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   Table of Contents - Current issue
May-August 2021
Volume 36 | Issue 2
Page Nos. 1-43

Online since Monday, August 2, 2021

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Exclusive pediatric trauma emergency services in India: A need of hour p. 1
Ajai Singh
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Comparitive study of functional and radiological outcome of open-wedge high tibial osteotomy versus proximal fibular osteotomy in patients with osteoarthritis knee p. 3
Sparsh Jaiswal, Parit Mangal, Arunim Swarup, Avinash Rastogi
Aim: Proximal fibular osteotomy (PFO) and valgus high tibial osteotomy (HTO) are the well-established treatment options for patients with K-L grade 2, 3 medial compartment knee osteoarthritis where replacement may not be the treatment of choice. The aim of the present study was to compare the radiological and clinical outcomes following HTO and PFO. Materials and Methods: During the duration of 2 years, two groups of 30 patients each undergoing PFO with a mean age of 53.9 years (range 40–65 years) and HTO with a mean age of 54.7 years (range 40–65 years) were compared and followed up for 1 year. They were compared on the basis of preoperative and postoperative range of walking distance, Numerical Pain Rating Score, American Knee Society Score, Knee Injury and Osteoarthritis Outcome Score, femorotibial angle, and medial joint space narrowing. Results: In PFO group, immediate postoperative functional scores improved and maintained for 3 months during follow-up. Following which there was the decline in the functional score up to 1-year follow-up, whereas in the HTO group, the improvement is seen with a gradual increase in postoperative functional scores that progressed positively for the entire follow-up period of 1 year. Conclusion: Both PFO and HTO lead to good and comparable radiological and functional results. However, HTO provided slow but long-term success in terms of functional and radiological scores after the follow-up period of 1 year.
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Evaluation of outcomes of distal femoral fractures treated by retrograde nailing technique p. 8
Raj Kumar Bhartiya, Santosh Kumar Singh, Pulkesh Singh, S P S. Gill, Luxminath Mishra, Jitesh Arora
Background: Distal femur fractures are less common injuries accounting for approximately 1% of fractures in the elderly. They occur due to high-velocity injury in adults and simple fall in the elderly. Management of these type injuries in the elderly is more challenging because of osteoporosis. Retrograde nailing represents an established fixation method for fractures of the distal femur and offers an alternative to the existing technique of antegrade nailing. Materials and Methods: Prospective study of 70 patients, aged between 16 and 85 years, whose distal femoral fractures were treated with a retrograde femoral nail from December 2016 to November 2018 in the department of orthopedics of a tertiary care centre in North India were followed to assess the outcome of treatment. The fracture was caused by a motor-vehicle accident in 58 patients (82.85 percent) and a fall on the ground in 12 (17.14%). 26 (37.14%) of the fractures were open. All the patients were followed up at about 3 weeks, 6 weeks, 3 months, 6 months, and 1 year. On each visit pain, functional range of movements was noted and the union was assessed clinically and radiologically at regular intervals. Results: Out of 70 patients, 60 patients were males and the remaining patients were female. Twenty-six patients had open fractures and 44 patients had closed fractures. All the patients in our study united without any case of nonunion and knee infection. The mean time required to achieve union was 5.42 ± 2.48 months in closed fractures, while in open fractures, it was 5.7 ± 1.65 months. The mean range of knee movement in open fractures was from 15.0° ± 12.57° to 113.75° ± 14.69 °, while in closed fractures, it was from 5.38° ± 6.43° to 122.18° ± 15.0°. Five patients had loosening of the distal interlocking screws impinging on the skin. Based on the criteria recommended by Schatzker the outcome was assessed as excellent in 33 (47.14%) cases, good in 27 (38.57%) cases, and fair in 7 (10%) cases. The outcome in 3 (04.29%) cases was graded as poor. Conclusions: Retrograde intramedullary nailing makes possible a biological osteosynthesis of distal femoral fractures. It also produces good functional results even in elderly patients.
