International Journal of Research in Orthopaedics

Advancing patient care: unleashing the potential of artificial intelligence in orthopaedics

Arjun Ganesh — 2023-10-26

I am writing to highlight the remarkable strides that artificial intelligence (AI) has taken in the field of orthopaedics, paving the way for transformative changes in patient care and clinical outcomes. As the realm of medical science evolves, integrating AI into orthopaedics has the potential to revolutionize diagnosis, treatment, and management strategies, enhancing both the precision and efficiency of orthopaedic care.

How to avoid knee tunnel convergence when performing a combined anterior cruciate ligament reconstruction and lateral extraarticular tenodesis utilizing the antero medial window

Wesson Pious A. Espiritu — 2023-10-26

The anterolateral structures of the knee have been demonstrated to have a significant impact on reducing rotational instability and the forces applied to the anterior cruciate ligament reconstruction (ACL) graft after surgical reconstruction. Combined ACL reconstruction and lateral extraarticular tenodesis are being performed at an increasing number due to its promising outcome in properly indicated patients. However, tunnel convergence in combined ACLR and lateral extraarticular tenodesis can lead to graft damage and possible failure defeating the purpose of this very effective technique. This technical note describes how to avoid knee tunnel convergence when performing a combined ACL reconstruction with lateral extraarticular tenodesis utilizing the “Antero medial window”.

Comparing conventional and patient specific instrumentation in total knee arthroplasty: an early analysis of function and satisfaction

Goncalo Vaz Pinto — 2023-10-26

Background: Patient specific instrumentation (PSI) in TKA is a surgical technique created to improve the accuracy of implantation, surgical time, blood loss and workflow that has been a growing trend over the past decade. Our work aims to determine if there are improvements in patient satisfaction and functional results using PSI in comparison with conventional instrumentation (CI) in TKA.

Methods: The authors evaluated 716 patients from the past 10 years that underwent TKA, either by PSI (n=456) or by CI (n=260). The authors recorded the WOMAC index, articular range of motion, and the six-minute walking test at pre-op and day 90 post-op. T-student and Mann-Whitney tests were used considering p<0.05.

Results: The functional scores achieved 90 days after surgery were better for PSI compared to CI. The respective differences are found in the extension (p=0.022), gait distance (p=0.010) and in the pain and function WOMAC index (respectively p=0.018 and p=0.020). No statistical differences were found in satisfaction.

Conclusions: 90 days after TKA, the functional scores achieved with PSI were better compared to CI. However, better results in this area did not translate to significantly higher satisfaction in the patients. There seems to be a tendency in favor of better functional results in patients that underwent TKA by PSI in comparison to those submitted to CI. These results seem to follow the tendencies demonstrated in available literature.

A comparative study of the outcome of displaced fractures neck of femur treated with unipolar prosthesis and fenestrated bipolar prosthesis in active elderly patients

Mohammad Aminul Islam — 2023-10-26

Background: Fractures of the neck or femur are among the most serious surgical problems affecting older groups. These fractures constitute a large burden on families and society due to the inability to stand and walk. Objectives were to compare the functional outcomes of unipolar (Austin-Moore) versus uncemented bipolar hemiarthroplasty in displaced fractures neck femur among these active elderly patients.

Methods: This prospective interventional study was carried out at NITOR, Dhaka, Bangladesh in total 60 patients. Among them, 30 patients were treated with unipolar and 30 patients were treated with fenestrated bipolar prosthesis through a lateral approach.

Results: There was no significant age difference between the two groups. Regarding the functional outcome, 6 (20%) patients in the unipolar group and 11 (36.67%) patients in the bipolar group had excellent outcomes. About the same number of patients had good outcomes 36.67% in the unipolar and 43.33% in the bipolar group; the fair and poor outcome was more in the unipolar group than the bipolar group. So, the final outcome after 6 months of operation, 57.57% of patients had satisfactory results in the unipolar group whereas 80% of patients had satisfactory results in the bipolar group. The average Harris hip score was 77.14±14.58 in the unipolar group and 84.63±10.15 in the bipolar group and the p=0.01 which is below 0.05. So, the result is statistically significant.

Conclusions: Uncemented bipolar hemiarthroplasty with a fenestrated stem can give better functional outcomes for displaced intracapsular femoral neck fractures in active elderly patients compared to Austin-Moore prostheses.

The association of late carpal tunnel syndrome with carpal misalignment following distal radius fracture in old Jordanian women

Ashraf Jbarat — 2023-10-26

Background: Late carpal tunnel syndrome following distal radius fracture is a frequent hazard especially after conservative management. Objective was to assess the association of radiological carpal alignment with the intensity of late carpal tunnel syndrome in old Jordanian women during 1 year of distal radius fracture.

Methods: Our retrospective investigation recruited 100 women, aged more than 50 years with unilateral distal radius fracture managed conservatively during one year of the fracture at Royal Jordanian Rehabilitation center, Jordan, between January 2021 to April 2023. Participants were split into 2 groups. Group I comprised of 50 patients with clinical features of late carpal tunnel syndrome (nocturnal or diurnal) and group II comprised of 50 women without clinical features. CTS-6 assessment tool score (1-6) was recorded to evaluate the intensity of the condition. Electrophysiological and radiological evaluation were performed to record carpal alignment. Student t-test was used to assess the variables.

Results: There was a remarkable discrepancy between groups in terms of the radiological variables of carpal alignment (The average of radio-capitate distance, volar tilt and volar prominence height were: -10.69 mm, -19.89 D angle and 1.45 mm, respectively in group I). There was a positive association between reduction in the variables of carpal alignment and the intensity of late CTS. Volar tilt was positively engaged in the late CTS. The threshold of the volar tilt was -19.41 D angle (p<0.005).

