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BACKGROUND: The expression pattern of micro-RNAs (miRNA) has been implicated in the pathomechanism of various bone disorders, and has a role in differentiation of osteoblasts and osteoclasts. The purpose of the study was to investigate the differential miRNA profiles of osteoporotic hip fractures compared to young patients with hip fractures. METHODS: Blood samples from ten osteoporosis patients and ten young, healthy patients, presenting with acute hip fractures were collected and subjected to an initial miRNA profiling to detect those miRNAs with significant variations between the two groups based on polymerase chain reactions performed in duplicate. A real-time quantitative polymerase chain reaction-based analysis was then performed for validation of specific miRNAs that were significantly different between the two groups. RESULTS: A total of 182 miRNAs were analyzed. Thirty-nine of them showed significant differences between the two groups in the initial miRNA profiling. The validation results suggested that five miRNAs related to bone metabolism had significantly different expression among the osteoporotic hip fracture group compared to the young, healthy group: miR-23b-3p and miR-140-3p were up-regulated; miR-21-5p, miR-122-5p and miR-125b-5p were down-regulated. CONCLUSIONS: Differential expression of selected miRNAs in patients with osteoporotic hip fracture suggests a possible role of miRNAs as potential biomarkers in prevention or timely prediction of osteoporotic fractures in the elderly. Further research is required to elucidate the mechanism of their involvement in osteoporosis. LEVEL OF EVIDENCE: Not applicable.

BACKGROUND: Accurate prediction of operative duration is necessary for efficient operating room scheduling, minimizing cancellations, shortening waitlists, better risk stratification, and effective preoperative counseling. Prolonged operative duration is also associated with negative patient outcomes. Posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) is typically a lengthy surgical procedure with variable operative duration. The purpose of this study is to identify patient-, procedure-, and surgeon-specific variables that influence the operative duration in PSF for AIS and determine its impact on early postoperative outcomes. METHODS: Hospital records of 150 AIS patients who underwent PSF at a single center were retrospectively reviewed. Various patient-, procedure-, and surgeon-specific variables—deemed to be possibly affecting the operative duration—were analyzed. A multivariate regression model was used to identify independent predictors of operative duration. The association between operative duration and early postoperative outcome measures was determined. RESULTS: The final model obtained from the multivariate regression analysis included the following factors: experience of the chief surgeon (β = −0.36), Cobb angle of the major structural curve (β = 0.35), number of screws inserted (β = 0.28), coronal deformity angular ratio (β = 0.20), and apical vertebral rotation (β = −0.21 to 0.03). The model could explain 44% of the variability in the operative duration (R (2) = 0.44). The operative duration had a significant correlation with estimated blood loss, need for perioperative blood transfusion, and length of hospital stay. CONCLUSIONS: A set of variables that predict the variability in operative duration during PSF for AIS was identified, with the experience of the chief surgeon and the severity of the curve being the strongest predictors. CLINICAL RELEVANCE: The results of this study emphasize the need for each hospital and surgical team to identify predictors of operative duration in their setup in order to better anticipate prolonged operative duration. LEVEL OF EVIDENCE: 3.

Background: Abnormal anatomy is a contributory factor to wrong-level surgery. Variations in the number of vertebrae in populations from different races and geographical regions have been described. A ∼10% prevalence of variations in number of thoracic and lumbar vertebrae in adolescent idiopathic scoliosis (AIS) patients has been previously reported. The objectives of present study were (i) to find out the prevalence of variations in the number of thoracic and lumbar vertebrae and the presence of lumbosacral transitional vertebrae (LSTV) in Indian AIS patients and (ii) to correlate these variations with gender and type of curve. Methods: Hospital records and imaging of 198 AIS patients were reviewed retrospectively. A standardized numbering strategy was used to identify the number of thoracic vertebrae, number of lumbar vertebrae, and presence of LSTV. Patients9 gender and curve type were correlated with the presence of an abnormal number of thoracic or lumbar vertebrae. Radiology reports and operation notes were reviewed to find out instances when the radiologist or surgeon had identified an abnormal number of vertebrae. Results: Forty patients (20.2%) with abnormally numbered thoracic or lumbar vertebrae were identified. Twenty patients (10.1%) had abnormally numbered thoracic vertebrae, and 33 patients (16.7%) had abnormally numbered lumbar vertebrae. The prevalence of LSTV was 18.2%. Presence of variations did not correlate with gender or curve type. Radiology reports identified 2/40 patients with variations, whereas operation notes showed 4/40 patients had been correctly identified to have abnormally numbered vertebrae. Conclusions: There is high prevalence of variation in the number of thoracic or lumbar vertebrae in AIS patients, with most of those missed being identified by radiologists or surgeons. The patient9s preoperative imaging must be scrutinized to identify these patients and take the variation into account to avoid wrong selection of fusion levels. Level of Evidence: 3. Clinical Relevance: Text. The study raises awareness about possibility of wrong selection in fusion levels due to anatomical variations in surgery for AIS.

