International Journal of Research in Orthopaedics

Static antibiotic loaded cement spacer application in 2-stage management of native and prosthetic hip joint infections: a case series and review of the literature

Charles I. Ayekoloye, Mosimabale J. Balogun, Temitope O. Alonge — Tue, 25 Feb 2025 00:00:00 +0530

Two-stage revision including interval cement spacer application is the gold standard treatment for both prosthetic and native hip infection with joint destruction. We present a summarised case series of our experience of successfully treating 8 infected joints in 6 patients treated with 2-stage revision using interval static spacers. Two patients with 3 native joint infections and 4 patients with 5 prosthetic joint infections were treated with 2-stage arthroplasty with interval static spacer application consisting of static block spacers or cement beads. There were 2 females and 4 males. Mean age is 40.5 years and range 24-60 years. Mean interval between the first and second stage is 8weeks. One case has not undergone the second stage as he is unable to fund the operation. Organisms cultured include methicillin- sensitive staphylococcus aureus, enterococcus. All underwent cementless hip reconstruction with one patient undergoing hybrid hip reconstruction. At mean 36-month follow-up (range 30-44 months) all patients have normalized inflammatory markers and improvement in Oxford hip score (OHS) from pre-operative mean 16.6 (range 15-19) and post-operative mean OHS 43.7 (range 35-50). Patients continue to be followed up. We recommend this cement spacer option as part of a 2-stage procedure when faced with moderate to severe acetabular bone loss. It is effective in treating native or prosthetic hip joint infections and joint infections in patients with sickle cell haemoglobinopathy.

Functional outcome of displaced clavicle fractures treated with locking compression plate

Shivananad S., Radhakrishna A. M., Veeresh N., Prajwal P. Thumati — Tue, 04 Feb 2025 00:00:00 +0530

Clavicle fractures, common in young, active individuals, often occur due to trauma or repetitive stress and account for about 2.6% to 5% of all fractures. These fractures typically happen in the midshaft and are often displaced. Historically, they were treated conservatively, but this approach often led to malunion and poor shoulder function. Recent studies show that surgical interventions, particularly with locking compression plates (LCP), improve healing, shoulder function, and reduce complications like non-union and malunion. Surgical treatments, such as open reduction internal fixation (ORIF) or closed reduction internal fixation (CRIF), are especially beneficial for displaced fractures or those with additional complications. LCPs provide better stability, especially in osteoporotic patients, although potential complications include screw loosening and infection. Overall, evidence supports surgical treatment with LCPs for better functional outcomes and fewer complications compared to nonoperative methods. This study is being done to assess functional outcome of clavicle fractures managed with open reduction with LCP. A prospective interventional study was conducted to assess functional outcome of clavicle fractures managed with ORIF with LCP. Constant-Murley score was evaluated before the treatment and were repeated after 6 weeks (T1), 12 weeks (T2) and 24 weeks (T3). The study involved 30 participants with an average age of 31.23 years, consisting of 80% males and 20% females. Of these, 53% had right-sided clavicular fractures, and 47% had left-sided fractures. Most surgeries were performed within 2-3 days of admission, with 93.33% of fractures showing union within 12 weeks. The constant Murley’s score, which measures functional outcomes, improved significantly over time: from 5.28 before surgery to 91.09 after 24 weeks. The functional outcome was graded excellent in 90% of patients. Statistical analysis showed significant improvement in scores post-surgery (p<0.001). Age had a weak positive correlation with better outcomes, while time from admission to surgery and time to union had strong negative correlations with functional outcomes. These findings suggest that faster surgery and quicker union lead to better functional recovery, and age has a slight impact on outcomes.

A study on functional outcomes of ‘Joshi’s external stabilization system distractor’ in the correction of deformities in neglected, resistant or relapsed cases of congenital talipes equinovarus

Rajesh Kumar Sharma, Anuradha Upadhyay — Tue, 25 Feb 2025 00:00:00 +0530

Early intervention by an optimal treatment modality in the management of congenital talipes equinovarus (CTEV) or club foot is of paramount importance in order to preserve the functional efficacy of foot. Neglected, resistant, or relapsed cases of clubfeet are even more challenging to treat, as with time the deformities become fixed and the feet develops secondary adaptive bony changes. Joshi’s external stabilization system (JESS) distractor is an effective treatment modality for such kind of deformities with a precise viability and efficacy. This case series study was conducted to evaluate the functional outcomes of JESS distractor in the correction of the deformities in neglected, resistant or relapsed cases of CTEV and to assess the complications associated with the procedure. Total 22 club feet (15 patients) included in this case series considering inclusion and exclusion criteria. JESS distractor was applied and distraction done as per distraction schedule, followed by its removal and corrective cast application. Functional outcome was based on the Pirani score with one year follow-up. The statistically significant (p value <0.05) improvement was found in all clinical and radiological parameters after the procedure in all the post-operative patients. Pirani score improved to good score (0-2) in comparison to its pre-operative poor score (5-6) without any significant complication. Considering the parents compliance, JESS distractor is a good alternative for neglected, resistant or relapse cases of club feet, as it avoids soft tissue as well as bony procedures to correct the deformity of CTEV while preserving the normal foot anatomy.

Calcaneum tuberculosis-an uncommon phenomenon: narrative review

Sumit Kumar, Rajendra Kumar, Neeraj Jayant, Chandrakant Gautam, Vipul Aggarwal — Tue, 25 Feb 2025 00:00:00 +0530

The Mycobacterium tuberculosis is the cause of tuberculosis (TB), a dangerous and highly contagious infection that is a major source of morbidity and mortality. One to three percent of cases have osteoarticular TB, and 10% of these cases involve foot and ankle involvement. The bone in the foot most frequently attacked by TB is the calcaneus. There are currently relatively few case series studies and case Report available that describe this uncommon phenomenon. The aim of this narrative review is to find information on the calcaneum tuberculosis-An uncommon phenomenon. We evaluated the medical records of some patients with 4 to 68 years, who had isolated calcaneal tuberculous osteomyelitis. As part of the systematic search, the phrase "calcaneal tuberculosis-an uncommon phenomenon" was created in relation to integrative, along with its synonyms, and the search database was used. The Google search engine was used to manually search PubMed and Google Scholar. The database did not include any further articles. According to the study's conclusions, Mycobacterium tuberculosis is the main cause of TB, a dangerous and communicable infectious illness. Calcaneal tuberculosis is uncommon. A high degree of clinical suspicion, in addition to positive imaging data, GeneXpert findings, and Gram stains, can aid in the diagnosis of TB calcaneus because it is an uncommon illness. To stop the illness from spreading to other bones and joints, early identification is crucial. Patient was treated with antitubercular medication and had a successful operation to correct the abnormalities.