Conclusions: Modification of the carpal tunnel following distal radius fracture with carpal dorsal misalignment leads to late CTS. Reducing volar tilt and volar prominence height and radio-capitate distance are the main remarkable independent anticipators of late CTS in non-surgically treated distal radius fracture.

Acceptable time of surgical delay for hip fracture surgery in elderly patients: comparison between American Society of Anaesthesiologists physical status classes I–II versus classes III–IIV

Arus Nalamliang — 2023-10-26

Background: Elderly patients with high American Society of Anaesthesiologists (ASA) physical status (classes III–IV) have higher reported postoperative mortality for hip fracture. Whether the acceptable time of surgical delay among patients with high ASA scores (classes III–IV) and those with low ASA scores (classes I–II) is different has not been clearly investigated.

Methods: A retrospective cohort study was conducted on 2,035 patients aged ≥60 years who underwent hip fracture surgery between January 2005 and December 2020. The 1-year mortality rate was compared between patients with waiting times beyond the indexed day versus those within the indexed day of 1 to 5. The least time point detecting a significant difference was considered the acceptable time of surgical delay.

Results: There were 1,099 cases (54.0%) in the high ASA group. In the low ASA group, the 1-year mortality rate was significantly lower than the high ASA group (3.5% versus 6.5%, p=0.003), and patients with a waiting time >4 days had a higher mortality rate than those receiving surgery ≤4 days (5.4% vs. 1.8%, OR 2.98, 95%CI 1.40–6.34, p=0.003). For the high ASA group, patients with a waiting time >2 days had a higher mortality rate than those receiving surgery ≤2 days (7.2% versus 3.1%, OR 2.31, 95% CI 1.01–5.25, p=0.036).

Conclusions: The elderly with hip fractures in ASA classes I–II could wait for surgery up to 4 days and 2 days in ASA classes III–IV without a significantly increased 1-year mortality.

Mini open anterolateral rotator cuff tear repair with the help of suture anchor

M. B. Lingayat — 2023-09-18

Background: It is generally accepted that mini open rotator cuff tear repair with the help of suture anchor gives satisfactory results in the long term, although most studies have so far shown a fairly high rate of good structural and functional outcome. The purpose of this study is to asses functional outcome of mini-open anterolateral rotator cuff tear repair with the help of suture anchor.

Method: The 30 consecutive rotator cuff tear patients were selected from outpatient department at medical college. All patients were diagnosed with full thickness rotator cuff tear and subsequently treated with mini-open anterolateral approach technique. Each patient was clinically assessed with DASH questionnaire and constant Murley score for their satisfaction.

Results: After a minimum of 12 month follow up period, the average clinical outcome scores all improved significantly at the time of final follow up.

Conclusions: Patient with mini-open anterolateral rotator cuff tear repair with the help of anchor suture showed improvement in their functional outcome and range of motion.

Interlocking nailing for treating comminuted fractures of the shaft of femur

Krishan Kumar — 2023-10-26

Background: The fracture of the femoral shaft is one of the most frequent fractures seen in orthopaedic practise. The purpose of this study was to evaluate the operative procedure for managing communited fractures of the femoral shaft using interlocking fixation.

Methods: This prospective study was conducted in Pathankot, Punjab, with patients who presented to our emergency department as participants. We included all patients over the age of 18 who presented to our emergency department with a comminuted femoral shaft fracture. All patients underwent interlocking nailing.

Results: During the study period, 62 patients fulfilled our inclusion and exclusion criteria, 79% of which were males. In the present study, 50% of the patients demonstrated clinical union of the fracture in 12 to 14 weeks, 24% had clinical union in 10 to 12 weeks, while 26% had clinical union in 14 to 16 weeks. Similarly, majority of the patients showed radiological union of the fracture in 16 to 18 weeks (48%). Radiological union occurred in 23% in 14 to 16 weeks and in 29% in 18 to 20 weeks. Majority (77%) of the patients stayed in hospital for 10 to 14 days and the functional outcome as measured by Klemm and Borner criteria was excellent in 63% patients. Infection (5%) and limb length discrepancy less than 5 mm (3%) were the only complications observed in our patient population.

Conclusions: Our results show that Interlocking nailing results in good functional outcome with minimal complications.

Accelerated versus standard Ponseti cast in the management of idiopathic congenital talipes equinovarus at a tertiary care centre in North India: a comparative study

Suraydev Aman Singh — 2023-10-04

Background: Congenital talipes equinovarus varus (CTEV) is one of the most common congenital anomalies of foot and ankle. With a male dominance pattern, this deformity is bilateral in around 50% cases. It is characterized across varying degrees and severity of components manifesting with: forefoot adductus, midfoot cavus, hindfoot varus and hindfoot equinus. Severity is accessed using Pirani score (0 to 6). Insights into the basic patho-anatomy of this complex 3-dimensional deformity has helped to correct it using the method given by Ignacio Ponseti, a Spanish orthopedician, in which serial manipulations of foot are done and weekly casts are applied, followed by a tendoachilles tenotomy in selected cases to correct the equinus component which is then followed by splintage of the feet in foot-ankle orthosis initially for 23 hours day for 3 months and then 12 hours a day for 3 years. Parental counselling regarding the importance of compliance with maintenance braces remains the most important component of treatment.

Methods: This was a double blinded randomized prospective study including 40 patients with 61 feet of only idiopathic clubfoot, conducted in the department of orthopaedics, government medical college, Jammu over a period of 01 year.

