Anteroposterior View Research Articles

Clinical Examination and Diagnosis of Nasal Bone Fracture; Is There Really a Need for X-ray Nasal Bone?

Objective: To evaluate the role of clinical examination in diagnosing nasal bone fracture. Methodology: This Prospective Observational study was carried out in the departments of Otolaryngology-Head and Neck Surgery and Radiology at the Pakistan Institute of Medical Sciences, Islamabad, from Jan 2022 to Dec 2023. About 1000 patients of nose trauma patients coming to ENT emergency were evaluated clinically by thorough nose examination by ENT surgeon and radiologically by X-ray nasal bone both lateral and anteroposterior view. Based on examination if nasal bone fracture was suspected patient was referred to radiology department for X-ray nasal bone which was reported by radiologist if the bone is fractured or not. The clinical findings were correlated with X-ray reports to find out if there really is a need for X-ray nasal bone for diagnosing nasal bone fracture. The diagnostic accuracy of clinical examination was calculated. Results: When clinical and radiological findings were compared regarding the diagnosis of nasal bone fracture a statistically significant association was found between the two (p=<0.001) showing patients with clinical suspicion of fracture actually had fracture on X-ray. The diagnostic accuracy of clinical examination was very high with Positive Predictive Value, Negative Predictive Value, Sensitivity, Specificity, False Negative Rate and False Positive Rate being 96.1%, 93%, 88.5%, 97.7%, 11.5% and 2.3% respectively. Conclusion: We concluded that almost all patients with suspected nasal bone fracture actually had fractures on X-ray. Fractured nasal bone can correctly be diagnosed clinically by ENT surgeon and there is no real need for X-ray nasal bone just for diagnosing nasal bone fracture.

A significant difference of synovial mast cells in synovium from rotator cuff arthropathy compared to rotator cuff tears: A histological pilot study

ObjectiveAim of the present study was to compare the presence of Mast Cells (MCs) in synovial samples from gleno-humeral osteoarthritis (OA) and from control group. MethodsSynovial tissue samples were obtained during arthroplasty from 23 patients with gleno-humeral OA due to rotator cuff arthropathy (RCA) and from 20 patients without OA, constituting OA group and control group respectively. Before surgery self-reported pain was assessed using VAS score and OSS was used to value functional ability. Shoulder radiograph (Antero-posterior, Y-view and Grashey views) was evaluated by musculoskeletal radiologist and graded according to modified Samilson-Prieto classification.Synovial tissue, obtained during arthroplasty and arthroscopic procedure, was prepared to immunohistochemical analysis with anti-CD31 and anti-CD117 antibodies, to detect respectively endothelial cells and MCs at 40x magnification. Synovitis scores have been assessed. Under the control of the image processing system the distribution and the total number of vessels and MCs were determined. ResultsThe numbers of MCs and the area fraction (20x magnification) occupied by them were significantly higher in OA samples than in control tissue. The synovitis score was higher in OA patients with a positive correlation. Vessels number and area fraction were higher in OA patients than in controls. Analysis of MC number in relation to clinical data indicated positive correlation with the VAS score. ConclusionsThe distribution of MCs on synovium significantly differ between OA and control groups. Despite the design of the study could not conclude the cause-effect relationship, the presence of MCs might have role in OA pathogenesis. Level of evidenceHistological study.

Estimating infant age from skull X-ray images using deep learning

This study constructed deep learning models using plain skull radiograph images to predict the accurate postnatal age of infants under 12 months. Utilizing the results of the trained deep learning models, it aimed to evaluate the feasibility of employing major changes visible in skull X-ray images for assessing postnatal cranial development through gradient-weighted class activation mapping. We developed DenseNet-121 and EfficientNet-v2-M convolutional neural network models to analyze 4933 skull X-ray images collected from 1343 infants. Notably, allowing for a ± 1 month error margin, DenseNet-121 reached a maximum corrected accuracy of 79.4% for anteroposterior (AP) views (average: 78.0 ± 1.5%) and 84.2% for lateral views (average: 81.1 ± 2.9%). EfficientNet-v2-M reached a maximum corrected accuracy 79.1% for AP views (average: 77.0 ± 2.3%) and 87.3% for lateral views (average: 85.1 ± 2.5%). Saliency maps identified critical discriminative areas in skull radiographs, including the coronal, sagittal, and metopic sutures in AP skull X-ray images, and the lambdoid suture and cortical bone density in lateral images, marking them as indicators for evaluating cranial development. These findings highlight the precision of deep learning in estimating infant age through non-invasive methods, offering the progress for clinical diagnostics and developmental assessment tools.

