Background: The tibial diaphysis is the most common site of fracture in the tibia and approximately 80% of these fractures have associated fibular fractures. Expert Tibia Nail System (ETNS) system provides extra stability in comparison to conventional intramedullary tibial nail due to multiaxial locking system. Objective: The aim of this study was to evaluate the midterm functional outcome of distal tibial fractures using the ETN. Materials and Methods: This prospective study was conducted from June 2016 to August 2019 comprising a total of 30 cases who were treated by Expert tibial nail fixation for distal tibial fractures. Clinical evaluation was done at each follow-up and final evaluation was done at 9 months postoperatively. The evaluation method at 9 months follow-up was the clinical examination and radiographic imaging. Results: Of 30 patients, majority were men. Male-to-female ratio was 3:1 with 22 men (73.33%) and 8 women (26.66%). The mean age of patients was 32 years with a range from 20 to 60 years. Left limb was involved more 16 (53.33%) frequently than right 14 (46.66%). Majority of the patients had trauma due to road traffic accidents (46.66%), fall from height/stairs (26.66%), twisting injuries (23.33%), and sports injuries (3.33%). There were 1 patient with superficial infection which resolved with wound care and antibiotics, 2 with anterior knee pain, 1 with malunion, 1 with delayed union, and 1 patient with nonunion. According to Johner and Wruh’s criteria, excellent results were achieved in 20 patients, good in 5 patients, fair in 4 patients, and poor in 1 patient. Conclusions: Expert tibial nailing is a new and innovative procedure for distal tibial fractures. It is safe and effective with the added advantage of providing additional stability and preventing rotational malalignment for distal third tibial fractures in comparison to conventional nailing. Further studies need to be conducted to validate the advantages of this procedure over conventional nailing.

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We are talking about evidence-based medicine (EBM) for decades. Now each and every field of medicine has adapted evidence-based practices and the same is true for orthopedics also. There are thousands of reasons to support an evidence-based approach in the teaching and practice of orthopedics but hurdles and challenges are also there. So it’s time to revisit the challenges of EBM in orthopedic teaching and practice.

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Coronavirus disease-2019 (COVID-19) pandemic has changed the seen in each and every field of the globe and is true for orthopedic clinics as well. As the second surge of COVID-19 pandemic is fading away, number of patients in orthopedic clinics of hospitals, nursing homes, and even private chambers is increasing day by day. Very soon we will see a sudden surge of patients in orthopedic OPD (outpatient department) as the cold cases have been differed for the last one and half years. Visiting/handling the increasing number of patients in the same space of consulting and waiting area will be a challenge and it is quite possible that we may commit a mistake by compromising the protective guidelines, as we did during the beginning of this year. However, the first surge was fading away, which resulted into the entry of second surge of COVID pandemic. Therefore, it is time to revisit the situation in terms of safety measures while attending the patients in orthopedic clinic.

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Background: The craniovertebral junction (CVJ) is mainly affected by various bony developmental anomalies. Other causes of compression include trauma, tumors, atlantoaxial instability, and infection (tubercular/pyogenic). We have surgically treated 38 patients of CVJ utilizing different procedures over a span of 4 years and done retrospective study. The purpose of this paper is to analyze the outcome of surgeries around CVJ. Materials and Methods: In our institution, from September 2015 to August 2019, 38 patients underwent surgeries by different methods around CVJ and a retrospective analysis was done. Clinico-radiological evaluation was done to assess the results. The neurologic recovery rate was calculated by Japanese Orthopaedic Association (JOA) score. Results: There were 31 male and 7 female patients in our study with a mean age of 49.8 years (2–86 years). Three (3) anterior surgeries, one (1) combined anterior-posterior 360º fusion, and 34 posterior surgeries including 22 atlantoaxial fixations were done. Average JOA pre-op was 11.6 (range 4–16), at last follow-up average JOA is 14.1 (range 6–16). Radiologically, fusion was achieved in all except two cases. Conclusion: We conclude that CVJ procedures are safe and effective, posterior-only surgery gives promising results with high fusion rate and neurological improvement in most of the patients.

