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   Table of Contents - Current issue
January-April 2023
Volume 38 | Issue 1
Page Nos. 1-129

Online since Thursday, April 20, 2023

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Ethics, spirituality, and the surgeon/physician Highly accessed article p. 1
Vijendra Devisingh Chauhan
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Physiological adaptations of skeletal muscle and bone to resistance training and its applications in orthopedics: A review p. 3
Chandra Prakash Pal, Vipul Agarwal, Richa Srivastav, Mayur Gupta, Sanjai Singh
Resistance training is defined as practicing the execution of different physical exercises that steadily upsurges the muscular force production for improving musculoskeletal strength, power, and endurance. It is of several types and utilizes specific equipment that provides gradational weight increases and can direct them toward the aimed muscle group. Physiological adaptations occur in muscles in response to increasing resistance at levels of muscle fibers and neuromuscular motor units. It increases the cross-sectional area of the individual muscle fiber causing muscle hypertrophy, which is expressed as increased diameter, thickness, and strength of the muscle. There is an increase in the number of motor units recruited, the firing rate of each motor unit during a maximal contraction, activation, and force generation by the muscle. Resistance training enhances bone mineral content and density. New bone formation occurs in areas experiencing mechanical strain that exceeds a minimum force level encountered in daily activities. Benefits of resistance training include significant improvements in general health, balance, coordination, physical vigor, and mental well-being. Functional gains occur in terms of boosted joint function and reduced potential for injury due to increased bone, muscle, tendon, and ligament strengths. It has been safely used across a multitude of disorders requiring physical therapy. It plays a credible role in the rehabilitation of orthopedics patients suffering from disabling musculoskeletal weakness after fracture treatment and chronic painful ailments such as osteoarthritis, osteoporosis, rotator cuff tendinopathy, and neck and low back pain. We here present a review of the varied musculoskeletal physiological adaptations seen in the human body in response to resistance training and its applications in orthopedics.
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Study on results of laminectomy with short-segment pedicle screw fixation in dorsolumbar fractures with respect to anatomical reduction, functional recovery and pain Highly accessed article p. 11
Deepanshu Maheshwari, Gyaneshwar Tonk, Sumit Agarwal
Background: The aim of this study was to report the results of laminectomy with short-segment pedicle screw fixation in thoracolumbar fracture. Materials and Methods: Forty-two patients were analyzed prospectively, followed up in the outpatient department for the period of 24 months. Results: Most of the patients in the study had reasonable to good neurological recovery in the postoperative period assessed in the form of American Spinal Cord Injury Association (ASIA) score. There was also an excellent improvement in the components of anatomical reduction such as vertebral height, Cobb’s angle, and anterior wedge angle, which was directly related to functional recovery of the patient. Patients postoperatively also got relieved in pain in the dorsolumbar region assessed based on Denis pain scale. Conclusion: Laminectomy with pedicle screw fixation is an excellent option for patients with thoracolumbar fracture; it not only decompresses the spine but also provides stability with minimal manageable complications.
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To assess the functional and radiological outcomes of intra-articular fractures of distal end radius by open reduction and internal fixation with locking distal radius volar plate p. 18
Ashutosh Verma, Atul Kumar Saroj, Ankit Kumar, Upendra Patel, MC Prajwal
Background: Intra-articular fracture distal radius is a common fracture and remains one of the most challenging fractures to treat without any complications. In unstable intra-articular fractures, re-establishment of intra-articular integrity of the wrist and maintaining the radiological parameters are often not possible with close methods. In such cases where an open reduction is required, various surgical methods and fixation materials can be used. Materials and Methods: A total of 35 patients with clinico-radiological diagnoses of intra-articular fractures of the distal end of the radius participated in the study. All the patients were followed up for a minimum of 6 months after the procedure, and the observations thus made were tabulated. Results: Functional outcome in terms of Quick DASH was excellent to good in 88.6% patients on the basis of Quick Dash Score Grading with no significant loss of radiographic reduction and a better range of movements throughout the follow-up period. Conclusion: Volar plate fixation is viable and one of the most favorable means of management with maximum anatomical restoration and functional gain.
