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   Table of Contents - Current issue
September-December 2022
Volume 37 | Issue 3
Page Nos. 109-187

Online since Thursday, December 15, 2022

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Changing trends: Evolving subspecialties p. 109
Ashish Kumar
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Evaluation of the result of total knee replacement in various arthritic condition of knee p. 110
Jaydeep Patel, Rajat Kapoor, Ashutosh Verma, Randheer Chauhan, Sushil Saini, Chandra Prakash Pal
Introduction: Osteoarthritis is the most common form of the arthritis and is a leading cause of disability in older adults. The management of knee arthritis depends upon severity of arthritis. It starts from conservative management in earlier stage and goes upto the total knee replacement (TKR) in severely advance stage. TKR is an operation to restore pain-free motion to a joint, muscle, ligament, and other soft tissue structures that control joint. The goal of total knee arthroplasty is as simple as to relieve pain, provide motion, maintain stability, and simultaneously correcting deformity. The purpose of this study is to evaluate pain, mobility, stability after TKR in arthritis and to evaluate functional outcome. Materials and Methods: The case material for present study was selected from the out patient Department of Orthopaedics, S.N. Medical College and Hospital, Agra. Each patient would be subjected to detailed clinical history and examination and necessary radiological and pathological investigation. Data was collected by interviews, observation of clinical and radiological findings and assessment of function done using knee society knee score (having 100 points). Results: In this study, evaluation of 10 total knee arthroplasty was performed in S.N. Medical College and Hospital, Agra. In our study most of cases (70%) have age ≥60 years and most of (70%) cases are female in whom TKR was performed. The pre-operative ROM at knee were between 51⁰ and 80⁰ in all the cases (100%). But post-operative after 6 months all the cases have their range of motion between 91⁰ and 110⁰. Maximum number of the cases (80%) have moderate continuous pain at knee before the operation and rest 20% have moderate occasional pain at their knee preoperatively. After the operation, maximum number of cases (90%) have no pain or mild occasional pain after the operation. Maximum number of cases (90%) have ≥30⁰ increase in their range of motion, after operation. Similarly after TKR, there is an increase in post-operative functional knee scores at 6 months (86.5%) as compared preoperative scores (21%). Though there is an initial fall (16.5%) in the functional score in initial 15 days after operation, it then starts increasing at 1 month and ultimately at 6 month. Conclusions: Total knee arthroplasty should definitely be performed over 60 years of age having pain at knee not responding to analgesics with or without any significant deformity at knee. As we found that is no or occasional pain with good range of movement after 6 month of operation so that patient satisfaction level is very high. But large number of patient and ling follow-up is required for long-term result.
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Comparison between functional outcomes of close reduction versus K-wire fixation in fracture distal end radius p. 114
Karuna Shankar Dinkar, Rajat Kapoor, Vivek Mittal, Brijesh Sharma, Sushil Kumar Saini, Ashutosh Verma
Background: Fracture of distal radius usually occurs as a result of high energy trauma in younger individual with good bone density and is associated with substantial articular and periarticular tissue injury. The fracture of distal radius was previously known for being common in elderly with low function demand who sustained a low energy trauma. Purpose of study was to compare the functional and radiological outcomes between percutaneous K-wiring and close reduction with below elbow cast application in treatment of distal end radius fracture. Methodology: 30 cases of closed reduction and casting and 30 cases of percutaneous K-wire fixation were included in the study. The data obtained from the two groups was analysed by using unpaired student’s t-test for continuous variables. All cases were followed up after 2 weeks, 4 weeks, and 6 weeks and were functionally and radiologically assessed for re-displacement. Results: There was no statistically significant difference in the range of movement outcomes between the two groups. The unpaired student’s t-test on the values obtained from both groups yielded a P-value of 0.9816. Conclusion: Closed reduction with percutaneous K-wiring and below elbow cast application is a simple, minimally invasive technique that provides additional stability and better radiological outcome in the treatment of extra-articular distal radius fracture as compared to closed reduction and below elbow cast application.
