A study on vitamin D status among orthopaedic patients

Background: There is an alarmingly high prevalence of hypovitaminosis D in orthopaedic patients, regardless of whether or not, they require surgical intervention. Vitamin D plays an essential role in bone formation, maintenance, and remodelling, as well as muscle function and deficiency could affect adversely in multiple ways. Many reports recently demonstrated high rates of vitamin D deficiency, in numerous segments of Indian population, but there is no study reported so far from India, which focuses specifically on vitamin D status in orthopaedic patients.Methods: It is a descriptive study to estimate vitamin D levels in patients scheduled to undergo orthopaedic surgery. Vitamin D, calcium, phosphorus and alkaline phosphatase (ALP) levels in 310 patients, who were admitted at our institution, from December 2015 to August 2017 were measured.Results: Out of 310 patients included in our study, 189 (61%) were males and 121 (39%) females. Vitamin D deficiency (<20 ng/ml) was present in 232 patients, insufficiency (<30 ng/ml) was present in 63 patients and only 15 patients had desirable levels (>30 ng/ml). Patients younger than 60 years and males had more prevalence of Vitamin D abnormality. 168 (72.4%) of the patients, with deficiency presented in winter, compared to 64 (27.6%) in summer.Conclusions: Statistically significant vitamin D deficiency was seen during winter months, in patients undergoing hip hemiarthroplasty, and in patients admitted for degenerative disease of the spine, hip and knee. Screening and treating hypovitaminosis D appears to be important in orthopaedic patients as vitamin D deficiency is prevalent across all age groups in the population studied

Reconstruction of complex distal femur open fracture with distal femoral locking plate and primary autologous free fibular graft

Background: Distal femur fractures are high velocity injuries which accounts for 7-10% of all femoral fractures. These injuries are complex injuries which are difficult to manage. Despite advances in techniques and implants, treatment remains a challenge, in many situations.Methods: We present a retrospective review of 8 cases, involved in high velocity road traffic accident who presented to emergency department at St. John’s Medical College, Bangalore, Karnataka, India between September 2011 to December 2015, with complex open fracture of the distal femur with bone loss. All were managed with initial wound debridement and skeletal traction. Subsequently fractured femur was reconstructed with distal femoral locking plate stabilization, along with autogenous non vascularised fibular graft and cortical-cancellous graft bridging the bone defect. Radiological union, functional outcome measured with Tegner and Lyslom scores, KOOS score and complications were assessed.Results: At average 5 years follow up, all the fractures have united well, with good functional outcome. X-ray showing united fracture with incorporation of the fibular graft. According to Tegner and Lyslom scoring, 6 patients had good rating, 2 had satisfactory rating. Average KOOS score was 82.15. Shortening of 2 cm and 4 cm in couple of patients was the major complication. Conclusions: Delayed primary surgery, using autologous non vascularised free fibular graft in conjunction with a locking compression plate, with autogenous cortico-cancellous graft is an effective, less technically demanding and cost effective means of reconstruction option to manage bone defects in complex open fractures of the distal femur. An overall acceptable results in terms of fracture union, fibular incorporation, adequate restoration of knee motion and early rehabilitation can be expected

Functional outcome of antegrade interlocking intramedullary nailing for humeral shaft fractures

Background: Humeral shaft fractures which account for approximately 1-3% of all fractures and 20% of humeral fractures have potential to cause significant disability in the young which is often temporary and in the old often permanent disability. The use of locked intramedullary nailing for the treatment of humeral shaft fractures is gaining popularity because of its biomechanical and biological advantages.Methods: We present a descriptive retrospective review of 20 consecutive patients with acute humeral shaft fractures treated using an antegrade interlocking nail. Fracture union, functional outcome measured with Constant–Murley shoulder score and American shoulder and elbow surgeons (ASES) shoulder score and complications were assessed.Results: Patient age ranged from 20 to 74 years (average, 36 years) and average follow-up was 30.7 months (range, 12–48 months). There were 13 male patients and 7 female patients. Fracture of the middle third was most common accounting to 80% (16/20) of the fractures. Fracture union was achieved in 90% (18/20) of our cases. 2 patients had nonunion for which secondary surgeries were needed. According to Constant–Murley score, shoulder function was excellent in 70% (14/20) and good in 25% (5/20). Average ASES score was 93.3%. None of the patients had radial nerve palsy postoperatively. Conclusions: Gentle progressive reaming, correct entry point, minimal damage to rotator cuff, properly embedding the tip of the nail, good apposition of fracture fragments, static locking will help make antegrade intramedullary nailing, a dependable solution for the treatment of humeral shaft fractures and in achieving successful union with preserved/good shoulder and elbow function

