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1.  Efficacy and safety profile of combination of tramadol-diclofenac versus tramadol-paracetamol in patients with acute musculoskeletal conditions, postoperative pain, and acute flare of osteoarthritis and rheumatoid arthritis: a Phase III, 5-day open-label study 
Journal of Pain Research  2014;7:455-463.
Objective
We aimed to evaluate the safety and efficacy of a fixed-dose combination (FDC) of tramadol and diclofenac versus a standard approved FDC of tramadol and paracetamol, in patients with acute moderate to severe pain.
Methods
A total of 204 patients with moderate to severe pain due to acute musculoskeletal conditions (n=52), acute flare of osteoarthritis (n=52), acute flare of rheumatoid arthritis (n=50), or postoperative pain (n=50) were enrolled in the study at baseline. Each disease category was then randomized to receive either of two treatments for 5 days: group A received an FDC of immediate-release tramadol hydrochloride (50 mg) and sustained-release diclofenac sodium (75 mg) (one tablet, twice daily), and group B received an FDC of tramadol hydrochloride (37.5 mg) and paracetamol (325 mg) (two tablets every 4–6 hours, up to a maximum of eight tablets daily). The primary efficacy end points were reductions in pain intensity from baseline at day 3 and day 5 as assessed by a Visual Analog Scale (VAS) score.
Results
Group A showed a significant reduction in the VAS score for overall pain from baseline on day 3 (P=0.001) and day 5 (P<0.0001) as compared with group B. The combination of tramadol-diclofenac resulted in few mild to moderate adverse events (nausea, vomiting, epigastric pain, and gastritis), which required minimal management, without any treatment discontinuation. The number of adverse events in group A was nine (8.82%) compared with 22 (21.78%) in group B, after 5 days of treatment.
Conclusion
An FDC of tramadol-diclofenac showed a significantly greater reduction in pain intensity and was well tolerated compared with tramadol-paracetamol, resulting in better analgesia in patients suffering from moderate to severe pain due to acute musculoskeletal conditions, postoperative pain following orthopedic surgery, or acute flare of osteoarthritis and rheumatoid arthritis.
doi:10.2147/JPR.S67817
PMCID: PMC4140236  PMID: 25152629
tramadol and diclofenac combination; moderate to severe pain
2.  High sensitive C-reactive protein-Effective tool in determining postoperative recovery in lumbar disc disease 
Indian Journal of Orthopaedics  2014;48(4):354-359.
Background:
It is common in medical practice to see patients having persistent pain and radiculopathy even after undergoing discectomy surgery. Inflammatory cytokines, such as interleukins are produced at the site of disc herniation and are now considered responsible for the pain perceived by the patient. This study has used high sensitive C-reactive protein (HSCRP) assay for predicting inflammation around the nerve roots on very same principle, which has used HSCRP for predicting coronary artery diseases in current clinical practice. Thus, purpose of this study is to test whether HSCRP can stand as an objective tool to predict postoperative recovery in patients undergoing lumbar discectomy. That is, to study association between preoperative HSCRP blood level and postoperative recovery with the help of modified Oswestry Back Disability Score.
Materials and Methods:
A study group consisting of 50 cases of established lumbar disc disease and control group of 50 normal subjects, matched with the study group. Both the study and control groups were subjected to detailed evaluation with the help of modified Oswestry Low Back Pain Scale both pre and postoperatively at 3 months, 6 months and 1-year. The preoperative blood samples were analyzed to assess the HSCRP concentration. All the cases underwent surgery over a period of 1-year by the same surgeon.
Results:
The level of HSCRP in the study group was between 0.050– and 0.710 mg/dL and in the control group, 0.005-0.020 mg/dL. There was highly significant positive correlation between preoperative HSCRP level and postoperative score at P < 0.005. Cases with HSCRP level in the range of 0.1820 ± 0.079 mg/dL, showed better recovery (score improved > 10 points), while those with HSCRP level in the range of 0.470 ± 0.163 mg/dL, showed poor recovery (score improved < 10 points).
Conclusion:
HSCRP will serve as a good supplementary prognostic marker for operative decision making in borderline and troublesome cases of lumbar disc disease.
doi:10.4103/0019-5413.136216
PMCID: PMC4137511  PMID: 25143637
Lumbar disc disease; sciatica; discectomy; high sensitive C-reactive protein; Lumbar; disc; herniated; sciatica; blood proteins
3.  A Rare Case of Horse Shoe Shaped Lipoma of the Upper Extremity 
Horse shoe shaped lipoma of the upper extremity is a very rare entity. We present a case of 45 years old female who presented with painless progressive swelling over the distal forearm and tingling and numbness over the ulnar nerve territory. MRI and surgical exploration showed a horse shoe shaped multilobulated lipoma encasing the distal ulna. The mass was excised in toto, and the sensory alterations were completely relieved at three months follow up. We would like to highlight this rare occurrence of a horse shoe lipoma and present a detailed history of this case to increase awareness amongst clinicians regarding this condition.
PMCID: PMC4238334  PMID: 25489503
Horse shoe shaped lipoma; Upper extremity
4.  Association between single nucleotide polymorphism in collagen IX and intervertebral disc disease in the Indian population 
Indian Journal of Orthopaedics  2012;46(4):420-426.
Background:
Symptomatic intervertebral disc degeneration is being recently reported in younger population, questions the basis of its degenerative etiology. Latest evidences show that genetics play a significant role. Collagen IX, an important constituent of disc, is found to be altered in genetically predisposed individuals. Mutations have been reported in COL9A2 and COL9A3 genes, which encode Collagen IX, in Finnish and various other populations. The purpose of the present study is to test the significance of these genes in the Indian population.