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Vitamin D status among patients with chronic low back pain attending a tertiary care hospital: A cross-sectional study p. 119
SP Saha, Sudip Deb, Mohit Singh, Vidhu M Joshy, Sarvesh Kumar Pandey, Rahul Khare, Ajay Kumar Yadav, Deepak Kumar
Introduction: Low lower back pain (LBP) is one of the maximum commonplace health troubles related to economic losses in the society. Chronic LBP (CLBP, pain for more than 3 months) is not an unusual cause of disability and absence from work from obligation. Etiologically, decreased lower back ache is a multifactorial disease with numerous possible symptoms and causes. Vitamin D plays a critical role in the immune system and bone healing. Despite the fact that Indians receive ample sunshine throughout the year, hypovitaminosis D continues to be a developing problem. Aims and Objectives: The aim of this study is to describe the association between vitamin D deficiency and chronic low backache attending OPD of a tertiary care hospital in Andaman and Nicobar Island and to compare the data with that of Mainland India. Materials and Methods: A prospective cross-sectional study was conducted during the period from 1 January 2019 to 31 December 2020. The primary inclusion criterion for CLBP is defined as self-reported pain in the low back area for more than half of the time in the past 3 months, following the standardized criteria proposed by Dionne et al. Serum 25-hydroxyvitamin D is considered as a marker for the recent status of vitamin D levels in the blood. Results: In our study, we took 664 patients with the mean age of 40.45 ± 15.2 years. We also found that 174 patients were vitamin D-deficient (26.20%). Vitamin D insufficiency was seen in 310 patients (46.69%), and 180 patients were vitamin D-sufficient (27.11%). The mean vitamin D level in females was 28.46 ± 17.12 and that in males was 29.02 ± 13.54. Conclusion: To conclude, the majority of the patients with chronic low backache have vitamin D deficiency or insufficiency, and supplementation of vitamin D should be considered.
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To elucidate the difference in diagnostic accuracy of radiological and histological modalities of bone tumors: A tertiary care experience p. 125
Deepak Kumar, Sanjiv Kumar, Ashish Kumar, Siddharth Deshwal, Ankit Kumar, Punit Agarwal
Introduction: The objective of this study was to retrospectively compare the difference in diagnostic accuracy of radiological and histological modalities of bone tumors. Materials and Methods: Imaging techniques such as X-ray, computerized tomography (CT) scan, and magnetic resonance imaging (MRI) were compared with the Histological findings in 1314 patients with bone tumors. Results: Histologically, 27.4% were malignant bone tumors, whereas 72.60% were benign. The X-rays showed a diagnostic accuracy of 87.3%, with sensitivity of 81.8%, specificity of 90.0%, positive predictive value (PPV) of 79.5%, and negative predictive value (NPV) of 91.2%. CT scan presented a diagnostic accuracy of 76.08%, with 80.4%, 68.5%, 74.1%, and 78.4% of sensitivity, specificity, PPV, and NPV, respectively. The MRI documented a diagnostic accuracy of 97.4%, sensitivity of 97.7%, specificity of 96.8%, PPV of 98.05%, and NPV of 96.4%. Conclusion: These data showed a good correlation between radiological and histological modalities.
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A short-term study of clinical and radiological outcomes of total knee replacement using all polyethylene tibial component: A prospective observational study p. 129
Sankalpa Jaiswal, Sarvesh Kumar Pandey, Ajay Kumar Yadav, Rahul Khare, Devender Singh
Osteoarthritis (OA) of bone peripherally is frequently associated with pain, physical disability and worsening quality of life, which in turn leads to a considerable burden on the society and individuals. The surgical management of OA comprises of arthroscopy, high tibial osteotomy (HTO), unicompartmental knee arthroplasty and total knee arthroplasty (TKA). High tibial osteotomy and unicompartmental knee arthroplasty are potential alternatives if only a single compartment is involved with more data supporting unicompartmental knee arthroplasty as a good treatment option in this scenario. To conclude, early tibial component designs were almost uniformly all polyethylene and still continue to dominate the market. The total condylar designs using these tibial components have continued to show greater than 90% survivorship. No statistically significant improvement was seen in the radiological outcomes in patients undergoing All-Polyethylene tibial component at short term follow up. In this study, there was a significant improvement in the Knee society score, WOMAC score and Oxford score post operatively.