Assessment of automated TICI scoring during endovascular treatment in patients with an ischemic stroke

BackgroundThe extended Thrombolysis in Cerebral Infarction (eTICI) score is used in digital subtraction angiography (DSA) to quantify reperfusion grade in patients with an ischemic stroke who undergo endovascular thrombectomy (EVT)....

Single versus double percutaneous pinning of pediatric distal radius fractures.

The aim of this study was to compare early clinical and radiographic results of single- versus double-pin fixation of unstable pediatric distal radius fractures. A total of 103 consecutive closed distal radius fractures treated with either single or double percutaneous pinning at a tertiary level I pediatric hospital were analyzed. All patients had open physes and had fractures that failed initial closed reduction and casting. Postoperative fracture displacement was assessed by measuring the difference in angulation of the radius in the anteroposterior and lateral views from intraoperative fluoroscopic images to postoperative radiographs taken on the day of pin removal. Complications were identified from the medical record review. In 103 operative distal radius fractures in 101 patients (70 males, 31 females), 52 and 51 distal radius fractures were treated with single and double pinning, respectively. The median [interquartile range (IQR)] age at the time of surgery was 12.1 (9.0-14.0) years, with the single-pinning group being younger by 1.9 years (P < 0.01). Median (IQR) postoperative angulation in the anteroposterior radiograph (coronal plane) was 2° (1-7°) with one pin versus 1° (0-2°) with two pins (P < 0.01). Median (IQR) postoperative angulation in the lateral radiograph (sagittal plane) was 3° (1-10°) with one pin versus 1° (0-2°) with two pins (P < 0.01). There were no significant differences in complications between the single- and double-pinning groups. Double-pin fixation resulted in a statistically significant, but clinically negligible, reduction in postoperative fracture displacement compared with single-pin fixation. Complication rates were similar in both groups. These findings suggest that either single- or double-pinning techniques can be effective, provided appropriate reduction and postoperative immobilization are achieved.

Paper 17: Does Higher Quality CAM Resection Correlate with Better Patient-Reported Outcomes?

Objectives: The relationships between CAM resection quality and patient-reported outcomes (PROs) are unknown in the literature. This study aimed to investigate the correlation of CAM resection quality with patient’s self-reported International Hip Outcome Tool (iHOT) scores collected annually post-surgery. Methods: A retrospective analysis was conducted including patients who underwent primary hip arthroscopy for femoroacetabular impingement (FAI) between 2012 and 2019. Inclusion criteria were pre-operative radiographic signs of CAM-type impingement (alpha angle &gt; 55 °) and post-operative plain radiographs. Exclusion criteria were radiographic signs of a pincer or mixed impingement, history of femoral neck or proximal femur fracture, and treatment of concomitant hip pathologies. The following data were collected: demographic information, radiographic findings, and iHOT scores. CAM resection quality data were categorized based on findings from three plain radiographs (anteroposterior (AP) pelvis, frog leg lateral, and 45° Dunn views). High quality resections were defined as those post-operative alpha angle &lt;55°. Results: This study included 148 participants who underwent CAM resection. From Frog leg views, 88% of patients had high-quality resections and presented superior post-operative iHOT scores compared to the 12% of patients with poor resection quality during the 1-year to 5-year follow-up period. Likewise, from Dunn views 82% of patients with a high-quality CAM resection displayed a similar trend in post-operative iHOT scores compared to 18% of patients with poor resection quality on Dunn views. However, this positive association between resection quality and post-operative iHOT scores was not evident in AP imaging. With AP views, 82% of patients with high-quality resections did not show a significant difference in iHOT scores compared to 18% of patients with poor resection quality. Conclusions: This study found that high quality CAM resection from arthroscopic surgery correlated with better iHOTs up to 5-years post-surgery from the Dunn and frog leg radiographic imaging views.

Clavicular tunnel widening in chronic acromioclavicular joint instabilities after primary versus revision arthroscopically-assisted acromio- and coracoclavicular stabilization.