Results: The mean days of plaster duration in accelerated casting group was 18.45 days as compared to 47.25 days in standard casting group (statistically significant, p<0.05). Also, Pirani score at the end of last follow up was comparable in both the groups. Tenotomy rate was slightly higher in accelerated casting group (89.5%) as compared to standard group (85.7%) which may be attributed to higher initial Pirani score in former (5.5) as compared to later (5.0).

Conclusions: The clubfoot in developing countries has social stigma, the early and the promising result of the accelerated method of Ponseti casting has a dramatic impact on both parents and the treating orthopaedician. The accelerated Ponseti casting has remarkably reduced the overall duration of the treatment of Ponseti casting without any complication.

Osteological morphometric analysis of instrumentation safe zones of C1 and C2 vertebra in North Indian population: a multicentric study

Tushar Gogia — 2023-10-09

Background: The complex anatomy and critical functional role of the C1 and C2 vertebrae necessitate precise understanding of safe zones for instrumentation to mitigate risks during surgical interventions. This study aimed to conduct a comprehensive morphometric analysis to identify and characterize safe zones for instrumentation within C1 and C2 vertebrae. Though there are multiple radiological based studies, actual osteological measurements are not available for North Indian population.

Methods: 200 atlas and axis vertebrae were measured within an accuracy of 0.01 mm to ascertain various dimensions, distances and angles to guide safe exposure and instrumentation. To the best of our knowledge this observational morphometric study is first to provide actual osteological measurements in large number of C1 and C2 vertebrae in North Indian population.

Results: The morphometric analysis revealed precise measurements of pedicle dimensions, transverse foramen parameters, and distances from key anatomical landmarks within C1 and C2 vertebrae. Safe zones for instrumentation were identified based on these measurements, considering the optimal implant size and trajectory to minimize the risk of neural or vascular damage. Differences between the morphology of North Indian, South Indian and Turkish C1 and C2 morphology was also identified.

Conclusions: This study provides critical insights into the morphometric parameters which can be used to identify safe zones for instrumentation within the C1 and C2 vertebrae. The identified safe zones and associated measurements are essential for optimizing surgical strategies, enhancing instrumentation accuracy, and ultimately improving patient outcomes during craniovertebral surgical procedures. Spine Surgeons can utilize this data to tailor surgical approaches and implant placements, promoting safer and more effective interventions in the challenging anatomical region of the craniovertebral junction.

Prospective review of open reduction and internal fixation with Kirschner wires (K-wires left exposed) fixation in displaced and rotated (Song V) lateral humerus condyle fractures in children

Vishal Prakash — 2023-10-12

Background: Fractures of the lateral condyle of the humerus account for 10-15% of all elbow fractures in children. These include Salter Harris type 2 and type 4 growth plate injuries in which the fracture crosses the distal humeral growth plate and enter the elbow joint. Open reduction and internal fixation with K wire is treatment of choice for the displaced as well as minimally displaced lateral condyle fractures of children to prevent malunion, nonunion and further displacement.

Methods: This was prospective analytical study conducted in Rajendra Institute of Medical Sciences, Ranchi from December 2020 to December 2022 which consisted of 30 patients (of whom only 27 were present for follow ups) who were treated by ORIF with K-wires fixation. We followed the classification pattern given by Song et al. Results were evaluated according to the criteria given by the Hardacre et al.

Results: Major culprit for injuries was fall from height (44.4%), followed by playing indoor games (25.9%). RTA and sports each constituted of (14.8%). Functional outcomes based on Hardacre criteria are excellent (85.1%), good in 11.1% cases and fair in 3.7% cases.

Conclusions: Our findings demonstrate that open reduction and internal fixation with 2 or 3 K-wires (which were left exposed) and immobilization with casting for 3-4 weeks is sufficient for most of displaced and rotated fractures of the lateral condyle of the humerus.

Dynamic hip screw versus proximal femoral nail in the treatment of intertrochanteric fracture of femur

Krishan Kumar — 2023-10-26

Background: As the elderly population grows, the number of hip fractures continues to increase. This study aims to compare the clinical outcomes of dyanamic hip screw and proximal femoral nail in the fixation of intertrochanteric fracture of femur.

Methods: After obtaining approval of the ethics committee, a prospective study was conducted in the department of orthopedics, SKR Hospital, Pathankot from January 2021 till December 2022. Informed consent was taken from patients who fulfilled the inclusion/exclusion criteria and relevant clinical information was collected, including intra and post-operative details.

Results: During the study period, 65 patients with intertrochanteric fracture were included in the study, of which 33 were treated with PFN and 32 with DHS. It was observed that 91% of the patients who underwent PFN had blood loss less than 100 ml, while 72% of the patients who had DHS had blood loss between 100-300 ml. Mobilization started on the first postoperative day in 67% of PFN patients while as compared to 13% of DHS patients (p value <0.01). Among late complications, there was one case of implant failure among PFN cases, while there were two cases of non-union, two cases of implant failure and one case of late infection among DHS group of patients. It was observed that 91% of PFN group patients had excellent outcomes, while outcome was excellent in 66% of DHS group patients.

Conclusions: Our study showed that PFN is a superior method of osteosynthesis as compared to DHS in the treatment of intertrochanteric fractures.

Assessment of clinical and functional outcomes after single dose injection of autologous platelet rich plasma in patients with chronic lateral epicondylitis: a prospective and brief follow up study

Rohit N. Garg — 2023-10-26

Background: Lateral epicondylitis is a chronic, painful, and debilitating elbow condition. The introduction of platelet-rich plasma as an adjunct to the conservative and operative treatment has revolutionized the research in this topic. PRP is considered to be the ideal autologous biological blood-derived product which helps in regenerating the degenerated tissue rather than just repairing it and helps in relieving pain and improving function.