EOS® imaging is a proprietary imaging technology that was launched in 2007. Based on a gaseous particle detector with a multi-wire proportional chamber, it offers several advantages over other imaging modalities: low dose of radiation, ability to create 3D reconstructions, ability to conduct whole body imaging, high reproducibility in measuring various parameters of alignment and faster imaging time. EOS® imaging is slowly gaining widespread acceptance as its applications in various disorders continue to evolve. It has been found to be particularly useful and has opened up new avenues of research in the field of spinal deformities. This narrative review seeks to provide an overview of the proprietary technology behind EOS® imaging, compare it to existing imaging modalities, summarize its current applications in various spinal disorders and outline its limitations.

BACKGROUND: During the COVID-19 pandemic, public health measures to encourage social distancing have been implemented, including cancellation of school and organized sports. A resulting change in pediatric fracture epidemiology is expected. This study examines the impact of the COVID-19 pandemic on fracture incidence and characteristics. METHODS: This is a retrospective cohort study comparing acute fractures presenting to a single level I pediatric trauma hospital during the COVID-19 pandemic with fractures during a prepandemic period at the same institution. The "pandemic" cohort was gathered from March 15 to April 15, 2020 and compared with a "prepandemic" cohort from the same time window in 2018 and 2019. RESULTS: In total, 1745 patients presenting with acute fractures were included. There was a significant decrease in the incidence of fractures presenting to our practice during the pandemic (22.5±9.1/d vs. 9.6±5.1/d, P

Study Design: Prospective, comparative.Purpose: To compare the histopathological and electron microscopic changes in the ligamentum flavum (LF) between degenerative lumbar canal stenosis (LCS) and lumbar disk herniation (LDH).Overview of Literature: The LF has been implicated as a key structure in the pathogenesis of LCS. With aging, the LF undergoes morphological changes–a decrease in the elastic component and an increase in the collagen component, in addition to other focal changes. By comparing the histopathological and electron microscopic picture of the LF in elderly patients with LCS with that in young patients with LDH, the role of this ligament in the pathogenesis of LCS may be clarified.Methods: Forty patients were prospectively recruited and divided into two groups: group 1 included 20 patients with degenerative LCS aged >55 years and group 2 included patients with LDH aged

Study Design: Retrospective cohort. Objective: ( a) To compare the recommendations of Lenke and Peking Union Medical College (PUMC) classifications in choosing distal fusion levels in Lenke 1 adolescent idiopathic scoliosis (AIS) curves and ( b) to analyze whether the variability in distal fusion levels influences treatment outcomes. Methods: Hospital records of Lenke 1 AIS patients operated for single stage, posterior-only deformity correction were analyzed. Distal fusion levels recommended by Lenke and PUMC classifications were calculated and were compared with the actual distal fusion levels. The study population was divided based on whether the actual distal fusion levels were in agreement, shorter or longer than those recommended by Lenke classification. Subgroup analysis of Lenke 1C curves was done. The groups were compared with regard to the following outcome measures: Cobb angle correction, postoperative sagittal vertical axis, postoperative C7 offset, and Scoliosis Research Society–22r (SRS-22r) score at 24 months. Results: The distal fusion levels recommended by the 2 classifications were in agreement in 92 of 104 cases. In all the cases with disparity, Lenke classification recommended shorter fusions than the PUMC classification. No statistically significant difference was observed in the outcome measures—whether the actual distal fusion levels were in agreement, shorter, or longer than those recommended by the Lenke classification or whether or not the recommendations for selective fusion of any of these classifications were adhered to. Conclusion: Lenke classification can save fusion levels without compromising on treatment outcomes when compared with PUMC classification. Variability in choice of distal fusion levels is not clinically significant at 24-month follow-up.