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A comparative study between platelet-rich plasma, corticosteroid, and autologous whole blood injection in patient of plantar fasciitis p. 141
Utkarsh Ravikant, Ashish Kumar, Imran Sajid, Siddharth Dubey, Shashank Kumar Pal
Introduction: Majority of the patient with heel pain are diagnosed with plantar fasciitis (PF). PF is the condition characterized by isolated inferior heel pain particularly with the first steps of the day or after sitting for hours and the reason is due to degeneration of the plantar fascia and perifascial structures. Regular walking on hard surfaces, wearing hard sole footwear, and obesity are the risk factors for this condition. Injecting steroids is the most popular method of treating the condition but has its own advantages and disadvantages. There have been cases reported of rupture of plantar fascia after giving corticosteroid injections, especially when it was given repeatedly. Platelet-rich plasma (PRP) is known to enhance the healing process of the body as it has platelet-derived growth factors that boost the healing of soft tissue, bone healing, and also tendon healing. Aims and Objective: The objective of our study was to know among the PRP injection, autologous whole blood steroid injection which is a superior mode of intervention in PF management. Materials and Methods: A sample size of 225 was taken and patients were divided into 3 groups, in which Group A was given PRP injection, Group B was given steroid injection, and Group C was given whole blood. The follow-up was done on 2 weeks, 4 weeks, and 12 weeks. Patients of age more than 18, those who were clinically diagnosed PF, and those who were not improving with 3 months of conservative management were included in the study. Patients with any ligament injury or with Buerger’s disease, pseudo-gout, and Haglund disease were excluded from the study. All patients were asked for their pain to quantify it according to visual analog scale (VAS) scale and the score was noted on pre-injection follow by on 2 weeks, 4 weeks, and 12 weeks. Results: The VAS score before infiltration was almost similar (P > 0.05) in Group A (7.8 ± 1.26), Group B (7.5 ± 1.05), and Group C (7.8 ± 0.87). The VAS score significantly decreased in Group B who were injected steroids in the initial 2 weeks when compared to that of Group A who were injected PRP and Group C who were injected whole blood. A significant decrease in VAS was seen in Group A at after 12 weeks when compared to Group B and Group C. Conclusion: Our study showed that autologous PRP therapy can lead to a sustained reduction in symptom complaints when compared to corticosteroid injections and autologous whole blood. PRP injection holds promise as a potential therapy to hasten the healing of chronic PF.
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Comparison of dual plating with single lateral locking plate supplemented with two medial cannulated cancellous screws for AO type C tibial plateau fractures—An experience from central India p. 146
Nikhil Jain, Saurabh Agarwal, Abhishek Nagaich
Background: Type C tibial plateau fractures are complex injuries, and an ideal method for their treatment is still controversial. In the present study, we discuss the outcomes of Arbeitsgemeinschaft für Osteosynthesefragen (AO) type C tibial plateau fractures treated with dual locking plating and single lateral locking plate supplemented with two medial cannulated cancellous (CC) screws. Materials and Methods: This prospective study included 34 patients of AO type C tibial plateau fractures divided into two groups. Dual locking plating and single lateral locking plate supplemented with two medial CC screws were the treatment methods in group 1 and groups II, respectively. The patients were evaluated using the Rasmussen clinical grading system at 1 and 2 years postoperatively. Results: The range of motion (ROM) was observed as 121.0° ± 1.9° and 126.3° ± 2.6° in group II, whereas in group I, ROM was 112.5° ± 3.1° and 120° ± 1.5° at 1 and 2 years, respectively. Pain, walking capacity, and final outcome were significantly better in group II at 1 and 2 years postoperatively. No significant difference was observed in two groups in terms of radiological results. Conclusion: Lateral locking plate supplemented with two medial CC screws proves to be a better method to treat AO type C tibial plateau fractures in adults, with minimal complications.
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Role of bioactive collagen peptide in the management of monoidoacetate induced osteoarthritis and its comparison with diacerein in rat model: An experimental study p. 152
Ravi Kant, Parul Rao, Gyaneshwer Tank, Rohit Gupta
Osteoarthritis is the most common joint disorder. Currently, there are no stabilized pharmacological agents capable of retarding the progression or preventing OA. This is a fundamental and important area of current research. Therefore, the present study was to investigate the action of Bioactive Collagen peptide against Monosodium Iodoacetate induced Osteoarthritis in rat models and its comparison with Diacerein. Nine experimental groups were taken. Osteoarthritis was induced by intraarticular injection of Monosodium Iodoacetate (MIA) in knee joints. Bioactive Collagen peptide was given to groups 7, 8 and 9 for 1, 2 and 3 months respectively, then histopathological examination was done. Diacerein was given to groups 4, 5 and 6 for 1, 2 and 3 months respectively followed by histopathological scoring. Significant (P < 0.05) chondroprotection was observed after treatment of Bioactive Collagen peptide when compared with MIA control group as well as Placebo treated group. Significant improvement was also observed when compared with Diacerein treated groups for 1 and 2 monthsIt was concluded that both Bioactive Collagen Peptide and Diacerein are potent chondroprotective agent, but Collagen peptide is far better than Diacerein.
