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Year : 2015  |  Volume : 49  |  Issue : 7  |  Page : 1-32
Proceedings of IOACON 2014, Hyderabad 19 th-22nd November, 2014

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Date of Web Publication15-Nov-2014

How to cite this article:
. Proceedings of IOACON 2014, Hyderabad 19 th-22nd November, 2014. Indian J Orthop 2015;49, Suppl S1:1-32

How to cite this URL:
. Proceedings of IOACON 2014, Hyderabad 19 th-22nd November, 2014. Indian J Orthop [serial online] 2015 [cited 2019 Dec 12];49, Suppl S1:1-32. Available from:
Abstract ID: 1163

MRI based comparison of tibial bone coverage by five knee prosthesis: Anthropometric study in Indians

Sourabh Shah, Shekhar Agarwal, Shekhar Srivastav, Simon Thomas

Sant Parmanand Hospital, Delhi, India

Introduction: Morphologically the medial tibial plateau is larger than the lateral one yet tibial component of knee prosthetic design from many manufacturers have a symmetrical tibial tray. This leads to uncovered area in the medial tibial plateau. Anatomic or asymmetrical tibial trays with larger medial dimension have been introduced so as to improve tibial coverage. Implant designs have focused on gender difference in femoral components. There is a need to assess whether such a difference occurs in tibia also in order to design gender specific tibias with better outcomes. This study aimed to see if there is any difference in tibial coverage between asymmetric tibial trays and difference in sizes of tibial surface between males and females.

Materials and Methods: One hundred fifty patients in the age group 18-50 who underwent MRI scans for sports related soft tissue injury between January 2012 and September 2013 were included in study. An axial slice 8-10 mm below the lateral tibial plateau was taken as it represents the mean resection height during total knee arthroplasty (TKA). The tibial trays of the 5 most commonly used TKA designs were scanned along with a sizing marker. The first 4 trays were symmetric and the last was asymmetric. Two softwares were used in this study EDGE PACS DICOM viewer and Adobe Photoshop CS6. Comparison of the dimensions of the male and female tibia was done along with the relative coverage offered by the tibial base plates.

Results: The mean total tibial coverage of asymmetric and all symmetric tibial tray designs was >80%. Of the total 150 MRI scan of knee studied asymmetric baseplate had maximum total tibial coverage and maximum rate of optimal fit both posterolaterally and posteromedially, with 2% rate of absolute overhang posterolaterally. There was significant difference in the AP, ML diameters and the cross sectional area between males and females.

Conclusion: Females had significantly better (P < 0.05) coverage of the tibia with base plates for both asymmetric and symmetric tray design.

Keywords: Total tibial coverage, knee prosthesis, tibial tray design

Abstract ID: 1328

Primary total knee arthroplasty - Drain or no drain: A prospective randomised trial

VV Raja Sekhar, P. Satish kumar

Icon Krishi Hospital, Visakhapatnam, Andhra Pradesh, India

Introduction: Primary total knee arthroplasty (TKA) for osteoarthritis of knee are being routinely performed at many centres. The clinical use of closed suction drain, which aims to reduce postoperative wound haematomas and infection, is common. There are different practices being followed regarding placement of suction drain in every case of TKA. This study was performed to determine whether closed suction driange is safe and effective in promoting wound healing and reducing blood loss compared to no drain.

Materials and Methods: 50 patients who underwent primary TKA for osteoarthritis between June 2013 and December 2013 were included in this randomized trial study. They were randomly assigned in two groups drain or no drain. They were assessed postoperatively in the terms of wound healing, postoperative fall in haematocrit and need for transfusions, oozing from the wound and need for change in dressings, functional recovery and pain. Both groups were compared statistically and P < 0.05 is taken as significant.

Results: The closed suction drainage reduces the rate of dressing reinforcement (P = 0.03) but increases the need for blood transfusions (P = 0.02). No significant difference was observed in incidence of wound healing, infection, functional recovery and pain (P > 0.05).

Conclusions: Our results of comparison between closed suction drainage and no drainage in primary TKA have indicated that routine use of closed suction drainage in primary TKA may be of no much benefit.

Keywords: Postoperative drain, total knee arthroplasty, suction drainage

Abstract ID: 1508

Incidence and impact of low back pain and lumbar spine disorders in patients undergoing total knee replacement

GN Harsha, Dhanasekara Raja. P

Ganga Hospital, Coimbatore, Tamil Nadu, India

Introduction: The incidence of symptomatic osteoarthritis of the knee and degenerative lumbar spinal disorders is increasing in our aging population. Co-existing back pain due to substantial degeneration of the lumbar spine is present in approximately 54% of patients with osteoarthritis of knee. Knee osteoarthritis causes abnormal gait and altered spinal sagittal alignment due to limitation of extension of the knee this can result in altered spinal biomechanics and eccentric loading, increasing the degeneration resulting in axial back pain. The aim of study was to determine the incidence of low back pain in patients with end-stage knee osteoarthritis undergoing total knee replacement, to evaluate the effect of total knee replacement on reducing low back pain and important preoperative parameters that are predictive of persistence of low back pain after TKR.

Materials and Methods: 202 patients with end stage osteoarthritis of knee who underwent TKR constituted this prospective study. Preoperatively all patients were subjected to a detailed questionnaire using Oswestry Disability Index (ODI) for back related symptoms along with visual analogue scales (VAS) for pain analysis using body map. All patients underwent lumbar sagittal spinal radiographs for evaluating degenerative changes of spine and MRI if there is evidence of radiculopathy or neurological deficits. Post TKR the patients were followed up using VAS and ODI, at 6 months and 1 year.

Results: The mean age was 62 years. Back pain was present in 98 patients (49%). There was significant correlation (P, 0.005) of coronal plane and sagittal plane deformities of knee with preoperative back pain. Followup evaluation showed 82% (n = 80) had resolution of back pain with significant improvement in VAS and ODI scores. Patients with co-existing back pain and having following parameters FFD < 100, coronal plane deformity upto 100, preoperative VAS of < 4 and preoperative ODI < 30 had resolution of back pain on followup evaluation. Eighteen Patients had persistence of back pain on followup. Two patients underwent spine surgery

Conclusion: The incidence of low back pain is 49%, degree of coronal and sagittal plane deformity of knee, preoperative VAS and preoperative ODI are prognostic indicators for resolution of back pain following TKR.

