiopathic scoliosis with combined anterior-posterior approach in terms of correction of deformity radiologically in coronal and sagittal plane, clinically with SRS scoring and associated complications.Materials and methods: A prospective study of clinical and radiological outcome of 32 patients with adolescent idiopathic scoliosis, treated surgically during February 2006 to June 2008 with combined approach (anterior release and posterior instrumentation) was performed. Preoperative evaluation in the form of plain anterior, posterior and lateral bending films and MRI spine to rule out any congenital anomaly were performed. All of these patients had Cobb’s angle > 60 with average being 73°± 13.4º and stiff scoliosis. Single stage surgery was performed in all these patients with anterior release, deformity correction and posterior instrumentation in form of eith...

To evaluate the correlation of kyphosis and wedge angles with pain relief and functional outcome after percutaneous vertebroplasty (PV). 15 men and 19 women aged 41 to 85 (mean, 62) years who presented with osteoporotic wedge compression fractures of the dorsolumbar spine below T5 and had failed conservative treatment were included. Patients were assessed before and one year after PV. Kyphosis and wedge angles were measured on standardised radiographs. Pain and function were assessed using the visual analogue scale (VAS) score and the Ronald Morris Disability Questionnaire (RMDQ) score, respectively. Patients were dichotomised based on their preoperative kyphosis (≤ 10 vs. >10 degrees) and wedge angles (≤ 7 vs. >7 degrees). Outcomes were classified as excellent, fair, and poor in terms of VAS scores (<3, 3-6, >6) and RMDQ scores (<8, 8-16, >16). Correlations between the kyphosis and wedge angles and VAS and RMDQ scores were assessed. VAS and RMDQ scores correlated ...

We studied the callus pattern seen in femoral lengthening using monolateral external fixator to determine whether callus types and shapes can predict the final outcome of the procedure. The radiographs of 41 cases of femoral lengthening (33 unilateral and 8 bilateral) in 33 patients with a mean age 11.9 years (range 4-22 years) were retrospectively analysed by four observers and classified into different shapes and types in concordance with the Ru Li classification. The classification was tested for concurrence and reproducibility by inter-observer studies. An average of 6.2 cm of lengthening (range 3-10.8) was achieved with an external fixator index of 36.5 (range 20.9-55.3). The fusiform type of callus (fixator index 32.04, maturation index 21.6) showed the best result followed by the cylinder type of callus (fixator index 35.7, maturation index 22.3) and the lateral type of callus (fixator index 33.2, maturation index 21.5). However, the concave type of callus showed poor results...

Stretching has its impact on both contractile and noncontractile tissues and is the most important rehabilitation technique utilised used to prevent and treat joint stiffness. Passive manual stretch (PMS) and muscle energy technique (MET) are two of the most commonly used techniques. Our study evaluates the effectiveness of isolytic form of MET in gaining knee range of motion (ROM) and