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Background: Forensic anthropology plays a key role in sexual dimorphism. It is possible to establish a profile and identification of the sex of an individual from the available parts of the skeleton. Several bones present dimorphism and have been studied to increase the approach for forensic identification. Objective: We morphometrically evaluated the human scapula and compared the measurements between scapula bone in cadavers of both sex to derive a logistical regression formula for sex determination of the south Indian population. Materials and Methods: Eighty adult scapulae were used in the study. Scapulae were measured in millimeters for 11 parameters with the help of the sliding caliper. Results: The most common shape of glenoid cavity recorded in this study in men and women was pear shape (54.92% and 51.02%) followed by inverted comma shape (31. 49% and 33.73%). The least common shape was oval (13.57% and 15.28). The mean (standard deviation [SD]) of parameters studies in men vs. women: MSH––143.3 ± 10.23 vs. 138.2 ± 11.89 mm; the MSB––105.3 ± 12.45 vs. 93.5 ± 9.23 mm; SpW––120.0 ± 0.81 vs. 104.0 ± 0.95 mm; ACW––87.0 ± 0.58 vs. 80.0 ± 0.53 mm; L2––44.7 ± 0.46 vs. 35.3 ± 0.39 mm; L4–50.5 ± 8.6 vs. 45.3 ± 9.51; L6–60.1 ± 7.71 vs. 56.8 ± 8.55 mm; SI glenoid diameter––37.63 ± 7.58 vs. 35.5 ± 4.75 mm; the anteroposterior glenoid diameter 1––24.50 ± 5.86 vs. 22.5 ± 6.93 mm and the anteroposterior glenoid diameter 2––16.30 ± 2.16 vs. 13.57 ± 5.58 mm; and mean glenoid cavity index was 65.10 ± 8.67% vs. 63.4 ± 9.23%. All parameters measured showed statistically significant values (P < 0.05) for the male scapula. Conclusion: The scapula can potentially be used in medicolegal investigations in terms of sexual dimorphism. Thus, the results of these studies can provide the baseline values increasing the range of options in the forensic investigation in sex determination.

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Background: The anterior cruciate ligament (ACL) reconstruction is conducted to improve the stability and function of the knee. Bone-patellar tendon-bone (BPTB) graft is still considered as one of the best grafts for ACL reconstruction. The purpose of this paper was to assess outcomes of BPTB ACL reconstruction at 7 years of follow-up. Materials and Methods: This was a retrospective study in which records of 26 patients, who had ACL reconstruction using BPTB graft from 2013 to 2015, were done and the outcomes of results were analyzed by clinical Tegner activity levels and Lysholm score at 6–8 years of follow-up. Results: The follow-up study has revealed excellent long-term results. Approximately 87% of 26 patients had negative pivot shift examination with the remaining 13% having grade 1 ligament laxity. Tegner activity levels were similar to preinjury levels and Lysholm score was 91. All patients were satisfied with the procedure. Conclusion: BPTB ACL reconstruction using transtibial tunnel provides a satisfactory mid-term follow-up outcome.

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Background: Osteoarticular infections in infants, such as osteomyelitis and septic arthritis, are a growing problem with a potential for not only systemic after-effects but also irreversible joint damage and limb deformity. Therefore, early treatment is necessary to reduce permanent damage/deformity. The purpose of this study is to find out the demography and impact of early initiation of definitive institutional management in osteoarticular infections. Materials and Methods: This study was conducted after approval by the institutional review board. All neonates and infants admitted between June 2019 and May 2021 with a clinical and laboratory diagnosis of osteoarticular infection were included in this study. Data for each patient were collected using the Hosp Gestor program. Patients having a history of pain, redness, swelling in joints associated with fever, and discharging sinus from bone were studied for unknown risk factors and atypical presentations. The impact of definitive management and sequelae were noted in all patients. Results: In this study, males were affected more than females. Osteoarticular infection of septic arthritis (53%) is the most common followed by osteomyelitis (43%) affecting predominantly the hip joint. In the majority of the cases, atypical risk factors like congenital talipes equinovarus and preterm delivery were noted. The most common organism isolated was Staphylococcus aureus (35%); however, atypical organism was Acinetobacter haemolyticus (2.5%). Among treatment methods, surgical cleaning, arthrotomy, and drainage was the most common procedure. The greater the delay in institutional visit, the more severe was the complications. Worst outcomes and sequelae are seen when the delay is >3 months, namely epiphyseal growth arrest, varus deformity, and destroyed head of the femur; good outcomes are seen when a delay is for a few days. Conclusion: Early detection and institutional visit resulted in good outcomes. This study proves the truth behind the fact that delay in diagnosis and initiation of definitive treatment causes more complications and sequelae. This study also serves as a clinical guide to identify risk factors, awareness about early detection, and effective institutional treatment of osteoarticular infections in infants and neonates.

