Objectives: Post-operative care and rehabilitation intends to make patients pain free and to return to pre-injury functional state. This can be provided in hospital or be home based. Early home care prevents economic burden to hospital and can achieve superior or similar outcomes with reduced complications. This study was carried out to compare the clinical and functional outcomes among “early” versus “late” discharged patients. Methods: This was a retrospective analysis. Patients aged 12-65years operated for upper/lower limb injuries and agreed for home care were included. Exclusions were spinal and pelvi-acetabular trauma, mentally unsound patients and polytrauma patients with chest/ abdomen/head or vascular injury. “Early” discharge group- patients discharged within 48hours of surgery and “late” group- discharged after 48 hours. Both groups were taught medications, dressings and rehabilitation. Follow-up was as per standard protocol. Outcome measures like pain, ROM, ADL, fracture union and complications like infection were noted. Results: A total of 80 patients operated from 2018 to 2019 with 40 each in “early” and “late” group were considered for analysis. Mean age of patients was 39.1±18.6 years in “early” group and 42.9±19.8 years in “late” group. Males were slightly more in “early group(82.5%) than “late” group(75%). Lower limb trauma was 85% in “early” and 72% in “late” groups. Around 80% were closed fractures in both groups. Infection was more in “late” group (20%) versus 10% in “early group. Union time, ADL, ROM, outcomes and expectation scores were comparable in two groups. Conclusions: The current study indicates that the functional outcomes are similar in early and late discharge groups. Infection rate was less in early discharge group. The length of hospital stay does not have statistically significant impact on the clinical and functional outcomes. The economic burden is reduced by home care. To overcome limitations, larger sample size, longer duration of follow-up and incorporating patient’s socio-economic profile for effect on outcome is suggested.

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Background: Tha choice of implant for the fixation of extra articular distal humerus fracture has always been a matter of debate among the treating surgeons. Plates of various shapes and designs have been in use. An anatomically pre-contoured Locking compression plate (LCP)- Extra articular distal humeral plate(EADHP) has been developed for sturdy fixation of distal humeral extra articular fractures and has solved the dilemma of the treating surgeon regarding the choice of implant. This study focuses on the functional outcome of distal third extra articular humeral fractures fixed with the above mentioned plate. Material and methods: Twenty four patients presenting to our casualty and OPD with extra articular distal humerus fracture were operated between June 2014 and December 2016. All patients were operated by triceps splitting approach. Patients were regularly followed and clinico-radiological outcome was recorded in terms of elbow range of movement, fracture union time, implant failure, secondary displacement, non union, infection and other complications. Mayo elbow Performance score was calculated and used for final functional outcome. Results: A total of 24 patients were operated (19 male and 5 female). Twenty three patients had radiological union after a mean of 3.5 months. One patient went into non union. The average follow up period was 18 months. Mean flexion of elbow achieved at last follow-up was 125±18.5⁰(Range 75-135⁰) and the mean loss of extension was 5⁰±5.5⁰ (Range 0-15.5⁰).Average Mayo elbow performance score at the final follow up was 88.6±6.5. There was one case of infection, no neurovascular deficit post operatively or implant failure in any of the cases. Conclusion: Anatomical precontoured distal humeral locking plates allow for stable fixation and initiating early elbow physiotherapy thereby yielding satisfactory functional and radiological outcome with minimal to no complication.