Pedicle screw instrumentation is currently the “gold standard” in scoliosis surgery. However, placement of pedicle screws in thoracic spine is considered challenging. Previous studies have described morphometric changes in the pedicle when a larger screw is inserted, with pedicle expansion preceding screw cutout and pedicle fracture. We report an unusual case of neurological deficit due to cord compression by an expanded pedicle following pedicle screw insertion on the concave side of the apical vertebra in a 14-year-old patient with Lenke Type 3C(-) adolescent idiopathic scoliosis. Identification of the expanded pedicle as the cause of neurological symptoms, prompt action, and deferring the corrective surgery while accepting less correction helped us in negotiating the problem without causing permanent neurological deficit. Pedicle expansion in an immature spine can cause neurological complications. The screw diameter at the apical vertebrae on the concave side should be carefully selected.

Minimal access surgery has revolutionized most surgical disciplines and spine surgery is no exception. Minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) was devised to reduce the approach-related morbidity of open TLIF and has flourished in the last decade. With expanding indications, standardization of technique and equipment, publication of more studies on its results and complications being brought to light – an update of the existing knowledge on MI-TLIF is imminent. We provide a review of the indications, technique, results and complications of MI-TLIF while also highlighting its variations and utility in special situations.

Study Design: Retrospective cohort.Purpose: To report the demographic characteristics, clinico-radiological presentation, laboratory findings, and outcomes of “middlepath” treatment in patients with spinal tuberculosis from a single public healthcare facility in a developing country.Overview of Literature: Tuberculosis is a global health problem that is endemic in developing countries and undergoing resurgence in developed ones. Spinal tuberculosis can cause disabling back pain, progressive deformity, and neurological involvement. However, there is a lack of large-scale epidemiological studies quantifying the size and severity of the problem of spinal tuberculosis.Methods: Hospital records of spinal tuberculosis patients treated at a single center over a period of 5 years were retrospectively reviewed. A diagnosis of spinal tuberculosis was based on standard clinical, radiological, microbiological, and histopathological evidence. Patients were treated in accordance with the “middle-path” regimen; surgery was reserved for selective indications.Results: A total of 1,652 patients were included. Their median age was 32.4 years, with 53% being male. Axial pain (98%) was the most common presenting symptom; 19% of patients had neurological deficit. Lumbar spine (37%) was the most common site of involvement, with a paradiscal pattern (82%) of involvement predominating. Multi-level involvement was seen in 19% of patients; skip lesions were noted in 2.8%. Transpedicular biopsy was performed in 667 patients; at least one tissue test was diagnostic of tuberculosis in 65% of patients. Forty-four patients had drug resistance to rifampicin. Surgery was required in 10.5% of patients. The “middle-path” regimen was associated with high compliance and significant improvements in pain (Visual Analog Scale score) and function (36-Item Short Form Health Survey).Conclusions: Our findings confirm the widespread prevalence of spinal tuberculosis and describe various epidemiological characteristics of a large sample of spinal tuberculosis patients. Adoption of the “middle-path” regimen is associated with high compliance and favorable outcomes in spinal tuberculosis.