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Background: The treatment of distal-third extra-articular fracture of the humerus with large butterfly fragment is challenging and often controversial. The aim of this study is to see the result of open reduction and internal fixation of such fractures fixed with pre-contoured extra-articular anatomical locking plate in context to percentage of union, time of union and functional capability. Materials and Methods: This is a prospective study comprising of 28 cases from 2016 to 2019 with average follow-up of 19 months. In this study, all the cases included were extra-articular fractures of distal humerus having large butterfly fragments and were comminuted. The simple distal humeral extra-articular fractures without comminution were excluded from study. All the patients were operated on with posterior triceps reflecting approach and fixing the fractures with 3.5 mm pre-contoured extra-articular locking plate. Results: Out of 28 cases, there were 17 males and 11 females with mean age of 34.8 years. 4 patients were having post injury radial nerve palsy. None of the patients in our series were treated conservatively. The average time of operation after injury was 7 days and the average time of union was 20 weeks. 3 of the patients post operatively developed radial nerve palsy which completely recovered within 5 months. The results were evaluated with Mayo elbow performance score. Conclusion: Distal humeral comminuted extra-articular fractures are complex and difficult to manage. A pre-contoured distal humeral plate is a good option and gives adequate purchase for distal fixation. Moreover, the triceps sparing approach is good and chances of nerve injury and stiffness are less. We are happy with this plate and type of fixation.

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Vertigo is a perception of movement either of the environment or of one’s own body, which may be of rotation or swaying. Vertigo or nonvestibular dizziness is one of the most common complaints of the patients, but there are a number of causes for that. Very few literatures are available on vertigo. The purpose of this article was to provide an overview and literature review.

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Background: Management of osteoarticular tuberculosis is primarily based on pulmonary tuberculosis guidelines. Guidelines usually do not take into consideration specific organ system affection, though tube pathology and healing of affected organ is not the same. Therefore, routine guidelines are difficult to follow in osteoarticular tuberculosis and many treatment regimes are in vague. Therefore, routine tuberculosis (TB) treatment is not followed, and many regimes are in vague. The current study is undertaken to objectively evaluate daily drug regime in osteoarticular TB and has specific guidelines. Materials and Methods: Drug-sensitive osteoarticular TB cases were evaluated for daily anti-tubercular treatment (ATT) guided by clinical and radiological healing. Patients were categorized based on stage, severity, and site of infection. Vitamin C and iron were also included in the daily treatment regime. Ethambutol was included in the continuation phase. Outcomes in terms of radiological healing and duration of daily regimen were studied. Results: All patients at 6 months of daily ATT showed clinical improvement but persistent disease on imaging. On magnetic resonance imaging, 16 out of 52 patients showed worsening at 6 months. Earliest healing appeared at 8 months. Healing appears to be faster in surgically treated patients. There was no relapse till the shortest follow-up of 2 years. Conclusion: The directly observed treatment strategy (DOTS), three times a week, is enough in osteoarticular TB. Daily drug with a minimum duration of 9 months is necessary. Diagnosis is usually delayed due to deep-seated infections, hence advance diagnosis modalities and high index of suspicion help. The study does not encounter any case of drug resistance. Addition of vitamin C appears to increase effectiveness of drugs. Duration of ATT should be determined by the pre-treatment disease activity and response to ATT.