Methods: This is a prospective study where 40 patients diagnosed with tennis elbow, failing other conservative treatment modalities were enrolled; and treated with single dose injection of autologous PRP; and were evaluated for clinical and functional outcomes using the visual analogue scale and disabilities of arm, shoulder, and hand scores on the follow-ups.

Results: Out of the 40 patients enrolled, there were 15 males and 25 females. The mean age of the population was 45.88±8.87 years. All the patients had improved statistically significant differences in mean VAS and DASH scores (p value<0.001) on each follow-up as compared to the baseline score with VAS score and DASH score improvement being more than 77% and 65% respectively at final follow up.

Conclusion: Our study concludes that a single local injection of autologous PRP appears to be the promising and safe modality of treatment in lateral epicondylitis, helping to improve the pain as well as the clinical and functional outcomes.

Headband technique of reimplantation of a partially amputed finger: a first reported in literature

Gunjan Upadhyay — 2023-10-26

Background: Reimplantation of a partially amputee finger is a challenging task especially in resource limited country like India. In most of the scenario it lands in total amputation either due to delay in arrival at operative set up or due to lack of plastic surgery facility.

Methods: We developed an innovative approach (1st reported in literature) of “headband technique “of reimplantation of such partially amputee fingers and toes. Partially amputee fingers and toes with viability were selected for the operative treatment and for the study. The study was conducted from January 2020 to 2021 with a follow up period for 6 months at our institution. The innovative suturing technique involved a single stitch at the tip of the pulp and rest on adjacent to nail bed securing the neurovascular structures. The patient was in age group of 9 months to 94 years, mostly traumatic injury, with 40 male and 15 female patients. Patients who reported with fully amputee fingers, black escharotic finger were excluded from the study.

Results: To our accomplishment out of 55 operated patients, more than 50 have fully recovered.

Conclusions: With this simple technique of reimplantation even doctor at PHC’S can save fingers from getting amputed. Our study is with small number of patients; hence we advocate a larger study for to have conclusive evidence for the same.

Surgical management of supracondylar fracture femur by retrograde intramedullary Green Seligson Henry nail: a clinical study

Rudraraju Venkata Sai Charan — 2023-10-26

Background: Femoral shaft fractures in young people are frequently due to some type of high-energy collision. The most common cause of femoral fracture is a motor vehicle crash. Treatment for the femoral shaft is at most priority. Hence, the study is aimed to evaluate the results of the retrograde femoral nailing in supracondylar femoral fractures concerning knee flexion, mobilization of patients, and early weight-bearing.

Methods: The study is conducted from October 2019 to October 2021 with 25 patients having supracondylar fractures of the femur. The age group of patients was 15-70 years. Patients with midshaft femur fractures, nonunion, malunion, and pathological fractures were excluded. Chest X-ray post anterior view electrocardiography was performed in patients. Operative procedure was followed and postoperative management was done for all the patients. Radiological evidence of callus and consolidation was analyzed. Neer’s rating system and Sander’s functional evaluation scale were used to find the points for pain, working and walking capacity, range of motion and radiological appearance, etc.

Results: In the study, 25 patients are admitted with supracondylar fractures of the femur. The closed or open reduction method and the retrograde intramedullary supracondylar Green Seligson Henry (GSH) nail were used for internal fixation. The patients were followed for a period of 3 to 24 months. The results of Neers and Sander’s evaluation scoring system determined good to excellent results in 65% of cases.

Conclusion: To conclude from the study results, it was noted that retrograde intramedullary supracondylar nail is an ideal fixation system for distal third femoral fractures, especially the extraarticular type.

Comparative efficacy of intra-articular hyaluronic acid and corticosteroid injections in the management of knee osteoarthritis

Narendra Singh Kushwaha — 2023-10-26

Background: Osteoarthritis management includes a myriad of treatment modalities. This study compared the effects of corticosteroid and Hylan G-F 20 injections on knee osteoarthritis outcomes.

Methods: Patients were randomized to receive either corticosteroid or Hylan G-F 20 injections. Outcome measures included the Western Ontario and McMaster Universities Osteoarthritis Index, knee society rating system scores, and visual analog scale scores, collected at baseline, 3 months, and 6 months.

Results: Baseline demographic and clinical parameters were comparable between both groups. The corticosteroid group demonstrated a significant decrease in the WOMAC score over time (p<0.001). Hylan G-F 20 group showed significant improvements in both the WOMAC scores and Visual Analog Scale scores over time (p<0.01). Gender-based sub-analysis suggested both treatments were effective in men, while in women, significant benefits were seen only with Hylan G-F 20.

Conclusions: Both corticosteroid and Hylan G-F 20 demonstrated efficacy in managing knee osteoarthritis, albeit in different domains. The results suggest the need for individualized treatment plans and further research into potential gender-based variations in treatment response.

Anatomical pre-contoured plates in management of distal tibia fracture: a prospective study

Jayanta K. Laik — 2023-10-26

Background: Distal tibial fractures are complex injuries with high complication rate. Management of such fractures are often complicated by soft tissue injuries. Precarious vascularity around distal tibia also results in high non-union rates. This study aims to study and analyse the outcome of distal tibia fracture managed by anatomical contoured plate.

Methods: In this prospective observational study, we attempted to assess the functional and radiological outcome of distal tibia fracture managed by with distal tibia fracture with average follow up of 24 weeks. ORIF/MIPO with plating was done for fracture distal tibia with anatomical precontoured plates.

Results: Patients were evaluated using AOFAS and measure of ankle range of motion. Average functional score was 88 with complications in 3 patients.

Conclusions: We believe precontoured plates provide for better biological fixation than conventional plates.