Keywords: Low back pain, incidence, total knee replacement

Abstract ID: 1942

Role of primary total knee arthroplasty in severe degenerative arthritis of knee in govt. sector-scenario

Ch. Vamshi Krishna, Jagan Mohan Reddy Velpula,

S Sreenivasa Reddy, VKV Prasad, Y Thimma Reddy

Rajeev Gandhi Institute of Medical Sciences, Ongole, Andhra Pradesh, India

Introduction: Osteoarthritis of knee is a degenerative disease of eldery population. It has got both conservative and surgical methods of management depending on the severity of disease. This study was conducted to know the role of primary total knee arthroplasty in severe degenerative arthitis of knee in a Govt. General Hospital.

Materials and Methods: This study was conducted in Department of Orthopaedics, Osmania General Hospital, Hyderabad between January 2007 and August 2013 on 32 patients with grade 3 or 4 degenerative arthritis and were operated with total knee arthroplasty free of cost. They were followed up for a period of 3-4 years. The results were drawn according to knee society scores. The study excludes grade 1 and grade 2. OA knees.

Results: Out of 32 pts 13 (n = 13) were males and 19 (n = 19) females with range from 50 to 75 years and 4 operated bilaterally and remaining unilaterally. Only 24 were available for followup postoperatively for an average period of 24 months. According to Oxford Knee scores 6 pts (25%) have shown excellent results, 14 (58%) good, 3 (12.5%) fair, 1 (4.1%).

Conclusion: This was a prospective study of 32 cases of grade 3 and 4 osteoarthritis of the knees. Severe osteoartritis of knee joint can be treated with total primary knee arthroplasty with excellent to good results.

Key words: Degenerative disease, govt. sector, knee society scores, Osmania General Hospital, osteoarthitis, total knee arthroplasty

Abstract ID: 1943

Role of total hip arthroplasty in the management of severe osteoarthritis of hip in Govt. Hospital-scenario

S Sreenivasa Reddy, Ravikiran, Y Thimma Reddy,

M Lakshmi Narayana, G Veera Reddy

Osmania General Hospital, Afzal Gunj, Hyderabad, Andhra Pradesh, India

Introduction: Osteoarthritis of hip can be either primary or secondary. In severe cases the management is usually surgical unless contraindicated. This study was done to study the role of total hip arthroplasty in the management of severe osteoarthritis of hip in govt. sector which is expensive and out of reach to common man.

Materials and Methods: The study was conducted in Department of Orthopaedics, Osmania General Hospital, Hyderabad between January 2007 and July 2013, patients with severe primary or secondary osteoarthritis of hip with cemented total hip arthroplasty. The average age of the study population was 61 years. They were followed for a period of 1-3 years and the results were drawn based on Harris hip scores. The study excluded early OA hip joints and secondary OA hips.

Results: Out of 79 pts 57 were males and 22 were females. Of these 10 were operated bilaterally and rest unilaterally. Only 75 were available for followup for an average period of 2 years. The mean Harris hip scores improved from preoperative score 36 ± 17 to postoperative score of 90 ± 10. One case of posterior dislocation and three cases of superficial and one deep infection were the complications.

Conclusion: It is a prospective study of severe osteoarthritis of hip can be treated with total hip arthroplasty with excellent to good results and our results were comparable to sophisticated corporate setup in terms of cost effectiveness.

Keywords: Harris hip score, infection, Osmania General Hospital, osteoarthrits of hip, posterior dislocation, total hip athrolasty


Abstract ID: 1715

Outcome analysis of anterior cruciate ligament reconstruction and high tibial osteotomy and its correlation with posterior tibial slope angle

GR Arun, Ashok Selvaraj, David Rajan, Vinod K

Ortho One Hospital, Singanallur, Coimbatore, Tamil Nadu, India

Introduction: Open wedge high tibial osteotomy is considered to be an effective treatment for medial compartmental osteoarthritis. It is generally admitted that tibial slope increases after open-wedge high tibial osteotomy and decreases after closing-wedge high tibial osteotomy. Young patients with ACL deficiency along with medial compartment osteoarthritis need a combined procedure of ACL reconstruction along with high tibial osteotomy in order to regain physiological knee kinematics and to avoid chondral damage. The aim of this study is to analyse the outcome of ACL reconstruction and high tibial osteotomy in relation to the posterior tibial slope angle.

Materials and Methods: We prospectively analysed data from 30 patients who underwent Arthroscopic ACL reconstruction along with medial opening wedge osteotomy from January 2004 to June 2014 with a minimum followup of 2 years. The preoperative and postoperative posterior tibial slope was measured, functional outcome was analysed using clinical, radiological criteria, IKDC scoring and Tegner activity scale. The data was analysed statistically.

Results: The patients who had posterior tibial slope >5° decrease compared to the preoperative value had statistically significant (P < 0.001) functional scores (IKDC and Tegner). The mean posterior tibial slope angle decreased from 14.35° preoperatively to 9.27° in the postoperative followup (P < 0.001). Visual analogue scale (VAS) score changed from 7.192 before surgery to 0.15 after surgery (P < 0.001).

Conclusion: Our study has shown that decreasing the tibial slope has functionally favourable effect on the reconstructed ACL graft and outcome. It is known that increasing slope causes an anterior shift in tibial resting position that is accentuated under axial loads. This suggests that decreasing tibial slope may be protective in an ACL deficient knee. Hence by placing the tricortical graft posterior to midline in the opening wedge reduces the posterior tibial slope and thereby reduces the stress on the graft leading to better functional outcome.