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Background: Intra-articular fracture of the distal end of the radius can be treated by various methods. The purpose of this study is to evaluate the functional outcomes of open reduction and internal fixation (ORIF) by volar locking plate (VLP) of intra-articular distal radial fractures. Materials and Methods: This is a single centre retrospective study conducted from April 2017 to May 2019 on adult patients having intra-articular distal radius fractures, who were treated by ORIF with VLP. As per medical records, the number of such patients for the study was 12. The fractures were classified as per the Frykman classification system. After operation, patients were followed up for a minimum of 24 weeks. Functional evaluation of the patients was done at the last follow-up according to the demerit point system of Gartland and Werley. Results: Twelve adult patients of intra-articular distal radius fractures were analysed retrospectively for functional outcomes of ORIF with VLP. The age ranged from 22 to 54 years, and males outnumbered females by a ratio of 2:1. The commonest mode of injury was found to be road traffic accidents (75%). The fractures were classified as per the Frykman classification system. Type III was the most common (50%), followed by Type IV (25%). The majority of the cases (58.3%) were operated in 2–5 days following injury. The mean time for union was 8 weeks. Functionally 11 (91.3%) patients had satisfactory (excellent + good) result at the final follow-up. Conclusion: ORIF with volar locking plate is a reliable, efficient, and rewarding procedure for intra-articular fracture of distal radius as it allows stable fixation with restoration of anatomy and function.

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Background: Distal radioulnar joint (DRUJ) instability is an important cause of ulnar-sided wrist pain in distal radius fractures. By this study, it was tried to identify clinical factors associated with DRUJ instability in distal radius fractures. Materials and Methods: We prospectively reviewed all 87 patients who underwent surgery for unstable, unilateral distal radius fractures in a tertiary trauma center. Assessment of DRUJ instability was examined preoperatively, during surgery, and immediate postoperatively. Patients with clinical DRUJ instability were followed up at 6 weeks, 3 months, and 6 months, with clinical assessment of the DRUJ instability whether symptomatic or not. Results: Preoperative DRUJ instability was found in 23 patients as checked by the distal ulna ballottement test. Of these 23 patients, postoperative DRUJ instability was found in 9 patients and persisted as symptomatic DRUJ instability with ulnar-sided wrist pain till the last follow-up. Conclusion: Every distal radius fracture should be seen with the suspicion of associated DRUJ instability and the stability of DRUJ be thoroughly checked intraoperatively and postoperatively for better wrist function and better outcome after the union of distal radius fracture.

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Background: The choice of graft for anterior cruciate ligament (ACL) reconstruction is a matter of debate with hamstring and bone-patellar tendon-bone being the most popular autologous graft options. Objective: The objective of this study was to conduct a prospective randomized control trial comparing doubled semitendinosus and gracilis graft versus bone-patellar tendon-bone graft. Materials and Methods: Sixty patients with chronic unilateral rupture of ACL underwent arthroscopically assisted ACL reconstruction using quadrupled hamstring and bone-tendon-bone graft after randomization. Both groups were comparable with demographic data, preoperative activity level, mechanism of injury, the interval between injury and operation, and preoperative laxity of the knee. The same well-proved surgical technique and aggressive rehabilitation were used in all cases. The outcome assessment was done using the visual analog scale, Lysholm score, Tegner activity level, and International Knee Documentation Committee (IKDC) evaluation system. Results: At 2-year follow-up, we found that results within the same groups showed statistically significant improvement as assessed by IKDC, Tegner’s, and Lysholm operative scores. There was also a significant correlation between the manual Lachman test and stress laxometry findings. There was no statistically significant difference between the scores of the two groups (hamstring and bone patella tendon). In the hamstring group, we recorded a higher incidence of femoral tunnel widening, and in the bone-patellar tendon-bone group the higher incidence of kneeling discomfort and increased area of decreased sensation in the skin. Conclusions: Arthroscopic ACL reconstruction by either hamstring tendon graft or bone-patellar tendon-bone graft gives equally satisfactory results.

