Background Distal diametaphyseal tibia fracture though requires operative treatment is difficult to manage. Conventional osteosynthesis is not suitable because distal tibia is subcutaneous bone with poor vascularity. Closed reduction and minimally invasive plate osteosynthesis (MIPO) with locking compression plate (LCP) has emerged as an alternative treatment option because it respects biology of distal tibia and fracture hematoma and also provides biomechanicaly stable construct. Objectives To find out suitability of MIPO with LCP for distal diametaphyseal tibia fracture including union time and complicatios and compare wih other available management options in literature. Methods Twenty patients with closed distal diametaphyseal tibia fracture with or without intra articular extension (AO classification: 12 type 43A1, 4 type 43A2, 2 type 43A3 and 2 type 43B1) treated with MIPO with LCP were prospectively followed for average duration of 18.45 months (range 5-30 months). Results Average duration of injury-hospital and injury-surgery interval was 12.8 hrs (range 2-44 hrs) and 4.45 days (range 1-10 days) respectively. All fractures got united with an average duration of 18.5 weeks (range14-28weeks) except one case of delayed union which was managed with percutaneous bone marrow injection. Two patients had union with valgus angulation < 5 degees but no nonunion was found. There were two superficial and one deep post operative wound infection. All infections healed with extended period of intravenous antibiotics besides repeated debridemet for deep infection. Implants were removed in eight patients among whom six (30%) had malleolar skin irritation and pain due to prominent hardware. Conclusion The present case series shows that MIPO with LCP is an effective treatment method in terms of union time and complications rate for distal diametaphyseal tibia fracture. Malleolar skin irritation is common problem because of prominent hardware.DOI: http://dx.doi.org/10.3126/kumj.v9i2.6291Kathmandu Univ Med J 2011;9(2):62-8

Background Though some vertebral lesions have typical imaging findings, histological/ microbiological evidence are required for definitive diagnosis and management, specially for tumor and infective lesions so that wrong diagnosis and wrong treatment can be avoided. Conventionally, open biopsy methods are used. With availability of CT scan, MRI, percutaneous transpedicular vertebral biopsy has now become popular as a minimally invasive technique for biopsy of vertebral lesion.Objective To describes technique and to analyzes safety and feasibility of percutaneous transpedicular vertebral biopsy with fluoroscopy guidance for thoracic and lumbar vertebral body lesions.Method Twenty three patients who underwent percutaneous transpedicular vertebral biopsy under fluoroscopy guidance were retrospectively evaluated for demographic data, indication for biopsy, anatomical locations, histological/microbiological diagnosis, complications and final outcome of treatment. True positive, true negative, false positive and false negative cases were defined.Result There were 17 males and 6 female patients of mean age 47 (range 22-73 years). Biopsies were performed in 17 dorsal and six lumbar vertebral bodies. Adequate sample were obtained in all cases. Seventeen patients (12: tubercular pathology, 1: primary tumor, 3: metastasis, 1: osteoporotic fracture) had definitive histological/ microbiological diagnosis. Four patients had no granuloma and tumor. Two had histological features of chronic non specific inflammation. True positive cases were 17, true negative were four and false negative case were two. Overall accuracy was 92%. One patient developed small hematoma at biopsy site.Conclusion Fluoroscopy guided percutaneous transpedicular biopsy of is a safe procedure with high adequacy and accuracy and low complication rate for thoracic and lumbar vertebral body lesion.

Study Design: Cross-sectional study.Purpose: To compare bone density by computed tomography Hounsfield unit (CTHU) between the original pedicle trajectory (OPT), cortical bone trajectory (CBT), and modified cortical bone trajectory (MCBT).Overview of Literature: The significant pullout strength in CBT is believed to be due to increased screw–cortical bone contact; however, it allows for shorter/less-diameter screw placement, and the fixation is limited to the posterior one-third of the vertebral body, compromising the screw anchorage in the anterior vertebra.Methods: Computed tomography transverse sections of the L1–L5 (1,000 vertebrae) of 200 patients were cut into three planes: (1) horizontal to the pedicle, representing the plane for OPT; (2) in the caudocranial plane in the sagittal plane and divergent in the transverse plane representing the CBT; and (3) the caudocranial plane in the sagittal plane and parallel in the transverse plane representing the MCBT. For each trajectory, the CTHU of four points, namely, posterior cortex, mid-pedicle, midbody, and anterior cortex, were compared within the area of screw insertion.Results: The mean CTHUs of OPT, CBT, and MCBT were 354.2±70 HU, 529.9±75 HU, and 457.3±90 HU, respectively (p <0.01). The CTHU of the posterior cortex in MCBT was 65.6% higher than that in OPT and 14.9% lower than that in CBT. A comparable decline in CTHU with age was noted in CBT and MCBT (Pearson’s r : −0.20 vs. −0.22; adjusted R 2: 0.040 vs. 0.047). However, a higher decline in CTHU with age was observed in OPT (Pearson’s r =−0.38, adjusted R 2=0.14).Conclusions: MCBT has a significantly higher CTHU than OPT. The density in the posterior cortex in MCBT is comparable to that in the CBT trajectory. MCBT appears to be an alternative trajectory for lumbar spine fixation.

