Background: Halo-traction device has been seen with favorable outcome in managing the patients with severe kyphotic deformities preoperatively, however, associated complications are inevitable. Slight modifications can improve the outcome and clinical efficacy. Case Description: A 14-year-old boy was presented with severe kyphotic deformity of 141° from T1 to T10 thoracic vertebrae with diffuse paraspinal calcification in thoracic spine and complete loss of power of both lower limbs. A modified halo-pelvic distraction device was applied before the definitive surgery. The device comprised halo and pelvic assembly, the halo ring was connected to the head with 06 pins, while pelvic assembly had Ilizarov half pins connected to the arches. The assembly construct had four threaded rods, two of them were placed anterolateral and the other two were posterolateral. Distraction at the rate of 3 mm/day was started from 1st postoperative day for 35 days. The neurology improved in both lower limbs and kyphotic angle reduced to 56° from 141°. Surgery at this stage was done and a standalone solid titanium cage was placed from T1 to T10 vertebral body after debridement. No peri- or post-operative complications were observed. Conclusion: The application of halo-pelvic distraction before corrective surgeries can not only reduce the severity of the kyphotic deformity making the definitive surgery easy but neurology can also be improved. The high-risk complications associated with acute correction of deformities can be minimized using our modified halo-pelvic distraction device.

To characterize the scores of disc degeneration, inflammation, and nerve density in herniated disc samples and associate findings with the presence of vertebral endplate (VEP) changes on magnetic resonance imaging (MRI). Overview of Literature: Considering the role of disc composition in spontaneous regression and persistence of pain during conservative management, it is important to identify the influencing factors. VEP changes are highly associated with disc degeneration, but their correlation with herniated disc composition has not yet been reported. Methods: Fifty-one discs were obtained from patients undergoing surgery for herniated disc. Their ages ranged from 19-65 years, and 31/51 were male. Pre-surgical T1 and T2 weighted lumbar-spine MRIs were analyzed to observe Pfirrmann grade, VEP defects, herniation type, Modic changes, and high-intensity zones (HIZ) at the affected level. Five-micron thick sections were stained with hematoxylin and eosin, Alcian blue periodic acid-Schiff stain; examined for histological degeneration scores (HDS; 0-15), inflammation (0 [absence]-3 [severe]), and presence of cartilaginous endplate (CEP). Three-micron thick sections were stained with protein-geneproduct 9.5 and expression was counted/mm 2 . Data was analyzed, and p<0.05 was considered to indicate statistical significance. Results: VEP defects, Modic changes, and HIZ were respectively observed in 30/51, 16/51, and 6/51 of the samples. CEP was observed in 26/51 samples and in 23/51 with endplate defects. Discs with adjacent VEP defects showed increased HDS (p<0.001) and inflammation (p<0.001). Discs with adjacent Modic changes also revealed increased HDS (p=0.01). Histological sections with CEP showed increased HDS (p<0.001) and inflammation (p<0.001), and nerve density was significantly positively correlated with HDS (r=0.27, p=0.02). Conclusions: VEP changes can modulate degeneration and inflammation of herniated discs. Presence of these changes is highly predictive of the occurrence of CEP in herniated discs, which leads to slow resorption and persistent clinical symptoms.

An 18-year-old man presented with complaints of pain and swelling around the left ankle region. Local examination revealed diffuse, hard, mildly tender swelling with ill-defined margins over the medial aspect of the left ankle joint just below the medial malleolus. Radiographic and computed tomographic assessment revealed osteolytic lesion with moderately defined margins. Provisional diagnosis of Campanacci grade 2 giant cell tumor was made, which was later confirmed on histopathology. Extended intralesional curettage and reconstruction with polymethylmethacrylate cement was done under spinal anesthesia. Full weight bearing was allowed at 4 weeks when the below knee back slab was removed. Radiographic assessment was done every 3 months during the first year of follow-up and then every 6 months. No evidence of recurrence of tumor, collapse of talus, or avascular necrosis was found during follow-up. Managing such rare form of bone tumors with extended intralesional curettage and bone cement is an appropriate treatment and gives good functional results. Level of Evidence: Level V

A 19-year-old morbidly obese man presented with infected nonunion of femoral shaft fracture. Patient had history of 13 failed fixation surgeries, assessment revealed 3-centimetre limb-length discrepancy with 3-centimetre gap nonunion. Wound debridement, primary compression and external fixation using a customised Ilizarov external fixation assembly were planned. A four-ring customised assembly was applied. Partial weight bearing was allowed from first postoperative day on walker. Patient was kept on a monthly follow-up. After complete union at 10 months after surgery, frame was dynamised. After 6 months of dynamisation, frame was removed, at that time patient was full weight bearing. Knee was still stiff with a range of motion of 0°–20°, and there was 6 cm of limb length discrepancy, which was managed with a shoe raise. At 9 months after frame removal, patient is mobile with fully united bone. Ilizarov external fixator can be a good managing option in such difficult and complicated cases.

A 9-year-old girl presented with malunited Salter-Harris type I fracture of distal femur treated by bone-setter (unreliable-practitioner). Assessment revealed 3 cm limb-length-discrepancy and affected leg was unable to bear weight, knee was stiff with no active-range of motion; radiographs showed displaced sagittally malunited femoral condyle with 163° posterior distal femoral angle (PDFA). Correction planned with circular-ring-external Ilizarov fixator using distraction-osteogenesis through supracondylar osteotomy and gradual anterior opening. Partial weight bearing allowed from first postoperative day on walker. Eight weeks follow-up showed restored anatomical position of femoral condyle and PDFA. During anterior-distraction and angulation correction, tibia subluxated posteriorly, for that assembly extended to tibia which gradually translated tibia anteriorly and reduced knee. Twenty weeks after removal of assembly patient was advised knee-ankle-foot-orthosis. At 40 weeks of frame removal, patient was walking without support and pain. Managing such rare injuries with distraction-osteogenesis technique allows gradual correction and monitoring, till desirable degree of correction is achieved.