Integration of advanced imaging and surgical navigation in the treatment of unstable thoracolumbar spine fractures: a systematic review of functional, neurological and postoperative outcomes

Tue, 11 Feb 2025 00:00:00 +0530

Advanced imaging and surgical field have improved treatment and management of unstable thoracolumbar spine fractures significantly. Its emergence is boosting surgical accuracy, efficiency and its use has increased patient recovery rate. This systematic analysis is conducted to explore how these technologies affect functional, neurological and postoperative outcomes. Our aim is to evaluate and investigate previous evidences and various studies. This systematic analysis will be based entirely on retrospective analyses, randomized controlled trials, and other systematic reviews. While conducting methodology, we assessed several factors like pedicle screw placement accuracy, surgery time, radiation exposure and noted overall patient outcomes across different navigation systems like intraoperative CT navigation (iCT-Nav), 3D navigation, and augmented reality. The primary results of this systematic review revealed pedicle screw placement accuracy was high (up to 96.9% with iCT-Nav), with fewer revision surgeries needed. 3D navigation reduced fluoroscopy time significantly (p=0.0002) while still maintaining accuracy and evidence confirmed these techniques also helped lower blood loss (p<0.05) and improved spinal alignment without adding significant time to the surgery. Evidence showed radiation exposure remained an issue with varying levels of dose-length product (DLP) but it was dependent on the complexity of the procedures. Conservative management failed in 9.2% of cases while long-segment stabilization helped prevent further vertebral fractures. After all these results, we came to a conclusion that advanced imaging and navigation technologies have revolutionized thoracolumbar fracture management because its use has improved accuracy and patient outcomes which is confirmed. These technologies are also seen to reduce the need for revision surgeries and made minimally invasive surgeries more effective and also helped stabilize the spine in the long term. The challenges linked to these procedures are radiation exposure, standardization and costs which need to be carefully handled and need attention. Future research should explore what the role of artificial intelligence is and how it can work to bring maximum outcomes while making these technologies more accessible is also critical.

Diagnostic accuracy of ultrasound in common shoulder pathologies: a retrospective cohort study and literature review

Osama Mohamed, Jerry Sam, Satya Kanth Pydah, Kanwalnaini Cheema — Tue, 25 Feb 2025 00:00:00 +0530

Background: This study aims to evaluate the diagnostic accuracy of shoulder ultrasound in detecting common shoulder pathologies, including rotator cuff tears, AC joint diseases, glenohumeral joint diseases, subacromial impingement, and long head of biceps conditions. The research question focuses on comparing ultrasound findings with arthroscopy results.

Methods: We conducted a retrospective cohort study of 60 patients who underwent preoperative ultrasound followed by shoulder arthroscopy. Sensitivity, specificity, and diagnostic accuracy were calculated for each pathology, comparing ultrasound to arthroscopic findings.

Results: Ultrasound demonstrated high sensitivity (90%) for detecting rotator cuff tears but showed lower sensitivity and specificity for AC joint diseases, subacromial impingement, and glenohumeral joint diseases. Ultrasound was particularly limited in identifying early biceps tendon pathologies.

Conclusions: Ultrasound is highly sensitive for diagnosing rotator cuff tears and serves as a valuable initial diagnostic tool. However, it is less reliable for other shoulder pathologies, where additional imaging modalities may be needed to confirm diagnoses. Improved operator training could enhance diagnostic accuracy.

Vancomycin in anterior cruciate ligament graft preparation; does it really reduce infection rate?

Sari M. Osman, Ali Abdullah Mohammed Al Lawati — Tue, 25 Feb 2025 00:00:00 +0530

Background: The aim of our study is to evaluate how the incidence of septic arthritis or postoperative infection is affected by the use of vancomycin in preparation of grafts during anterior cruciate ligament (ACL) reconstruction.

Methods: This is a retrospective comparative study conducted between two groups, first group operated in the period from August 2017 to August 2018, second group operated in the period from December 2022 to December 2023. It focuses on the incidence of post-operative infection rate in ACL reconstruction surgeries. All patients who had ACL reconstruction were included, all surgeries were performed by a single surgeon at the same hospital with the same set up and consumables. Infection was defined as a return to the operating room for irrigation and debridement within 90 days after surgery.

Results: Total of 130 patients were included in the study, first group (vancomycin group) or second group (non-vancomycin group) no patients suffered from postoperative deep infection, neither on the immediate post operative follow up, nor at the end of their final follow up. Comparing the two groups, more revision anterior cruciate reconstructions included in the second group, yet no single case of infection took place in any of the two groups.

Conclusions: In conclusion we found no difference between adding vancomycin to the graft or not adding it, as both groups showed no infection.

Outcome of closed intramedullary fixation of femoral shaft fracture by titanium elastic nail in children

Tue, 25 Feb 2025 00:00:00 +0530

Background: Femoral shaft fractures are most common fractures in paediatric orthopaedic age group. The best treatment between six to fourteen years of age is a matter of debate. Titanium flexible elastic intramedullary nailing has become a well-accepted method of treatment of paediatric femoral shaft fractures. This study aims to evaluate the functional outcome of treatment of femoral shaft fracture by closed intramedullary titanium elastic nail (TEN) in children age between 6 to 14 years.

Methods: This prospective observational study was conducted over a period of two years from July 2017 to June 2019. Thirty children (23 boys, 7 girls) aged 6-14 years with femoral diaphyseal fractures were stabilized with retrograde titanium elastic nail. The results were evaluated by using Flynn’s TEN scoring criteria. Two nails were used in each fracture.

