We are talking about evidence-based medicine (EBM) for decades. Now each and every field of medicine has adapted evidence-based practices and the same is true for orthopedics also. There are thousands of reasons to support an evidence-based approach in the teaching and practice of orthopedics but hurdles and challenges are also there. So it’s time to revisit the challenges of EBM in orthopedic teaching and practice.

Background: Osteoarticular infections in infants, such as osteomyelitis and septic arthritis, are a growing problem with a potential for not only systemic after-effects but also irreversible joint damage and limb deformity. Therefore, early treatment is necessary to reduce permanent damage/deformity. The purpose of this study is to find out the demography and impact of early initiation of definitive institutional management in osteoarticular infections. Materials and Methods: This study was conducted after approval by the institutional review board. All neonates and infants admitted between June 2019 and May 2021 with a clinical and laboratory diagnosis of osteoarticular infection were included in this study. Data for each patient were collected using the Hosp Gestor program. Patients having a history of pain, redness, swelling in joints associated with fever, and discharging sinus from bone were studied for unknown risk factors and atypical presentations. The impact of definitive management and sequelae were noted in all patients. Results: In this study, males were affected more than females. Osteoarticular infection of septic arthritis (53%) is the most common followed by osteomyelitis (43%) affecting predominantly the hip joint. In the majority of the cases, atypical risk factors like congenital talipes equinovarus and preterm delivery were noted. The most common organism isolated was Staphylococcus aureus (35%); however, atypical organism was Acinetobacter haemolyticus (2.5%). Among treatment methods, surgical cleaning, arthrotomy, and drainage was the most common procedure. The greater the delay in institutional visit, the more severe was the complications. Worst outcomes and sequelae are seen when the delay is >3 months, namely epiphyseal growth arrest, varus deformity, and destroyed head of the femur; good outcomes are seen when a delay is for a few days. Conclusion: Early detection and institutional visit resulted in good outcomes. This study proves the truth behind the fact that delay in diagnosis and initiation of definitive treatment causes more complications and sequelae. This study also serves as a clinical guide to identify risk factors, awareness about early detection, and effective institutional treatment of osteoarticular infections in infants and neonates.

Background: The tibial diaphysis is the most common site of fracture in the tibia and approximately 80% of these fractures have associated fibular fractures. Expert Tibia Nail System (ETNS) system provides extra stability in comparison to conventional intramedullary tibial nail due to multiaxial locking system. Objective: The aim of this study was to evaluate the midterm functional outcome of distal tibial fractures using the ETN. Materials and Methods: This prospective study was conducted from June 2016 to August 2019 comprising a total of 30 cases who were treated by Expert tibial nail fixation for distal tibial fractures. Clinical evaluation was done at each follow-up and final evaluation was done at 9 months postoperatively. The evaluation method at 9 months follow-up was the clinical examination and radiographic imaging. Results: Of 30 patients, majority were men. Male-to-female ratio was 3:1 with 22 men (73.33%) and 8 women (26.66%). The mean age of patients was 32 years with a range from 20 to 60 years. Left limb was involved more 16 (53.33%) frequently than right 14 (46.66%). Majority of the patients had trauma due to road traffic accidents (46.66%), fall from height/stairs (26.66%), twisting injuries (23.33%), and sports injuries (3.33%). There were 1 patient with superficial infection which resolved with wound care and antibiotics, 2 with anterior knee pain, 1 with malunion, 1 with delayed union, and 1 patient with nonunion. According to Johner and Wruh’s criteria, excellent results were achieved in 20 patients, good in 5 patients, fair in 4 patients, and poor in 1 patient. Conclusions: Expert tibial nailing is a new and innovative procedure for distal tibial fractures. It is safe and effective with the added advantage of providing additional stability and preventing rotational malalignment for distal third tibial fractures in comparison to conventional nailing. Further studies need to be conducted to validate the advantages of this procedure over conventional nailing.