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Volar plating vs. external fixator with cross k-wire for distal radius fracture: A comparative study p. 161
Saurabh Agarwal, Abhishek Nagaich, Nikhil Jain, Arvind Shah
Background: Now a days there is increased utilization of volar locking plates fixation over external fixation. However, the comparative complications and outcomes of both surgical methods are still unclear. Purpose: The purpose is to compare if volar locking plate is superior to external fixation for distal radius fractures with comparison of complications associated with both surgical methods. Materials and Methods: An observational study was done from 2020 to 2022 among patients presented with displaced distal end radius of 30 patients in which 15 were treated with external fixator with cross k – wire and 15 were treated with volar locking plate with an average of 12 month or longer follow up. Results: Acceptable functional outcomes were observed with DASH scoring in 70% of study population. The functional outcome score was higher in younger population with an overall complication rate of 17% including pin track infection, hardware related issues, tendon injury, nerve dysfunction. Conclusions: In the volar plating patients outcomes (DASH SCORE), In the first 3 and 6 months is better than External fixation, However after 1 year the outcomes of both techniques found equal with little difference in terms of range of motion, grip strength, osteoarthritis.
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Role of teriparatide (rh PTH) in fracture healing of osteoporotic patient p. 165
Vinod Kumar, Jaydeep Patel, Ashutosh Verma, Rohit Yadav, Chandra Prakash Pal
Introduction: Osteoporosis a disease where decreased bone strength increases the risk of a fracture. It is the most common reason for fracture among the elderly. Osteoporosis, an imbalance between bone resorption and bone formation. The diagnosis of osteoporosis can be made using conventional radiography and by measuring the bone mineral density. Osteoporosis is diagnosed when the bone mineral density is less than or equal to 2.5 standard deviations below that of a young reference. Teriparatide, a recombinant form of parathyroid hormone (identical to a portion of human parathyroid hormone (PTH)), intermittent use activates osteoblasts more than osteoclasts, which leads to an overall increase in bone turnover. Teriparatide is the only anabolic agent (i.e., bone growing) indicated for use in postmenopausal women with osteoporosis at a high risk for fracture or with a history of osteoporotic fracture, patients with multiple risk factors for fracture. It has been FDA-approved since 2002. Materials and Methods: Over duration of october 2016 to march 2018, 60 patients who have fracture with osteoporosis admitted in S.N. Medical College, Agra. Patient suspected to have osteoporosis based on conventional radiography. Selected patients in the study undergone confirmation of osteoporosis by dual energy absorptiometry and those who are below 2.5 standard deviation are kept in study. Patients fitting into inclusion criteria would form the study group. Data collected by interviews, observation of clinical and radiological findings. 60 patients divided in two groups as cases and controls. Cases are subjected to teriparatide therapy and controls given placebo. Results: Bone formation marker alkaline phosphatase were 150% above baseline after 8 weeks in the teriparatide-treated patient. At 8 weeks, approximately 91.037% in the teriparatide group showed improved healing of osteoporotic fracture compared to 57.14% in the placebo group. Conclusion: Our findings suggest that teriparatide provide selective advantages to fracture healing or functional recovery in the management of osteoporotic fractures. Teriparatide effective in accelerating and increasing the rate of fracture healing. However, more randomized controlled trials are needed to evaluate with certainty the impacts of Teriparatideosteoanabolic role in fracture healing to decide on incorporate this drug as a standard option for conservative management of osteoporotic fracture.
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Functional and radiological outcome of isolated shaft of humerus fracture managed with functional cast brace p. 172
G Naresh, Sankalpa Jaiswal, Ajay Kumar Yadav, Sarvesh Kumar Pandey, Naman Kamboj, Ravi Rajan, Rahul Khare
Purpose: Functional Cast Bracing is a most common, universally following method of conservative management of shaft of humerus fracture. The objective of this study were to assess union rate, complications and risk factors associated with non-union of shaft of humerus fracture and same were evaluated with functional cast brace. Materials and Methods: The study was designed as a Descriptive observational study. Patients who presented with closed isolated shaft of humerus fracture as diagnosed by clinical and radiological were included in the study (n = 83). Patients were managed with closed reduction and “U” slab application for about 2nd weeks. On 3rd week of post injury “U” slabs were removed and functional cast braces were applied. Functional (Constant-Murley score) and radiological outcome were assessed on 4th, 6th and 12th weeks of post injury. Results: Total 83 patients were included in this study. Union rate was 84.4% (n = 70), non-union rate was 15.6%(n = 13) and the risk factors which associated with non-union were occupation (more in laboured, n = 9(37.5%)), socioeconomic status (more in lower socioeconomic status, n = 9(50%)), smoking (more in smoker, n = 9(60%)) and type of fracture (more in spiral fracture, n = 7(50%)). Conclusion: Union rate was (84.4%) more and non-union rate was less (15.6%) of shaft of humerus fracture managed with functional cast brace. Occupation, socioeconomic status, smoking and spiral type of fracture were associated with non-union.