Results: Mean age was 11.1±1.8 years with male female ratio 3.3:1. Male patients were predominant in this study. Type of fracture were observed that 10(33.3%) cases were oblique, 18 (60.0%) cases were transverse and spiral 2 (6.7%). Radiological union in all cases were achieved in a mean time of 9.6±1.9 weeks. Objective evaluation showed that 21 (70.0%) patients had knee flexion >130°, 7 (23.3%) had restricted motion of 120–130°, and 2 (6.7%) had a range of 100–120°. The results were excellent in 23 patients (76.7%), satisfactory in 7 patients (23.3%) and there was no poor result.

Conclusions: TEN fixation of paediatric femoral shaft fractures is an excellent method of treatment in children aged 6-14 years.

Comparative study of the role of pronator quadratus repair versus no pronator quadratus repair in volar plate fixation of distal radius fractures

Shubham Kumar, Rakesh Choudhary, Shamir Rahman — Sat, 18 Jan 2025 00:00:00 +0530

Background: There is a controversy regarding the merits of repairing pronator quadratus (PQ) following volar plate fixation of distal radius fracture via Henry’s approach. The aim of this study was to evaluate and compare the post-operative functional outcome between those with PQ repair vs those without PQ repair.

Methods: The 41 patients (33 males and 8 females) were included in this randomized controlled trial as per our inclusion and exclusion criteria. Of these 21 patients were in group A in which PQ repair was done and 20 patients were in group B in which PQ repair was not done. Both groups were compared with DASH score, wrist range of motion, post-operative pain and grip strength.

Results: The patients were followed up for minimum 1 year. Patients in both the groups shared similar baseline and demographic characteristics. There was no significant difference in the mean DASH score and mean grip strength at any point of time in follow up. However, wrist flexion at 6 weeks was better in group A (p=0.03) along with post-operative pain at 2^nd and 6^th week (p=0.035, 0.039).

Conclusions: PQ repair during volar plating of distal radius fractures does not provide any significant better functional outcome, range of motion and grip strength, especially in long run. But it reduced early post-operative pain significantly.

Magnetic resonance imaging knee joint measurements for the prediction of the population at risk of anterior cruciate ligament tear injuries

Mohammed Raiyan, Shaikh M. Fahim, Madhusudhan D. Nigesh — Tue, 21 Jan 2025 00:00:00 +0530

Background: This study aims to investigate whether patient-related anterior cruciate ligament (ACL) damage is associated with measures of various knee joint components.

Methods: Patients who had magnetic resonance imaging (MRI) and suffered from ACL injuries were included in this retrospective case-control study. There was also a control group of individuals who had normal MRI results for knee diseases. The following 14 knee variables were gathered: lateral and medial (MFC) femoral condyle sphere diameter; lateral and medial tibial plateau length; patella tendon horizontal and vertical diameter; lateral meniscus (LM) posterior horn height, length, depth, and volume; and medial meniscus (MM) posterior horn height, length, depth, and volume. The two groups were compared using a multivariate logistic regression that took into account the patella tendon horizontal diameter, MFC sphere diameter, MM posterior horn length, MM volume, LM posterior horn depth, and receiver operating characteristic curve.

Results: We enrolled 98 patients in total; 48 had ACL injuries, and 50 had normal knee MRIs as a comparison group. The results of the logistic regression analysis showed that the following factors independently predicted the risk of ACL rupture: decreased MM posterior horn length (OR=0.45; 95% CI=0.33-0.630; p<0.001), increased LM posterior horn depth (OR=1.78; 95% CI=1.37- 2.03; p<0.001), and MFC sphere diameter (OR=1.27; 95% CI=1.01-1.60; p=0.0354).

Conclusions: Individuals with an ACL injury had shorter MM posterior horns, deeper LM posterior horns, larger MFC sphere diameters.

Diagnostic overview of nature and pathogenesis of shoulder dislocation

Rajesh K. Ambulgekar, Ajay A. Gour, Priyanka T. Ahire — Tue, 21 Jan 2025 00:00:00 +0530

Background: Shoulder dislocation, soft tissue and bony injuries around shoulder has close relation and hence, detail investigation and diagnosis plays a crucial role in prognosis and further treatment.

Methods: The study of diagnostic arthroscopy aimed to determine the incidence of secondary intra-articular shoulder lesions in acute and chronic anterior shoulder instability patients. Study investigated the occurrence of intra-articular shoulder lesions in a series of 30 patients with acute and chronic traumatic anterior instability.

Results: Prospective observational study was done on patients with acute shoulder dislocation. After ab arthroscopic evaluation, majority 77% of patients had capsulo-labral detachments. 61% of first dislocations showed capsulo-labral detachment/Bankart lesions and all the recurrent dislocations had partial or complete capsule-labral detachment or Bankart lesions. Glenohumeral ligament integrity was disturbed in 58% of recurrent and that of 11% of first time shoulder dislocation cases. Hillsach lesions are in total of 57% of all soft tissue injuries. Bony Bankart lesions were found in 50% of recurrent dislocations. Rotator tears are mainly in recurrent dislocation cases mainly >40 years of age.

Conclusions: Patients with chronic shoulder instability are more likely to have secondary intra-articular lesions, compared to those with acute, likely due to the repeated episodes of dislocation or subluxation. These associated lesions are a consequence of the ongoing instability, which leads to additional damage within the joint. Early intervention plays an important role, as the conditions for surgical intervention are optimal after initial shoulder dislocation.

Age, gender, and site-specific variations in bone mineral density: a cross-sectional analysis of osteoporosis risk factors

Tue, 21 Jan 2025 00:00:00 +0530

Background: Osteoporosis is major health issue defined by decreased bone mineral density (BMD) and elevated fracture susceptibility. This study aimed to analyze age, gender, and site-specific variations in BMD and examine osteoporosis risk factors in an Indian population.

Methods: This study was conducted with cross sectional design on 77 participants (54 females, 23 males) aged 20-83 years undergoing 3 Dimensional quantitative computed tomography (QCT) for BMD assessment at a tertiary care hospital in India. BMD measurements of the spine and bilateral hips were analyzed along with demographic and clinical data. Statistical analyses included t-tests, multivariate logistic regression, correlation analysis, and Chi-square tests.