Materials and Methods:
One hundred proven cases of intervertebral disc disease (IDD) of various regions of spine were selected for the study, along with matched controls. They were tested for the above mentioned alleles by allelic discrimination method with real-time polymerase chain reaction (PCR) study after isolation of DNA from blood sample. Each blood sample was classified into one of the three types – homozygous, heterozygous, and wild (normal) type allele – separately for COL9A2 and COL9A3 genes.
Results:
Homozygosity for COL9A2 allelic variation was associated with 100% occurrence of the disease. Heterozygous allele of COL9A2 was significantly higher in the study group (42%) as compared to the control group (17%). In contrast, allelic variation in COL9A3 gene was found to have no significant correlation with disc disease. There was no single patient with homozygous allelic variation for COL9A3, suggesting predominance of COL9A2 variation in the Indian population.
Conclusion:
This candidate gene strategy approach adds considerably to our knowledge of genetic makeup of Indian populations in relation with disc disease. This study highlights importance of COL9A2 gene variation especially of homozygous variety in contrast to COL9A3 variation in causing disc disease in Indian population.
doi:10.4103/0019-5413.97261
PMCID: PMC3421932  PMID: 22912517
Allelic discrimination; COL9A2 and COL9A3 genes; intervertebral disc disease; real time PCR
5.  Clinical Comparative Study: Efficacy and Tolerability of Tolperisone and Thiocolchicoside in Acute Low Back Pain and Spinal Muscle Spasticity 
Asian Spine Journal  2012;6(2):115-122.
Study Design
We performed a multicentric, randomized, comparative clinical trial. Eligible patients were randomly assigned to receive 150 mg of Tolperisone thrice daily or 8 mg of Thiocolchicoside twice daily for 7 days.
Purpose
To assess the efficacy and tolerability of Tolperisone in comparison with Thiocolchicoside in the treatment of acute low back pain with spasm of spinal muscles.
Overview of Literature
No head on clinical trial of Tolperisone with Thiocolchicoside is available and so this study is done.
Methods
The assessment of muscle spasm was made by measuring the finger-to-floor distance (FFD), articular excursion in degrees on performing Lasegue's maneuver and modified Schober's test. Assessment of pain on movement and spontaneous pain (pain at rest) of the lumbar spine was made with the help of visual analogue scale score.
Results
The improvement in articular excursion on Lasegue's maneuver was significantly greater on day 3 (p = 0.017) and day 7 (p = 0.0001) with Tolperisone as compared to Thiocolchicoside. The reduction in FFD score was greater on day 7 (p = 0.0001) with Tolperisone. However there was no significant difference in improvement in Schober's test score on day 3 (p = 0.664) and day 7 (p = 0.192). The improvement in pain score at rest and on movement was significantly greater with Tolperisone (p = 0.0001).
Conclusions
Tolperisone is an effective and well tolerated option for treatment of patients with skeletal muscle spasm associated with pain.
doi:10.4184/asj.2012.6.2.115
PMCID: PMC3372546  PMID: 22708015
Tolperisone; Thiocolchicoside; Skeletal muscle relaxant; Low back pain; Muscle; Spasm
6.  The split tibialis anterior muscle flap – A simple solution for longitudinal middle third tibial defects 
Background:
The tibialis anterior flap is an underused flap, mainly because it is not an expendable muscle and is small in size.
Aim:
To study the use of the tibialis anterior muscle flap for longitudinal middle third tibial defects.
Materials and Methods:
We have analysed the use of tibialis anterior flap in five patients by the function preservation technique.
Results and Conclusion:
Function preservation techniques used in the harvesting of this flap will be able to cover narrow and linear defects on middle third of tibia comfortably. Size and pliability of the muscle must be assessed before initiation of harvesting of the flap. Flap harvesting is initiated by a saggital split incision to preserve maximum blood supply to the muscle. Transverse incisions may be employed to obtain the desired reach of the flap. This flap is a simple alternative for linear wounds with small transverse dimensions on middle third of the leg, where the tibialis anterior muscle is uninjured.
doi:10.4103/0970-0358.96585
PMCID: PMC3385399  PMID: 22754153
Longitudinal tibial defect; tibialis anterior function preservation; tibialis anterior flap
7.  Polyarthritic, symmetric arthropathy in reactive arthritis 
Reactive arthritis (ReA) is an immune mediated disease, clinically associated with oligoarthritis of the lower limbs and sometimes with urethritis and conjunctivitis. In our case, a 24-year-old male presented with severe mutilating arthritis involving both upper and lower extremities in contrast to conventional Reiter's syndrome which presents with asymmetric oligoarthritis. He had multiple well-defined, irregular, erythematous, hyperkeratotic, scaly and itchy plaques, not easily distinguishable from pustular psoriasis. The patient also gave history of circinate balanitis and urethritis. He was started on methotrexate (7.5 mg/week, later escalated to 15 mg/week with 15 mg/day folinic acid supplementation) to which he responded. But when he stopped it on his own, the symptoms recurred. Hence, methotrexate was restarted, but still the patient suffers from fixed flexion deformities in affected joints. Histopathological examination of skin lesions is also suggestive of ReA. Thus, this case report suggests that diagnosis of Reiter's should be considered in symmetrical, mutilating polyarthritis patients with typical skin lesions.
doi:10.4103/0976-9668.92312
PMCID: PMC3276018  PMID: 22346240
Mutilating arthritis; reactive arthritis; Reiter's syndrome

Results 1-7 (7)