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Problems faced in open fractures of the distal third tibia are usually associated with soft-tissue coverage, infection control, and union of the bone. Tibia is commonly associated with impaired healing if soft tissues are severely damaged. Not all cases can be treated with flaps due to its unavailability in acute settings, high learning curve, and cost. We present the outcomes of a case of an open Grade III-B Gustillo–Anderson distal tibia fracture treated with debridement and deliberate bony shortening which helped in primary closure of the wound. A 61-year-old gentleman, a known hypothyroid, had an alleged history of accidental cut injury over right lower limb by a machine used for cutting trees. He sustained a 7 cm × 4 cm laceration over the anteromedial aspect of the distal tibia with blown-out soft tissues and bone exposed. Wound debridement and stabilization with ankle spanning external fixation were immediately done. Wound could be primarily closed because the tibia and fibula were deliberately shortened during the external fixation. Many free bone fragments were removed during debridement leaving a bony void. One week later bone graft was used to fill the void after redebridement of the wound and wound could be primarily closed. Negative wound therapy was used as an adjuvant. One month later the external fixator was converted to Ilizarov fixator, which was removed at the end of 5 months, showing a fully healed fracture without soft-tissue complications at the end of 6 months follow-up. Debridement and shortening of the open tibia is a powerful technique to provide bony apposition and allow primary wound closure without tension, averting the need for any secondary reconstructive procedures.

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Calcific myonecrosis is a rare entity characterised by a latent formation of dystrophic calcified mass occurring most commonly in the anterior compartment of the leg and is usually a posttraumatic condition. Diagnosis is based on the history of trauma and typical radiological features. Symptomatic patients require complete excision of the mass. We report such a case not only for its rarity but also for challenging diagnosis and treatment.

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The acromion and coracoid process fractures are uncommon injuries and may be missed in cases of bad quality radiographs or inappropriate patient positioning during radiography. The complex shoulder region anatomy calls for careful observation and clinical suspicion to rule out these injuries. Concomitant coracoid and acromion process fracture is a rare pattern of injury. We report a case of minimally displaced acromion process fracture with undisplaced fracture of base of the coracoid process. Conservative management was done and a satisfactory outcome was noted in the mean follow-up of 9 months on using the DASH score.

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Fibrous dysplasia has a considerable risk of pathological fractures particularly in proximal femur in younger age group. These are challenging to treat, especially in pediatric population. Several treatment modalities have been proposed, each having its own pros and cons. Attention should be given in pediatric population in choosing technique and selection of implants to preserve growth of the limb and to prevent implant prominence and soft tissue irritation. We are reporting a case of pathological neck of femur fracture secondary to fibrous dysplasia, in an 11-year-old obese boy, managed with curettage, iliac crest bone grafting and osteosynthesis with PHILOS plate (a plate routinely used in adults for humerus neck fractures). At 6 months follow-up, he shows a good consolidation of iliac crest graft at fracture site with stable implant and an excellent functional outcome in terms of pain and range of motion, without any radiological sign of recurrence.

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The impact factor (IF) for peer-reviewed orthopaedic journals has increased in the recent years, so has the number of journals. The publication of high-level research in orthopaedics has considerable importance of citing good quality evidence for impact on day-to-day practice. Transparency and rigorous engagement of reviewers and authors in the peer review process may improve the quality of publication which may help developing practice guidelines. This article seeks to suggest simple ways to have effective peer review process which can maximize publication success and improve the IF.

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Floating knee is a lesion entity first described in 1975 by Blake and McBride. Bilateral involvement is exceptional. It occurs for high-energy trauma and is usually accompanied by other potentially life-threatening lesions. Our patient presented a trauma of lower limbs following a motorcycle accident. The clinically evoked diagnosis was confirmed after standard radiological assessment.

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Intraosseous schwannomas are rare and represent 0.2% of all bone tumors. Their occurrence in tibia is extremely rare and only five cases have been reported till date. We report an additional case of intraosseous schwannoma in right tibia of a 46-year-old female whose plain radiograph of right knee joint revealed an osteolytic expansile lesion with trabeculations in the proximal tibia. Magnetic resonance imaging study showed a well defined, lobulated mass in the anteromedial aspect of upper tibia. Histopathological examination of the excised specimen revealed schwannoma which was confirmed by positivity for S-100 on immunohistochemistry.

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Patients with isolated capitellar fractures mostly present with painful swelling of the elbow with definite local tenderness on clinical examination. These fractures become evident in the radiograph. In this paper, we report a young girl with an isolated capitellar fracture that was missed in the initial radiograph of the elbow and became evident in computed tomography (CT) and subsequent X-ray. This patient was treated successfully with open reduction and internal fixation by two headless screws (Herbert screw).

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Many factors contribute to decision making for success or failure in the management of trochanteric fractures. The purpose of this article is to address key operative decisions pertaining to these factors with evidence from current literature.

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