Results: The study revealed a high prevalence of osteoporosis (55.8%) and osteopenia (27.3%). Marked disparities in spine bone mineral density were noted between genders (p=0.023) and among age cohorts (p<0.0001). Age showed moderate negative relationship with spine BMD (r=-0.552, p<0.0001) and was recognized as a major predictor of osteoporosis (p<0.0001). Gender was not a significant predictor of osteoporosis after adjusting for age in our study.

Conclusions: This study highlights the critical role of age in BMD reduction and osteoporosis risk, with older individuals showing higher rates of osteoporosis. While gender differences in BMD were observed, age emerged as the primary predictor of osteoporosis risk. These findings emphasize the importance of age-related assessments in osteoporosis screening and management strategies.

A prospective study of the surgical management of malleolar fractures around the ankle

Arun Mammen Mathew, Ashwin Roby, Nasneem M. — Tue, 25 Feb 2025 00:00:00 +0530

Background: Ankle fractures are commonly occurring fractures, especially in the aging population, where they often present as fragility fractures.

Methods: Malleolar (mono, bi and tri malleolar) fracture patients treated at a tertiary healthcare centre located in South Kerala, India were included in this prospective study. The present study comprised of 27 patients over 20 years of age with closed, unstable or displaced ankle malleolar fractures treated surgically attending the study centre over a period of 6 months. After a clinical evaluation, a full survey was done to rule out major damage. After surgical intervention, follow-up occurred every 6 weeks for at least 8 months. The study used Baird and Jackson's subjective, objective and radiographic ankle scoring method to assess functional outcome.

Results: The findings indicated that the predominant injury types according to the lauge hansen classification were supination-external rotation (40.7%) and pronation-external rotation (40.7%). The results indicated that the majority of participants achieved excellent scores (59.25%), followed by good scores (18.5%), fair scores (14.8%) and poor scores (7.4%).

Conclusions: The study of surgical interventions for malleolar fractures at the ankle demonstrates that open reduction and internal fixation (ORIF) is an effective treatment method, leading to improved functional outcomes. The findings underscore the importance of precise anatomical alignment and stable fixation in mitigating issues such as malunion and non-union.

A study to evaluate the functional outcome of supracondylar intercondylar fracture femur fixed by open reduction internal fixation using distal femoral locking plates in a tertiary care centre

Ashwin Roby, Nasneem M., Arun Mammen Mathew — Tue, 25 Feb 2025 00:00:00 +0530

Background: Supracondylar Intercondylar fractures frequently exhibit greater complexity than supracondylar fractures and may result in considerable complications if not appropriately managed. The present study assessed the benefit of open reduction internal fixation (ORIF) of supracondylar-inter-condylar fracture femur using distal femoral locking plates in terms of functional outcome of the patient.

Methods: The present descriptive study conducted in a tertiary healthcare centre located in Kollam, Kerala. The study included patients suffering from supracondylar intercondylar fracture femur fixed by ORIF using distal femoral locking plates. The patients were treated and assessed using range of motion, Knee society score and time taken for weight bearing. These findings were then compared for association with demographic and clinical variables. The data was analysed using chi-square test and p<0.05 was considered as statistically significant.

Results: The study involved a total of 63 patients with supra-condylar intercondylar femur fractures, with most being females over 70 years old. Postoperatively, most patients showed a range of motion of 91-120 degrees, and the time for radiological union was less than 6 months. The mean KSS score improved significantly at 12 months, with the majority having excellent scores. The study also found significant differences in mean range of motion based on age, type of fracture, and open/closed fractures. The time taken for full weight bearing was also associated with the type of AO fractures.

Conclusions: The study reveals significant differences in weight-bearing outcomes after ORIF of supracondylar intercondylar femur fractures. C₁ fractures showed positive recovery, while C₂ and C₃ required extended rehabilitation. The study emphasizes fracture classification and personalized treatment for improved patient outcomes.

Prospective evaluation of functional outcome in anterior cruciate ligament reconstruction with peroneus longus graft: a hospital-based study

Tue, 25 Feb 2025 00:00:00 +0530

Background: Anterior cruciate ligament (ACL) reconstruction using the peroneus longus tendon (PLT) graft is emerging as a viable alternative to traditional autografts, offering comparable strength and reduced donor site morbidity. This study evaluates the functional outcomes and complications of ACL reconstruction using this PLT graft.

Methods: A hospital-based prospective study was conducted on 50 patients with isolated ACL tears. Outcomes, including Lysholm, IKDC, Tegner activity, and modified Cincinnati scores, were assessed preoperatively and postoperatively at 6 and 12 months. Visual analog scale (VAS), range of motion (ROM), and complications were also recorded. Statistical significance was set at p<0.05.

Results: Significant improvements were observed in Lysholm (46.2±10.3 to 89.4±6.7), IKDC (38.1±9.7 to 85.2±5.9), and modified Cincinnati (37.5±8.2 to 85.3±5.1) scores (p<0.001). ROM increased from 115°±15° to 140°±5°, and pain (VAS) decreased from 7.4±1.2 to 1.5±0.7. Complications were minimal, with a 2% graft failure rate and mild donor site morbidity.

Conclusions: ACL reconstruction with the peroneus longus graft provides excellent functional outcomes and minimal complications, making it a reliable alternative to conventional autografts.

Comparative analysis of tension band wiring and cannulated cancellous screws for displaced medial malleolus fractures: a prospective study

Karthik Aiyanna N. C., Deekshith Shetty K., Manjunath Swamy, Kiran J. Kailath — Tue, 25 Feb 2025 00:00:00 +0530

Background: The displaced medial malleolus fractures require surgical intervention, and the management includes tension band wiring (TBW) and cannulated cancellous screws (CCS).

Methods: This prospective randomized study was conducted from December 2019 to December 2022. Sixty patients with closed displaced medial malleolus fractures were randomized into two groups: group A (TBW) and group B (CCS). Patients were evaluated based on radiological fracture union and functional outcomes assessed using the modified Olerud and Molander ankle score (OMAS). Follow-ups were conducted for two years to assess healing, range of motion, complications, and functional outcomes.