Background: The choice of graft for anterior cruciate ligament (ACL) reconstruction is a matter of debate with hamstring and bone-patellar tendon-bone being the most popular autologous graft options. Objective: The objective of this study was to conduct a prospective randomized control trial comparing doubled semitendinosus and gracilis graft versus bone-patellar tendon-bone graft. Materials and Methods: Sixty patients with chronic unilateral rupture of ACL underwent arthroscopically assisted ACL reconstruction using quadrupled hamstring and bone-tendon-bone graft after randomization. Both groups were comparable with demographic data, preoperative activity level, mechanism of injury, the interval between injury and operation, and preoperative laxity of the knee. The same well-proved surgical technique and aggressive rehabilitation were used in all cases. The outcome assessment was done using the visual analog scale, Lysholm score, Tegner activity level, and International Knee Documentation Committee (IKDC) evaluation system. Results: At 2-year follow-up, we found that results within the same groups showed statistically significant improvement as assessed by IKDC, Tegner’s, and Lysholm operative scores. There was also a significant correlation between the manual Lachman test and stress laxometry findings. There was no statistically significant difference between the scores of the two groups (hamstring and bone patella tendon). In the hamstring group, we recorded a higher incidence of femoral tunnel widening, and in the bone-patellar tendon-bone group the higher incidence of kneeling discomfort and increased area of decreased sensation in the skin. Conclusions: Arthroscopic ACL reconstruction by either hamstring tendon graft or bone-patellar tendon-bone graft gives equally satisfactory results.

Background: Distal radioulnar joint (DRUJ) instability is an important cause of ulnar-sided wrist pain in distal radius fractures. By this study, it was tried to identify clinical factors associated with DRUJ instability in distal radius fractures. Materials and Methods: We prospectively reviewed all 87 patients who underwent surgery for unstable, unilateral distal radius fractures in a tertiary trauma center. Assessment of DRUJ instability was examined preoperatively, during surgery, and immediate postoperatively. Patients with clinical DRUJ instability were followed up at 6 weeks, 3 months, and 6 months, with clinical assessment of the DRUJ instability whether symptomatic or not. Results: Preoperative DRUJ instability was found in 23 patients as checked by the distal ulna ballottement test. Of these 23 patients, postoperative DRUJ instability was found in 9 patients and persisted as symptomatic DRUJ instability with ulnar-sided wrist pain till the last follow-up. Conclusion: Every distal radius fracture should be seen with the suspicion of associated DRUJ instability and the stability of DRUJ be thoroughly checked intraoperatively and postoperatively for better wrist function and better outcome after the union of distal radius fracture.

Floating knee is a lesion entity first described in 1975 by Blake and McBride. Bilateral involvement is exceptional. It occurs for high-energy trauma and is usually accompanied by other potentially life-threatening lesions. Our patient presented a trauma of lower limbs following a motorcycle accident. The clinically evoked diagnosis was confirmed after standard radiological assessment.

Patients with isolated capitellar fractures mostly present with painful swelling of the elbow with definite local tenderness on clinical examination. These fractures become evident in the radiograph. In this paper, we report a young girl with an isolated capitellar fracture that was missed in the initial radiograph of the elbow and became evident in computed tomography (CT) and subsequent X-ray. This patient was treated successfully with open reduction and internal fixation by two headless screws (Herbert screw).

Intraosseous schwannomas are rare and represent 0.2% of all bone tumors. Their occurrence in tibia is extremely rare and only five cases have been reported till date. We report an additional case of intraosseous schwannoma in right tibia of a 46-year-old female whose plain radiograph of right knee joint revealed an osteolytic expansile lesion with trabeculations in the proximal tibia. Magnetic resonance imaging study showed a well defined, lobulated mass in the anteromedial aspect of upper tibia. Histopathological examination of the excised specimen revealed schwannoma which was confirmed by positivity for S-100 on immunohistochemistry.