Iatrogenic femoral nerve palsy after a routine knee ligament surgery

Peripheral nerve injuries following surgery can have a significant impact on the rehabilitation process. We report a case of a 25-year-old male who was unable to actively raise his leg and extend his knee following knee surgery (Arthroscopic Posterior cruciate ligament reconstruction and Posterolateral corner reconstruction). Following the surgery, it was noticed that the patient's knee range of movements and power was 0/5 as per the Medical Research Council (MRC) scale. On subsequent evaluation, it was found to be due to femoral nerve axonal neuropathy. We report such a case of femoral nerve axonal neuropathy following arthroscopic posterior cruciate ligament (PCL) reconstruction and posterolateral corner (PLC) reconstruction

Trans-osseous intraoperative limb length measurement in hip replacement surgery

Background: Discrepancy of the limb length following total hip replacement is one of common complication. To reduce the occurrence, various modalities are used like pre-operative templating, navigation assisted measurements and intraoperative methods. This study was done using trans-osseous method of measurement using hip gauge which provides a faster, simpler assessment of limb length.Methods: A prospective study of 25 patients who underwent uncemented hip arthroplasty was taken in the study and the LLD was measured before and after the surgical procedure. Patient were re-assessed for limb length discrepancy after 6 months with functional Harris hip score and radiological analysis on weight bearing standard X-ray antero-posterior view of the pelvis with bilateral hip joint.Results: The results showed significant improvement in limb length discrepancy, and analysis of postoperative radiographs found the mean length difference of 2.44 mm and average Harris hip score was 95.5. No device related complications were reported, and none of them complained of the discomfort related to limb-length discrepancy after surgery. Conclusions: Trans-osseous fixed method using hip gauge provides a faster, reproducible and simpler method for the assessment of Limb length and aids with offset placement, acetabular anteversion for precise cup placement. This is a reliable method as it can be used both in the primary and revision hip surgery and most importantly doesn’t require any additional intraoperative imaging

Arthroscopic management of neglected complex knee injury

Meyers and mckeevers type IV comminuted pattern of avulsion fracture of the anterior tibial eminence is not an uncommon injury, however its association with root avulsions of lateral and medial meniscus is very rare combination of injury and the management of the neglected case of this complex knee injury is challenging. A 43-year-old gentleman who came with a history of pain, recurrent instability, locking of his right knee for 2 weeks with restricted activity of daily living. He also had a road traffic accident 5 years ago. He was evaluated clinically, radiologically by X Rays and MRI Scan which revealed complete tear of anterior cruciate ligament (ACL) with loose fragments, root tear anterior horn lateral meniscus and posterior horn tear with posterior root avulsion of the medial meniscus. He was managed with arthroscopic removal of large loose body with other loose bony fragments, ACL Reconstruction with hamstring autograft, anterior root repair of lateral meniscus with pull out sutures, with all inside repair of posterior horn tear of medial meniscus using fast-fix 360 device (Smith and Nephew, Andover, MA). At 4 years follow-up the patient was analysed clinically, and the functional outcome was measured with international knee documentation committee (IKDC) and knee injury and osteoarthritis outcome score (KOOS) Scoring system which showed good outcome. Patient has returned to his pre-injury activity level with no limitation of his activity of daily living. There is no set protocol of managing these kinds of neglected complex knee injury. Sometimes you need to think out of the box. A thorough knowledge of anatomy and pathomechanics of knee combined with appropriate technique of repair to save the meniscus and reconstruction of ACL and rehabilitation can yield good result