To evaluate joint reduction (loss of reduction [LOR]; dynamic posterior translation [DPT]) and clavicular tunnel widening (cTW) in patients treated with arthroscopically-assisted acromioclavicular joint (ACJ) stabilization after previously failed nonoperative versus surgical treatment. Patients undergoing arthroscopically-assisted ACJ stabilization (bidirectional tendon allograft with a low-profile TightRope) after previously failed nonoperative versus surgical treatment were included retrospectively. Bilateral anteroposterior stress views served for evaluating LOR (side-comparative coracoclavicular distance [CCD]) and cTW at a 6-weeks- and 6-months-follow-up (FU) and for evaluating the filling ratio (FR, vertical device insertion depth relative to clavicle height) at the 6-weeks-FU. Postoperative DPT was assessed on Alexander's views. Twenty-seven patients (20 male, mean age 46.1 ± 14.8 years) were included (prior treatment: nonoperative: n = 15; surgical: n = 12). There were no differences in LOR, DPT or cTW between groups postoperatively. Initial CCD-symmetry at the 6-weeks-FU (CCD: -0.1 mm [95% confidence interval, CI, -2 to 1.4 mm]) was followed by LOR at the 6-months-FU (CCD: -3.5 mm [95% CI, -5.2 to -1.9 mm]; p < 0.001). cTW increased towards the inferior cortex, compared to the superior cortex and the intermediate level (p < 0.001, respectively). cTW at the inferior cortex was associated with more LOR (r = -0.449; p = 0.024) and DPT (r = 0.421; p = 0.036), dependent on a smaller FR (r = -0.430; p = 0.032). Patients undergoing arthroscopically-assisted ACJ stabilization for chronic bidirectional ACJ instabilities showed comparable radiologic results after previous nonoperative versus surgical treatment. cTW increased towards the inferior cortex and was associated with recurrent vertical and horizontal instability, related to a smaller FR. More research into reduced cTW, for example, by a more filling device, should be performed. Level III, retrospective comparative study.

Avascular necrosis after surgery of developmental dysplasia of the hip in children after walking age: incidence and risk factors

Introduction Developmental dysplasia of the hip (DDH) is a common congenital anomaly in children. It includes a spectrum of anatomic abnormalities ranging from acetabular dysplasia to frank hip dislocation. Avascular necrosis (AVN) is one of the main complications associated with the treatment of DDH. It is a devastating problem that can lead to acetabular dysplasia and joint incongruity and cause premature osteoarthritis. The study aims to evaluate the incidence and risk factors of AVN after open reduction of developmental dislocation of the hip in children after walking age. Patients and methods Between the period of April 2014 and April 2019, a retrospective cohort evaluation of DDH cases was managed by surgery in the form of open reduction and pelvic osteotomy with or without femoral shortening. All grades of Tönnis classification were included. This study included 200 cases with an age range from 1 to 7 years, and the average age is 3.5 years at the time of last follow-up. The mean follow was 2.29 years, which ranged from 1 to 4 years. Plain radiography obtained in anteroposterior and frog lateral views after 1 year follow-up to diagnosis AVN as established in the literature. Results In this study, the mean time of intervention was 2.26 ± 0.97 years with an age range from 1 to 5 years. Twenty-six (13%) cases were managed only by open reduction and capsulorrhaphy, 174 (72.5%) cases had pelvic osteotomies, either Salter or Dega osteotomy, of whom 104 had femoral shortening and derotational osteotomy (59.77%). No AVN was reported in 159 (79.5%) cases, while AVN was evident in 41 (20.5%) cases. Discussion Incidence of AVN after open reduction depend on variable factor discussed in this study with total incidence of AVN 41 (20.5%) cases. This result is similar to other studies, with the incidence of AVN ranging from 15 to 30%. In the present study, the incidence of AVN increased 17 times in cases with postoperative immobilization in the hip spica more than or equal to 60° in the form of 21 cases showed AVN. Conclusion Postoperative hip immobilization in spica less than 60° as children with postoperative hip abduction more than or equal to 60° showed an increase incidence of AVN.