Keywords: ACL reconstruction, high tibial osteotomy, posterior tibial slope

Abstract ID: 1818

Radiological evaluation of placement of femorotibial footprints of anterior cruciate ligament in two different techniques of anterior cruciate ligament reconstruction: A prospective cohort study

Sagar Naik, Kiran Acharya, Vivek Pandey

Kasturba Hospital, Manipal University, Manipal, Karnataka, India0

Introduction: Anatomic tunnel positioning is important in ACL reconstructive surgery. Recent studies have suggested the limitation of transtibial technique to place graft within the anatomic tunnel position of the ACL on the femur. The purpose of the study is radiological evaluation of placement of femorotibial footprints of anterior cruciate ligament in two different techniques of anterior cruciate ligament reconstruction.

Materials and Methods: In 39 patients single bundle ACL reconstruction using hamstring tendon autograft was performed. Femoral tunnel locations was measured with quadrant methods on medial to lateral view of the lateral femoral condyle. Tibial tunnel locations were measured in anatomical axis on the top view of the proximal tibia. These measurements were compared with reference data on anatomical tunnel position.

Results: With quadrant method, femoral tunnel centers of the transtibial technique and anteromedial portal technique were located. The mean (±standard deviation) was 48.40 ± 9.49% and 31.59 ± 9.49% respectively, from the over the top along the notch roof (parallel to the blumensaat line) and at 17.47 ± 9.76% and 37.42 ± 8.20%. From the notch roof (perpendicular to the blumensaat line). The tibial tunnel centers of the transtibial technique and anteromedial portal technique were located at 44.27 ± 4.40% and 37.32 ± 5.97% respectively, of the anterior to posterior tibial plateau depth and at 45.37 ± 3.14% and 45.19 ± 2.82%, of the medial to lateral tibial plateau width. The anteromedial portal technique used in this study placed femoral tunnel more closer to the anatomical ACL center, (slightly higher and deeper). In contrast, transtibial technique placed femoral tunnel more shallow and higher from anatomical position, resulting in more vertical grafts.

Conclusions: After single bundle ACL reconstruction, three dimensional CT scan showed that anteriomedial technique allows for placement of the graft closer to anatomical femoral tunnel position when compared to transtibial technique.

Keywords: ACL foot prints, ACL reconstruction, radiological evaluation

Abstract ID: 1583

Computed tomographic evaluation of femoral and tibial tunnel in arthroscopic anatomic single bundle ACL reconstruction using ruler measurement technique

Raskesh Malhotra, Amite Pankaj

University College of Medical Sciences (UCMS) and GTB Hospital, Delhi, India

Introduction: Surgical techniques of ACL reconstruction is evolving decade by decade. The focus has been to provide an anatomic reconstruction of ACL to restore normal biomechanical functions of knee. There is controversy over the use of which technique to place the femoral and tibial tunnels in anatomic midbundle position. The ruler measurement technique has been shown in cadaveric studies to be effective in anatomic placement of tunnels.

Materials and Methods: We did three-dimensional computed tomographic scan of 30 knees operated with arthroscopic anatomic single bundle ACL reconstruction using ruler measurement technique. 3-D CT image models were used and substraction of femoral medial condyle done to visualize the medial wall of lateral condyle. Femoral tunnel position assessed with described quadrant and anatomic coordinate axes method. Then, substraction of femur was done to visualize the tibial articular surface and the position of tibial tunnel assessed with described anatomic coordinate axes method.

Results: In 4 × 4 grid, on the medial wall of lateral femoral condyle, the centre of femoral tunnel aperture was located at 2b in 23 cases, at 1b in 6 cases, at 2a in 1 case. With quadrant method, the mean of distance (in term of percentage of total depth and height of lateral condyle) of the femoral tunnel in parallel and perpendicular direction of Blumensaat line were 28.65% ± 5.82% and 34.92% ± 4.93% respectively. With anatomic coordinate axes method, the mean (and standard deviation) of distance (in term of percentage of total distance) of femoral tunnel, in anatomic posterior to anterior direction and proximal to distal direction were 20.78% ± 6.86% and 44.59% ± 7.47 respectively. With anatomic coordinate axes method, the mean (and standard deviation) of distance (in term of percentage of total distance) of tibial tunnel in antero posterior tibial plateau depth and medio-lateral tibial plateau width were 34.93% ± 7.19% and 51.57% ± 7.55% respectively. There was no significant difference (P > 0.05) between values from our study and those in previous studies.

Conclusion: We recommend the use of ruler measurement technique for placing the femoral and tibial tunnels in anatomic mid-bundle position in clinical practice.

Keywords: Ruler measurement technique, femoral tunnel, tibial tunnel, ACL reconstruction

Abstract ID: 1038

Effect of drainage tube on muscle strength and knee function after arthroscopically assisted anterior cruciate ligament reconstruction

Atul Mahajan, P. Sripathi Rao

KMC, Manipal, Karnataka, India

Introduction: A significant proportion of surgeons use intraarticular drains after arthroscopic anterior cruciate ligament (ACL) reconstruction. However there is a paucity of literature evaluating the use of intraarticular drains after arthroscopic procedures. Recent studies have not encouraged the routine use of postoperative drain after arthroscopic surgery. This study is to determine the effect of postoperative drain use on muscle strength and knee function after arthroscopically assisted anterior cruciate ligament (ACL) reconstruction with quadrupled hamstring graft.

A prospective randomized study with 44 consecutive arthroscopic ACL reconstruction patients randomized for either intraarticular suction drain group or non drain group. All arthroscopic ACL reconstructions using a four strands hamstrings graft as auto graft were included in the trial. Outcome assessment was done on postoperative day 4, day 10, 1 month, 3, 6 and 12 months after the surgery in which patients were asked to complete a visual analogue pain scale (0-10, with 10 being the worst pain). They were assessed for range of motion in flexion and extension with a universal double armed goniometer, knee effusion, measurement of quadriceps and hamstrings using KIN-COM dynamometer.

Results: The two groups were comparable in surgical findings and procedures performed. Comparison of quadriceps strength between the two groups showed no statistical significant difference at 30° (P < 0.167) and 90° (0.115) of knee flexion. Statistically significant difference was seen at 60° knee flexion (P = 0.036). Both treatment and control groups showed no statistical significant difference in flexion of the knee through the range of motion (P = 0.116) as measured by independent sample t-test. The percentage reduction in knee effusion was found to be statistically significant at 4 th (P < 0.001), 10 th (P < 0.001) 16 and 1 month (P = 0.012) in between treatment and control group. The overall pain difference between the two groups was not found to be statistically significant (P = 0.198) as calculated by independent sample t-test. During the study period, there were no complications in either group.