A comparative study of Ilizarov ring fixators and limb reconstruction system fixators in the treatment of compound tibial shaft fractures

Aadil H. Lone — 2023-10-26

Background: Tibia is the most commonly fractured long bone, and the prevalence of compound fractures has risen due to an increase in high-energy traumatic incidents. In addressing challenging tibial fractures with significant soft tissue damage, infected tibial nonunion, and compound tibial fractures, medical professionals have turned to specialized treatments, such as Ilizarov ring fixators and limb reconstruction system fixators. These fractures typically cannot be managed effectively with traditional internal fixation methods. To facilitate early weight-bearing, limb lengthening, and efficient wound care, two minimally invasive fixation systems have been developed: the Limb Reconstruction System and the ring fixator.

Methods: The study was conducted on 40 patients with compound tibial shaft fractures treated by Ilizarov ring fixators and limb reconstruction system fixators with the aim to evaluate the functional outcome, union rate and amount of limb lengthening using Ring and ILRS fixators in compound tibial fixators.

Results: In our study, a significant portion of the participants fell within the age range of 28 to 37 years, comprising 45% of the total sample. Furthermore, the majority of the study subjects were male, constituting 65% of the participant pool. The primary mode of injury reported in our study was road traffic accidents, accounting for 77.5%.

Conclusions: The study concluded that LRS fixators show good and promising results like easy to apply, carry, compress, distract and clean while Ilizaro ring fixator is technically demanding, difficult to carry and cumbersome to the patient.

An anthropometric study of intercondylar femur notch with MRI analysis

Aditya Patidar — 2023-10-26

Background: Anterior cruciate ligament is the most common ligament injury of knee. The bony anatomy of femur and tibia is responsible for normal knee kinematics and static stability. Intercondylar notch dimensions is considered as a significant predictive risk factor for ACL tear. Narrow femoral intercondylar notch width in either sex were major correlating factors. Aim was to evaluate the intercondylar femur notch dimensions in patients of knee injury using magnetic resonance imaging at RD Gardi Medical College, Ujjain, Madhya Pradesh.

Methods: This is a prospective study consist of 400 patients carried out from October 2020 to August 2022 in the Department of Orthopaedics, RDGMC Ujjain. All the patients of knee injury including ACL tear and age 18 years to 60 years are included in the study. Patient less than 18 years and more than 60 years were excluded from the study. Dicom radiant software is used as statistical tool to analyse the data. Various intercondylar notch dimensions in different sections are measured using MRI in the dicom software.

Results: The cut off values of axial NWI, NSI, NDI as 0.238, 0.662, 0.472 respectively.

Conclusions: We conclude that narrow femoral intercondylar notch, lower notch width index increases the risk of an ACL tear in the given population. This would help in identification of people at risk for ACL injuries. Our study provides a comprehensive analysis on the risk factor of ACL tear, which would help in betterment of the patients at danger for anterior cruciate ligament injury. People with decreased notch dimensions should be educated on the high risk of ACL tear and be given proper prophylactic precautions.

Avascular necrosis hips: management with core decompression bone graft and bone marrow aspirate concentrate

H. R. Jhunjhunwala — 2023-10-26

Background: Avascular necrosis of the femoral head is a disorder that can lead to the collapse of the femoral head and can progress to secondary osteoarthritis, which would ultimately require a total hip replacement. It can be avoided if the disease is diagnosed at an early stage. Intra-osseous pressures can be reduced, thereby aiding in halting the disease progression by core decompression along with bone marrow aspirate concentrate with morselized bone allograft. Aim was to evaluate the role of core decompression with BMAC with bone grafting for the treatment of early stage AVN of the hip by clinical and functional outcomes of the patient.

Methods: A prospective observational study done to evaluate the clinical and functional outcomes by using the Harris hip score with domains for pain, functional activity, range of motion, and gait. Pre-operative and 18-months post-operative HHS was calculated in 30 samples between 30-50 years undergoing core decompression with BMAC and bone grafting in AVN hip upto Ficat Arlet stage IIb.

Results: There was a significant increase in HHS from 67.66±9.87 pre-operatively to 92.4±7.4 post-operatively (p<0.05) which is statistically significant), indicates marked pain relief and functional well-being of the patients.

Conclusions: Core decompression with BMAC and bone grafting is safe and effective in the early stages of AVN of the femoral head and is helpful in delaying the progression of AVN leading to THR based on clinical and functional outcomes of the patients at 18 months follow up.

An alternative osteosynthesis technique: single column anatomical plate fixation for distal humerus diaphyseal fractures

Benjamin Vinodh J. — 2023-10-26

Background: The treatment of distal humerus diaphyseal fractures presents significant challenges for orthopedic surgeons. The goal of this study is to evaluate the effectiveness and outcomes of a single column anatomical plate as an alternative method of osteosynthesis for fixing distal humerus diaphyseal fractures.

Methods: A Prospective analysis of patients who underwent surgery for distal humerus diaphyseal fractures at a tertiary care medical center was conducted. Patients who received treatment using a single column anatomical plate were included in the study. Preoperative, intraoperative, and postoperative data, including fracture type, surgical approach, complications, range of motion, and radiographic outcomes, were collected and analyzed.

Results: Type B2 fractures were more common in our study i.e., 80%. The maximum incidence was between 18 to 59 years i.e., 21 cases (77%). Average radiological union was seen at 15 weeks. This study shows Excellent outcome in 67% and Good in 30% of patients. Average post-operative ROM at 1 year was mean flexion 120°(SD 7), mean extension of 6 degrees (SD 4.7), mean pronation 81.25°(SD 2.5) and mean supination 82.5°(2.8). Average MEPS score was 95.5 at 1 year. The mean metaphyseal-diaphyseal angle was 85°, the mean humeral-ulnar angle was 14°, which was within the normal limits.