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Undoubtedly the Orthopaedic field has seen enormous developments in the last few years. Inspite of state of the art instrumentation and cutting edge technology, there are certain musculoskeletal conditions, of diverse etiology, which are still not amenable to treatment. Of late there has been a substantial interest in the “biologic therapy” or so called regenerative medicine the potential ability of the stem cells to self renew and regenerate has opened up a plethora of avenues where they can be used. Brittberg et al [1] was the first to introduce cell based therapy to Orthopaedics. They injected autologous chondrocytes in the cartilage defect of knee, which led to the formation of hyaline cartilage. Stem cells are primitive cells that are capable of self renewal & differentiation into various tissue lines. They can be broadly classified as embryonic and adult stem cells. The embryonic stem cells (ESCs) are derived from the blastocysts whereas adult stem cells can be derived from tissues like the bone marrow, adipose tissue, skeletal muscles, dental pulp etc. Yamanaka et al in 2006, developed pluripotent stem cells from fibroblasts & called them induced pluripotent stem cells (iPScs) [2]. Though ESCs are far better but ethical concerns & their potential to from teratomas, preclude their use in clinical setting. Mesenchymal stem cells (MSCs) are multipotent stem cells that were first identified by Friedenstein et al [3] and can be derived from bone marrow, muscle, adipose tissue, brain etc. It has now been established the cell yield is 500 times greater in adipose tissue than bone marrow [4]. The MSCs have been used in various musculoskeletal conditions like bone defects, non union, avascular necrosis, tendinopathies etc. The management of large bone defects has traditionally been autologous/allogenic graft. Quarto et al [5] in 2001 used a hydroxyapatite scaffold loaded with MSCs which was implanted in the long bone defect. There was 100% integration of the scaffold to the parent bone. There have been many studies, which have shown the safety & efficacy of MSCs for managing bone defects. Hernigou et al [6] was first to add Bone marrow aspirate concentrate (BMAC) to core decompression for osteonecrosis of the femoral head (ONFH). They reported good to excellent results. Sen et al [7] conducted a controlled trial on 51 osteonecrotic hips in 40 patients. 26 hips were treated with core decompression & autologous BMAC, whereas 25 hips underwent only core decompression. The follow up showed significant improvement in the clinical score and mean hip survival in the BMAC group. Recently many investigators have used MSCs isolated from the bone marrow aspirate for ONFH [8, 9, 10]. The use of MSc derived from bone marrow is now more or less an established from of treatment for Ficat state I & II of ONFH. The use of MSC in bone healing has been studied extensively [11,12,13]. They have been used for non - unions, tibial osteotomies, distraction osteogenesis, spinal fusion & fractures. Unlike bone, which has a great healing potential, articular cartilage has a limited regeneration potential. Any damage to AC eventually leads to osteoarthritis. Though most studies report encouraging results of MSC, injection into the knee joint. There are certain unanswered questions like the frequency & no. of injections, efficacy & safety of allogenic cells & efficacy in advanced O.A. There have been a few studies on the role of MSCs in tendon regeneration & tendinopathies. All these studies have reported positive results; however there is paucity of well - controlled studies. Though extensive research in the field of stem cells has opened up many new avenues and raised hope of new treatment approaches, but at the same time there are many questions that need to be answered. The most important among them is the possibility of stem cell therapy & tumour formation. The probability of cultured cells undergoing mutations is another concern. The role of stem cells in bone repair, tendon and cartilage regeneration is well established and here to stay. Diseases which are being managed surgically may be treated by simple injection of cells. A time may come when the syringe will replace the scalpel!!

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Introduction: Management of bone defects due to trauma, bone infection, congenital defects or extensive excision of malignant tumors is very challenging. The approach is multi disciplinary and patients should be prepared for a long course of multiple surgeries and possible complications. The small size gaps management is easier with cancellous bone graft or non-vascularized bone-grafting. Larger defects require other options like; vascularized bone-grafts, bone transport, non-vascularized grafts, allografts and fibular grafting. These techniques are associated with their morbidity, complications and require expertise. Masquelet technique is a relative new technique used in the management of large bone defects. Material & Method: We performed masquelet induced membrane technique in 10 patients Out of ten patients two involving infected nonunion tibia were treated with bone grafting and plaster cast application as they had smaller bone defect of less than 5cm size, two patients with infected gap nonunion humerus were treated with intra-medullary interlocking nail and bone grafting. Rest all were treated with bone grafting and locking plate fixation. The average size of the bone defect after debridement was 13 cm (4- 25 cm). Conclusion: Membrane induced technique given by Masquelet is very effective two staged procedure to treat long bone defects seen in infected non-union, gap non-union seen in fractures with bone loss. No expertise is required