Conclusion: This study showed that following surgery, clinically the increment in the muscle strength was more in the drain group compared to the no drain group but was statistically significant only for quadriceps at 60° flexion in drain group. Clinically the drain group showed faster pain relief, lesser effusion and early return to motion compared to the no drain group.

Keywords: ACL reconstruction, drainage tube, muscle strength

Basic Science

Abstract ID: 1193

Antibiotic beads in musculoskeletal infection: An outcome analysis

Krunal Patel, Shyamasundar Bhat N, Nishant Shetty

Kasturba Medical College, Manipal, Karnataka, India

Introduction: Musculoskeletal infections are commonly encountered in clinical practice, but difficult to eradicate completely. Various factors can influence the eradication and recurrence of infection. This study was conducted to know efficacy of polymethylmethacrylate (PMMA) beads in antibiotic sensitive and resistant organism in musculoskeletal infection and to know the recurrence of infection.

Materials and Methods: All patients with musculoskeletal infections of various etiologies seen at Kasturba Hospital, Manipal from 2008 to 2013 period were enrolled in this retrospective cohort study. Each patient underwent comprehensive clinical, radiological and hematologic evaluation and classified according to Cierney and Mader classification. All patients were treated with debridement and application of antibiotic loaded PMMA beads. Appropriate antibiotics were given as per culture and sensitivity of swabs taken at the time of surgery. Beads were removed after 3 weeks. The comparison of gentamicin sensitive and resistance group and recurrence of infection were assessed by chi-square test.

Results: Eighty one patients with various etiology of musculoskeletal infections were enrolled, out of which 10 patients were lost to followup so remaining 71 patients were evaluated (52 male, 19 female). The most common site of bone involvement was femur (46%) followed by spine (24%) and the most common causes were open fracture (43%) followed by infected osteosynthesis (42%). The most common microorganism found was methicillin resistance staphylococci aureus (44%). Microorganisms found resistant to gentamicin were (53%) compared to cefuroxime (77%) and vancomycin (9%). Recurrence of infection was found in 10% overall with (43%) in gentamicin sensitive group and (50%) in gentamicin resistant group of patients. Though the organism was resistant to gentamicin in 41% patients no recurrence was found in 90% patients. Recurrence of infection was more common in Cierney and Mader Type B host of (63%). The comparison of gentamicin sensitivity and resistance to recurrence of infection were assessed with P < 0.001.

Conclusion: There is significant decrease in recurrence of infection in patients with musculoskeletal infections with use of antibiotic beads. Resistance to gentamicin is not related to effective ness of antibiotic beads probably due to high local concentration. This result supports the use of antibiotic loaded PMMA beads in treatment of musculoskeletal infections.

Keywords: Musculoskeletal infection, antibiotic beads, gentamicin beads, polymethyl methacrylate

Abstract ID: 1405

Assessment of the geometry of proximal femur for the placement of proximal femoral nails-An observational study in dry femora and living subjects

Pathrot D, Ul-Haq R, Agarwal A, Bhatt S, Nagar M

UCMS & GTB Hospital, Delhi, India

Background: Intramedullary devices are becoming popular methods for fixation of unstable intertrochanteric and subtrochanteric fractures. These implants have been designed for the use of in the Western population whose constitution vary from there of Indian population. This study is done to assess the geometry of proximal femur for the placement of proximal femoral nails in Indian population.

Materials and Methods:The study was conducted in three groups in 101 human dry femora (anthropometrically and radiologically) and 102 patients with pertrochanteric fractures (radiologically). The neck shaft angle, minimal neck width, neck width at 130°, neck width at 135°, trochanteric shaft angle , trochanteric offset, distance from the tip of greater trochanter to the lower border of lesser trochanter on the femoral shaft axis (X), distance between the tip of greater trochanter and the point where the neck axis crosses the line joining the tip of the greater trochanter to the lower boarder of the lesser trochanter on the femoral shaft axis (Y) and canal width at 10,15,20 cm from tip of greater trochanter were measured. The various parameters of commonly used cephalomedullary nails available for fixation of pertrochanteric fractures were measured.

Results: The mean parameters observed were as follows: neck shaft angle 128.070±4.97, minimum neck width 28.7±2.73mm (anthropometrically), 29.59±2.84mm (radiologically), neck width at 1300 30.12±2.86mm, neck width at 1350 30.66±3.02mm, trochanteric shaft angle 10.450±2.340, X was 65.73±6.45mm, Y was 38mm and canal width at 10, 15, 20cm from tip of greater trochanter was 13.46±2.34mm, 11.40±2.27mm and 11.64±2.04mm respectively.

Conclusion: We compared our observations with the available cephalomedullary nails. We recommend that certain modifications are required in the presently available short PFN designs to better fit the anatomy of our subset of population.(a)two nails of 1250 and 1350, (b)five distal width (9-13mm), (c)two femoral neck screw placement (35mm and 45mm from tip of nail). (d)The mediolateral angle should be at 65 mm from the tip of the nail.

Keywords: Geometry, proximal femur nail, anthropometry

Gold Medal

Abstract ID: 1800

Modified Dunn's procedure: Is it safe for severe slipped capital femoral epiphysis?

Praveen Kumar Khot, Venkatadass

Ganga Medical Centre and Hospitals Pvt. Ltd., Coimbatore, Tamil Nadu, India

Introduction: Though in-situ screw fixation for SCFE remains the gold standard treatment for SCFE, the modified Dunn's procedure (MDP) is gaining popularity with encouraging results from few centers. The potential advantages of modified Dunn's procedure are restoration of proximal femoral anatomy to near normal and nullification of chances of Femoro Acetabular Impingement (FAI). There is only one study published from India till date. This study was done to analyse the functional and radiological outcome of patients who underwent modified Dunn's procedure for SCFE and to analyse the incidence of complications and FAI.