Poster 291: Entry Point-Transition Point Angle as a Novel 3-Dimensional Metric of Patellar Instability

Objectives: Three-dimensional (3D) modeling has increasing utility in identifying differences in trochlear morphology in patients with patellar instability when compared to historical 2-dimensional (2D) attempts. Distortions in the proximal medial ridges of trochleas are a distinguishing feature of trochlear dysplasia. Recently, the entry-point to transition-point (EP-TP) angle was established as a novel 3D metric to quantify degree of dysplasia, as it captures the tracking of the patella within the trochlea. However, previous attempts relied on 3D prints, which are not widely accessible. The purpose of this study is to validate this new measurement and compare differences between patients with patellar instability and the general population. Methods: Forty-three patients with recurrent patellar dislocations who were treated by a single surgeon between January 2020 and July 2023 were included. The study received an institutional review board exemption. Individuals from the New Mexico Decedent Image Database with no history of patellar instability or patellofemoral pain were used to obtain computed tomography (CT) images from the general population. Stereolithography (STL) models of distal femurs in 3D were generated from CT images using ScanIP. Minimum and maximum principal curvature maps were taken as screenshots from maps generated in MeshLab. Two people independently conducted measurements using a custom measuring tool displaying anteroposterior views and curvature maps of the distal femur. The measurers were asked to locate the medial and lateral ridges, transition point, and apex of the trochlea groove for each femur. A Mann–Whitney U test was performed to evaluate whether the recurrent dislocators had higher EP-TP values. P values below 0.01 were regarded as significant. Interclass correlation for both raters (ICC (1, k), reliability of values within this study) and single rater (ICC (1,1), reliability of measurement within clinical practice) and the 95% CI thereof, was computed for the 2 independent measurements. Results: A total of 100 femurs were measured, including 43 recurrent dislocators and 57 population femurs. The recurrent dislocator cohort had a mean EP-TP of 40.9° with a standard deviation of 16.4°. The general population cohort had a mean EP-TP of 11.3° with a standard deviation of 12.3°. EP-TP for dislocators and general population was significantly different. (p &lt; 0.001). ICC (1, k) was 0.81 with a 95%-confidence interval of 0.72 to 0.87. ICC (1,1) was 0.69 with a 95% CI of 0.57 to 0.78. Conclusions: EP-TP angle is a novel metric that helps quantify trochlear dysplasia, which can help clinicians better understand patellar instability. In this study, we validate EP-TP angle by showing that EP-TP angle was significantly different between femurs of recurrent dislocators and the general population.

Three-Dimensional Bowing Measurement of Distal Femur at Actual Size and Clinical Implications of Total Knee Arthroplasty.

Background and Objectives: To assess femoral shaft bowing (FSB) in coronal and sagittal planes and introduce the clinical implications of total knee arthroplasty (TKA) by analyzing a three-dimensional (3D) model with virtual implantation of the femoral component. Materials and Methods: Sixty-eight patients (average age: 69.1 years) underwent 3D model reconstruction of medullary canals using computed tomography (CT) data imported into Mimics® software (version 21.0). A mechanical axis (MA) line was drawn from the midportion of the femoral head to the center of the intercondylar notch. Proximal/distal straight centerlines (length, 60 mm; diameter, 1 mm) were placed in the medullary canal's center. Acute angles between these centerlines were measured to assess lateral and anterior bowing. The acute angle between the distal centerline and MA line was measured for distal coronal and sagittal alignment in both anteroposterior (AP) and lateral views. The diameter of curve (DOC) along the posterior border of the medulla was measured. Results: The mean lateral bowing in the AP view was 3.71°, and the mean anterior bowing in the lateral view was 11.82°. The average DOC of the medullary canal was 1501.68 mm. The average distal coronal alignment of all femurs was 6.40°, while the distal sagittal alignment was 2.66°. Overall, 22 femurs had coronal bowing, 42 had sagittal bowing, and 15 had both. Conclusions: In Asian populations, FSB can occur in coronal, sagittal, or both planes. Increased anterolateral FSB may lead to cortical abutment in the sagittal plane, despite limited space in the coronal plane. During TKA, distal coronal alignment guides the distal femoral valgus cut angle, whereas distal sagittal alignment aids in predicting femoral component positioning to avoid anterior notching. However, osteotomies along the anterior cortical bone intended to prevent notching may result in outliers due to differences between the distal sagittal alignment and the distal anterior cortical axis.

Indian Hand Anthropometry: Computer Tomography-Based Morphometric Analysis of Metacarpal.