Historically, osteoarticular tuberculosis (TB), including spinal TB, was treated with prolonged course of antitubercular therapy (ATT). Due to various challenges, there has been reluctance to explore the use of short-course ATT in spinal TB. However, with the success of short-course ATT being demonstrated in other forms of extrapulmonary TB, the subject is open for debate again. Therefore, we systematically reviewed various published literature to determine whether short-course treatment regimen (6 months) of ATT provides equivalent results in terms of disease healing as long-course treatment regimen (≥9 months) in the management of spinal TB. Five electronic databases (PubMed, MEDLINE, EMBASE, CENTRAL, and Web of Science) and their reference lists were searched to identify relevant randomized controlled trials with at least 1 year of follow-up that compared short-course with standard-course ATT for treatment of spinal TB. The methodological quality of included studies was assessed, and their data were extracted. A meta-analysis was used to calculate pooled effect sizes and 95% confidence interval (CI). The outcome measure was healed status of the disease at the final follow-up. Of 331 publications identified through literature search, eight publications describing six randomized studies were included. Moreover, 375 of 414 patients (90.58%) who received 6 months of ATT had healed status at their final follow-up compared to 404 of 463 patients (87.26%) who received ≥9 months of ATT. Overall, the healed status of spinal TB was equivalent in patients in both groups (pooled relative risk, 0.98; 95% CI, 0.92–1.04; p =0.439). However, there was considerable heterogeneity among the trials (I2=40.8%, p =0.149). The results suggest that the use of short-course (6 months) chemotherapy may be considered for the treatment of spinal TB in view of the similarity in the healing response achieved compared to treatment regimens of longer duration.

There are no established guidelines regarding the surgical strategy to be adopted in congenital scoliosis with multiple hemivertebrae—decision has to be guided taking into account the contribution of each hemivertebra to the deformity and its growth potential. We describe a case of a 12-year-old woman with congenital scoliosis due to unbalanced multiple hemivertebrae. Preoperative imaging revealed the presence of three hemivertebrae—at D7, D10 and L5. Our surgical strategy was guided by various factors—the morphology of the hemivertebrae, the location, the contribution of each hemivertebra to the deformity and their relationship to each other. Based on this, we performed a selective hemivertebrae resection—completely resecting L5 hemivertebra and performing ‘egg-shell’ decancellation of D7 hemivertebra and in situ fusion of D10 hemivertebra, yielding satisfactory results. This case report illustrates a rational thought process that can guide a paediatric spinal deformity surgeon in treating scoliosis with multiple hemivertebrae.

Oncogenic osteomalacia (OO) is an uncommon paraneoplastic syndrome occurring due to the presence of a tumour that oversecretes fibroblast growth factor-23, which impairs renal phosphate handling. In most cases, the tumour is a morphologically distinct entity called ‘phosphaturic mesenchymal tumour’ (PMT). Spinal tumours causing OO are exceedingly rare. A 55-year-old man presented with multiple bone pain and proximal muscle weakness in the lower limbs. The constellation of biochemical findings (hypophosphataemia, normocalcaemia, increased alkaline phosphatase, low–normal serum vitamin D and hyperphosphaturia) with radiographical rarefaction of the skeleton and pseudofractures led us to consider OO as a possibility. Functional imaging (68Ga DOTA-NOC positron emission tomography/CT scan) localised the tumour to the D2 vertebra. Complete surgical resection led to resolution of symptoms, improved ambulatory status, normalisation of biochemical parameters and healing of pseudofractures. PMT should be considered in the differential diagnosis of hypophosphataemic osteomalacia with hyperphosphaturia. Tumour localisation with functional imaging and complete surgical resection produces satisfactory outcome.

Tears of the posterior roots of the medial and lateral meniscus are relatively uncommon injuries, but can be seen concurrently with anterior crucial ligament (ACL) injuries in young athletes. Despite a wealth of research on the diagnostics and therapeutics of root tears in the adult population, pediatric root tears have been relatively understudied despite the increasing incidence of youth sports participation and thus increasing ACL injuries. With an understanding that repair of the meniscal root is paramount to positive outcomes in the adult population, it is therefore crucial to understand the incidence, presentation, and treatment of this pathology in pediatric patients as well. Our aim is to review the available literature on pediatric meniscal root tears, as well as special considerations for anatomy and diagnosis of this injury in children and adolescents.