Materials and Methods: This is a longitudinal study both prospective and retrospective in nature done in patients with SCFE treated by modified Dunn procedure in our institution between January 2009 and June 2013. We had 49 patients who were treated for SCFE in our database in the above period out of which 18 patients fulfilled the inclusion criteria and were taken up for the study. There were 12 males and 6 females and the mean age of presentation was 14.2. The presentation was acute in 2, chronic in 12 and acute on chronic in 4 patients. Of the 18 slips, 14 were stable and 4 were unstable. Patients were followed up at 6 weeks, 3 months, 6 months, 1 year and yearly thereafter. Radiological assessment was done with head-shaft angle for the severity of slip and angle for incidence of FAI. Functional analysis was done using Harris Hip Score and BASH Score.

Results: Clinical outcome as assessed by Harris Hip Score and BASH Score was excellent in 86.66%, good in 6.66% fair in 6.66%. None of the patients had poor out come. Mean slip angle correction was 34.05°. Mean preop slip angle was 62.11° which was corrected to 28.05°. In our series three patients developed AVN amounting to 16.66%. The AVN rate in unstable slips was 50% and that in stable slips was 7.14%. One patient with chronic stable slip developed chondrolysis. Though the mean alpha angle was 67.25, only two patients had clinical FAI. There was significant correlation found between preop slip angle and alpha angle with P value 0.041.

Conclusion: Modified Dunn's Procedure gives good clinical results for moderate and severe SCFEs. The AVN rates are significantly high for unstable SCFEs compared to stable SCFEs. In severe slips, there is a possibility of development of FAI even after modified Dunn's procedure.

Keywords: Femoral epiphysis, slipped capital femoral epiphysis, femur acetabular impingement, Dunn procedure

Abstract ID: 1795

A comparative study of management of idiopathic CTEV by accelerated and standard Ponseti methods

Mazhar Abbas, Mohd. Faizan, Satyaprakash Modanwal

J.N. Medical College, India

Introduction: Standard Ponseti method has become the gold standard for the management of CTEV in the last two decades. Recently an accelerated Ponseti method for correction of CTEV has emerged in which similar correction can be achieved in shorter duration. So we conducted a study to compare the accelerated Ponseti and standard Ponseti methods for the management of idiopathic clubfoot in children up to 2 years of age.

Materials and Methods: Twenty two patients were treated by accelerated Ponseti method and 25 patients were treated by standard Ponseti method between November 2012 to June 2014. Clinical assessment of precorrection clubfoot and postcorrection clubfoot was done by Pirani scoring.

Results: Excellent to good correction was achieved in all patients. All patients required tenotomy except two patients treated by accelerated and one patient treated by standard Ponseti method. Average total numbers of cast required was 7 in both methods. Mean precorrection Pirani score in accelerated group was 4.80 and in standard group was 4.84. Mean postcorrection Pirani score in accelerated group was 0.40 and in standard group was 0.54. Average number of days in cast in accelerated group is 28 days and in standard group is 56 days.

Conclusion: Ponseti method is an effective method for the management of idiopathic congenital talipes equino varus and similar correction is achieved with accelerated Ponseti method in shorter duration of time.

Keywords: CTEV, Ponseti method, congenital, foot

Abstract ID: 1235

Analysis of treatment of osteonecrosis of femur head by core decompression and fibular strut grafting (midterm followup)

Prasad Soraganvi, Ramknath Rajagopalakrishnana, Narayan Gowda B S

PESIMSR, Kuppam, Andhra Pradesh, India

Introduction: The diagnosis of avascular necrosis accounts for 5-10% of total hip replacement. Core decompression and fibular strut grafting is one of the simplest of joint preserving surgeries. Success rate has been reported ranging from 61% to 99%. Objective of this study was to determine clinical and radiological outcome of core decompression and fibular strut grafting in Ficat and Arlet stage I, II and III.

Materials and Methods: 22 cases (32 hips) of nontraumatic avascular necrosis of femur head treated for Ficat and Arlet stage I, II, and III treated by core decompression and fibular strut grafting done at PES medical college 2005-2013 were included in the study. Patients were followed up to 3 months, 6 months and as late as patient came for the followup. Harris hip score used to asses the preop and postop functional outcome.

Results: The study consisted of 22 cases and 32 hips of nontraumatic avascular necrosis of head of femur treated by core decompression and fibular strut grafting. 12 patients had unilateral and 10 had bilateral AVN with 9, 14 and 9 in stage IIA, IIB and III. The followup period was ranging from 18 months to 66 months. According to modified Harris's hip score evaluation 4 hips (14%) had excellent, 15 hips (56%) had good, 6 hip (20%) had fair and 3 hips (10%) had poor results. All the patients had significant pain relief and were satisfied with the treatment. Core decompression and fibular strut grafting results have ranged from 17% to 90% at short term to mid-term followup in various studies. In our study we have 70% cases with good to excellent results with all patients showing significant pain relief.

Conclusion: Core decompression and fibular strut grafting is one simple and effective method in forestalling the need for THR patients in stage I, II and III osteonecrosis of femoral head. In order to provide mechanical support to infarct and to prevent collapse, graft has to be placed at centre of lesion under subchondral bone.

Keywords: Femur head, osteonecrosis, fibular graft, core decompression, avascular necrosis

Abstract ID: 1355

Swashbuckler approach: A modified anterior approach for the distal femur fractures

Rajkumar Natesan

Ganga Hospital, Coimbatore, Tamil Nadu, India

Introduction: In the management of distal femur fractures with intrarticular involvement, anatomical reduction and rigid fixation has been proven to give excellent functional outcomes. The Swashbuckler approach to distal femur described by Starr et al. allows excellent exposure of the entire articular surface of the distal femur. With this background we have analysed the functional and radiological outcome of patients with distal femur fractures treated by Swashbuckler approach in our hospital.

Materials and Methods: 82 patients who underwent locking plate osteosynthesis using this approach from September 2009 to September 2012 were included. They were evaluated for functional and radiological outcome during followup. Functional outcome was graded using Neer's criteria and lower extremity functional score (LEFS). Radiological evaluation was done to check for union and malalignment in all three planes.