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Background: Surgical management of compound fractures of tibia either or without bone loss are full of complications. These injuries are complicated both for patient and the treating surgeon. Many operative procedures are needed for treating such patients. Along with providing a stable fixation it employs the principal of distraction osteogenesis to fill the bone gap. It is a less invasive surgery with minimal blood loss. Immediate weight bearing prevents disuse osteoporosis and muscle atrophy with consequent preservation of limb function. There is no need of bone grafting. Compared to ilizarov this construct is less bulky, it is easier to apply, post op dressing is easier and it is less cumbersome for the patient. Hence LRS fixator can be used as a good treatment option in such patients. This study was conducted to analyze the efficacy, functional and radiological outcome of Limb Reconstruction System (LRS) in management of open fractures of tibia with or without bone loss as a primary and definitive tool. Methods: We treated 20 patients with compound injuries of tibia between December 2014 and November 2018 with Limb Reconstruction System (LRS) as a primary and definitive tool. 15 males & 05 females were included in this study with age ranging from 20 - 50 years. All the patients had compound fractures of tibia (except Type III C) with or without bone loss. Results: Average follow up period was 36.45±4.7 weeks ranging from 06 - 18 months. There was sound bony union in all of the cases with resolution of infection. The mean time of full weight bearing was 10.45±2.25 weeks and bone union time was 23.26±6.33 weeks. ASAMI score (Association for the Study and Application of the Method of Ilizarov) for bony outcome was Excellent in 13 (65%) patients, Good in 5 (25%) patients, Fair in 1 (5%) patient and Poor in 1 (5%) patient. ASAMI score for functional outcome was Excellent in 14 (70%) patients, Good in 4 (20%) patients, Fair in 1 (5%) patient and Poor in 1 (5%) patient. Rail external fixator was sufficient enough for wound healing & bony union. Conclusion: Limb Reconstruction System (LRS) offers an alternative option to treat compound fractures of tibia because of simplicity of application, its good fracture stability, adjustable geometry, light weight, affordable cost, patient friendly and can induce/enhance fracture healing by compression and distraction osteogenesis.

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Osteochondromas are the rare benign and malignant tumour of the growing bone, usually affecting the young adults. Solitary osteo cartilaginous exostosis is more common than the hereditary multiple exostosis (HME). The first 3 decades of life has maximum chances of getting affected with osteochondroma and hardly occurs in craniofacial bones because of the fact that these bones are not formed by endochondral ossification. Most of the symptoms occur at the periphery of the bone tissues, with commonest site been around the knee. Since it mostly occurs in the bone growing phase, the tumor characteristically grows away from the joint. Diagnosis is difficult at symptomless stage; incidentally it is diagnosed when X-ray is carried out. Malignant transformation is their most severe complication. However, deformities and interference with major joint function are the most frequent complaints in patients with hereditary multiple osteochondroma. Treatment should therefore aim not only at surgical resection of the masses but also at prevention of deformities. This article reports observations made on 24 patients with solitary osteochondroma, with a mean follow-up of 2.5 years

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Complications are associated with most of the surgical procedures, It is the acumen, proficiency in skill of the surgeon that minimizes them, Post-Operative dislocation of THA are not uncommon but vascular complications are rare and every effort should be made to reduce their occurrence. We report a case of femoral neck fracture in young adult in whom Common femoral artery injury occurred along with dislocation of hip following THA leading to disarticulation of Hip. A short review of literature is also presented to make us aware of neurovascular complications with THA.

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A humeral fracture is the most likely fracture to be associated with nerve injury. Approximately 12% of fractures of the shaft of the humerus are complicated by immediate radial nerve paralysis. Fractures of the humeral shaft associated with median nerve palsy are exceedingly uncommon because it is protected throughout its course from direct contact with bone by muscles of varying thickness. Here we report the case of a young man who sustained a fracture at the junction of middle 1/3rd and distal 1/3rd of the humeral shaft associated mainly with median nerve palsy.

