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author:("Garg, rudhira")
1.  Role of fine-needle aspiration cytology and core needle biopsy in diagnosing musculoskeletal neoplasms 
The management of musculoskeletal neoplasms requires an accurate diagnosis, histologic type, and degree of tumor differentiation.
The present study was undertaken to compare the accuracy of fine-needle aspiration cytology (FNAC) and core needle biopsy (CNB) in the diagnosis of musculoskeletal tumors and further to compare the results with histopathological examination of surgical specimens. Grading of malignant tumors was also compared on these techniques.
Materials and Methods:
This prospective study was conducted on 50 patients with musculoskeletal neoplasms. Detailed history, clinical examination, and radiological investigations were undertaken. FNAC followed by CNB were performed in each case. The tumors were categorized as benign and malignant with a definitive histotype diagnosis. For malignant neoplasms, cytologic and histologic gradings were done into three grades. The sensitivity and specificity of FNAC and CNB were compared.
Of the 50 cases with musculoskeletal neoplasms, 32 (64%) were bone tumors and 18 (36%) were soft tissue tumors. The sensitivity of FNAC and CNB for categorizing bone tumors into benign and malignant was 94.7%. For soft tissue tumors, FNAC had a sensitivity of 90.9% and CNB had a sensitivity of 100%. The specificity of both the techniques, FNA and CNB for bone and soft tissue tumors was 100%. For malignant bone tumors, cytologic grade was concordant with CNB grade in 72.2% of the cases. Cytologic grade was concordant with the grade on CNB in 81.8% cases for malignant soft tissue neoplasms.
FNAC and CNB alleviate the need for an open biopsy in diagnosing and grading musculoskeletal neoplasms, thus facilitating appropriate therapeutic intervention.
PMCID: PMC4782412  PMID: 27011434
Bone; core needle biopsy (CNB); fine-needle aspiration (FNA); histopathology; neoplasm; soft tissue
2.  Cytological diagnosis of small cell osteosarcoma of the bone 
Small cell osteosarcoma (OS) is a rare histological variant of OS that poses unique diagnostic difficulties. We present a case of a 10-year-old child who underwent fine needle aspiration cytology (FNAC) from a mass in the right thigh. The cytological findings were those of a malignant small round cell tumor, closest to small cell OS. The FNAC findings were confirmed on histopathology.
PMCID: PMC4520049  PMID: 26229255
Bone; fine needle aspiration; small cell osteosarcoma
3.  Navigated pedicle screw placement using computed tomographic data in dorsolumbar fractures 
Indian Journal of Orthopaedics  2014;48(6):555-561.
Computed tomographic (CT) based navigation is a technique to improve the accuracy of pedicle screw placement. It is believed to enhance accuracy of pedicle screw placement, potentially avoiding complications arising due to pedicle wall breach. This study aims to assess the results of dorsolumbar fractures operated by this technique.
Materials and Methods:
Thirty consecutive skeletally mature patients of fractures of dorsolumbar spine (T9–L5) were subjected to an optoelectronic navigation system. All patients were thoroughly examined for neurological deficit. The criterion for instability were either a tricolumnar injury or presence of neurological deficit or both. Patients with multilevel fractures and distorted spine were excluded from study. Time taken for insertion of each pedicle screw was recorded and placement assessed with a postoperative CT scan using Laine's grading system.
Only one screw out of a total of 118 screws was misplaced with a Laine's Grade 5 placement, showing a misplacement rate of 0.847%. Average time for matching was 7.8 min (range 5-12 min). Average time taken for insertion of a single screw was 4.19 min (range 2-8 min) and total time for all screws after exposure was 34.23 min (range 24-45 min) for a four screw construct. No neurovascular complications were seen in any of the patients postoperatively and in subsequent followup of 1-year duration.
CT-based navigation is effective in improving accuracy of pedicle screw placement in traumatic injuries of dorsolumbar spine (T9-L5), however additional cost of procuring CT scan to the patient and cost of equipment is of significant concern in developing countries. Reduced radiation exposure and lowered ergonomic constraints around the operation table are its additional benefits.
PMCID: PMC4232823  PMID: 25404766
Dorso lumbar spine; Laine's grading; navigation; paired point matching; Spine; spinal fractures; bone screws; neuronavigation; tomography
4.  Outcome of Kienbök’s disease in twelve cases: a mid-term follow-up study 
Singapore Medical Journal  2014;55(11):583-586.
No single study has established the superiority of one treatment of Kienböck’s disease over the other. Pooled outcome data is presently considered the best way to add to the knowledge and understanding of Kienböck’s disease.
A total of 12 patients (9 male and 3 female) with Kienböck’s disease were included in the present case series. The mean age of the 12 patients was 28 years. One patient presented in Lichtman stage I, five in Lichtman stage II, five in Lichtman stage IIIa, and one in Lichtman stage IV. Univariate and multivariate analyses of the obtained data were performed to identify any correlations.
The mean follow-up time was 62 months, and the mean modified Mayo wrist score improved from the preoperative value of 29.5 to the final value of 89.6. Lichtman stage at presentation showed moderate positive correlation with the duration of symptoms (r = 0.56), and a strong negative correlation with the preoperative and final modified Mayo scores (r = –0.89 and r = –0.77, respectively). The final modified Mayo score showed moderate negative correlation with the duration of the symptoms (r = –0.55). There was a significant difference in the preoperative modified Mayo scores of patients who presented in stage II and those of patients who presented in stage IIIa (p = 0.03). However, the difference in the final modified Mayo scores of the patients in these stages was not significant (p = 0.14).