Background: Treatment of distal radius fractures has seen a paradigm shift since the use of volar locking plates became popular. However, there is a subset of fractures, which includes extreme distal volar rim fractures, that is often not amenable to fixation by volar locking plates as there is insufficient bone mass to put screws. These fractures as such are quite rare but carry a huge morbidity due to frequent lack of anatomical reduction and fixation. A number of different techniques like hook plates, specially designed distal volar locking plates and loop wire techniques have been described for these fractures, but they have been found to be less helpful when the fracture fragments are very small. Methods: Herein, we describe our experience on 6 patients, using a novel surgical technique for fixation of distal radius volar rim fractures which works equally well even when the fragments are quite small (2–3 mm). The technique uses low cost and readily available implants (K wire and conventional volar locking plate) without the need of any special implants. Results: The total of 6 cases of distal radius volar rim fractures (AO/OTA Type B3 = 4, Type C1 = 2) were operated. The mean age was 50.83 years (range: 31–72). The mean follow-up duration was 43.3 months (range: 26–66). The mean size of the volar fragment was 3.66 mm (range: 2–5). The mean pronation and supination were 72.5° (60–80) and 74.2° (60–85). The main flexion and extension were 52.5° (40–75) and 58.3° (50–80) respectively. The mean grip strength was 19.8 kg (4–38) and it was mean 79.3% (40–130%) compared to uninjured side. The mean PRWE score was 12.3 (2–31). One patient developed symptoms of Complex Regional Pain syndrome 1 (CRPS 1) which resolved with conservative management and no other complications were noted. Conclusion: Our technique offers an indigenous, cost-effective way for fixation of extreme volar rim fracture fragments which can be easily adopted and used by surgeons in developing countries.

INTRODUCTION: Spinal metastases are the most commonly encountered spinal tumors. With increasing life expectancy and better systemic treatment options, the incidence of patients seeking treatment for spinal metastasis is rising. Radical resections and conventional low-dose radiotherapy have given way to modern ‘separation’ surgeries and stereotactic body radiotherapy which entails lesser morbidity and improved local control. This article provides an overview of the decision making and currently available treatment options for metastatic spinal tumors. METHODS: A MEDLINE literature search was made for studies in English language reporting on human subjects, describing results of various treatment options that are a part of multidisciplinary management of metastatic spinal tumors. The highest-quality evidence available in the literature was reviewed. DISCUSSION: Treatment of patients with metastatic spinal tumors is largely palliative, with radiotherapy and selective surgery being the mainstays of management. Multidisciplinary management that incorporates factors like patient performance status, expected survival and systemic burden of disease and employs well-validated decision-making frameworks for guiding treatment holds the key to an effective palliative treatment strategy. Effective pain management, achieving local control, adequate neurological decompression in the setting of epidural cord compression and surgical stabilization for mechanical stabilization are the main goals of treatment CONCLUSION: The management of metastatic spinal tumors has been rapidly evolving; currently, limited decompression and stabilization followed by postoperative SBRT for local tumor control are associated with less morbidity and may be referred to as the current standard of care in these patients.

Meniscocapsular separations of the posterior horn of the medial meniscus, also known as ramp lesions, are common injuries associated with anterior cruciate ligament (ACL) tears. Though there is ample literature on ramp lesion diagnosis, treatment, and outcomes in adult populations, there is scarce work in pediatric populations where increasing ACL tear rates and different injury patterns make more studies and discussion on this topic paramount. We therefore review here the available literature on ramp lesions as it relates to pediatric populations as well as anatomic and technical considerations that should be considered in this group of patients.

The endeavour to make spine surgery safe with reproducible, consistent outcomes has led to growing interest and research in the field of intraoperative imaging, navigation and robotics. The advent of surgical robot systems in spine surgery is relatively recent - with only a few systems approved for commercial use. At present, pedicle screw insertion remains the primary application of robotic systems in spine surgery. The purported advantages of robot-assisted pedicle screw insertion over other conventional techniques are its increased accuracy, reproducible consistency and reduced radiation exposure. Many of these claims have been supported or refuted by individual studies - and high quality evidence for the same is lacking. Robotic spine surgery also has its share of limitations which include increased operative time, considerable learning curve and technical pitfalls unique to the robotic systems. The applications of robotic spine surgery are evolving and expanding to spinal deformity, spine oncology and needle-based interventional treatments. This review provides an overview of the evolution and current status of robotic spine surgery along with an evidence-based discussion of its current applications in spine surgery.