Conclusion: The use of a single column anatomical plate for fixing distal humerus diaphyseal fractures appears to be a promising alternative method of osteosynthesis. However, further prospective studies with larger sample sizes and longer follow-up periods are warranted to validate the efficacy and safety of this technique.

Biopsy tract seeding in musculoskeletal sarcomas: myth or reality?

S. Subbiah Shanmugam — 2023-10-26

Background: It is a common practice in oncology in general and musculoskeletal oncology that the biopsy tract must be resected together with the tumor while performing limb-sparing surgery. Our study aims to assess the need for routine excision of biopsy scars in musculoskeletal malignancies by analyzing the presence of tumor in the biopsy tracts.

Methods: We conducted a prospective study from January 2021 to April 2023, including 48 soft tissue and bone sarcoma patients. Neoadjuvant chemotherapy was administered to all cases of Ewings sarcoma and osteosarcoma. All of them underwent surgical resection with appropriate reconstruction. Biopsy tracts were sent separately and analyzed for tumor infiltration.

Results: Two of the 48 patients included in the study had tumor deposits in their biopsy tracts. One patient with undifferentiated pleomorphic sarcoma and another patient with high-grade myxoid liposarcoma had tumor seeding in their biopsy tracts.

Conclusions: The rate of biopsy tract seeding in our study was 4.2% (2 out of 48). Even though this might seem very less, it is still significant considering the rarity of bone and soft tissue sarcomas. Despite the low risk of tumor seeding, it is advisable to continue routinely excising the biopsy tract. Whether inappropriately placed biopsy tracts warrant an amputation instead of limb salvage is a question that will be best answered in the future with large-scale prospective randomized studies.

A radiological evaluation of loop length change in adjustable versus fixed loop femoral cortical fixation devices in arthroscopic anterior cruciate ligament reconstruction: a prospective study

Aruddha Sarkar — 2023-10-26

Background: In anterior cruciate ligament reconstructions, fixed devices require over-drilling to flip the button whereas loops of adjustable devices can be adjusted intraoperatively, and they minimize over-drilling. But they can loosen rendering the reconstruction incompetent. Most studies comparing them are bio-mechanical studies. Our aim was to record and compare loop length change radiologically in adjustable versus fixed devices in clinical settings.

Methods: 32 patients were divided into 2 groups of 16 patients each. Hamstring graft were prepared. It was loaded in the suspension device and the apex of the graft was marked using silicon vascular radio-opaque marker. In adjustable devices, lengthening was checked after cycling and re-tensioning was done intra-operatively. Post-surgery, digital X-ray of the knee was taken in true antero-posterior and lateral view. Distance between the centre point of the button and the centre-point of the radio-opaque inert silicon marker was recorded at immediate post-operative and at 6 weeks respectively and compared.

Results: 15 patients in each group were incorporated. Intra-operatively, loop lengthening was seen in all 15 patients with adjustable loop and re-tensioning was done. 2 of the 15 cases showed evidence of radiological loop lengthening however in both cases the lengthening was less than 3 mm and thus was not significant.

Conclusions: We in in vivo radiology based clinical study did not find any significant loop lengthening in patients with adjustable loop devices. Hence fixed and adjustable loop devices are comparable.

Evaluation of clinical and functional outcome of total hip arthroplasty in avascular necrosis of head of femur in adults

M. B. Lingayat — 2023-09-08

Background: Aim of the study was to evaluate clinical and functional outcome of bipolar hemiarthroplasty in avascular necrosis (AVN) of HIP in adults.

Methods: Thirty patients of either sex between age group 20-80 years of age came for the treatment at government medical college and hospital Aurangabad. Between December 2020 to December 2022. Patients were followed every day till the discharge. Patients were discharged after they were mobilised with assistance of physiotherapist. Functional and clinical outcome was measured at 6, 12 and 24 weeks postoperatively according to Harris hip score (HHS).

Results: the methods show significant improvement in HHS in patient undergoing total hip replacement.

Conclusions: total hip replacement is a very good option for AVN of head of femur in all age groups.

Assessment of vitamin C supplementation as an adjuvant analgesic therapy and evaluating its efficacy in terms of clinical and functional outcomes in post-operative patients undergoing surgical decompression for prolapsed intervertebral lumbar disc

Rohit N. Garg — 2023-10-26

Background: Post-operative pain is one of the most debilitating condition following lumbar spine surgery, which negates the clinical and functional outcomes. Vitamin C (ascorbic acid) due to its anti-oxidant, neuroprotective and neuromodulating properties; was evaluated to have adjuvant analgesic effects in these patients.

Methods: This prospective study included 50 patients undergoing single level lumbar disectomy; randomly divided into group A (vitamin supplementation, n=25) and group B (no supplementation, n=25). Both the groups were evaluated on the follow ups for the clinical outcomes (visual analog scale-VAS score), functional outcomes (Oswestry disability index-ODI score) and total analgesia consumed.

Results: Both the groups showed statistically significant improvements in clinical and functional outcomes with respect to pre-operative status. Group A showed statistically significant (p<0.05) improvement in VAS and ODI scores as compared to group B at 4^th, 6^th and 8^th week follow up, however at 2^nd and 12^th week follow up the difference was found to be insignificant. Total analgesia consumed by group A patients was statistically lower than that consumed by group B patients.

Conclusions: Vitamin C has analgesic effects in certain clinical conditions, thus reducing post-operative pain and improving the overall satisfaction and outcome of the surgery. It helps in bringing about the improvement in clinical as well as the functional outcome of the spine surgery and has an effective dose-sparing and adjuvant effect on the post-operative analgesia.