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Is tension band wiring (osteosynthesis) with three Kirschner wires provide better outcome as compared with two Kirschner wires in patella fracture: A prospective randomized study p. 24
Sachin Kumar, Mohit Singh, Satish Kumar, Rahul Khare, Ajay Kumar Yadav, Deepak Kumar
Background: Fractures of the patella constitute approximately 1% of all skeletal injuries, resulting from either direct or indirect trauma. Many forms of internal fixation for patellar fractures have been described in the literature but perfect anatomical reduction during surgery has an excellent outcome irrespective of the method of fixation used. The conventional method of patellar tension band wiring (TBW) is being done always with the help of two parallel Kirschner wires (K-wires). Objectives: Here in our prospective study, we intended to see whether the use of three parallel K-wires in comparison to the conventional one results in superior functional outcomes. Materials and Methods: A prospective cohort study was carried out in New Delhi from November 2016 to November 2019 in a total of 44 patients with patellar fractures operated by TBW with 22 patients in two parallel K-wires and three parallel K-wires groups, respectively. Patients were followed up postoperatively for 1 year and assessed by Lysholm knee score (LKS), pain status, working status, and other variables Normality of data was tested by Kolmogorov–Smirnov test and paired t test/Wilcoxon rank-sum test. Results: The total mean age was 40.27 years (41.86 in 2K-wire and 38.68 in 3K-wire) in this study. LKS (0.00 in both groups on first day; 99.23 and 99.45 after 1 year in 2K-wire and 3K-wire groups, respectively, pain status (was 5.0 in both groups on the first day and 1.0 after 6 month), and working status (was 5.0 in both groups on the first day and 1.09 after 1 year), were not significantly different throughout the mean to follow up periods for both groups (P > 0.05). Conclusions: No significant difference was observed between patellar TBW in 3K-wire and 2K-wire groups.
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Active range of motion of bilateral hip joint in young adults with chronic low back pain versus healthy controls: A comparative study p. 32
Amit Saraf, Naman Kumar Parakh, Vakul Mahipal, Angad Singh Sandhu, Tarun Aggarwal, Poonji Gupta
Background: Loss of quality of life, increased medical costs, and time away from work are all linked to chronic low back pain (CLBP). CLBP is recognized as a complex problem due to its biopsychosocial character. To remedy the issue of this incapacitating condition, it is critical to pinpoint potential contributing elements. The intersegmental parts of the kinematic chain connecting the lumbopelvic and knee joints are the hip joints. This complex runs in unison during both practical and leisurely physical activity. Materials and Methods: This was a single-center, observational study conducted in young adult patients with nonspecific CLBP and healthy controls who were compared for their active range of motion in bilateral hip joints. Results: There was no significant difference in the mean ages and gender distribution in both groups. The flexion, extension, internal rotation, external rotation, and abduction range of motions at bilateral hips were significantly reduced in the case group as compared with the healthy control group. Conclusion: The lumbopelvic compensation in the patients with CLBP affects the range of motion at the hip joint due to kinematic of the lower body musculature. The restriction in movement increases with the activities involving excessive hip joint motions.
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Comparative prospective study between medial and lateral distal tibial locking compression plates for distal third tibial fractures p. 39
Johney Juneja, Mahesh Pradhan, Mahendra Prakash, Naresh Saini, Anurag Talesra, Ramesh Sen
Purpose: The surgical method of repairing distal tibial fractures remains controversial. Open reduction and plating constitute a popular method that can result in good fixation and retention of the achieved position. The usual approach for open plating is anterior. Although it offers good exposure to the tibia, the medial plating is at high risk of wound problems and nonunions. Also, if fixation of the fibula is required, an additional incision must be made on the lateral side of the shin. Lateral plating using a single lateral approach for treating distal tibial and fibular fractures has been reported to have good results; however, most of these studies were small series. Materials and Methods: This prospective clinical study involved 40 patients with distal tibial fractures admitted in Department of Orthopaedics, RNT Medical College and Hospital, Udaipur, Rajasthan, India, from December 2021 to November 2022. Of these, 20 patients were allotted in each group, that is, Group A and Group B. Group A is designated for patients those are operated with distal tibia medial locking compression plate (LCP). Group B is designated for patients those are operated with distal tibia anterolateral LCP. Results: All patients achieved union at the end of study. The mean time for fracture union was 24.6 weeks with medial plating group and 24.2 weeks with anterolateral plating group. In medial plating group, callus appeared at an average of 13 weeks and in anterolateral plating group, callus appeared at 12 weeks. Out of 20 patients in medial plating group, 11 patients had excellent Olerud and Molander ankle (OMAS) score and nine had good OMAS score at final follow-up. Out of 20 patients in anterolateral plating group, 13 patients had excellent OMAS score and seven patients had good OMAS score. The average OMAS score for Group A was 88.5 and for Group B, it was 90. Conclusion: Lateral plating of distal tibia is safe and feasible, which can provide biological fixation and prevent the soft tissue complications associated with medial plating.
