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Supracondylar humerus fractures are the most common fractures around the elbow in children between 4 and 10 years of age. The treatment of supracondylar humerus fractures can vary from conservative treatment to operative treatment depending on the fracture type. All around the world, the most commonly used classification system is the Wilkins-modified Gartland classification of supracondylar humerus fractures. Currently, the decision to operate or conserve the fracture is taken on basis of this classification system. Non-operative treatment for type I fractures and operative treatment for type III fractures have been well-established in literature. The management of type II supracondylar humerus fracture creates confusion in the minds of numerous orthopaedic surgeons around the world. We have tried addressing this using a classification-based treatment algorithm. Other classification systems like the AO classification, Lagrange and Rigault classification and Bahk classification with special reference to special fracture patterns that require attention and pre-op planning have also been mentioned. It is important to understand that operative management of each supracondylar humerus fracture is unique as regards fixation method and it is important to consider the fracture pattern before internal fixation.

BACKGROUND: In the era of increasing drug resistance in pulmonary tuberculosis (TB), it is prudent to assess causes of poor response to anti tubercular therapy (ATT) and drug sensitivity pattern (DSP) in osteoarticular TB. MATERIALS AND METHODS: As a part of Bombay Orthopaedic society’s research project, members were asked to refer non responders to ATT to our institute. Cases were enrolled from October 2010 to March 2014. Deep tissue samples were obtained in all but five cases and subjected to a battery of tests including histopathology (HPE) and TB culture and sensitivity. The DSP was compared with the study performed by the principle author from 2004 to 2007 and published in 2009. RESULTS: 39 male and 50 female patients with a mean age of 24.85 years (2–66) were included and classified in four groups after results. (1) Culture and HPE positive-36. 24 had MDR and three XDR TB. Primary resistance to even second line drugs and deterioration of DSP since last study was noted, (2) culture negative and HPE positive-21. The cause of poor response was surgical in more than half cases, (3) non representative samples or lost to follow-up-15, (4) TB mimics-16. CONCLUSION: There is increasing incidence of primary resistance to second line drugs, primary resistance in children and worsening of resistance patterns as compared to older studies. ATT initiation is a fateful decision and every attempt should be made to rule out TB mimics and establish DSP before initiation.

BACKGROUND: Modified Dunn procedure has become popular for the treatment of severe cases of slipped capital femoral epiphysis (SCFE). We assessed the outcomes in a consecutive series of thirty Indian adolescents treated by the modified Dunn procedure. MATERIALS AND METHODS: All patients treated by the modified Dunn procedure by a single senior Paediatric Orthopaedic surgeon over six years were retrospectively reviewed. Only moderate and severe slips undergoing modified Dunn procedure were included. Clinical records and radiographs were reviewed to obtain demographic information; to classify the slips by duration of symptoms, severity and physeal stability; and to assess the outcomes by Harris Hip Score, radiological changes and rate of complications. RESULTS: Thirty consecutive hips with 19 stable and 11 unstable slips were included. Mean age was 13.05 years, 25 boys and 5 girls; six were acute slips, six chronic and eighteen acute-on-chronic. There were 20 moderate and 10 severe slips. Slip angle correction was on average 43.63° ± 8.42° (p

CASE A full-term neonate presented with right lower extremity ischemia at birth because of spontaneous thrombosis of the right common iliac artery. He was initially managed with supportive treatment, anticoagulation, and dressings; however, advanced gangrenous changes precluded salvage of the ischemic limb. A guillotine amputation was performed at day 15 of life, and the stump went on to heal well by secondary intention. CONCLUSION Thromboembolic events occurring in infancy are well-recognized phenomena; however, it is far rarer to encounter a neonate born with "congenital gangrene". We discuss the etiology, approach to diagnosis, and treatment of this rare but devastating condition.

Background: Treatment of Congenital Psuedarthrosis of Tibia (CPT) often poses significant challenges due to difficulty in achieving union and subsequent complications like refractures, implant failures, etc. Our new comprehensive protocol is aimed at achieving crossunion between the tibia and fibula. Aims and objectives: The aim of the present study is to evaluate the short-term results of our new protocol and to compare the results with our previously used techniques. Materials and Methods: 10 patients with mean age 2.35 years (1 to 6.5 years) who were treated by our new comprehensive protocol were included in Group A, and 11 patients with mean age 2 years (1 to 5.5 years) who primarily underwent intramedullary rodding with bone graft were included in Group B. The new comprehensive protocol consisted of pre-operative Zolendronate infusion, surgery consisting of intramedullary fixation of tibia supplemented with Ilizarov ring fixator and bone grafting aimed at achieving tibia-fibula cross-union. Retrospective evaluation of serial radiographs was performed and outcomes with respect to union and subsequent complications were analysed. Results: 10/10 (100%) patients in Group A united, whereas union was achieved in only 8/11 (72%) patients in Group B. The index surgery was successful in achieving union in all 10 patients in Group A, whereas in Group B 2.25 (1 to 4) surgeries were needed to achieve union. The time to union was significantly shorter in Group A (4.68 months) as compared to Group B (30.88 months). The cross sectional area of union was significantly greater in Group A (3.82 cm2) as compared to Group B (1.18 cm2). One patient in Group A needed a subsequent corrective osteotomy for tibial valgus, and one patient underwent tibia lengthening; whereas in Group B, two patients needed corrective osteotomes for residual malaligments. Conclusion: Our study demonstrates that the new comprehensive protocol is extremely effective for achieving sound union in Congenital Pseudarthrosis of Tibia.