Results: All the patients were retrospectively analysed for radiological and functional outcome. Fracture was considered to be united if bridging callus was seen over 3 of 4 cortices and no pain on weight bearing. Functional outcome was assessed and graded according to Neers scoring and lower extremity functional scoring (LEFS).Radiological examination was done to look for fracture union and coronal and sagittal plane malalignment and loss of alignment. Normal coronal alignment was considered 5-7° valgus, and normal sagittal alignment was neutral. Malalignment was defined as greater than a 5° deviation from normal coronal or sagittal alignment. Loss of alignment was defined as greater than a 3° change in angular measurements between postoperative and followup radiographs. The average time for union in our series was 4.5 months. The average mean value of functional outcome according to Neer's criteria was 82% and lower extremity functional score was 85%. We had 3 cases of implant failure (3.6%), 4 cases with infection (4.8%) and 4 cases required secondary intervention (4.8%) in the form of bone grafting for delay in union.

Conclusion: Swashbuckler approach gives direct visual to all critical areas of the distal femur, including the trochlea, entire medial compartment, and both posterior femoral condyles resulting in good anatomical reduction and stable fixation. Quadriceps muscle bellies are spared which facilitates good functional outcome and does not compromise future arthroplasty surgery.

Keywords: Swashbuckler approach, Neers scoring, LEFS

Abstract ID: 1672

Is there a difference between limb salvage compared to limb amputation in conventional appendicular osteosarcoma? A systematic review of recent literature

Aditya Maheshwari, Joseph Munn, Robert Pivec, Bhaveen Kapadia

SUNY Downstate Medical Center, New York, NY, USA

Introduction: The treatment for osteosarcoma has gradually changed over the past several decades from a condition that was initially treated primarily with limb amputation and resection-arthrodesis in the 1970s to the current methods of limb salvage in the 2000s. We systematically review the recent literature with an emphasis on studies published within the past 5 years and those with long term followup to determine the outcomes of limb salvage versus amputation in appendicular osteosarcoma.

Materials and Methods: A search of the electronic medical databases PubMed, Medline, Embase, and Scopus to identify all papers reporting on the survivorship of either limb salvage or amputation. Articles that reported objective outcome measures and disease-free survivorship were included in the final analysis. Outcome data was extracted for each study and pooled; the differences between salvage versus amputation were compared for survival, local recurrence, metastasis, medical and implant-related complications. Secondary outcomes measured were patient satisfaction and cost.

Results: The search returned 104 articles, 43 published after 2000 and 61 before. Another 21 articles were found upon review of the references from the original 104 for a total of 125 English articles. For the purposes of this review, we have followed the convention of previous papers which have grouped rotationplasty together with amputations, 52 papers were included overall. We observed a mean survival rate for salvage was 62% and 58% for amputation. The local recurrence rate was 8.2% (salvage) and 3.0% (amputation), while the metastatic rate of 33% and 38%, respectively. The pooled complication rate was 8.4% for medical complications and for patients treated with limb salvage, 11.5%. When implant-related complications were taken into account this increased to 31.2%, the most common complication being aseptic loosening. General health measures were the same for both groups but salvage had higher levels of cosmetic satisfaction. Cost was substantially higher for limb salavage which was been estimated to be ~$160,000 higher.

Conclusions: Despite the heterogeneity of studies available for review, we observed similar survival rates and metastatic rates at final followup. The local recurrence rate was slightly higher for limb salvage. Aseptic loosening remains the most common complication; however, the overall incidence of medical complications is low for both treatment types. Cosmetic satisfaction may be higher with limb salvage but no difference is observed on measured of general health and function. Amputation may be less expensive but this may change as new, more expensive high-functioning prosthesis are developed.

Keywords: Osteosarcoma, limb salvage, amputation


Abstract ID: 1271

Management of midshaft clavicular fractures: Comparison between nonoperative treatment and plate fixation in 60 patients

Naveen Basavaraj Manibanakar, Gururaj Joshi

Armed Forces Medical College, Pune, Maharashtra, India

Introduction: Clavicle fracture is one of the common traumatic injury. Majority of the fractures occur in its middle third. Both nonoperative and surgical methods have been described for the management of this injury. However, there is no uniform consensus on the definite choice of treatment. Hence, a randomised prospective cohort study was undertaken to compare nonoperative and primary internal plate fixation in terms of functional outcome, the rate of nonunion, malunion and local complications in patients with midshaft clavicular fractures.

Materials and Methods: Patients with displaced midshaft clavicle fractures (Robinson type 2B) in age group of 20-50 years were recruited and randomly allocated into two groups, consisting 30 patients each. Group 1 patients were managed conservatively, with a figure-of-eight bandage whereas patients of group 2 were treated surgically by plate fixation. Followup was done at 06 weeks, 03 months and 06 months using patient's subjective evaluation, constant shoulder score, radiographic assessment and other complications.

Results: In Group 1, 28 patients had fracture union and 2 patients had nonunion. The mean time for union was 11.29 weeks. In group 2, fracture united in all patients and the mean time for union was 9.27 weeks. Subjective outcome was inferior in group 1 with only 22 patients satisfied with the treatment, 6 partially satisfied and 2 unsatisfied as compared to group 2 in which 25 were satisfied and 5 partially satisfied. Constant shoulder score was significantly lower in group 1 by 7.9 points at 6 and 12 weeks followup and by 4.4 points at 6 months as compared to group 2. There were 6 malunions with cosmetic deformity, 2 nonunions and 1 patient with restriction of shoulder movements in group 1. In group 2, one patient had malunion, 3 had surgical scar related problems and 2 with hardware prominence.

Conclusion: Open reduction and plating gave superior results as compared to conservative management in displaced midshaft clavicle fractures in terms of union and function.