Three-dimensional printing (3DP) is one of the latest tools in the armamentarium of the modern spine surgeon. The yearning to be more precise and reliable whilst operating on the spine has led to an interest in this technology which has claimed to achieve these goals. 3D printing has been used pre-operatively for surgical planning and for resident or patient education. It has also found its way to the operation theatre where it is used to fabricate customized surgical tools or patient-specific implants. Several authors have highlighted significant benefits when 3D printing is used for specific indications in spine surgery. Novel applications of this technology in spine surgery have also been described and though still in a nascent stage, these are important for this technology to sustain itself in the future. However, major limitations have also come to light with this technology in use. This article seeks to review the current status and applications of 3D printing in spinal surgery and its major drawbacks while briefly describing the essentials of the technology. It is imperative that the modern spine surgeon knows about this important innovation and when and how it can be applied to improve surgical outcomes.

Background: Despite the rapidly expanding anterolateral ligament (ALL) literature base, little has focused on the reliability of its detection on MRI. This is especially important in the pediatric population where the scarcity of pediatric cadaveric specimens hinders the accurate estimation of its prevalence. Purpose: The purpose of this study was to assess the visibility of ALL on common MRI pulse sequences and to calculate the inter-rater reliability among multiple expert readers in a cohort of normal pediatric knee MRIs. Methods: A series of 3T pediatric knee MRIs obtained from 8/2018-4/2019 were reviewed to identify patients without significant knee pathology. Knee laterality, age, gender, and regional physeal status were also recorded. One orthopedic surgeon, 1 pediatric musculoskeletal (MSK) radiologist, and 1 adult MSK radiologist, independently reviewed each MRI pulse sequence (T1-weighted, PD-weighted, and PD-weighted fat-suppressed images) separately, to determine the presence or absence of the 3 parts of the ALL (femoral, tibial, and meniscal proper). Inter-rater reliability was calculated using Fleiss’ Kappa (K). Results: Inclusion criteria were met for 75 patient knees with a mean age of 12.7±3.42y (3-19) and a greater proportion of females (57.3%). The distribution of regional physeal status was: Open-48.0%, Closing-29.3%, and Closed-22.7%. Inter-rater reliability was slight to fair (K: 0.141-0.340) for visualizing any specific ALL component on a unique MRI sequence (Table 1). For visualizing a specific attachment on any MRI sequence, there was slight to moderate agreement (K: 0.018-0.411). Visualizing any ALL attachment on any MRI sequence also yielded slight agreement (K: 0.190). Inter-rater reliability between specialities (i.e. Ortho vs. MSK Radiology) did not differ substantially from group findings. No single study sequence demonstrated enhanced reliability for all ALL components. Conclusion: The reliability of ALL detection on MRI across multiple clinicians was slight to moderate for all components in this cohort of normal 3T pediatric knee MRIs. No single sequence was consistently better for ALL detection agreement. This is in contrast with previous work showing substantial agreement among raters and describing PD-weighted imaging as preferable for viewing the ALL. Experience in musculoskeletal imaging did not confer improved agreement. Establishing diagnostic reliability should be a prerequisite for use of an imaging finding in the research or clinical setting. Existing literature drawing conclusions from ALL findings on MRI may need to be interpreted with caution if reliability testing is not described. [Table: see text]

Isolated traumatic brachialis muscle tears are uncommonly reported – leading to occasional misdiagnosis and misdirected treatment. The rarity of brachialis muscle tear may promote misdiagnosis or mistreatment of this injury. We report an isolated brachialis muscle tear in a young female, possibly caused by strenuous exercise in the gymnasium. The diagnosis was made clinically and confirmed by magnetic resonance imaging. The patient was subsequently managed adequately with conservative treatment. We herein present a 35-year-old woman who was diagnosed with an acute brachialis muscle tear being diagnosed with a combination of clinical signs and imaging and successfully managed non-operatively. A chronologically arranged review of literature is also presented.