Introduction Metacarpal fractures are common and have various treatment options, but understanding their morphometry is crucial for optimizing fixation techniques and reducing complications. Accurate assessment of metacarpal anatomy is challenging in conventional radiographs but feasible with computed tomography (CT) scans, which offer precise views. This study aimed to provide accurate anatomical data on metacarpals within an Indian population using CT scans and to compare the results with existing literature. The findings have implications for surgical procedures, including plating, pinning, and intramedullary screw fixation. Materials and Methods This retrospective analysis utilized CT scans of 100 hands, including 50 males and 50 females, from two hospitals in India. Inclusion criteria included complete metacarpal visualization with a slice thickness of 0.6 mm, while exclusion criteria involved trauma, deformity, or underlying pathologies. Various parameters of all metacarpals were measured using RadiAnt DICOM Viewer 2021.1, providing accurate anteroposterior and lateral views. Results Male and female cohorts had mean ages of 38.58 ± 12.02 and 43.60 ± 13.61 years, respectively. The study showed good to excellent reliability in measurements. The 2nd metacarpal was consistently the longest, and the general length pattern was 3rd > 4th > 5th > 1st metacarpal in both genders. Men generally had larger metacarpal dimensions than women, except for intramedullary diameter, which showed minimal sex-related differences. Notably, the medullary cavity's narrowest part was at the 4th metacarpal, and the thumb had the widest intramedullary diameter. Conclusion This study provides valuable anatomical reference data for metacarpals in an Indian population, aiding in optimizing surgical techniques for metacarpal fractures. The 2nd metacarpal consistently stood out as the longest, and men generally had larger metacarpal dimensions than women. These insights into anatomical variations can inform clinical decisions and stimulate further research in this field. However, a larger and more diverse sample would enhance the study's representativeness.

Reverse Shoulder Arthroplasty for Proximal Humeral Fractures: Is the Bigliani-Flatow Stem Suitable for Tuberosity Fixation and Healing?

Background/Objectives: The aim of the study was to investigate the clinical, functional, and radiographic results of patients affected by three- or four-part proximal humeral fractures treated with reverse total shoulder arthroplasty, to investigate whether a prosthetic stem nonspecifically designed for fractures (i.e., the Bigliani-Flatow stem) promotes tuberosities' healing, and to evaluate the impact of tuberosity fixation and healing on the outcomes. Methods: Patients' data such as gender, age, side and dominancy, comorbidities, complications during or after surgery, and time lapse between trauma and surgery were prospectively collected. The type of fixation of the stem, the thickness and type of liner, and whether the tuberosities were fixed or not were also recorded. The Constant score weighted on the contralateral limb, QuickDASH, Oxford Shoulder Score, and Subjective Shoulder Value were collected. Tuberosities' healing was assessed with X-rays (anteroposterior, Grashey, and axillary views). Results: Overall, 34 patients were included, with an average follow-up of 42 months. Tuberosities were reinserted in 24 cases and their healing rate was 83%. The mean values were the following: a Constant score of 64, Oxford Shoulder Score of 39, Subjective Shoulder Value of 71, and QuickDASH score of 27. There were no significant differences in the scores or range of motion between patients with tuberosities healed, reabsorbed, or not reattached. There was a better external rotation in the group with healed tuberosities and a longer duration of surgery to reattach tuberosities. Conclusions: The treatment of proximal humerus fractures with the Bigliani-Flatow stem is associated with good clinical and functional results. The healing rate of the tuberosities was high and comparable, if not even better, than the mean rates reported for the stems dedicated to fractures of the proximal humerus and was, therefore, also appropriate for this indication.

Tip-apex distance as a risk factor for cut-out in cephalic double-screw nailing of intertrochanteric femur fractures.

Proximal femur fractures treatment can involve anterograde nailing with a single or double cephalic screw. An undesirable failure for this fixation is screw cut-out. In a single-screw nail, a tip-apex distance (TAD) greater than 25 mm has been associated with an increased risk of cut-out. The aim of the study was to examine the role of TAD as a risk factor in a cephalic double-screw nail. A retrospective study was conducted on 112 patients treated for intertrochanteric femur fracture with a double proximal screw nail (Endovis BA2; EBA2) from January to September 2021. The analyzed variables were age, sex, BMI, comorbidities, fracture type, side, time of surgery, quality of reduction, pre-existing therapy with bisphosphonate for osteoporosis, screw placement in two different views, and TAD. The last follow-up was at 12 months. Logistic regression was used to study the potential factors of screw cut-out, and receiver operating characteristic curve to identify the threshold value. A total of 98 of the 112 patients met the inclusion criteria. Overall, 65 patients were female (66.3%), the mean age was 83.23 years (SD 7.07), and the mean follow-up was 378 days (SD 36). Cut-out was observed in five patients (5.10%). The variables identified by univariate analysis with p < 0.05 were included in the multivariate logistic regression model were screw placement and TAD. The TAD was significant with an odds ratio (OR) 5.03 (p = 0.012) as the screw placement with an OR 4.35 (p = 0.043) in the anteroposterior view, and OR 10.61 (p = 0.037) in the lateral view. The TAD threshold value identified was 29.50 mm. Our study confirmed the risk factors for cut-out in the double-screw nail are comparable to those in the single screw. We found a TAD value of 29.50 mm to be associated with a risk of cut-out in double-screw nails, when good fracture reduction is granted. This value is higher than the one reported with single-screw nails. Therefore, we suggest the role of TAD should be reconsidered in well-reduced fractures treated with double-screw intramedullary nail.