Keywords: Clavicle, fracture, nonoperative, plating

Abstract ID: 1404

Functional outcome of middle third clavicle fractures with anterior plating

Yellala Ramakrishna Reddy, V.J. Senthil

Dr. G.V.N. Institute of Medical Sciences, Trichirappalli, Tamil Nadu, India

Introduction: Displaced middle third clavicle fractures are treated conservatively with figure of 8 harness. Fracture of middle third clavicle shows a rotatory postero-superior angular displacement of the medial fragment where by the trapezius muscle is penetrated and soft tissue interposition prevents fragments from contacting each other. Current management trend in treating displaced clavicle fractures with internal fixation provides rigid immobilization and pain relief avoiding nonunion, shortening and deformity. This study retrospectively evaluates the functional outcome with middle third clavicle fractures treated surgically.

Materials and Methods: We retrospectively reviewed 52 patients of middle third clavicle fractures who underwent anterior plating in our hospital between June 2011 and June 2013. Mean age group was 35 years (range 25-62 years). Forty patients were males. Predominant mode of injury was RTA. All patients were evaluated with A-P view radiograph of the involved shoulder after a thorough clinical examination. All comminuted middle third fractures with complete displacement and marked shortening of the clavicle (>2 cm) were included. Also included were surgery done for cosmesis. All open fractures, multiple fractures and paediatric fractures were excluded. Patients were followed up on 3, 6, 8, 12 weeks. With maximum followup of 2 years. Functional outcome was assessed at their latest followup by using UCLA and QUICK DASH scoring. Statistical analysis was done by using one-way ANOVA.

Results: The fracture united in an average period of 10 weeks (range 8-12 weeks). At the time of latest followup, all of the patients had returned to their pre injury activity level. There was 1 case of skin break down, 2 cases of wound infection and 2 cases of haematoma. The average UCLA SCORE was 29 (range 25-32) suggesting good to excellent outcome. The average QUICK DASH score was 6.8 (range 4.5-13.6).

Conclusion: The anterior plating of clavicle provides a stable fixation and early return of shoulder function. (2) It avoids risk to the neuro vascular structures below the clavicle. (3) It has a low rate of implant - prominence problems. Thus we recommend the use of anterior plating as an effective alternative technique to other modalities in comminuted displaced mid clavicular fractures.

Keywords: Clavicle, fracture, nonoperative, plating

Abstract ID: 1300

Comparision of Schatzker and Duparc classification and role of CT scan in tibial plateau fractures

Gaurav Garg, S.P. Gupta

S.M.S. Medical College and Hospital, Jaipur, Rajasthan, India

Introduction: Tibial plateau fracture occurs mainly in a young population due to direct trauma to knee following road traffic accidents. Extent of displacement and degree of communition must be accurately defined before planning on treatment. CT scans provide exact location and extent of plateau involvement. Reviewing the literature on classifications for tibial plateau fractures we found that performance of Schatzker classification has already been studied. However, Duparc classification has not been evaluated. The aim of this study was to compare Schatzker and Duparc classification used for tibial plateau fractures in preoperative assessment and to analyse the role of CT scan in assessment of tibial plateau fractures.

Materials and Methods: We retrospectively studied 50 patients with fracture invloving tibial plateau and proximal tibia. Standard radiographs and CT scans were done in all patients. 2D sagittal and coronal and 3D reconstruction images were taken. All patients were analysed with Schatzker and Duparc classifcation. Twenty one patients were operated, 29 patients were managed conservatively.

Results: Age of patients ranged from 19 years to 54 years. Duparc classification had the advantage of being more reproducible and allowing a greater number of fractures to be classified. These two classification systems only overlap for Duparc lateral unicondylar fractures, which corresponds to Schatzker types I, II, III. Posteromedial fractures were not classified in Schatzker. In Schatzker type IV, intercondylar eminence can be involved which can be classified as spinocondylar in Duparc classification taking displacement into consideration. Schatzker type V fractures are bicondylar fractures that do not take into account potential comminution. Schatzker type VI fractures have the advantage of association with diaphysis fracture, but they do not allow tibial plateau fractures to be classifed, which can be done in Duparc classification.

Conclusion: Although the information obtained from plain X-rays is of value if viewed carefully, however CT scans offer a clear picture of fractured tibial plateau and the extent of cortical comminution. Though sample size is small, we propose Duparc and Ficat classification to be better for classifying proximal tibial fractures in pretherapeutic assessment.

Keywords: Proximzal tibia, Schatzker classification, Duparc classification

Abstract ID: 1397

Segmental collapse in united fracture neck of the femur: Is it a mechanical failure rather than vascular insult

Ranjit Kr Baruah

Assam Medical College, Assam, India

Introduction: Development of avascular necrosis (AVN) of femoral head despite advanced methods of fixation brands fracture neck femur as unsolved. Acetabular runway and femoral head are not perfectly circular; mal reduction in any plane produces incongruity predisposing to degenerative changes, like fragility and attenuation. Considering this, Garden (1971), while studying in a larger number of cases doubted the role of ischaemia as cause of segmental collapse and put forwarded a biomechanical factor for same. Late appearance of such changes in united fractures also strengthens this doubt. With this concept in mind, we have retrospectively evaluated intracapsular fractures of neck femur and correlate X-ray findings of valgus malreduction to development of AVN changes.

Materials and Methods: 100 fresh intra capsular fractures of neck femur, who underwent internal fixation, between 1994 and 2010, were evaluated retrospectively. There were 12, 10, 58, 20 cases in Garden Stage 1, 2, 3, 4 respectively. There were 72 males and 28 females with age range of 27-55 years. All cases sustained fracture following simple fall. Two types of implants were used; multiple cancellous screws (n = 52) and DHS with derotation screw (n = 48). Immediate postoperative X-ray was evaluated to find out valgus malreduction as confirmed by Lateral Wedging of Joint space, Uncovering of Femoral Head, Cupid's Bow sign. Garden Index was unreliable due to the presence of implants. X-rays of the patients at 2 years were further evaluated to detect AVN.

Results: Out of 100 cases, 88% united; 16% of these cases showed AVN changes. Presence of implants made Garden Index unreliable in all cases whereas other signs were reliable to showcase valgus malreduction. Out of total cases of AVN, valgus malreduction was found to be in 93% cases.