Background: Chronic low back pain (CLBP) is a leading cause of morbidity. MRI studies have linked CLBP to various degenerative changes in the lumbar spine, but a clear correlation remains uncertain. This study explores MRI findings in the lumbosacral spine and their relationship with the Oswestry Disability Index (ODI) in patients with CLBP. Methods: This cross-sectional study included participants with CLBP who visited the spine clinic and were prescribed a lumbosacral spine MRI between June 2023 and August 2024 in a tertiary care center in Nepal. These patients completed questionnaires for the ODI and the Numerical Pain Rating Scale to assess back pain. The lower three lumbar levels degenerative findings were classified according to the standard classification system. Data were analyzed to determine correlations between these degenerative MRI findings and disability due to back pain. The ODI was categorized into two groups, and logistic regression analysis was performed to identify demographic and MRI-related factors predicting the disability. Results: MRI analysis included 300 discs from 100 participants (mean age: 39.9 ± 10.82 years, male: female = 51:49) focused on the L3/L4, L4/L5, and L5/S1 levels. The most common finding was disc herniation (63%), followed by disc degeneration (Pfirrmann’s grade ≥3) (47.67%), foraminal stenosis (36%), facet joint arthritis (32%), lumbar canal stenosis (19.67%), and Schmorl’s nodes (10.33%). Logistic regression analysis showed female gender, presence of Schmorl’s nodes at L5/S1, and L5/S1 facet joint arthritis significantly predicted the disability. Conclusions: Disc herniation and disc degeneration are the most frequently observed MRI findings in patients with CLBP, but they do not correlate with disability due to low back pain. Female gender, the presence of Schmorl’s nodes at L5/S1, and L5/S1 facet joint arthritis are significant predictors of disability due to CLBP.

Background: Distal metaphyseal forearm fracture is one of the common injuries in children. Closed reduction and above elbow cast is the standard method of treatment but reported to be associated with redisplacement rate of 7-25%. Closed reduction and fixation with percutaneous Kirschner wire is an alternative treatment option to prevent redisplacement. Methods: Thirty five children (group I) of age between 6 to 13 yrs with displaced ( more than 50% of cortical diameter) or angulated (more than 20°) distal metaphyseal forearm fracture managed with closed reduction and above elbow cast were compared with 21 children (group II) managed with closed reduction and percutaneous crossed Kirschner fixation. Clinical outcomes and complications were compared in both groups after 12 weeks of follow up. Results: Preoperative variables in both the groups were comparable. Mean loss of elbow flexion and extension (12° vs. 4°, p =0.08), wrist dorsflexion and palmerflexion (27° vs. 14°, p=0.12) and forearm supination and pronation (27° vs. 15°, p= 0.143) were more in group I but were statistically not significant. Complications rate (28.4% vs. 19.04%, p= 0.04) was higher in group I (such as fracture redisplacement and swelling) than in group II (pin tract infection). Conclusions: Grossly displaced or angulated distal metaphyseal forearm both bone fracture in children treated with either closed reduction and above elbow cast or closed reduction with crossed Kirschner wire fixation have no statistically significant clinical outcomes in terms of loss of movement of elbow, wrist and forearm but complication rate is higher in cast group. Percutaneous Kirschner wire fixation prevents redisplacement. DOI: http://dx.doi.org/10.3126/noaj.v2i1.8133 Nepal Orthopaedic Association Journal Vol.2(1) 2011: 1-6