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Joshi's external stabilization system versus locked compression plating in the management of tibial plateau fractures: A nonrandomized prospective study p. 14
Najmul Huda, Sandeep Bishnoi, Mir Shahid, Kumar Keshav, Danish Altaf, Kapil Kumar
Context: Among the myriad treatment options available for tibial plateau fractures, Joshi's external stabilization system (JESS) is one of the established treatment modalities as an external fixation device. Closed reduction has the advantage of biological fixation and preservation of the already jeopardized local blood supply to the bone. Aim: This study was conducted to compare the functional results between locked compression plate and JESS as a fixation method for tibial plateau fractures. Setting and Design: This is a prospective, single-center, and nonrandomized study. Materials and Methods: Fifty patients with tibial plateau fractures were included in the study, who presented to our hospital between January 2016 and December 2018 and were treated alternatively by either plating (Group P) or JESS (Group J). Modified Rasmussen functional score (MRFS) was used for assessing the functional outcomes. Statistical Analysis Used: Microsoft Excel and Statistical software SPSS version 21.0. Results: The mean age in Group J and P was 39.52 ± 9.27 years and 39.00 ± 10.82 years, respectively. The mean follow-up period was 12 months (range: 9–24 months). Schatzker Type II was the most common fracture pattern (n = 15). The average union time was 12.3 weeks in Group J and 14 weeks in Group P (P = 0.036). The mean MRFS at 3, 6, and 9 months of follow-up was significantly better in the J group (P value at 3 months was 0.0204, at 6 months was 0.0226, and at 9 months was 0.0048). Conclusion: The study shows that the functional outcome of JESS for the management of tibial plateau fractures is better than plating.
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To assess the functional and radiological outcomes in patients of medial compartment osteoarthritis of knee undergoing medial open-wedge high tibial osteotomy p. 21
Najmul Huda, Mir Shahid Ul Islam, Shubham Aggarwal, Sandeep Bishnoi, Sudhir Beri, Ravi Dholariya
Background: Varus malalignment at the knee can lead to medial compartment overload and progression of ipsilateral compartment osteoarthritis (OA). In such cases, a valgus-producing medial open-wedge high tibial osteotomy (MOWHTO) has been proposed to restore neutral mechanical alignment and alleviate excess load on the medial compartment. One distinct advantage of this procedure is the ability to correct deformities in the sagittal and coronal planes. The present study was conducted with the aim to analyze the difference in the pre- and postoperative functional scores and to estimate the changes in the pre- and postoperative radiological alignment in the patients managed by MOWHTO for uni/medial compartmental OA knee. Materials and Methods: Fifteen patients with medial compartment OA knee Kellgren–Lawrence Grade II and III with a mean age of 54.46 years were managed with MOWHTO. Clinical assessment was done using the Knee Society Score (KSS) preoperatively and postoperatively at 3, 6, and 9 months. Radiological assessment was done using the Puddu technique on the load-bearing lower limb antero-posterior X-ray extending from the hip joint up to the ankle preoperatively at postoperatively at 3 and 9 months. Results: All patients had pain relief and improvement in walking ability after the procedure. The mean KSS significantly improved from 35.50 ± 9.78 preoperatively to 55.07 ± 9.13, 67.14 ± 10.06, and 74.14 ± 4.09 at 3, 6, and 9 months postoperatively, respectively (P < 0.01). The mean varus angle significantly improved from 9.06° preoperatively to 1.43° varus at 3 months postoperatively (P = 0.001) and 1.64° varus at 9 months postoperatively and was found to be significant. Conclusion: After a follow-up of 9 months, we found that the MOWHTO of the tibia is an effective method to treat the medial compartment OA knees. It leads to significant improvement in both the clinical and radiological outcomes.
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Changing practices of delivering orthopedic and coronavirus disease 2019 care: Outcome of a pan-India survey p. 27
Kumar Keshav, Pulak Sharma, Amit Kumar, Anurag Baghel, Kumar Kaustubh, Najmul Huda, Prabhaker Mishra
Purpose: Coronavirus disease 2019 (COVID-19) pandemic has caused severe disruption of services for other health-related ailments. This study was done to assess change in practices of orthopedic surgeons, availability of proper training and personal protective equipment (PPEs), and changes in hospital setup/preparedness for the management of COVID-19 patients. Materials and Methods: A pan-India online survey was done among practicing orthopedic surgeons. Orthopedicians not practicing in India, trainees, and those who had left their practice before the pandemic were excluded from the study. Survey MonkeyR questionnaire and Google FormsR were sent to 10,055 orthopedicians, during the 7th week of nationwide lockdown in the month of May, 2020. Complete responses were received from 407 participants who were included in the final analysis. Results: Only a quarter (n = 100/407, 24.6%) of the doctors were visiting hospitals at a frequency similar to that before the pandemic. Onus of orthopedic care among COVID-19 suspected/diagnosed cases and routine COVID-19 patients were mainly borne by the government sector. Only 38.8% (n = 158/407) doctors felt that they received adequate training while 64.9% (n = 264/407) of the doctors had adequate supply of PPE kits. “Designation of specific areas of their hospitals exclusively for COVID-19 patients” was opined by 43.7% (n = 178/407), urgent diagnostic facilities by 52.8% (n = 215/407), and exclusive operation theaters by only 28.3% (n = 115/407) of the respondents. Conclusion: This study has shown a drastic fall in the frequency of hospital visits by orthopedic surgeons, predominant involvement of government sector orthopedicians, inadequate training of doctors and inadequate availability of PPE kits, lack of proper designated areas, operation theaters, and urgent diagnostic facilities for the management of COVID-19 patients.