Analysis of risk factors for failed closed reduction in pediatric Gartland Type III supracondylar humerus fracture

PurposeGartland Type III supracondylar humerus fractures are commonly treated using closed reduction followed by percutaneous pin fixation. However, conversion to open reduction may be necessary if closed reduction fails. This study aimed to identify risk factors associated with failed closed reduction and provide a theoretical basis for clinical decision-making in the treatment of Gartland Type III fractures. MethodsA retrospective analysis was conducted on children with Gartland Type III supracondylar humerus fracture who underwent surgical treatment between April 2017 and June 2018. Based on whether or not the closed reduction was successful, patients were split into the open reduction group and the closed reduction group. Within the closed reduction group, subgroup analysis based on surgery duration was carried out. Data were collected from medical records and X-ray images. Univariate and multivariate regression analyses were utilized to evaluate the relationship between variables and failed closed reduction. ResultsThe study included 36 patients in the open reduction group and 135 patients in the closed reduction group. Multivariate analysis revealed that the presence of angle (P=0.024, OR=3.199), rotation (P=0.000, OR=6.359), skin creases (P=0.013, OR=4.077), anterior-posterior displacement ratio (P=0.011, OR=4.337), fracture angle in the anteroposterior view (P=0.014, OR=0.939), and fracture distal displacement direction (P=0.002, OR=5.384) were independent risk factors for failed closed reduction. Subgroup analysis showed that fracture distal displacement direction (P=0.013), skin folds (P=0.013), lateral displacement ratio (P=0.016), and anterior-posterior displacement value (P=0.005) significantly influenced the duration of closed reduction surgery. ConclusionThe presence of sharp angle or rotation at the fracture ends, skin folds on the anterior elbow, minor anterior-posterior displacement of the fracture, higher medial inclination of the fracture plane, and distal fracture displacement towards the radial side are independent risk factors for failed closed reduction in pediatric Gartland Type III supracondylar humerus fracture.

Percutaneous injection of autologous platelet gel accelerate healing in diabetic tibial non union: On going longitudinal study

IntroductionIn this study the tibial shaft fracture non unions in diabetes mellitus are evaluated with percutaneous autologous platelet gel supplementation to accelerate union are compared with individually matched control group with autologous iliac crest bone marrow aspirate injection. Material and methodsThis present study was carried out on tibial non unions in diabetic patients recruited in an ongoing longitudinal study over a period of 2006 to 2017, treated by one surgeon at one institute, are included in this report. Each of 18 established tibial atrophic, aseptic non unions treated by percutaneous autologous platelets and iliac crest bone marrow aspirate were followed up on regular basis up till 9 months. The healing of non union was assessed clinically by painless full weight bearing and the radiological union was judged by bridging callus formation observed on at least 3 of 4 cortices in anteroposterior and lateral views. ResultsUnion was observed in 17 (94.4 %) patients of the autologous platelet group. The average time to union was 9.2 weeks (range 8 to 18 weeks) after percutaneous autologous platelet injection (P < 0.0517) .In the control group, union was observed in 14 (77.8 %) patients (P = 0.672). The average time to union following percutaneous bone marrow injection was 11.6 weeks (range 9 to 28 weeks). The proximal 1/3 shaft non union healed comparatively faster than the distal 1/3 shaft tibia (P ≤ 0.0612). No correlation was observed between the comminuted and non comminuted fracture non union (P = 0.789). A significant correlation was noted as regards the non union healing time duration in patients who were on insulin and oral hypoglycemic drugs (P ≤ 0.001) and also about the total duration of diabetes mellitus in years (P ≤ 0.003). ConclusionThis investigation showed that percutaneous autologous platelet gel delivery is sufficient method to obtain union in diabetic tibial fracture non unions, which is less invasive procedure than bone marrow injection. The efficacy of this autologous platelets is once again well established and this study reinforced categorically the previously published report by the author.