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A functional and radiological outcome of uncemented total hip arthroplasty in young adults p. 54
Johney Juneja, Dharmendra Jatav, Mahendra Prakash Jain, Naresh Saini, Anurag Talesra, Anamendra Sharma, Ramesh Sen
Background: End-stage arthritis in young patients requires surgical intervention. Total hip arthroplasty (THA) remains the treatment of choice for restoring function and activity in end-stage hip arthritis. The medium-term outcome of uncemented THA in the Indian population is less studied. Hence, this study was taken up with aim to study clinical and radiological outcomes of uncemented THA in patients with age less than 40 years. Materials and Methods: This study was a prospective study done on 50 patients admitted to RNT Medical College and M.B. Hospital Udaipur during December 2021 to September 2022 chosen based on the inclusion and exclusion criteria. Patients were informed about the study in all respects, and written informed consents were obtained. The follow-up period was at 12th day, 1 month, 3 months, 6 months, and 9 months for functional outcome assessment and radiological evaluation. Patients were evaluated preoperatively and postoperatively. Inclusion criteria: (1) adult age group 20–50 years; (2) patients with secondary arthritis of hip (posttraumatic, avascular necrosis of femoral head, or ankylosing spondylitis). Exclusion criteria: (1) active infection of the hip joint or any other active infection in body; (2) patient with uncontrolled diabetes mellitus, unstable cardiac disease, and with other grave medical concerns or severe comorbidity; (3) neuropathic joint; (4) not willing to participate; (5) with vascular insufficiency. Results: Bony ingrowth with no evidence of loosening was seen consistently both on femoral and acetabular side in all patients on X-ray. No statistically significant association was found between initial alignment of the femoral component and clinical outcome. Conclusions: Uncemented THA can be used in young patients with excellent to good functional and radiological outcome at mid-term follow-up, high satisfaction rate, and lower rate of complications.
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Long PFNA-II versus dynamic hip screw for treatment of unstable intertrochanteric femur fracture: A prospective comparative study p. 71
Sanjiv Kumar, Punit Agarwal, Deepak Kumar, Ashish Kumar, Atul Kumar Saroj, Ashutosh Verma, Rishabh Agarwal
Background: Intertrochanteric femur fractures are one amongst the most common hip fracture presenting to our centre. Clinical efficacy and safety of PFNA and DHS in the treatment of unstable intertrochanteric fractures in elderly patients and found that compared with the control group (DHS), the observation group (PFNA) experienced shorter operation time and fracture healing time and less intraoperative blood loss, and suffered a shorter incision. The purpose of this study was to compare the functional outcomes and related complications between DHS and PFNA in treatment of unstable intertrochanteric femur fracture. Methodology: Total of 60 patients having unstable intertrochanteric femur fracture were included in this study and was equally divided into two groups. Group-P included patients with unstable intertrochanteric femur fracture managed by PFN-A II while Group-D patients managed by DHS. The result was analysed using descriptive statistics and making comparisons among various groups. Categorial data were summarized as in proportions and percentage (%) while discrete as mean ± SD. Results: At final follow-up; it was found that 72.4% of the cases of PFNA have achieved excellent union as compared to 44.4% for DHS group, 24.1% cases of PFNA have good union as compared to 51.9% in DHS group and the difference of mean DHS was significantly higher for PFNA group (p=0.001). Conclusion: PFNA-II have benefits like minimally invasive procedure, less soft tissue dissection, less amount of blood loss and provides better result in terms of union. Therefore PFNA-II is recommended as a better choice as compared to DHS in management of unstable intertrochanteric fractures in terms of functional outcome.
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A rare case report of extradural cervical spine meningioma p. 78
Parwej Ahmed, Rahul K Gupta, Azad Khan, Areeb A Siddiqui
Introduction: Extradural spinal meningiomas of the cervical spine are relatively uncommon. The vast majority of meningiomas develop in intracranial, intradural locations, and the majority of meningiomas affect the thoracic spine. History: A 39-year-old man presented with complaints of weakness in all four limbs for the last 8 months with bowel bladder involvement. Clinical Features: The patient had spastic quadriparesis with bowel and bladder involvement with planter extensors and the presence of patellar and ankle clonus. Investigation: Histopathopathology and immunohistochemical markers were sent and diagnosis of meningioma was made.