Background: The purpose of our study was to compare magnetic resonance arthrography (MRA) as a diagnostic modality against the gold standard of wrist arthroscopy in the evaluation of chronic wrist pain. Materials and Methods: Thirty three patients with chronic wrist pain suspected to have ligament injuries of the wrist were prospectively recruited. They underwent MRA examinations followed by wrist arthroscopy. Arthroscopic findings were compared with radiological findings focusing on three important structures – triangular fibrocartilage complex (TFCC), scapholunate ligament (SLL), and lunotriquetral ligament (LTL). Results: For the 17 patients with TFCC tears/perforations on arthroscopy, MRA gave a sensitivity (SEN) = 88%, specificity (SPE) = 87.5%, positive predictive value (PPV) = 88%, and negative predictive value (NPV) = 87.5%. For the 13 patients with SLL tears on arthroscopy, MRA gave SEN = 77%, SPE = 100%, PPV = 100%, and NPV = 87%. For the 7 patients with LTL tears on arthroscopy, MRA gave SEN = 29%, SPE = 100%, PPV = 100%, and NPV = 84%. A composite correlation between findings on MRA and wrist arthroscopy revealed an overall SEN = 73%, SPE = 96%, PPV = 93%, and NPV = 85% for MRA, with overall accuracy = 88%. Conclusions: The presented diagnostic results of MRA are superior to those of magnetic resonance imaging quoted in literature. MRA is a potent tool for evaluating chronic wrist pain but tends to miss lesions of intrinsic carpal ligaments (SLL and LTL) more than TFCC. Wrist arthroscopy may be recommended when the clinical suspicion is strong.

Juvenile ossifying fibroma (JOF) is a rare benign fibro-osseous tumour occurring in craniofacial bones of children and young adults. An 8-year-old girl presented with low back pain since 10 months. Plain radiographs revealed a vertebra plana-like lesion of L3 vertebra. CT scan showed an osteolytic lesion with areas of ground-glass appearance interspersed with bone flecks involving the entire body, pedicles and laminae of L3 with well-circumscribed cortical margins. Biopsy was done—histopathological findings showed cellular fibrous stroma with bony trabeculae—which, on corroboration with clinical and radiological findings noted previously, confirmed the diagnosis of JOF. The patient underwent preoperative angioembolisation, curettage and posterior stabilisation. At follow-up of 15 months, the patient was asymptomatic—imaging revealed residual tumour in pedicles—which however did not progress radiologically. The case raises the importance of including this rare condition as a differential diagnosis in children and reports successful outcome with subtotal resection.

Aims and Objectives: Our study aims to outline and investigate the role of wrist arthroscopy as both a diagnostic and a therapeutic tool in patients with chronic wrist pain. Materials and Methods: Between April 2014 and June 2015, 33 patients with chronic wrist pain undiagnosed with routine x-rays and with clinical suspicion of ligament injuries of the wrist underwent arthroscopic examinations. Both radiocarpal and midcarpal joint spaces were visualized using standard arthroscopic portals. The surgeries were carried out as day care procedures under general anesthesia. Therapeutic interventions as deemed necessary were done in the same sitting. The arthroscopic findings were further correlated with radiological and clinical findings. Results: In the 33 wrists that were arthroscopically examined, 17 lesions of the triangular fibrocartilage complex (TFCC) were found—10 (58.8%) were central perforations which were arthroscopically debrided whereas 7 (41.2%) were tears of the TFCC at its peripheral attachment and were repaired. The treated patients at a mean follow-up period of 7.1 months displayed an improvement in their Mayo wrist scores. A total of 13 scapholunate tears and 7 lunotriquetral tears were seen—which were graded arthroscopically. Partial tears (60%) were treated by thermal shrinkage and ablation while complete tears (40%) underwent open reconstruction. Cartilage defects of varying degrees were also noted in 6 patients. One patient was found to have extensive cartilage damage and was advised wrist fusion. No complications were noted in the follow-up period. Conclusions: Wrist arthroscopy is a potent diagnostic tool and tends to pick up lesions of intrinsic carpal ligaments and the TFCC which are often missed by advanced imaging techniques. It aids in staging of the lesions, thereby guiding their treatment, and provides a host of therapeutic offerings. It may be recommended in cases of chronic wrist pain where the clinical suspicion is strong and the operating team is well-versed with the technique.