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Giant cell tumor of distal end radius managed by en bloc resection with wrist arthrodesis using fibula bone: A novel technique p. 176
Ashutosh Kumar, Saurabh Mittal, Narendra Harji Bamania, Bhawna Singh, T Somashekarappa
Introduction: Giant cell tumor is a benign but locally aggressive tumor typically found in the epiphysis of long bones. Patients are usually females typically presenting between ages 30 and 50. Confirm diagnosis is based on biopsy. Treatment includes radiation therapy, bisphosphonates, denosumab, extensive curettage with adjuvant treatment, and reconstruction. We managed our case by en bloc resection of the tumor with wrist arthrodesis with fibula bone. Result: The patient had a good functional grip with 80° of pronation and 60° of supination. Conclusion: Resection of the tumor along with ipsilateral nonvascularized fibular strut graft with wrist arthrodesis is a good option for wrist reconstruction and provides a good forearm function and strength.
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Mucoid degeneration of the anterior cruciate ligament: A case study p. 180
Sanjay Yadav, Vaibhav Mittal, Ankur Ojha, Wamique Ansari
Mucoid degeneration of anterior cruciate ligament (ACL) is a rare pathological condition characterized by knee pain and restriction of movements. In this condition, ACL is infiltrated by mucoid (glycosaminoglycans) like material within its substance. We discuss the case and present a review of literature including clinical and radiological features and management options. We encountered a 33-year-old female complaining of increasing pain in right knee since last 6 years with difficulty in squatting and sitting cross-legged. There was no history of significant trauma or instability of the knee. Clinical examination demonstrated pain on deep knee flexion, negative Lachman, and anterior drawer test. Plain radiograph of knee suggested early onset degenerative changes of knee in the form of medial joint space reduction. Magnetic resonance imaging (MRI) showed hyperintense signal in ACL substance in T1W and T2W images which is classically described as Celery Stalk appearance on T2 STIR images. This was often mistaken as partial tear of ACL. Patient was planned for diagnostic arthroscopy. During arthroscopy, ACL was occupying the whole intercondylar notch. It was hypertrophied, homogenous, and firm. Arthroscopic debulking of ACL was done cautiously and mucoid tissue was removed. The specimen was sent for histopathological examination which confirmed the diagnosis of mucoid degeneration. Post-operatively patient was relieved of symptoms and was doing well without any specific complaints like instability till last follow up at 18 months. Repeat MRI was not done as patient was not symptomatic. Mucoid ACL degeneration affects active persons in third to fourth decade of life without significant trauma. MRI is the most useful tool for diagnosis with specific findings. If this disease is considered preoperatively, it can be diagnosed early. Treatment with debulking or partial resection shows good functional results.
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Surgical management of symptomatic solitary osteochondroma of femur neck in an adult: A case report p. 183
Arpan Nag
Osteochondromas are the common benign bone tumors of the long bones, usually asymptomatic and mostly found incidentally in children and adolescents on radiographs. Osteochondromas are usually present as sessile and pedunculated swelling arising from the metaphyseal region of long bone ends. We reported a 35-year-old woman, who presented with a hard painful mass in the left gluteal region and decreased hip movements. Radiological examination showed a tumor arising from the base of femur neck. The appropriate surgical approach wasused for the complete resection of bone swelling, cartilage cap, and surrounding bursa without hampering surrounding structures as they are at risk of injury during surgical resection of the tumor. Histopathology confirmed the diagnosis of an osteochondroma. Proximal femur or neck of the femur is an unusual site for ostechondroma to occur; the risk of sarcomatous degeneration and malignant transformation of such swelling presenting late is more. Complete resection of such bone tumors keeping in mind the risk associated is the foremost aim.
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