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Bicondylar hoffa fracture: A rare variant of intra-articular fracture p. 81
Shailendra Singh, Prakhar Mishra, Ravindra Mohan, Deepak Kumar, Arpit Singh
A Shear fracture of posterior aspect of femoral condyles in coronal plane is known as Hoffa fracture. This fracture pattern, originally described by Hoffa, is an intra-articular fracture and radiologically and clinically silent most of the times and thus commonly missed. The bicondylar variant of this fracture is a rare injury. We report a case of 38-year old male patient presenting with one day old bicondylar Hoffa fracture managed with headless compression screw and cannulated cancellous screws.
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Distal tibial interosseous osteochondroma with impending fracture of fibula, deformity and deep peroneal nerve entrapment neuropathy: A case report p. 86
Johney Juneja, Gaurav Garg, Nitin Andrews, Ak Mehra, Ramesh Sen
Osteochondromas arising from the interosseous border of the distal tibia and involving distal fibula are uncommon. We present the case of a 34-year-old woman with an impending fracture, erosion, and weakness of the distal fibula, secondary to an osteochondroma arising from the distal tibia. Early excision of this deforming distal tibial osteochondroma avoided the future risk of pathological fracture of the distal fibula, ankle deformities, and syndesmotic complications.
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Long-segment myelitis after traumatic paraplegia in COVID-19 positive patient: An unusual case report p. 91
Ravindra Mohan, Yashvardhan Sharma, Akanksha Singh, Shailendra Singh, Arpit Singh
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has devastated the mankind globally, and countless lives have been lost all around the world. This disease has been linked to various extrapulmonary symptoms and consequences in addition to typical respiratory illness. This case highlights a probable neurological complication of SARS-CoV-2 infection. A 28-year-old healthy man, sustained wedge compression of D12 vertebra following road traffic accident, presented with paraplegia. One week following admission, the patient had a progressive neurological deterioration and developed high grade fever with weakness in both upper limbs. The patient developed quadriplegia 10 days after admission. Magnetic resonance imaging (MRI) brain and spine were done. MRI brain was normal, whereas MRI spine showed D11-D12 anterolisthesis with cord compression with T2 hyperintensity of cervical cord. His SARS-CoV-2 reverse transcriptase polymerase chain reaction turned out to be positive. We hereby report a case of posttraumatic long-segment myelitis with coronavirus disease 2019 as a probable etiology.
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Single-stage bilateral revision knee arthroplasty with unilateral tibial tubercle osteotomy: A rare case study in the management of bilateral aseptic loosening with literature review p. 100
Lavindra Tomar, Gaurav Govil, Pawan Dhawan
A revision total knee arthroplasty (Rev-TKA) for bilateral affection presents surgical complexities. Rev-TKA as a single stage has been rarely advocated. A 76-year-old woman presented with painful bilateral knees and a history of bilateral TKA done fourteen years ago. The right knee required unilateral tibial tubercle osteotomy with cerclage wire fixation to remove the incarcerated cemented tibial extension rod and extensile medial parapatellar approach for the left knee in single-stage. The osteotomy united at 14 weeks. At 2-year follow-up, range of movements improved, allowing pain-free walking without support and laxity. No radiological evidence of loosening or wear. Rev-TKA challenges include obtaining adequate joint exposure without compromising the integrity of the extensor mechanism. The crucial factors for achieving an uneventful single-stage surgery include thorough pre-operative planning, prophylactic thromboprophylaxis, measures to reduce blood loss, and meticulous execution of planned surgery. The bilateral Rev-TKA should be planned after the stratification of the risk-benefit ratio.
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Management of traumatic proximal tibia fracture with migrated bioscrew after anterior cruciate ligament reconstruction: A case report and a brief review of literature p. 106
Santanu Kar, Mohit Singh, Sarvesh K Pandey, Ajay K Yadav, Rahul Khare, Satish Kumar
The anterior cruciate ligament (ACL) is injured most during sports activity, which has to be reconstructed to regain painless, functional, and stable knee. Tibial plateau fractures after arthroscopic ACL reconstruction (ACLR) are being increasingly reported in the literature. Revision ACLR may be required after fracture union due to possible disruption of the previous reconstruction. Here is the case of operated bicondylar tibial plateau fracture with the excellent outcome at 2-year follow-up with a previous history of ACLR 5 years back with abutting of the tibial-sided biodegradable screw to the knee joint in a recreational soccer player. This case report of a 46-year-old male patient hereby describes the management of the fracture and possible factors responsible for bioscrew migration.