Full-thickness bilateral rotator cuff tears as a result of a bench-pressing accident: case report and literature review of treatment of bilateral rotator cuff tears

Lina Ismael — 2023-10-26

Rotator cuff injuries are frequent pathologies presenting to orthopedic surgeons. These injuries especially occur among older adults due to intrinsic or extrinsic degeneration. They can however present in young athletes, but as result of different etiologies. Overhead athletes may incur rotator cuff injuries due to repetitive trauma. Bilateral simultaneous traumatic shoulder dislocations have been reported in the literature following acute trauma or weight-lifting activity, but bilateral traumatic rotator cuff tears following bench pressing is an unusual presentation in a young individual. To our knowledge, there has been no previous report describing this injury. This article presents a case of a young male athlete who had bilateral rotator cuff tears after a barbell bench press. Both shoulders were treated operatively in a sequential manner, three months apart, and the patient regained excellent functional status 24 months postoperatively.

Double trouble-unveiling the hidden pain: bilateral paediatric parsonage-turner syndrome: an unprecedented encounter

Arjun Ganesh — 2023-10-26

Parsonage-turner syndrome (PTS), also known as idiopathic brachial neuritis, is a rare disorder characterized by sudden-onset severe shoulder pain followed by weakness and atrophy of the shoulder and arm muscles. This case report presents the clinical scenario of an 11-year-old girl diagnosed with PTS, highlighting the unique challenges and considerations in the paediatric population. In our case, a 11-year-old girl presented with sudden-onset severe bilateral shoulder pain, followed by weakness and atrophy of the shoulder and upper arm muscles. The clinical examination revealed muscle wasting and limited range of motion. The diagnosis of PTS was confirmed through MRI and electromyography (EMG) showing denervation in the affected shoulder muscles. Patient was managed with symptomatic supportive treatment in the form of analgesics and physical therapy. Patient is on the road to recovery and on regular follow up. We concluded that prompt recognition and appropriate management of PTS are crucial to optimize outcomes and prevent long-term disability, particularly in the paediatric population.

Floating knee with early onset fat embolism: a case report

Selva Kumar K. — 2023-10-26

Fat embolism syndrome in young adults is most commonly associated with the long bone fractures most commonly femur and tibia. Its concomitance with floating knee is reported scarcely in reviewing the literature. Though it has been proposed that onset of fat embolism presents following an asymptomatic interval for about 24 to 72 hours, our patient developed onset within 8 hours following trauma. This case report is of first in this kind ever reported in the literature. We present a caseof 26 year old male patientwith floating knee Fraser type1 and Early Onset Fat Embolism syndrome who developed within 8 hours ofinjury underwent staged intramedullary nailing of femur and tibia with an excellent functional outcome without any sequelae of fat embolismat 2 year postoperative followup. Appropriate clinical judgement and awareness to suspect fat embolism syndrome and timely immobilisation with proper supportive care and serial reassessment and planned surgery preferably intramedullary nailing in young patient would benefit the patient in toto in case of floating knee with early onset fat embolism.

Congenital absence of lunate and triquetrum with hypoplastic scaphoid – a case report and review of literature

Abhishek Dwivedi — 2023-10-26

The absence or hypoplasia of bones or deformities associated with various bones have been documented in the past by various authors. These absent or hypoplastic carpal bones have mostly been associated with various congenital syndromes and anomalies. Here, a case is reported with absent lunate and triquetrum with hypoplastic scaphoid bone without any congenital anomaly or syndrome.

Tubercular cold abscess: uncommon location of a common disease

Parth Jindal — 2023-10-26

Musculoskeletal tuberculosis is not rare to find, but presence of the disease and such extensive involvement at an unusual site without much of bone involvement is rare. Reporting a case of isolated cold abscess in a 60-year-old male with evening rise of temperature, weight loss and diffuse swelling in his leg involving almost entire anterior aspect of leg. Magnetic resonance imaging (MRI) was advised to investigate further and revealed large focal intra medullary heterogenous collection and large lobulated juxtacortical collection in tibialis anterior muscle. Hematoma/organised abscess, incision and drainage was done and sent for Z-N staining which showed acid-fast bacilli. Anti-tubercular treatment was administered- isoniazid (H), rifampicin (R), ethambutol (E), pyrazinamide (Z). Outcome was favourable and patient become symptomatic better. Drainage of the cold abscess and antitubercular coverage produced good results in this rare presentation of tuberculosis.

Case of left hip acute pediatric septic arthritis - polymicrobial etiology

Aghosh Mathiyoth Chalil — 2023-10-26

Septic arthritis is a true orthopedic emergency, involving a severe bacterial, viral, or fungal joint infection that triggers inflammation and the degeneration of joint tissues. It typically affects joints such as the knee, hip, shoulder, or wrist. Early diagnosis and treatment are crucial to avoid long-term complications. Herein, we describe the case of an 8-year-old male patient who presented with complaints of spontaneous onset of hip pain and an abnormal gait. The patient was diagnosed with left hip septic arthritis and underwent a left hip arthrotomy under general anesthesia (GA). The patient was administered intravenous antibiotics for 21 days while being kept on non-weight-bearing mobilization. After 3 weeks, the patient's intravenous antibiotics were switched to oral antibiotics for the next 3 weeks. On the second follow-up visit, the patient showed significant improvement, with laboratory findings within normal limits.