Results: Mean age was 41.46 years in group A (TBW) and 39.4 years in group B (CCS). Radiological union was achieved faster in group B (10.4 weeks) compared to group A (11.53 weeks, p=0.003). Functional outcomes showed excellent scores in 16.67% of group A patients and 30% of group B patients. Group B had fewer complications, with only one case of screw loosening compared to a higher rate of hardware prominence (30%) and exertional pain (10%) in group A, necessitating implant removal in 12 patients. No significant differences in range of motion were observed, although group B demonstrated slightly better functional outcomes.

Conclusions: Both TBW and CCS effectively achieve fracture union in displaced medial malleolus fractures. However, CCS fixation demonstrates superior functional outcomes, faster union rates, and fewer complications compared to TBW. Lower risk of hardware-related issues and reduced need for secondary surgeries, CCS is recommended as a preferred method for the surgical management of displaced medial malleolus fractures.

Result of tensor fascia lata muscle pedicle bone graft in early-stage avascular necrosis of femoral head in adults

Dilip Kumar Pal, Animesh Kumar Singh, Pranay Kundu, Anshu Aryan — Tue, 25 Feb 2025 00:00:00 +0530

Background: The avascular necrosis (AVN) of femoral head in young adults is a disabling condition. The core decompression along with Tensor fascia lata (TFL) Muscle pedicle bone graft (MPBG) fixed with screw at the base of the neck of the femur is a simple, effective, treatment method with excellent to good result in majority of the early cases of AVN.

Methods: In this retrospective study we operated on 32 hips with early or advanced AVN especially in young adults from May 2021 to April 2023, using core decompression along with TFL MPBG fixed with screw at the base of the neck of the femur. The final assessment was done on only those patients who were followed for at least 2 years post operatively using modified Harris hip score (mHHS).

Results: The mean age of the patients was 29.2 years. The mean duration of surgery was 129 minutes. The mHHS score was found to be excellent in 12, good in 15, Fair in 3 and poor in 2 patients. The correlation was found between AVN & mHHS. Those with early AVN had better mHHS compared to advanced one, whereas a few with advanced AVN had the tendency to progress to further advanced stage of AVN.

Conclusions: The core decompression along with TFL MPBG fixed with screw in the neck of the femur is a simple, effective and reproducible treatment modality with excellent to good results in early AVN in majority of young adults.

Outcome of the treatment of developmental dysplasia of the hip after walking age with open reduction, varus derotation osteotomy with femoral shortening and acetabular osteotomy

Al-Imran Mahmud, Saifullah Al Noman, M. C. Paul Minto — Tue, 25 Feb 2025 00:00:00 +0530

Background: The principles of treatment of developmental dysplasia of hip after walking age are different than those of infants and neonates. The purpose of this study is to evaluate the radiographic and functional results of open reduction, varus derotation osteotomy with femoral and acetabular osteotomy of DDH in older children.

Methods: Between March 2021 and August 2023, 22 patients underwent one-stage triple procedure of open reduction, varus derotation osteotomy with femoral shortening and acetabular osteotomy for the treatment of DDH. Clinical outcomes were assessed using the modified McKay’s criteria. Radiographic assessment was made using Severin’s scoring system.

Results: The mean age at the time of operation was 5.068±1.8535 years (range 3–8 years) with male to female ratio 1:2.66. Mean preoperative acetabular index of the study population was 48.55±7.63 which significantly reduced to 23.68±2.93 postoperatively (p<0.05). The McKay’s score was excellent in 14 (63.6%) hips, good in 02 (9.1%) hips, fair in 01(4.5%) and poor in 05(22.7%) hips. The modified Severin’s class excellent was in 14 (63.6%) hips, good was in 02(9.1%) hips, fair is in 01 (4.5%) hip and poor was in 05 (22.7%) hips at the time of final evaluation as compared to none at the time of presentation.

Conclusions: Young children having DDH can be safely treated with an extensive one-stage procedure of open reduction, varus derotation osteotomy with femoral shortening and acetabular osteotomy, without increasing the risk of AVN. This one-stage surgical procedure for managing DDH patients after walking age also revealed acceptable clinical and radiological outcome.

Impact of COVID-19 lockdown on pain and physical function in patients with advanced hip and knee osteoarthritis

Amaresh C. P., Puttakemparaju K. V. — Tue, 25 Feb 2025 00:00:00 +0530

Background: Osteoarthritis is the most common degenerative disease of joints that impairs quality of life and leads to disability. Hence, this study aims to assess the impact of lockdown on pain and physical function in patients with advanced knee and hip Osteoarthritis.

Methods: A total of 86 patients between the age of 35 to 80 years with advanced hip and knee osteoarthritis were considered for the study during the second wave of COVID 19 lockdown. The subjects were contacted over phone call and a questionnaire was put forward after obtaining their consent. Subsequently the interviews were repeated in the fourth week and at the end of lockdown. The observers were blinded for the previous results. Visual analogue scale (VAS), Tegner activity scale (TAS), McMaster Universities Osteoarthritis questionnaire (WOMAC) scores of the patients were obtained. Comparative analysis was made based on these parameters at pre, during and after lockdown period.

Results: Positive, strong to very strong and significant Pearson’s correlation was seen between VAS and WOMAC scores at all the time intervals in both the groups (knee and hip) and overall. Negative, moderate to strong and significant correlation was seen between VAS and TAS scores. A weak, moderate and significant correlation was seen between WOMAC and TAS scores.

Conclusions: Our study depicts that the COVID-19 lockdown had a significant negative impact on patients with end-stage hip and knee osteoarthritis resulting in increased pain and deteriorating joint function with reduced quality of life. We suggest that virtual education in the form of web physiotherapy, online knee and hip schools and holistic self-management strategies are vital to improve pain and physical function.

Role of physiotherapy in relieving osteoarthritis knee pain using Lysholm score

Garvit Khatod, Rajendraprasad Ramesh Butala, Sonali Das — Tue, 25 Feb 2025 00:00:00 +0530

Background: Knee osteoarthritis (OA) is a prevalent condition that significantly impacts quality of life. While pharmacological interventions are commonly used, non-pharmacological approaches like physiotherapy have gained increasing recognition. In this study, the Lysholm Knee Scoring Scale was used to assess how well physiotherapy worked in reducing knee pain and enhancing functional results for people with OA knee.

