Background:Tru-cut biopsy in suspected bone tumors can be performed even in less specialized centers. Tru-cut biopsy has been proved as safe with more than 90% accuracy. However, its usefulness was not widely studied in general hospitals where Tru-cut biopsy is performed by orthopedic surgeons. This study was conducted to find out the accuracy and adequacy of Tru-cut biopsy performed by an orthopedic surgeon not trained in musculoskeletal oncology, in a general hospital.Materials and Methods:A study was conducted through a prospectively collected database using a uniform protocol. All patients who had a malignant appearing bone lesion with a palpable soft tissue mass were included in the current study. Fifty such consecutive cases underwent Tru-Cut biopsy by orthopedic residents or registrars who were aware of the principles of Tru-cut biopsy and the recommendations of Musculoskeletal Tumor Society. When an open biopsy or a resection of the tumor was subsequently performed, the histological diagnosis was compared for accuracy with the diagnosis of needle biopsy. We evaluated adequacy of sample obtained and accuracy of diagnosis in terms of sensitivity, specificity, positive predictive value, and negative predictive value.Results:Seventy seven cases were initially enrolled. Out of which 18 were excluded and 59 patients were biopsied. Out of which 50 were analysed. Only 4 out of 50 biopsied specimens were inadequate resulting in an adequacy rate of 92%. Among 46 cases, which were analyzed for diagnostic accuracy, 84.78% had true-positive result, 8.69% had true negative, and 6.52% had false-negative report. The sensitivity and specificity of Tru-cut biopsy in our series was 92.85% and 100%, respectively, with positive predictive value of 100% and negative predictive value of 57.14%.Conclusions:Tru-cut biopsy can be recommended as an initial method of tissue diagnosis in musculoskeletal tumors with soft tissue extension.

Introduction: Stress fractures are common during military training but femoral neck stress fractures are uncommon and sometimes pose diagnostic and therapeutic challenges. An incomplete stress fracture with excellent prognosis, if left unprotected, can lead to displaced femoral neck fracture with almost 63% complication rate even with best of the treatment. The aim of this study was to analyze various aspects of the femoral neck stress fracture so that early diagnosis can be made to prevent devastating complications like osteonecrosis and non-union. Methods: The four year army hospital record of 16 patients with femoral neck stress fracture were studied. Their demographic profi le, type of fracture, presentation delay, on set of clinical symptoms and complication of femoral neck stress fracture were critically analyzed. Results: The mean age of the patient was 19.94 years. Total 74% of them developed fi rst symptoms of stress fracture between four to seven weeks of training. There was 3.4 weeks delay from the clinical onset of symptoms to the diagnosis of stress fracture. The type of femoral neck stress fracture were compression (31.25%), tension (18.75%) and displaced (50%). Out of eight displaced type of fractures, 5 (62.5%) had developed complications (3 osteonecrosis and 2 nonunion).Conclusions: Femoral neck stress fracture occurs in initial four to seven weeks of training. The high index of suspicion in initial period of training can help to detect and decreases significant morbidity.Key Words: displaced stress fractures, non-union, osteonecrosis, recruits

Background: Among various fixation methods for metacarpal fractures, plate osteosynthesis is the most rigid and allows early rehabilitation leading to early return to work. Many authors have reported high complication rates and most of them were because of thick plate. The aim of this study was to report early results of plate osteosynthesis of metacarpal fractures with low profile miniplate.Methods: This was a hospital based prospective study. Unstable and irreducible fractures were managed by open reduction and internal fixation with low profile miniplate and were followed up for 6 months. The functional outcome after fracture treatment was assessed by ability to perform acts of daily life and calculating American Society for Surgery of the Hand Total Active Flexion (ASSH TAF) score.Results: There were 16 patients with 17 metacarpal fractures, 87.5% were male with mean age of 31.50±9.02 years. Fourteen (87.5%) patients could perform their activities of daily living at four weeks. The mean Total Active Flexion was 261.76±24.87 at final follow up. Fourteen (87.5%) patients had excellent, one (6.25%) good and one (6.25%) poor out come at the end of 6 months. Conclusion:Low severity metacarpal fractures can be treated successfully by open reduction internal fixation with low-profile miniplate, allowing early and safe mobilization.