Management of type III acromioclavicular joint dislocation: A Delphi consensus survey by Shoulder & Elbow Society, India (SESI)

PurposeThe study aimed to report the results of the Delphi survey conducted by the Shoulder, Elbow Society India (SESI), to achieve consensus on ambiguous topics in managing type III acromioclavicular joint (ACJ) dislocations. MethodsThis study was based on responses from the Shoulder Elbow Society India (SESI) panel of peer-selected twenty senior surgeons practicing shoulder orthopedics. They participated in two rounds of the survey to obtain consensus on several topics pertaining to the management of type III ACJ dislocations. Consensus was achieved when at least 70 % of the panel members selected at least a 4-point on a 5-point Likert scale. ResultsOur Delphi survey reached a consensus on seven topics of ambiguity. An anteroposterior and axillary view of the shoulder without any traction or weight in hand is sufficient in the setting of a suspected type III ACJ dislocation. Magnetic resonance imaging (MRI) is not routinely indicated in type III ACJ dislocation. Either cross-arm adduction X-rays or clinical examination may be used to distinguish between ISAKOS (International Society of Arthroscopy, Knee surgery and Orthopaedics Sports medicine) IIIA and B classification of ACJ to identify stable and unstable injuries. Conservative treatment can be offered to patients who have stable injuries and who are not high-demand individuals in acute type III ACJ dislocations. In conservative management of type III ACJ dislocation, a two-week sling suffices. Jones strapping has no clear advantage over a shoulder sling. Coracoclavicular reconstruction with an autograft is an acceptable way to treat symptomatic, chronic grade III ACJ dislocation. ConclusionThe survey helped achieve consensus on several controversial issues related to type III ACJ dislocations. However, there remains ambiguity on the definition of chronicity of such dislocations, the necessity of bilateral Zanca views, and the duration of conservative trial before switching to a surgical line of management.

Clinical analysis of surgical outcome of 89 patients having large cerebral arteriovenous malformations.

The article analyzes the clinical features, morphological characteristics, surgical subtleties and long-term outcome of surgery in 89 cases of 'large' sized AVMs. During the period 2004 to 2022, 89 cases of 'large' arteriovenous malformations were operated in the neurosurgery departments of the authors. Large AVMs were defined as those that were more than 4cm on either lateral or antero-posterior view of digital subtraction angiogram. The factors that determined the extent of surgical difficulties included site and eloquence of the area, number of feeding vascular territories and draining veins, degree and rate of flow, presence of flow-related aneurysms, and the physical nature of the arteriovenous malformation. There were 59 males and 30 females and the average age was 32 years. Headache, giddiness and convulsions were the common presenting complaints. Six patients were unconscious after surgery. Of these, five patients died in the immediate post-operative period and one patient gradually recovered. Additionally, seven patients developed unilateral limb weakness that included hemiplegia (4 patients) and hemiparesis (3 patients) following surgery. Clinical follow-up ranged from 6 months to 18 years (average 43 months). All surviving patients are leading normal and essentially symptom free life and have recovered from their symptoms of headache, convulsions and giddiness. Large AVMs are amenable to 'curative' surgery with 'acceptable' results. The surgery can be challenging and appropriate case selection that is based on the surgeons experience is vital and decisive.

Radiological study of carrying angle among male and female and its clinical importance

: The long axes of the ulna and humerus form an acute angle when the upper limb is in its anatomical position and the elbow is fully extended is known as the carrying angle. It is typically larger in females than in males Anthropologists use the carrying angle to predict a person's sex; orthopaedic surgeons use it to surgically treat a variety of elbow disorders; and total elbow prosthetics. The study aimed to assess the carrying angle in an attempt to determine its value in both sexes, proposing a simple and reliable method for measuring it.The elbow radiographs taken in the normal anteroposterior and lateral views were assessed independently and uniformly by anatomists. A total of 70 adult radiographs between the ages of 18 to 76 years, 35 males and 35 females were gathered. To measure the angle, two lines were drawn: one along the mid-axis of the upper limb of the forearm, passing between the radius and ulna through the superior radioulnar joint, and the other along the mid-axis of the lower third of the humerus, where the angle is measured.The carrying angle is statistically more significant in females than in males among 70 radiographs. The p-value was 0.000 and the mean and SD for males were 14.3±2.740, while the mean and SD for females were 21.92±3.170.The current study concludes that there is a significant gender difference between females and males; carrying angle influences secondary sexual characteristics.