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Minimally invasive percutaneous plate osteosynthesis in distal femur fractures using locking compression plate (LCP): A prospective study p. 33
Raghvendra Choubisa, Saumya Agarwal, Dinesh Kumar Meena, Anamendra Sharma, Shivank Prakash
Background: Distal femoral fractures are frequently seen in high-velocity road traffic accidents. The introduction of locking compression plates with option of locked screws has provided the means to increase the rigidity of fixation in osteoporotic bone or in the presence of periarticular fractures. Materials and Methods: Fifty patients within the span of 3 years underwent internal fixation of distal end femur by LCP using minimal invasive percutaneous plate osteosynthesis (MIPPO) technique. All the patients were assessed using Modified Neer's criteria which assign points for pain, function, working ability, joint movements, gross, and radiological appearance. Results: Out of 50 patients, 48 patients (96%) showed radiological union within 20 weeks. Average time for union was 16.4 weeks. Average knee flexion was 120° with more than 60% of patients having knee range of motion more than 115°. Modified Neer's score was excellent in 32 (64%), good in 12 (24%), fair in 4 (8%), and poor in 2 (4%). There had been one patient each who developed nonunion, deep infection, and valgus malalignment. Conclusion: Locking compression plate used through MIPPO technique is an optimal tool for distal fractures of femur. It provides rigid fixation, where a widening canal, thin cortices, and frequently poor bone stock make fixation difficult.
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Retrieval of broken guide wire in femoral neck: A novel surgical technique p. 38
Atin Jaiswal, Yashwant Singh Tanwar, Gautam Chatterji
Perioperative breakage of implant or instrument in the hip joint is a nightmare for an orthopedic surgeon. Location of the broken metallic part near neurovascular bundle or joint surfaces necessitates its removal. In this article, we report a case of retrieval of broken guide wire from femoral neck during proximal femoral nailing for pertrochanteric fracture by engaging it in rigid cannulated reamer without causing any further iatrogenic injury. This is a novel and simple technique not described previously in literature and has its own unique advantages over other methods. Large core diameter of rigid cannulated reamer engages broken guide wire easily, is better than any other cannulated instrument, and can be a simple solution to a difficult problem. Regular checking and replacement of used instruments along with cautious use may prevent iatrogenic complications of instruments and implant breakage. However, if the situation arises, the surgeon must be familiar with all the techniques of removal of broken instruments and should choose the technique which is more convenient and less traumatic.
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Solitary tuberculous lesion involving the spinous process of the cervical vertebra p. 41
Sanchit Agarwal, Najmul Huda, Mir Shahid Ul Islam, Saurabh Agarwal
The higher incidence and prevalence of tuberculosis (TB) is a common health problem particularly in developing countries like ours. The most common site of TB is the pulmonary region followed by lymph nodes and osteoarticular TB. In the spine, the dorsal spine is the most commonly affected region and the paradiscal being the most common type, posterior elements being the least involved, particularly in isolation. Of the posterior elements, the most common to be involved are the laminae. Here, we are presenting the case of the tubercular osteomyelitis involving the spinous process of the C6 vertebra in isolation. A young female presented to our outpatient department with pain and swelling on the posterior side of the neck. The swelling was nontender, without any signs of acute inflammation, cystic in consistency, and lying deep to the muscles. X-ray of the cervical spine and contrast enhanced magnetic resonance imaging (MRI) suggested the diagnosis of tubercular osteomyelitis. Pus was aspirated. Cartridge-based nucleic acid amplification test revealed Mycobacterium tuberculosis. The patient was given anti-tubercular drugs as per the index TB guidelines of the WHO and was cured. This, to the best of our knowledge, is the only case reported from India. Though the TB of the spinous process is extremely rare, still the diagnosis should be kept in mind when examining a posterior neck swelling, especially in country like ours, where the incidence of TB is high. X-ray and MRI are good tools to reach a diagnosis. Antitubercular regimen should be started for treatment.
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