Methods: A randomized controlled trial from 1st February 2023 to 31st July 2023 at Department of Orthopaedics, Padmashree Dr. D.Y. Patil Medical College and Hospital, Nerul, Navi Mumbai, Maharashtra, India was conducted with 500 participants diagnosed with knee OA. Participants were randomly assigned to either the physiotherapy group (n=250) or the control group (n=250). The physiotherapy group received a 12-week standardized program consisting of exercise therapy, manual therapy and education. The control group received standard care. The primary outcome was the Lysholm Knee Scoring Scale, assessed at baseline, 12 weeks (post-intervention) and 24 weeks (follow-up). Secondary outcomes included the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), knee range of motion, muscle strength and quality of life.

Results: At baseline, the groups were comparable in terms of age, gender, body mass index and clinical characteristics. The physiotherapy group demonstrated significantly greater improvements in the Lysholm Knee Scoring Scale compared to the control group at 12 weeks (mean difference: 10.2, 95% CI: 7.4, 13.0; p<0.001) and 24 weeks (mean difference: 12.2, 95% CI: 9.2, 15.2; p<0.001). Similar patterns were observed for secondary outcomes, with the physiotherapy group showing significant improvements in WOMAC pain and function, knee range of motion, quadriceps strength and quality of life (all p<0.001).

Conclusions: This study provides evidence that physiotherapy interventions, including exercise therapy, manual therapy and education, are effective in relieving knee pain and improving functional outcomes in individuals with knee osteoarthritis, as measured by the Lysholm Knee Scoring Scale and other relevant clinical measures.

Effectiveness and cost-utility of lumbar facet joint blocks using bupivacaine with and without steroid in the treatment of chronic low back pain in adults

Ajay Reddy Aeerabolli — Tue, 25 Feb 2025 00:00:00 +0530

Background: Chronic low back pain (LBP) causes lot of pain and suffering thus contributing to frequent and increased cost and burden on health-care-facilities. In United Kingdom, it has been estimated that economic cost of LBP pain is around £12.3B per annum. It is also associated with increased incidence of depression, anxiety. These morbidities also lead to increased costs for patient. To study effectiveness and cost-utility of lumbar facet joint blocks using bupivacaine with and without steroid in the treatment of chronic LBP in adults.

Methods: Hospital-based randomized comparative study was carried out among 100 adult cases of chronic LBP. They were randomly assigned as 50 cases treated with bupivacaine without steroids and 50 cases treated with bupivacaine with steroids. Modified oswestry disability index was used to assess functional improvement and visual analogue scale to assess pain score. Patient data was used to assess cost-utility.

Results: Patients in group-II were significantly older, had more pain duration than group-I. Incidence of repeat procedure required was more in group-I compared to group-II (p<0.05). The functional level in both groups was comparable (p>0.05) at baseline. At one, three, six and twelve months, it improved more significantly in group-II compared to group-I (p<0.05). At baseline, pain score was significantly more in group-II compared to group-I (p<0.05). But, at one, three, six and twelve months, it was significantly lesser in group-II compared to group-I (p<0.05). Patients in both groups were comparable for physician cost and facility cost. But total number of procedures and average number of treatments per patient were lesser in group-II compared to group-I.

Conclusions: Thus, we conclude that bupivacaine with steroids is not only effective in relief of pain and returning normal functionality, but also cost-effective compared to bupivacaine without steroid in adult patients with chronic LBP.

Comparative analysis of suprapatellar vs infrapatellar approaches in intramedullary nailing for distal tibia fractures

Ankur Ojha, Pushprajan, Prince Maheshwari, Ajit Singh — Tue, 25 Feb 2025 00:00:00 +0530

Background: The current study delves into the clinical and functional outcomes of suprapatellar (SP) and infrapatellar (IP) intramedullary nailing techniques in treating distal tibia fractures, utilizing data accrued from King George’s Medical University, Department of Orthopaedics, between Jan 2022 to August 2023.

Methods: A retrospective analysis was carried out involving two groups of patients who underwent either SP or IP nailing techniques. Several parameters including surgical time, blood loss, pain score and functional outcomes were evaluated. Functional outcomes were assessed on the basis of AOFAS scores.

Results: The SP group demonstrated a reduced mean surgical time (85.7±14.8 minutes) compared to the IP group (96.3±16.7 minutes, p=0.011). Moreover, the SP group reported lower pain scores (20.2±3.9) than the IP group (27.5±3.6, p<0.001) and exhibited better functional outcomes as evidenced by higher AOFAS scores (94.1±4.3 vs 88.5±4.7, p<0.001). However, no significant difference was noted in blood loss or fracture healing time between the two groups.

Conclusions: The study underscores the potential superiority of the suprapatellar approach in terms of reduced surgical time, lower pain scores and better functional outcomes. Despite this, the infrapatellar approach had a higher incidence of fracture deformities, necessitating a cautious approach when selecting surgical strategies. Further research with larger sample sizes is warranted to substantiate these preliminary findings.

A study on submuscular bridge plating in paediatric femoral diaphyseal fracture

Tue, 25 Feb 2025 00:00:00 +0530

Background: Pediatric femoral diaphyseal fractures represent a significant orthopedic challenge, often resulting from falls or motor vehicle accidents. Conservative treatments like traction and spica casting suit younger children, but surgery is preferred for older children to reduce hospitalization and immobility. This study aimed to assess the efficacy and safety of submuscular bridge plating (SBP) as a treatment modality for pediatric femoral diaphyseal fractures.

Methods: This prospective study was conducted at Sylhet MAG Osmani Medical College Hospital between February 2023 and February 2024, involving 40 patients aged 6–15 years. The study included closed fractures (AO 32A123) and excluded open fractures, pathological fractures, supracondylar extensions, and infections. A minimally invasive technique with dynamic compression plates was used, with follow-ups at 6 weeks and 3 months.

Results: The study cohort had an average age of 10.4 years, with a male predominance (75%). Injuries were primarily caused by falls (60%) and road traffic accidents (30%). Fracture patterns ranged from oblique (40%) to comminuted (15%), with most located in the middle third of the femoral shaft. Postoperative complications occurred in 25% of cases, including superficial wound infections (15%) and deep infections requiring intervention (10%). Callus formation was observed at an average of 7.2 weeks, with minimal limb length discrepancies (mean: 1.2 cm). Functional outcomes, assessed using the Flynn score, were excellent in 85% of cases.