PROPOSAL OF A MODIFIED TIP APEX DISTANCE FOR PREDICTION OF LAG SCREW CUT-OUT IN TROCHANTERIC HIP FRACTURES

Lag screw cut-out is a serious complication of dynamic hip screw fixation in trochanteric hip fractures. Lag screw position is recognised as a crucial factor influencing the occurrence of lag screw cut-out. We propose a modification of the Tip Apex Distance (TAD) and hypothesize that it could enhance the reliability of predicting lag screw cut-out in these injuries.A retrospective study of hip fracture cases was conducted from January 2018 to July 2022. A total of 109 patients were eligible for the final analysis. The modified TAD was measured in millimetres, based on the sum of the traditional TAD in the lateral view and the net value of two distances in the anteroposterior (AP) view. The first distance is from the lag screw tip to the opposite point on the femoral head along the lag screw axis, while the second distance is from that point to the femoral head apex. The first distance is a positive value, whereas the second distance is positive if the lag screw is superior and negative if it is inferior. Receiver operating characteristic (ROC) curve analysis was used to assess the reliability of various parameters for evaluating the lag screw position within the femoral head.Factors such as reduction quality, fracture pattern according to the AO/OTA classification, TAD, Calcar-Referenced TAD, Axis Blade Angle, Parker’s ratio in the AP view, Cleveland Zone 1, and modified TAD were statistically associated with lag screw cut-out. Among the tested parameters, the novel parameter exhibited 90.1% sensitivity and 90.9% specificity for predicting lag screw cut-out at a cut-off value of 25 mm, with a p-value &lt; 0.001.The modified TAD demonstrated the highest reliability in predicting lag screw cut-out. A value of 25 mm may potentially reduce the risk of lag screw cut-out in trochanteric hip fractures.

New Anatomic Anterolateral Ligament Reconstruction Used in a Complex Revision ACL Reconstruction

Background: Anterior cruciate ligament reconstructions (ACLRs) are performed to restore knee biomechanics, increase knee stability, and slow the progression of osteoarthritis. After ACLRs, many patients still have residual anterolateral instability which is a risk factor for ACL graft failure. An anterolateral ligament reconstruction (ALLR) attempts to restore the native function of the anterolateral complex to augment the ACL. Performing an ALLR with an ACLR has been reported to reduce symptoms of instability and improve clinical outcomes. Indications: While no definitive indication for an ALLR has been set, current considerations include high posterior tibial slope &gt;12°, revision ACLR, high-grade pivot shift, skeletally immature patients, hyperlaxity, and patients in high-level sports. Technique Description: The preoperative assessment includes a thorough physical examination with special attention paid to rotational laxity assessed via the pivot-shift examination. Imaging should include standard radiographic series (anteroposterior, posteroanterior flexion, lateral, and sunrise views), long-leg mechanical axis views to assess coronal plane alignment and standing lateral ACL stress radiographs to assess sagittal alignment and objective instability. The iliotibial band ALLR graft is harvested first. An 8-cm long by 1-cm wide strip of the inferior iliotibial band is harvested in a standard fashion, leaving the distal aspect attached to Gerdy’s tubercle. An anchor is placed centered upon the native ALL distal tibial insertion. The native ALL femoral origin is identified at 4.7 mm posterior and proximal to the fibular collateral ligament, and a second suture anchor is placed at this point. Final fixation is performed after the final fixation of the ACLR graft. Results: A study by Pioger et al reported that patients with ACLR and ALLR had significantly less reoperation rate than patients with isolated ACLR, 8.9% versus 20.5% respectively. Lee et al found that a revision ACLR in combination with an ALLR was effective in reducing rotational laxity, which was assessed by the pivot-shift test. Discussion: We describe a technique for a new anatomic ALLR using the iliotibial band that attempts to restore the native ALL anatomy. This surgical technique effectively restores rotational laxity and improves knee stability. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.