Closed reduction, arthrography and hip spica application is the treatment of choice for DDH between 6 and 18 months. There is a lot of controversy about what exactly constitutes an “acceptable” closed reduction and arthrogram and the arthrography findings are often difficult to interpret. In this video, the authors describe the technique to perform the arthrogram as well as the interpretation of the same. Various static parameters such as the femoral head coverage, the medial dye pool and the hourglass constriction are shown. In addition, the validity of the safe zone is discussed. With this video technique article, the authors hope that it becomes easy for the budding paediatric orthopaedic surgeon to perform and interpret the DDH arthrogram with ease. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s43465-021-00493-4.

The Masquelet Induced Membrane Technique (IMT) is one of the tools in the surgeon’s armamentarium for the management of segmental bone defects. The first stage of the IMT includes the insertion of a cement spacer, which is typically fashioned by the free-hand technique. We propose a novel technique for preparation of the cement spacer using a split syringe barrel as a mould. This technique produces a uniformly cylindrical spacer with minimum cement spillage, while also minimizing thermal damage to the surrounding soft tissues. It is a simple and cost-effective method that can be adapted for use in any long bone in children.

BACKGROUND: CT-guided percutaneous drill resection (PDR) for osteoid osteoma fell out of vogue with the advent of radiofrequency ablation (RFA). However, the routine use of RFA is offset by its high cost and need for specialized instrumentation. AIMS AND OBJECTIVES: This study is an analysis of our series of patients treated with PDR, to know its efficacy, safety and cost-effectiveness. MATERIALS AND METHODS: This study is a retrospective analysis of prospectively collected data of 33 patients with a mean age of 10.03 years (2–21 years 13:10 M:F). The proximal femur was the commonest location, followed by shaft femur, tibial shaft, pubic ramus and lateral humeral condyle. Three were recurrences. The procedures were performed by one of four fellowship-trained paediatric orthopaedic surgeons, using a standard protocol with the help of a radiologist. CT-guided drilling was performed under sedation/short general anaesthesia using a guidewire for identification, followed by sequential drilling using a 6.5 mm cannulated drill or a triple ream drill. Patients were hospitalized overnight for pain relief and allowed protected weight bearing as per pain tolerance. They were evaluated weekly for 2 weeks and 3 monthly thereafter. RESULTS: The mean final follow-up was 19.72 months (6 months to 58 months). All patients had complete resolution of symptoms within 3 days of the procedure. There were no major complications and there were two minor complications (haematoma and cutaneous hypoaesthesia). There were no recurrences till the last follow-up. CONCLUSION: This study, one of the first and largest from India about CT-guided PDR, shows that this method can still be safely and effectively used as a primary treatment modality in OO, especially in economically challenged population. It is much more cost-effective than RFA, can be used even for recurrent tumours and can be safely be performed by a general orthopaedic surgeon without any special instrumentation.

CASE We report the case of a patient with a long-standing and progressive forearm deformity, secondary to underlying hereditary multiple exostoses (HME). A salvage surgery was performed with excision of the pathologic parts of the radius and the ulna, followed by the creation of a 1-bone forearm. CONCLUSION One of the common manifestations of HME is forearm deformity due to abnormal ossification and osteochondromas that affect the radius and/or the ulna. Progressive deformity can lead to increasing pain, joint instability, limited motion, and functional decline. Neglected or recalcitrant deformities pose a treatment challenge. At 1.5 years after surgery, the patient had a satisfactory outcome with a fully functional, pain-free forearm in a fixed, neutral position.