Medial collateral ligament (MCL) is the most commonly injured ligament in knee. The majority of MCL tears can be managed conservatively, and reconstruction or augmentation is required in few selected cases. Anatomic MCL and posterior oblique ligament reconstruction have good functional outcome, but it requires 2 tunnels each in the tibia and femur, which may be a limitation in cases in which multiligament reconstruction is required. Several studies report the use of semitendinosus tendon with intact tibial attachment for MCL reconstruction. Since the attachment of semitendinosus is anterior to MCL footprint, it is non-anatomic and anisometric, which may lead to increased laxity of the reconstructed ligament in due course of time. To prevent the laxity in long term, the reconstruction has to be isometric and anatomic. We, hereby, are reporting our unique technique of MCL and posterior oblique ligament reconstruction using intact semitendinosus at tibial attachment and re-routing to the MCL which makes the reconstruction anatomic and isometric. A supplemental video demonstration of the technique is attached with this article.

The reasons for the variability in activities between the two hospitals include the magnitude of the disaster, the functionality of the local medical system which was relatively preserved in Nepal and destroyed in Haiti and the mode of operation which was independent in Haiti and collaborative with a functioning local hospital in Nepal. Emergency medical teams (EMTs) may encounter variable caseloads despite similar disaster scenarios. Advance knowledge of the magnitude of the disaster, the functionality of the local medical system, and the collaborative possibilities will help in planning and preparing EMTs to function optimally and appropriately. However, as this information will often be unavailable, EMTs should be capable to adapt to unexpected conditions.

Meniscal tears are commonly encountered conditions of the knee. In the past, torn menisci were treated by excision of the loose flap. A better understanding of the meniscus anatomy and its biomechanical characteristics has led to the concept of meniscus preservation in eligible cases. Several suture-based repair techniques have been described in literature, including the outside-in technique. Although the outside-in technique of meniscus repair is commonly indicated for the anterior two-thirds of the meniscus, it can be used to repair the posterior part of the meniscus as well. Several modifications of this technique have been described in the literature. We hereby describe our modification of the outside-in technique of meniscus repair with the help of an epidural needle and highstrength sutures that is readily available in operating rooms. The advantages of our technique are that no large incision is required around knee joint, it's inexpensive, it can be performed with basic instruments, and even the tear of meniscus extending up to the posterior horn can be repaired. A supplemental video demonstration of the technique is included with this article.

Even after anterior cruciate ligament (ACL) tear, its remnant retains the vascularized synovial sheets, fibroblasts, myofibroblasts, and various mechanoreceptors within it. The aim of preserving the remnant is to retain these components during ACL reconstruction. In the recent past, there has been an increasing trend towards preserving remnants during ACL reconstruction. Although preserving remnants have physiological advantages, cyclops lesion and extension loss were among the most feared complications. Cyclops and loss of extension are due to the fallback of the remnant into the notch. Moreover, the mechanoreceptors present in the remnant are not active when the remnant is lax. These mechanoreceptors are active when the remnant is in tension. Thus, rather than merely preserving the remnant, it is essential to tension it for more physiological functions. Although there are various techniques of remnant tensioning described in the literature, these techniques require tampering of the fixation devices or an extra fixation device adding to the cost of surgery. We describe our modification of the remnant-tensioning method during anatomic ACL reconstruction. In this technique, the sutures holding the remnant are pulled out through the anatomic femoral tunnel and fixed with an interference screw along with the hamstring graft. This technique is cost-effective, reproducible, and does not require tampering with the fixation devices. Moreover, the direction of remnant pull will be the same as that of the reconstructed graft making both the graft and remnant anatomical in orientation. Suture management and visibility of the intraarticular structures during this procedure are a few downsides of this technique. The only prerequisite of this technique is a good quality remnant to hold the sutures.

Tuberculosis has been greatest mimicker in medicine. Tuberculosis of skeletal system can simulate a malignancy both clinically and radiologically. As tuberculosis of Ulna is a rare, we report a case of unifocaldiaphyseal tubercular osteomyeliti s of Ulna which resembled malignancy in a 60yrs male with mildly painful, gradually increasing swelling over dorso medial aspect of left distal forearm since 5 months durati on. Radiological fi ndings were suggesti ve of aggressive bone tumor and biopsy was planned. Tru-cut biopsy revealed sterile pus and open biopsy was performed. Intraoperati vely there was cheesy pus with fl akes of sequestra and multi ple breaches in ulna cortex. Histo-pathological examinati on revealed chronic infl ammatory granulomatous lesion suggesti ve of tubercular osteomyeliti s. We report this case not only because tuberculosis of ulna is rare, but also because it mimicked malignant bone tumor both clinico-radiologically leading to delay in diagnosis and insti tuti on of treatment.