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1.  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
2.  Posttraumatic osteonecrosis and nonunion of distal pole of scaphoid 
Indian Journal of Orthopaedics  2013;47(4):425-428.
Posttraumatic osteonecrosis of distal pole of scaphoid is an extremely rare with only two reported cases so far. We present a case of a 30-year-old male with a 2-year-old posttraumatic osteonecrosis and nonunion of distal pole of scaphoid left wrist. He presented with complaints of pain and restriction of movements. There was no evidence of radiocarpal arthritis. He was managed with open reduction and internal fixation with k-wires, supplemented by a pronator quadratus based muscle pedicle bone graft. The fracture union was achieved at 6 months. After 2 years, he had almost complete range of wrist motion and had returned to his preinjury level of functional activity. His MRI (magnetic resonance imaging) scans showed evidence of revascularization suggesting successful incorporation of bone graft.
PMCID: PMC3745701  PMID: 23960291
Posttraumatic osteonecrosis scophoid; posttraumatic nonunion scophoid; muscle pedicle bone graft
3.  Thoracoscopic decompression in Pott’s spine and its long-term follow-up 
International Orthopaedics  2012;36(2):331-337.
Video-assisted thoracoscopic surgery (VATS) has become an alternative tool for a variety of spinal conditions as this approach minimises much morbidity related to conventional thoracotomy. The purpose of this study was to determine the efficacy of VATS and its long-term results in patients with dorsal spinal tuberculosis.
Materials and methods
This retrospective long-term follow-up study of VATS-assisted surgical treatment of dorsal spine tuberculosis included 30 patients with a mean age of 33.5 years (range 15–60). Patients with dorsal spine tuberculosis who were suitable surgical candidates for VATS underwent a three-portal thoracoscopy for decompression with/without fusion of the spine along with routine chemotherapy for tuberculosis (TB). Patients were assessed for blood loss, duration of surgery, postoperative incision pain, duration of hospital stay, neurological recovery, and progression of deformity. Patients were observed for a minimum of five years.
The mean duration of surgery was 158.8 min (range 90–220 min) with mean blood loss of 296.7 ml (range 200–450 ml). Complications were seen in ten patients. The mean follow-up was 80 months (range 60–90 months) with neurological improvement and return of ambulatory power in all patients at final follow-up. There was an average increase in kyphus angle by 7.5° at final follow-up and 95% of patients achieved an excellent or good subjective outcome.
VATS-assisted surgical decompression can be a safe and effective technique for anterior debridement and fusion in tuberculosis of the dorsal spine to achieve neurological recovery with reduced morbidity, blood loss, and hospital stay compared to thoracotomy.
PMCID: PMC3282856  PMID: 22215368
4.  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
5.  Primary tumours and tumorous lesions of clavicle 
International Orthopaedics  2007;32(6):829-834.
Primary tumours and tumorous lesions of the clavicle are very rare, and little literature is available regarding their characteristics and outcome. We studied the clinical, radiological, and histopathological characteristics, and outcome of management of patients with primary tumours of the clavicle presenting to us from 1996–2005. Twelve cases of primary tumours of the clavicle presented during the above period. Seven patients were treated with partial or complete claviculectomy, and no reconstruction was done. These seven patients were evaluated for functional results with AMSTS scoring. Eight patients out of twelve had a primary malignant bone tumour, four of these being Ewing’s sarcoma. No particular predilection of location of the tumour within the clavicle was seen. Functional and oncological results of claviculectomy were good. The distribution of types of tumours in the clavicle is quite different from long-bone tumours. No reconstruction is required following partial or total claviculectomy.
PMCID: PMC2898940  PMID: 17583813
6.  Expandable self-locking nail in the management of closed diaphyseal fractures of femur and tibia 
Indian Journal of Orthopaedics  2009;43(3):264-270.
Intramedullary fixation is the treatment of choice for closed diaphyseal fractures of femur and tibia. The axial and rotational stability of conventional interlocking nails depends primarily on locking screws. This method uses increased operating time and increased radiation exposure. An intramedullary implant that can minimize these disadvantages is obviously better. Expandable intramedullary nail does not rely on interlocking screws and achieves axial and rotational stability on hydraulic expansion of the nail. We analyzed 32 simple fractures of shaft of femur and tibia treated by self-locking expandable nail.
Materials and Methods:
Intramedullary fixation was done by using self-locking, expandable nail in 32 patients of closed diaphyseal fractures of tibia (n = 10) and femur (n = 22). The various modes of injury were road traffic accidents (n = 21), fall from height (n = 8), simple fall (n = 2), and pathological fracture (n = 1). Among femoral diaphyseal fractures 16 were males and six females, average age being 33 yrs (range, 18- 62 yrs). Seventeen patients had AO type A (A1 (n = 3), A2 (n = 4), A3 (n = 10)) and 5 patients had AO type B (B1 (n = 2), B2 (n = 2), B3 (n = 1)) fractures. Eight patients having tibial diaphyseal fractures were males and two were females; average age was 29.2 (range, 18- 55 yrs). Seven were AO type A (A1 (n = 2), A2 (n = 3), A3 (n = 2)) and three were AO type B (B1 (n = 1), B2 (n = 1), and B3 (n = 1)). We performed closed (n = 27) or open reduction (n = 5) and internal fixation with expandable nail to stabilize these fractures. The total radiation exposure during surgery was less as no locking screws were required. Early mobilisation and weight-bearing was started depending on fracture personality and evidences of healing. Absence of localised tenderness and pain on walking was considered clinical criteria for union, radiographic criteria of union being continuity in at least in three cortices in both AP and lateral views. Patients were followed for at least one year.
The average operative time was 90 min (range, 55-125 min) for femoral fractures and 53 min (range, 25-115 min) for tibial fractures. Radiation exposure was minimum, average being 84 seconds (range, 54-132) for femoral fractures and 54 seconds (range, 36-78) for tibial fractures. All fractures healed, but few had complications, such as infection (one case with tibial fracture) bent femoral nail with malunion (n = 1), and delayed union (n = 3; 2 cases in femur and 1 case in tibia). Mean time of union was 5.1 months (range, 4-10½ months) for femoral fractures and 4.8 months (range, 3-9 months) for tibial fractures.
We found the nail very easy to use with effective fixation in AO type A and B fractures in our setting. Less surgical time is required with minimum complications. The main advantage of the expandable nail is that if affords. satisfactory axial, rotatory, and bending stability with decreased radiation exposure to operating staff and the patient.
PMCID: PMC2762176  PMID: 19838349
Diaphyseal fracture femur; diaphysial fracture tibia; expandable nail; self-locking nail; radiation risk

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