Three years follow up of open medial sub-talar dislocation of ankle: a case report

Arunodhaya Siddharth — 2023-10-26

Open medial sub-talar dislocation is a rare lesion in traumatology. Even after early treatment, these injuries progress to sub-talar arthrosis. Here we describe a case of 24 years male with open type 3B medial sub-talar dislocation with calcaneum sustentaculum tali fracture following road traffic accident. He underwent emergency wound debridement and internal fixation with K-wires and VAC application. He was on regular monthly follow-up for 6 months and then 6 monthly follow-ups till date. K-wires were removed 8 weeks after surgery and gradual range of movement was started. Partial weight bearing was started at 12 weeks. He was pain free and returned to work after 8 months. At 3 years follow up patient is able to walk without pain, normal painless ROM at ankle. To the best of our knowledge, long term follow-up of patient with these lesions is not reported. Here we present a case with 3 years follow-up showing good results in patient with open sub-talar dislocation after early management with internal fixation with K-wires and VAC dressing.

Contaminated bone grafts and tuberculosis in three spine surgery patients: a case series

Mustafa Naveed — 2023-09-05

Tuberculosis (TB) is a global health issue affecting millions of people every year. Previous articles displayed cases of TB resulting from contaminated bone grafts used in spinal surgeries. However, deeper understanding about the serious health consequences for patients affected by TB-infected bone grafts is lacking. Here, we discuss three unique patients who contracted TB after undergoing lumbar spinal surgery. We describe three patient cases in which individuals initially presented with back pain, underwent required lumbar spinal fusion surgery with bone graft implants, and, afterwards, contracted TB. All patients were given RIPE therapy, had additional surgery to remove the faulty hardware, and lived with significant and prolonged pain. In addition, patient X experienced night sweats, patient Y had a subcutaneous abscess positive for TB, and patient Z had severe burning pain, rash, and sweats. Altogether, we emphasize the importance of increasing our awareness about the potential risks and complications associated with utilizing contaminated surgical products. We encourage healthcare professionals to take necessary precautions to ensure the safety of their patients by screening bone grafts for potential pathogens and practicing proper sterilization techniques.

Twelfth rib syndrome: role of intercostal blocks: case series of 10 patients

Amit Prabhakar Phadnis — 2023-10-26

Twelfth rib syndrome (TRS) is a rare condition that causes severe pain in the loin. It is often misdiagnosed, leading to unnecessary investigations and treatments. Intercostal blocks in the 11^th and 12^th rib often resolve the pain for these patients. In this research paper, we aim to explore the role of intercostal block in the management of TRS based on our experience with 10 patients. Data of patients who were diagnosed with TRS were studied retrospectively from our hospital records who have been given intercostal block injection from the period of Jan 2022 to August 2023 as an audit. Four patients underwent intercostal blocks. VAS scores were measured in follow-up for 1 and 3 months. 4 patients were lost to follow up and hence not considered in this study. The male to female ratio was 7:3. There was a statistically significant reduction in VAS score at 1 month and 3 months compared to pre-injection times. Patients who have failed conservative management for TRS can be effectively managed with intercostal block injections.

Toronto extremity salvage score-patient reported outcome measures in upper extremity bone tumors treated with limb salvage surgery

Subbiah Shanmugam — 2023-10-26

Bone and soft tissue tumors of upper extremity are relatively uncommon than those of lower limb. Treating these patients while retaining a functional limb is quite a challenge. Along with musculoskeletal tumor society score, Toronto extremity salvage score (TESS) is most widely used patient-reported outcome measure for sarcomas of upper extremity. Retrospective analysis of patients with upper extremity bone tumors (24) treated with limb salvage surgery (20) from 2014 to 2022 was undertaken. Mean follow-up period was 26 months and mean age was 30.2 years. Out of 20, 11 humerus cases were of tumors arising from humerus, 5 in radius and 3 in ulna. 9 patients were treated with custom mega prosthesis reconstruction, 6 with fibular free flap, 6 radius underwent simple resection and 1 curettage. Majority of the cases were giant cell tumors (8) followed by osteosarcoma (3), fibromatosis (3), aneurysmal bone cyst (2), simple bone cyst (2), 1 Ewing sarcoma and 1 metastatic bone disease. The mean TESS score of the sample population was 69.7 Most of the patients (11) rated their disability to be of moderate degree and considered themselves to be moderately disabled. The mean TESS score for CMP group was 71.1, while that of autograft reconstruction was 68.3. Despite only half the population having received CMP as a reconstructive option, nearly 40% patients with disease of forearm where the results are not so great, our study population reported a reasonably good patient reported outcome score. A dedicated physiotherapy team with tailor made exercise protocol for each patient depending on their needs can help in improving the quality of life.

Inter-fragmentary compression using cannulated cancellous screws augmented with modified tension band wiring in transverse patella fractures

Sachin M. Khemkar — 2023-10-26

The classical Kirschner wires and tension band wiring technique, described by the AO foundation, has been the most widely used method for transverse patella fractures. In this study, we have adopted what we perceive to be an improved technique, the cannulated cancellous screws with modified tension band wiring. 20 patients with transverse patella fractures were included in our prospective single-blinded randomized control study with a duration of 3 years. All patients were operated on with modified tension band wiring with a 4 mm cannulated cancellous screw. Functional evaluation was made using the Tegner lysholm knee scoring scale. Roentgenograms were taken in AP and Lateral views to look for signs of radiological union and interfragmentary gap. The post-operative interfragmentary gap between fracture fragments with 65% of patients having a 0 mm gap, 25% of patients having a 1 mm gap, 5% of patients having a 2 mm gap, and 5% of patients having a 3 mm gap. The mean duration for the radiological union was 10 weeks. Mean Tegner lysholm score at 6 months was 88±4.7. We concluded that modified tension band wiring with cannulated cancellous screw is a safe, reliable, and better alternative method of fixation for transverse patella fractures with excellent union rate, range of motion, and functional outcome.