Conclusions: Submuscular bridge plating demonstrates a reliable and effective solution for managing pediatric femoral diaphyseal fractures, offering excellent functional outcomes and low complication rates.

Do parallel pinning offer advantage over crossed pinning for displaced supracondylar humerus fractures in children: a randomized trial

Mayank Daral, Vasu, Himanshu Agrawal, Rahul Bhargava, Paridhi — Tue, 25 Feb 2025 00:00:00 +0530

Background: To compare outcomes between cross pinning with lateral pinning for fixation of displaced supracondylar fracture of humerus in children.

Methods: Children (<12 years) with displaced supracondylar fractures of the humerus were randomized to receive either cross pinning (Group 1) or lateral pinning Group 2). Follow-ups were conducted at 3 weeks, 6 weeks, and 3 months. Clinic-radiological union, Baumann angle, loss of reduction, stability of fracture fixation, incidence of complications, and Flynn's score were compared.

Results: The mean age of children in group 1 was 7.2±2.1 and in group 2 was 6.7±2.3, respectively (independent t-test, p=0.259). The mean follow up was 6.4±2.3 and 6.54±2.1 months, respectively (p=0.356). There were no significant differences observed in Baumann's angle, change in Baumann angle, loss of reduction, carrying angle, loss of carrying angle, range of motion in flexion and extension of the elbow, or total loss of range of motion between the two groups. One patient (2.4%) in group 1 had ulnar nerve injury. Based on Flynn's grading, 32 patients (85.7%) in group I and 27 patients (67.5%) in group II achieved excellent results (Figure 2b &c). In group I, 9 patients (31.4%) and in group II, 10 patients (25%) had good results. group I had 1 patient (2.4%) with fair results, while group II had 2 patients (5%) with fair results. One patient (2.5%) in group II had poor results.

Conclusions: Both techniques ensure stable fixation, union, and good functional outcomes, except for iatrogenic ulnar nerve injury with cross pinning.

Comparison of surgical approaches of total hip arthroplasty in Crowe 3/4 dysplastic hips in adults: a systematic review and meta-analysis

Tue, 25 Feb 2025 00:00:00 +0530

Developmental dysplasia of the hip (DDH) presents unique challenges for total hip arthroplasty (THA) due to altered anatomy, requiring tailored surgical approaches. Differences in outcomes such as Harris Hip Score (HHS), leg length discrepancy (LLD), operative variables, and postoperative complications between THA approaches remain unclear. This meta-analysis aimed to evaluate variations in functional outcomes, operative data, and postoperative complications among THA approaches in adult patients with DDH, focusing on direct anterior (DAA), posterolateral (PLA), and anterolateral (ALA) approaches, as well as osteotomy versus non-osteotomy techniques. Following preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines, we systematically searched PubMed, Cochrane, and manual sources for retrospective studies published until March 2024. An inverse variance pooling meta-analysis was conducted. Thirty-five studies (1501 hips; 1246 patients; mean age 46.9 years; mean follow-up 7 years) were included. HHS improved by 47.08 points with no significant differences between approaches (p=0.81) or osteotomy groups (p=0.96). LLD reduced by 3.50 cm overall, with the posterior approach achieving the greatest reduction (-3.67 cm, p=0.03). Operative time (148.47 minutes) and blood loss (832.74 ml) did not differ significantly between DAA and PLA (p=0.59 and p=0.08, respectively). Minor complications, including nerve palsy and non-union, were rare. Dislocation rates were higher with the posterior approach (2%, p=0.04), while infection rates were negligible (0%). THA approaches in DDH yield comparable functional and operative outcomes. The posterior approach achieved the greatest LLD reduction but had a higher risk of dislocation, highlighting the need for careful approach selection.

Long term outcome of tibial adamantinoma: a case report and literature review

Tue, 25 Feb 2025 00:00:00 +0530

Adamantinoma is a rare malignant bone tumor that typically occurs in the tibia but can also occur in the jaw, forearm, hands, or feet. It commonly affects young adults between 20 and 40 years. It accounts for less than 1% of primary bone tumors. It is a slow growing tumor and often indolent but generally symptoms are persistent pain in the affected area, localized swelling, tibial bowing deformity and pathological fracture which occurs acutely. the diagnosis is based on imaging and a necessary biopsy to confirm the diagnosis, showing nests of epithelial-like cells in a fibrous stroma. The treatment consists of surgical resection and recurrence can be problematic and may occur even decades after initial treatment. Here, we report one case of tibial adamantinoma with atypical treatment and long-term evolution greater than 24 years and with no recurrence.

Isolated zone I vertical sacral fracture: a case report

Tue, 25 Feb 2025 00:00:00 +0530

Isolated sacral fractures are not common. This is attributed to the lack of segmental motion of the sacral bones, and most sacral fractures are transversely oriented. However, vertically oriented sacral fractures are never isolated and are usually associated with pelvic ring fractures due to the shearing force of the pelvic ring. There are only a few case reports of such injury presented in isolation. We are reporting a case of isolated zone I vertical sacral fracture in a 25-year-old female following a road traffic accident with a lateral compression mechanism of injury. Only a few cases related to isolated sacral fractures have been reported in the literature. To our knowledge, there have only been a few reports of vertical sacral fracture following a lateral compression injury. Complete vertical sacral fracture with significant displacement in isolation is a rare injury, as it is usually associated with pelvic ring injuries. Surgical stabilization is an indication of such injury to restore the stability of the pelvic ring.