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Tubercular flexor tenosynovitis with carpal tunnel syndrome mimicking as compound palmar ganglion: A rare case report p. 111
Swagat Mahapatra, Madhusudan Mishra, Jaydeep Patel, Prakhar Mishra, Devta Singh
Introduction: Tubercular flexor tenosynovitis is an infrequent condition, which has a mixed clinical picture, but with careful examination and investigation, it should be diagnosed earlier before the involvement of underlying bones and nerves. Case Report: We present a case of a 69-year-old man who came with complaints of progressive swelling over the palm and forearm. He was presented as compound palmar ganglion but finally diagnosed as a case of chronic flexor tenosynovitis with association of carpal tunnel syndrome of tubercular origin without involvement of the underlying bones and was treated by complete excision and antitubercular therapy. Conclusion: Tuberculous flexor tenosynovitis is a condition that can be managed by excision and antitubercular therapy. However, it presents as a challenge to the surgeons when the presentation is very late. Hence, early identification and treatment are the main goals of this article.
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Conjoint bicondylar Hoffa’s fracture with associated supracondylar fracture: A rare case p. 115
Adnan Anwer, Yasir Salam Siddiqui, Mazhar Abbas, Madhav Chowdhry
Conjoint bicondylar Hoffa’s fracture is a rare fracture pattern with a coronal split of posterior femoral condyles with an interconnecting bridge of bone. This fracture pattern generally occurs in high-velocity road traffic accidents and is associated with injuries around distal femur, proximal tibia, patella, or extensor mechanism at the knee joint. Due to extensive associated injury patterns, definitive surgical management often varies. This is a case of conjoint bicondylar Hoffa’s fracture with associated comminuted supracondylar fracture of femur. A 40-year-old male presented to the emergency room after sustaining injury to his right knee, previously ambulating on a malunited tibia. Radiographic examination demonstrated conjoint bicondylar Hoffa’s fracture with associated supracondylar fracture right distal femur. Open reduction and internal fixation was done using two T-plates fixed with screws. Due to malunited tibial and fibular fracture with intra-articular extension of the implant, the patient had a decreased range of motion (ROM) up to 120° preoperatively. Early physiotherapy was emphasized, and postoperatively similar ROM was achieved. Conjoint bicondylar Hoffa’s fracture is a rare fracture pattern, which can be associated with a supracondylar fracture of the femur. For this combined fracture fixation, open reduction internal fixation with two T-plates and screws offers a viable treatment option. The patient achieved complete preoperative ROM.
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Tibial hemimelia-polysyndactyly-triphalangeal thumb syndrome: Case report and review of literature p. 120
Adnan Anwer, Yasir Salam Siddiqui, Mazhar Abbas, Madhav Chowdhry
Triphalangeal thumb (TPT) is a rare clinical entity, with majority of cases being hereditary in origin. Two syndromes associated with TPT are triphalangeal thumb-polysyndactyly syndrome (TPTPS) and tibial hemimelia-polysyndactyly-triphalangeal thumb syndrome (THPTTS). Hypoplasia or aplasia of tibia is the primary difference between them. Although having many common clinical features, TPTPS and THPTTS are considered two different entities. Here, we report a rare situation of these two conditions occurring in the same family: a mother with TPTPS and her son with THPTTS. A 4-month-old male child presented to outpatient clinic with complaints of 2.5 cm shortening and clubfoot present on the right side. The child had five-fingered hands without thumbs or thenar muscles along with preaxial polydactyly with seven toes in the left foot and six toes in the right foot. Radiographic examination revealed hypoplasia of the right tibia (tibial hemimelia) with thickened and superolaterally displaced fibula. While applying cast for club foot to the child, his mother’s hands came into notice. The lady was 26 years old, born to nonconsanguineous parents, with no similar history in parents or siblings. Clinical examination of hands revealed TPTs in both hands. She had no difficulty in her activities of daily living. Her legs appeared normal. Her feet were normal except for the duplicated right great toe with fused nails and duplicated left great toe floating separately. TPTs, polydactyly of hands, and feet along with syndactyly of digits are cardinal findings seen in both TPTPS and THPTTS. Both can also be traced to 7q36. The presence of a tibial defect seems to be the only difference between the two disorders. In this case report, we highlight the occurrence of two seemingly different clinical entities within the same family, suggesting the possibility of an overlying common entity with a wide spectrum of clinical presentations.
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Vitamin D status among patients with chronic low back pain attending a tertiary care hospital: A cross-sectional study p. 125
Mahmood Dhahir Al-Mendalawi
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Unstable intertrochanteric fracture management by proximal femoral locking plate: Outcome of review studies and its extended role in difficult fracture scenario p. 126
Gaurav Govil, Lavindra Tomar, Pawan Dhawan
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