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Objectives: This prospective study has been done to evaluate the clinical and radiological outcome of open reduction and direct internal fixation of posterior malleolus in trimalleolar ankle fracture through posterolateral approach in prone position. Methods: This study is a prospective study of 12 cases of trimalleolar ankle fracture with posterior malleolus fracture treated with open reduction and direct internal fixation technique through posterolateral approach, admitted in the department of orthopaedics, L.L.R. Hospital, Kanpur from June 2017 to June 2019. All cases of posterior malleolus fracture were directly fixed with antiglide/buttress plate in prone position. All patients were assessed using American Orthopedic Foot and Ankle Society (AOFAS) score clinically and post traumatic arthritic score radiologically. Ankle joint mobility was also compared with unaffected side. Results: Mean follow-up period was 21 months (range: 18-24 months). There were 8 male patients and 4 female patients between 20 and 65 years of age (mean: 44 years). Average time to surgery was 7.5days(4-21days). According to AOFAS assessment, result was excellent in 8 patients and good in 4 patients. When compared with uninjured side, there was no significant difference in plantar flexion of ankle (p=0.325) but there was significant difference in dorsiflexion of ankle joint (p<0.001). Conclusion: Open reduction and direct internal fixation of small posterior malleolus provides satisfactory clinical and functional outcomes and facilitates rehabilitation by creating more stable construction. Posterolateral approach to ankle gives adequate access to the posterior malleolus allowing its anatomical reduction and stable fixation to maintain articular congruency without any step.

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Background: One of the most common causes of shoulder pain in adults is Subacromial impingement syndrome. Use of Platelet rich plasma is among the current emerging concepts in the treatment of this syndrome. This study aimed to compare the effects of subacromial injection of Platelet rich plasma (PRP) with Steroid injection in treatment of shoulder impingement syndrome. The clinical condition and functional outcome scores before and after the treatment were evaluated. Methods: The study was conducted in the department of orthopedics of a tertiary level centre. Cases were selected from the patients attending routine OPD of orthopaedics department from January 2015 to December 2017 that had not responded to conservative treatment with NSAID and exercises for 4 weeks. A total of 100 patients were selected for the study. These were divided into two equal groups of 50 patients each. Group A (n=50) patients were treated with Single dose injection of mixture of 1 ml of steroid (Depo-Medrol containing 40mg/ml of Methylprednisolone) and 5 ml of Xylocaine. Group B (n=50) patients were treated with Single dose injection of 3 ml of autologous platelet rich plasma. The patients were followed up at 2 weeks, 6 weeks and 6 months after treatment and evaluated clinically and functionally using visual analogue scale (VAS) score for pain and the Constant-Murley score. Results: There was an improvement in mean VAS scores and mean Constant-Murley scores in both the groups. The mean VAS score improved from 7.2 to 5.4 at 2 weeks, 2.8 at 6 weeks and 1.7 at 6 months in Group A. The mean VAS score improvement in Group B was 6.8 at 2 weeks, 5.7 at 6 weeks and 4.5 at 6 months compared to initial VAS score of 7.4 in this group. In Group A the mean Constant score increased from 37.5 at baseline to 51.6 at 2 weeks, 55.3 at 6 weeks and 63.7 at the end of 6 months after the injection; whereas it increased from 39.8 at baseline to 40.7 at 2 weeks, 42.1 at 6 weeks and 51.4 at 6 months of receiving the injection in Group B. Both the groups showed clinical improvement but the improvement in the mean Constant score and mean VAS score at 2 weeks, 6 weeks and 6 months was significantly better in Group A (Steroid) than Group B (PRP). This difference in improvement in both the groups was statistically significant (p Value <0.05). Conclusion: In our study the results for steroid injection were better than injection of platelet rich plasma for treatment of subacromial impingement syndrome. The clinical improvements as well as improvement in VAS scores and Constant scores were significantly greater with steroid injection than with PRP injection.

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A 10-years-old female presented with a 5-month history of a gradually increasing swelling of the left side of her face. A panoramic radiographic view of the mandible showed diffuse radiolucency in the ramus of the mandible. The computed tomography (CT) scan revealed destruction of the mandibular bone. The biopsy was consistent with tubercular osteomyelitis. Antitubercular therapy resulted in a marked reduction of the size of the swelling over a 18-month period.

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