A rapidly advancing intraosseous angiosarcoma masquerading as an infected pathological periprosthetic fracture: a case report

Jiawen Fong, Ho Chin Boo — Tue, 25 Feb 2025 00:00:00 +0530

We present a case of a rapidly progressive angiosarcoma that presented initially as a pathological fracture in our institution after a fall. Mdm A, a 74-year-old Chinese lady initially presented with non-specific thigh pain prior to an unwitnessed fall, following a recent bipolar hemiarthroplasty 3 months before current presentation. Blood markers were grossly within acceptable limits and computed tomography (CT) scan revealed displaced greater and lesser trochanteric periprosthetic fractures with subsidence of femoral stem, and findings suggestive of intramuscular haematomas. She subsequently turned septic on day of planned surgery for a revision arthroplasty with markedly raised inflammatory markers. Revision surgery was postponed, with repeat imaging noting evolving fluid collections suspicious of an infected prosthetic joint infection (PJI). Joint washout for presumptive PJI performed 1-week later yielded negative histopathology and cultures. She developed respiratory compromise a few days later. CT-thorax revealed bilateral pleural effusions with small spontaneous haemo-pneumothoraces which again yielded negative cultures and cytology. Eventually a repeat CT-hip 1-month post admission showed new soft tissue lesions in the superficial muscle layers. Biopsies performed returned as intermediate grade angiosarcoma with positive CD31 and ERG stainings. This is the first case study to describe an aggressive metastatic angiosarcoma mimicking a PJI on initial presentation. Angiosarcomas are very rare and presentations may also be highly varied. Diagnosis of angiosarcoma may be made difficult by the absence of clear lesions to biopsy, as in this particular case. A high clinical suspicion of a pathological periprosthetic fracture is needed when diagnosing patients who present atypically for PJIs.

Anatomic repair of a chronic distal biceps tendon rupture: a case report

Sanesh Tuteja, Timothy Rodricks — Tue, 21 Jan 2025 00:00:00 +0530

Chronic distal biceps tendon ruptures, common in weightlifting, pose significant challenges for surgical repair due to the high demands placed on the biceps muscle. Traditional repair techniques, such as direct suture fixation, may be inadequate for athletic patients. This case report presents a novel approach using the modified Boyd-Anderson two-incision technique, incorporating an endobutton and fiberloop to enhance tendon stability and functional recovery. A 40-year-old male weightlifter with a chronic distal biceps rupture underwent surgical repair after physical examination and imaging confirmed the injury. The modified Boyd-Anderson technique, involving two incisions, allowed optimal tendon exposure. An endobutton was used to secure the tendon to the radial tuberosity, while a fiberloop reinforced the repair. The procedure, performed under general anesthesia, minimized soft tissue damage. Postoperative rehabilitation focused on strength training and follow-up at 2 months showed significant improvement in range of motion, strength and overall function, enabling the patient to return to daily activities. This technique, with its use of the endobutton and fiberloop, provides a promising option for anatomical repair of chronic distal biceps ruptures in athletic individuals, offering effective restoration of function and strength. It underscores the importance of customized surgical approaches for tendon repair in active patients.

The enigma of xanthogranulomatous osteomyelitis: report of a rare case with review of literature

Arushi Gupta, Nehal Ahmad, Sabina Khan, Rubeena Mohroo, Aneesha Kataria — Tue, 25 Feb 2025 00:00:00 +0530

Xanthogranulomatous osteomyelitis (XO) is a rare chronic inflammatory condition histopathologically characterized by foamy macrophages, lymphocytes, plasma cells and fibrosis. It primarily affects organs like gallbladder and kidney but rarely involves bone. To date, only 21 cases of bone XO have been documented. XO mimics neoplastic bone lesions, creating diagnostic challenges necessitating a comprehensive approach that includes a thorough clinical history, detailed radiographic evaluation and definitive histopathologic examination. Hereby, we report a rare case of 25-year-old male presenting with pain, swelling and fever in the left forearm. Imaging revealed features suggestive of osteomyelitis and histopathological examination showed sheets of foamy macrophages, chronic inflammatory cells and fibrosis, thus clinching the diagnosis of XO. Through the case report we wish to highlight the importance of considering XO in the differential diagnosis of bone lesions so to avoid misdiagnosis of malignancy.

A pulmonary embolism secondary to fracture tibia: a clinical case report

Jaswant Singh, Saketh — Tue, 25 Feb 2025 00:00:00 +0530

Pulmonary thromboembolism (PTE) occurs when a thrombus, typically originating from venous thromboembolism, obstructs the pulmonary arteries, disrupting blood flow to the lungs. The thrombus often becomes lodged at the bifurcation of the main pulmonary artery or within the lobar branches, causing hemodynamic instability. Although the thrombus most commonly originates in the lower extremities as deep vein thrombosis (DVT), it can occasionally arise from the pelvic veins, renal veins, upper extremity veins, or the right side of the heart. Various factors can contribute to the development of deep vein thrombosis, but in the context of long bone fractures, it Deep vein thrombosis (DVT) typically develops 7 to 10 days after an injury. However, in rare cases, pulmonary thromboembolism (PTE) has been observed within 72 hours of the trauma. Several theories have been proposed to explain the mechanisms behind the early onset of PTE in such instances. Presenting a case which involves a 34-year-old male who developed pulmonary thromboembolism (PTE) following a roadside accident, and had segmental closed fracture of the right tibial shaft.

A current concept review of 9 year old boy with hemophilic arthropathy

Gurjot Singh Virdi, Mandeep Saund, Pahulpreet Kaur — Tue, 25 Feb 2025 00:00:00 +0530

The knee is frequently affected by severe orthopedic changes known as hemophilic arthropathy (HA) in patients with deficiency of coagulation factor VIII or IX and thus this manuscript seeks to present a current perspective of the role of the orthopedist, physiotherapist and pathologist in the management of these problems. Lifelong factor replacement therapy (FRT) is optimal to prevent HA, however adherence to this rigorous treatment is challenging leading to breakthrough bleeding. In patients with chronic hemophilic synovitis, the prelude to HA, Synoviorthesis is the optimal to ameliorate bleeding, judicious physiotherapy to prevent chronic joint disease.

Transthoracic discectomy for a rare presentation of calcified dorsal disc herniation

Lokendra Singh Chauhan, Mahendra Singh Tak, Lakshit Suthar, C. S. Shreyas — Tue, 25 Feb 2025 00:00:00 +0530

Thoracic disc herniation is rare entity, with incidence of 0.5%-4% of all disc herniation. Mostly are asymptomatic and does not need treatment if symptomatic cause intractable pain, intercostal neuralgia, persistent axial back pain and myelopathic symptom need surgical excision. We present a case of 74-year female with central calcified dorsal disc herniation at T11-12 level. surgical excision done by transthoracic discectomy.