Functional outcome following conservative management of acetabular fractures

Background: Acetabular fractures are complex injuries caused due to high velocity injury and constitutes about 18 % of Pelvic fractures. To obtain articular congruency and anatomical reduction is the gold standard in treating these fractures. In this study we have studied about the functional outcome in acetabular fractures managed conservatively with the long-term follow.Methods: A retrospective study with prospective analysis done between 2011-2020 involved 39 patients with acetabular fractures who were treated conservatively at St John’s Medical college Hospital. Patients were followed up at 6 months, 1 year, 2 years and at the end of 5 years for functional evaluation and assessment with the clinical outcome scores with Merle d’Aubigne and Postel score & Harris Hip Score.Results: Study included 39 patients with the average age of 41.3 years with 31 male and 8 female patients. Functional outcome score showed good to excellent results in 80%, fair to satisfactory results in 18%, 0.5 to 2% had poor result in the patient analyzed with both Merle d’Aubigne and Postel score and Harris Hip Score. 80 % of the patients were able to sit cross legged, 90% had returned to regular work and 10% of the patients changed their occupation to desk jobs.Conclusions: Conservative management of acetabular fractures gives a good long-term result following congruent reduction of the fracture, good early rehabilitation and gradual weight bearing. Return to activity of daily living was good even in congruently reduced acetabular dome fractures with good to excellent functional outcome scores

Ultra-High-Density Genetic Maps of <i>Jatropha curcas</i> × <i>Jatropha integerrima</i> and Anchoring <i>Jatropha curcas</i> Genome Assembly Scaffolds

Genetic maps facilitate an understanding of genome organization and the mapping of genes and QTLs for traits of interest. Our objective was to develop a high-density genetic map of Jatropha and anchoring scaffolds from genome assemblies. We developed two ultra-high-density genetic linkage maps of Jatropha curcas × Jatropha intergerrima using a backcross (BC1) population using SNP, AFLP and SSR markers. First, SNPs were identified through genotyping-by-sequencing (GBS). The polymorphic SNPs were mapped to 3267 Jat_r4.5 scaffolds and 484 Wu_JatCur_1.0 scaffolds, and then these genomic scaffolds were mapped/anchored to the genetic linkage groups along with the AFLP and SSR markers for each genome assembly separately. We successfully mapped 7284 polymorphic SNPs, and 54 AFLP and SSR markers on 11 linkage groups using the Jat_r4.5 genomic scaffolds, resulting in a genome length of 1088 cM and an average marker interval of 0.71 cM. We mapped 7698 polymorphic SNPs, and 99 AFLP and SSR markers on 11 linkage groups using the Wu_JatCur_1.0 genomic scaffolds, resulting in a genome length of 870 cM and an average marker interval of 1.67 cM. The mapped SNPs were annotated to various regions of the genome, including exon, intron and intergenic regions. We developed two ultra-high-density linkage maps anchoring a high number of genome scaffolds to linkage groups, which provide an important resource for the structural and functional genomics as well as for molecular breeding of Jatropha while also serving as a framework for assembling and ordering whole genome scaffolds

Pelvic bone anatomy vs implanted gold seed marker registration for image-guided intensity modulated radiotherapy for prostate carcinoma: Comparative analysis of inter-fraction motion and toxicities

Objectives: We compared the prostate motion variability and toxicities between patients treated with gold marker registration based IG-IMRT (IG-IMRT-M) and bony landmark registration based IG-IMRT (IG-IMRT-B). Methods: T1c-T3b (node negative), intermediate and high risk (non-metastatic) adenocarcinoma of prostate, age ≥18 years, Karnofsky Performance Status of ≥70 were included in this retrospective study. The prostate motion variability, acute and late radiation toxicities between the two treatment arms (IG-IMRT-M versus IG-IMRT-B) were compared. Results: Total of 35 patients (17 for IG-IMRT-M and 18 for IG-IMRT-B) were treated with a median radiotherapy dose of 76 Gray. The prostate variability observed with and without markers in millimeter was 4.1 ± 2.3 vs 3.7 ± 2.1 [Antero-Posterior (A-P); p = 0.001], 2.3 ± 1.5 vs 2.1 ± 1.2 [Superior-Inferior (S-I); p = 0.095] and 1.1 ± 1.7 vs 0.4 ± 1.4 [Left-Right (L-R); p = 0.003]. There was higher acute toxicity in IG-IMRT-B arm compared to IG-IMRT-M arm in terms of grade ≥2 diarrhea [50% vs 11% OR = 7.5 (1.3–42.7); p = 0.02] and grade ≥2 proctitis [38% vs 5.8%, OR = 10.1 (1.09–94.1); p = 0.04]. At a median follow up of 36 months, the late genitourinary toxicities grade ≥2 [27% vs 0%; p = 0.04] were higher in the IG-IMRT-B arm compared to IG-IMRT-M arm. Conclusions: IG-IMRT-M detects higher prostate motion variability as compared to IG-IMRT-B, inferring a significant prostate motion inside fixed pelvic bony cavity. The addition of marker based image guidance results in higher precision of prostate localization and lesser acute and late toxicities