Lichtman’s stage is moderately related to the duration of symptoms, suggesting natural progression of the disease. The final outcomes of stages II and IIIa were the same irrespective of the surgical treatment (radial shortening and/or vascularised bone grafting).
PMCID: PMC4294007  PMID: 25631969
Kienböck’s disease; lunate; wrist
5.  Hollow Mill for Extraction of Stripped Titanium Screws: An Easy, Quick, and Safe Technique 
Removal of jammed titanium screws can be difficult due to the problem of stripping of the hexagonal heads of the screws. We present a technique of extraction of stripped screws with the use of a standard 4.5 mm stainless steel hollow mill in a patient of peri-implant fracture of the radius fixed with a titanium locking plate 2 years back. The technique is quick, safe, and cost effective.
PMCID: PMC4090986  PMID: 25013544
Hollow mill; stripped screws; titanium locked plates; titanium plates
6.  Evaluation of analgesic effect of local administration of morphine after iliac crest bone graft harvesting: A double blind study 
Background and Objective:
Pain is a complex process influenced by both physiological and psychological factors. In spite of an armamentarium of analgesic drugs and techniques available to combat post-operative pain, appropriate selection, and effective management for relief of post-operative pain still poses unique challenges. The discovery of peripheral opioid receptors has led to growing interest in the use of locally applied opioids (intra-articular, intra-pleural, intra-peritoneal, and perineural) for managing acute pain. As bone graft harvesting is associated with significant post-operative pain and there is a paucity of literature on the use of peripheral opioids at the iliac crest bone harvesting site, the present study was planned to evaluate the analgesic efficacy of local administration of morphine after iliac crest bone graft harvesting.
Materials and Methods:
A total of 60 patients, 20-50 years of age scheduled to undergo elective surgery for delayed and non-union fracture both bone leg with bone grafting under general anaesthesia (GA) were randomly assigned to one of the four groups of 15 patients each: group 1: 2.5 ml normal saline (NS) +2.5 ml NS infiltrated into the harvest site at 2 sites + 1 ml NS intramuscularly (i/m); Group 2: 2.5 ml NS + 2.5 ml NS infiltrated into the harvest site at 2 sites + 5 mg morphine in 1 ml i/m.; Group 3: 2.5 mg (2.5 ml) morphine + 2.5 mg (2.5 ml) morphine infiltrated into the harvest site at 2 sites + 1 ml NS i/m; Group 4: 0.5 mg naloxone (2.5 ml) +5 mg (2.5 ml) morphine infiltrated into the harvest site at 2 sites + 1 ml NS i/m. Pain from the bone graft site and operative site was assessed for 24 h post-operatively.
The patients who had received morphine infiltration (Group 3) had significantly less pain scores at the graft site at 4, 6, and 10 post-operative hours. They also had significantly less morphine consumption and overall better pain relief as compared to the other groups.
Morphine administered peripherally provided better analgesia as compared to that given systemically and this effect was noticeable after 4 h post-operatively.
PMCID: PMC3788235  PMID: 24106361
Local morphine; iliac crest bone graft; post-operative analgesia
7.  Repair of the torn distal biceps tendon by endobutton fixation 
Indian Journal of Orthopaedics  2012;46(1):71-76.
A number of techniques have been described to reattach the torn distal biceps tendon to the bicipital tuberosity. We report a retrospective analysis of single incision technique using an endobutton fixation in sports persons.
Materials and Methods:
The present series include nine torn distal biceps tendons in eight patients, fixed anatomically to the radial tuberosity with an endobutton by using a single incision surgical technique; seven patients had suffered the injuries during contact sports. The passage of the endobutton was facilitated by using a blunt tipped pin in order to avoid injury to the posterior interosseous nerve. The patients were evaluated by Disabilities of the Arm, Shoulder and Hand (DASH) score and Mayo elbow score.
The average age of the patients was 27.35 years (range 21–42 years). Average follow-up was 41.5 months (range 24–102 months). The final average flexion extension arc was 0°–143°, while the average pronation and supination angles were 77° (range 70°–82°) and 81° (range 78°–85°), respectively at the last followup. All the patients had a Disabilities of the Arm, Shoulder and Hand (DASH) score of 0 and a Mayo elbow score of 100 each. All the seven active sports persons were able to get back to their respective game. There was no nerve injury or any other complication.
The surgical procedure used by us is a simple, safe and reproducible technique giving minimal morbidity and better cosmetic results.
PMCID: PMC3270609  PMID: 22345810
Autograft; biceps tendon; elbow; tendon repair; tendon rupture
8.  Results of operative treatment of acetabular fractures from the Third World—how local factors affect the outcome 
International Orthopaedics  2007;33(2):347-352.
The objective of this study was to assess the outcome of operations on acetabular fractures from a developing country in the presence of locally available facilities. Sixty-three acetabular fractures were assessed at an average follow up of 52.94 months after operation. Twenty-six patients operated upon in the first three years and 37 operated thereafter were separately studied to discover the effect of the learning curve. Regarding the fractures, 47 of 63 (74.6%) had excellent/good results (Harris Hip Score>80). The complications included broken drill bit in eight patients (12.69%), deep infection and heterotopic ossification in five patients (7.93%), avascular necrosis and sciatic nerve palsy in two patients (3.17%) and implant failure in one patient (1.58%). The results collected during the learning curve were inferior in the complex fractures (p value<0.001). Complications were common in patients opting for local implants and in those operated after over 2 weeks delay.
PMCID: PMC2899060  PMID: 17940767

Results 1-8 (8)