Background: Failed infected internal fixation produces significant pain and functional disability. In infected internal fixation of hip fractures with partial or complete head destruction, total hip arthroplasty (THA) can be technically challenging; however, it restores hip biomechanics. The present study is to evaluate the results and assess the complications of THA following failed infected internal fixation of these fractures. Materials and Methods: A retrospective review of prospectively collected data in a tertiary healthcare center was performed of 20 consecutive patients of THA following failed infected internal fixation operated between September 2001 and November 2007. There were 11 dynamic hip screw failures for intertrochanteric fractures, 6 failed osteotomies following transcervical fractures, and 3 failed screw fixations for transcervical fractures. Results: The average age of the patients was 48.5 years (range 28-70 years) and the average followup period was 6.5 years (range 3.5-10.5 years). An indigenously designed cement spacer was used in a majority of patients ( n = 15). The custom-made antibiotic impregnated cement spacer was prepared on-table, with the help of a K-nail bent at 130°, long stem Austin Moore′s prosthesis (n=1), Charnley′s prosthesis (n=1), or bent Rush nail (n=1). The antibiotic mixed cement was coated over the hardware in its doughy phase and appropriately shaped using an asepto syringe or an indigenously prepared spacer template. Nineteen of the 20 patients underwent two-stage revision surgeries. The average Harris hip score improved from 35.3 preoperatively to 82.85 postoperatively at the last followup. A significant difference was found ( P < 0.0001). None of the patients had recurrence of infection. Conclusions: The results were comparable to primary arthroplasty in femoral neck fractures. Thus, THA is a useful salvage procedure for failed infected internal fixation of hip fractures.

Background Spiral and comminuted fractures of the metacarpals are rotationally and axially unstable fractures with a tendency to shorten, which in turn causes significant extensor lag and loss of grip strength. We have designed a new, cheap and locally developed method of locked intramedullary nailing of these metacarpal fractures. We are presenting the results of our first 21 patients with 22 fractures treated by closed, fluoroscopically assisted, intramedullary K-wiring with proximal locking done by a specially designed locking pin. Materials and Methods This was a retrospective, observational cohort study of all patients with spiral and comminuted fractures of metacarpals with minimum of 1 year of follow-up and average follow-up of 14 months (range, 12 to 26 months). The patients were evaluated clinico-radiologically using range of motion, extensor lag, time to healing, amount of collapse, angulation and rotation and complications. Results All fractures had healed uneventfully with average time to union being 8 weeks. Average metacarpal shortening was 2.04±0.95 mm, while the average post-operative angulation of the fracture was 4.81°±1.7. The metacarpophalangeal range-of-motion recovered almost fully with the average extensor lag being only 5.22°±2.42. Other than extensor tendinitis in two patients, there were no other complications. Conclusions This method is cosmetically appealing, provides stable fixation, avoids periosteal stripping associated with open reduction and is associated with very low complication rate, and thus can be safely and effectively used for the treatment of these difficult fractures.

The surgical approach to the brachial plexus is of great importance during surgery for brachial plexus injuries--obstetric or traumatic. A number of different approaches have been described over the years for these injuries, with each 1 having its own advantages and disadvantages. We describe a novel approach to the supra-clavicular and infra-clavicular aspects of the brachial plexus, which has been used by senior author successfully for the past 15 years. It involves creation of 2 windows, 1 above and 1 below the clavicle in case of adult traumatic plexus injuries. A slight variation of joining the 2 incisions and creation of a laterally based cervicopectoral flap is used for obstetric brachial plexus injuries along with the use of clavicular osteotomy. The advantages of this approach are that it gives rapid access to the brachial plexus; wide exposure can be obtained for all regions of the plexus and donor nerves such as the spinal accessory nerve can be harvested in the same incision.

Background: Residual muscle weakness, cross-innervation (caused by misdirected regenerating axons), and muscular imbalance are the main causes of internal rotation contractures leading to limitation of shoulder joint movement, glenoid dysplasia, and deformity in obstetric brachial plexus palsy. Muscle transfers and release of antagonistic muscles improve range of motion as well as halt or reverse the deterioration in the bony architecture of the shoulder joint. The aim of our study was to evaluate the clinical outcome of shoulder muscle transfer for shoulder abnormalities in obstetric brachial plexus palsy. Materials and Methods: One hundred and fifty patients of obstetric brachial plexus palsy with shoulder deformity underwent shoulder muscle transfer along with anterior shoulder release at our institutions from 1999 to 2007. Shoulder function was assessed both preoperatively and postoperatively using aggregate modified Mallet score and active and passive range of motion. The mean duration of follow-up was 4 years (2.5-8 years). Results: The mean preoperative abduction was 45° ± 7.12, mean passive external rotation was 10° ± 6.79, the mean active external rotation was 0°, and the mean aggregate modified Mallet score was 11.2 ± 1.41. At a mean follow-up of 4 years (2.5-8 years), the mean active abduction was 120° ± 18.01, the mean passive external rotation was 80° ± 10.26, while the mean active external rotation was 45° ± 3.84. The mean aggregate modified Mallet score was 19.2 ± 1.66. Conclusions: This procedure can thus be seen as a very effective tool to treat internal rotation and adduction contractures, achieve functional active abduction and external rotation, as well as possibly prevent glenohumeral dysplasia, though the long-term effects of this procedure may still have to be studied in detail clinico-radiologically to confirm this hypothesis. Level of evidence: Therapeutic level IV