Conclusion: Although small in number, study reveals the possibility to look into so called AVN changes of femoral head after fracture neck of femur in a biomechanical perspective rather than vascular one.

Keywords: Femoral neck fracture, AVN, segmented collapse, ununited fracture neck femur

Abstract ID: 1728

A biomechanical study of different implants in Pauwel's type 3 fracture neck femur

Birju Manjhi, S.C. Goel

Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India

Introduction: Pauwel's type 3 fracture is most unstable of femoral neck fractures. There is no consensus on the implant to be used to fix it. Biomechanical studies have shown the role of individual factors like type of implant, type of fracture and quality of bone. We tried to find out the correlation among these factors in a cadaveric model of unstable fracture neck of femur (Pauwel's type 3) fixed with either: Proximal femoral nail, dynamic hip screw, dynamic hip screw with an antirotation screw or cannulated cancellous screws.

Materials and Methods: This study was conducted on 24 cadaveric bones (6 in each group) in which unstable fracture neck of femur (Pauwel's type 3) was created and fractures were fixed with either proximal femoral nail, dynamic hip screw, dynamic hip screw with an antirotation screw or 3 cannulated cancellous screws after creating a comparable group using DEXA scan. These were mounted and tested for axial loading on an electronic material testing machine at 2 cycles per second with a load of 200 kg. The test was observed for 10,000 loading cycles or till failure whichever occurred earlier. All specimens were compared with respect to the number of survived cycles, subsidence, load to failure, and failure mechanism.

Results: Five out of six specimens in PFN group survived upto 35,000 cycles or more, while 3 out of 6 specimens in DHS with ARS and DHS group survived upto 20,000 cycles and failed by loosening of screws while there was bending of screws in all specimens in CCS group at around 2500 cycles or before. Subsidence also was minimum in PFN group (8.26 mm) v/s DHS with antirotation screw group (14.06 mm) v/s DHS group (15.00 mm).

Conclusion: In various studies DHS or DHS with antirotation screw has been found to be stronger compared to 3 CCS model. PFN has not been used in any of these studies for proximal femoral fracture fixation. PFN constructs were stronger than the DHS, DHS with ARS and CCS constructs. However this data must be interpreted as strictly biomechanical, representing only part of the scenario at work in fixation and healing of these injuries in vivo.

Keywords: Fracture neck femur, Pauwel's type 3, implant, DHS, PFN, cadaver

Abstract ID: 1313

Physical quality of life after intramedullary nailing in diphyseal fractures of tibia and femur

Aditya Reddy

Sancheti Institute for Orthopedics and Rehabaillitation, Pune, Maharashtra, India

Introduction: Diaphyseal fractures of femur and tibia are commonly seen fractures in orthopaedic practice. We evaluate the physical quality of life after intramedullary nailing in diaphyseal fractures of femur and tibia.

Materials and Methods: A retrospective study of closed and Gustilo Anderson type I, II open fractures in diaphysis of tibia and/or femur was conducted at our institute. The outcome of operative treatment of diaphyseal fractures of tibia and femur were assessed between January 2009 and December 2012 in 169 patients.

Results: At final followup mean WOMAC score for pain was 23.73 ± 5.40, mean WOMAC score for stiffness was 9.01 ± 3.02, mean WOMAC score for ADL (activities of daily living) was 106.02 ± 12.01. The physical component score (PCS) of SF 36 scoring system was found to be 36.33 ± 8.25 and the mean mental component score (MCS) was 43 ± 7.07. At final followup, LEAS (lower extremity activity scale) was 10.95 ± 0.86 while VAS (visual analogue score) was 3.14 ± 0.87.

Conclusion: Intramedullary nailing should be considered as the treatment of choice for shaft fractures of weight bearing long bones of lower limbs (tibia and femur).

Keywords: Tibia/femur shaft fractures, long bone fractures, intramedullary nailing

Abstract ID: 1446

Operative management for diaphyseal nonunion of femur: A comparitive analysis

Vetri Chelvan, Dheenadhayalan

Ganga Medical Centre and Research Institute, Coimbatore, Tamil Nadu, India

Introduction: Diaphyseal nonunion of femur is disabling and it prolongs patient recovery. Nonunion rate in femoral fractures after intramedullary interlocking nail is 1-20%. Following lacunae were found in literature for nonunion of femur after ILIM nailing: Study comparing augmentation plating and exchange nailing with augmentation plating is lacking, type of augmentation plate needed has not been studied, guidelines for chosing a treatment modality has not been evaluated and number of cases studied is not sufficient to get good conclusion.

Materials and Methods: Patients with femoral nonunion admitted in orthopedic tertiary referral centre were studied. Inclusion criteria were nonunion of femoral diaphyses, associated ipsilateral fractures of the same limb, open or closed injuries. Exclusion criteria were age < 16 years, infective nonunion and pathological fractures. Augmentation plating (AP) was done in hypertrophic nonunion, stable implant and normal alignment (18 patients). Exchange nailing with augmentation plating (ENAP) was done in atrophic nonunion, broken implant and altered alignment. Bone grafting was done in all patients.Wave plate was used in 6 cases and DCP was used in 34 cases. All patients were followed for a minimum of 1 year. For statistical analysis, Chi-square test, Student t-test test and Pearson correlation analysis was done. We analysed union rate, union time and functional outcome using Lower Extremity Functional Scale score (LEFS).

Results: Forty patients of diaphyseal nonunion femur with mean age of 37.65 were studied. Study included 35 males and 5 females. Average union time was 3.8 months. AP group had an average union time of 4.5 ± 1.6 months and ENAP group had an average of 3.11 ± 1.7 months. Earlier union time in ENAP group was significant (P - 0.012). Mean postoperative LEFS at the end of 1 year was 57.55 (range 45-67). In AP group the average LEFS was 56.17 ± 5.3 (range 45-67). In ENAP group the average LEFS was 58.68 ± 4.7 (range 51-68). Better LEFS in ENAP group was not found to be statistically significant P - 0.125. Union rate was 100% in both groups. There was no association between age and LEFS. Union was early in females (P = 0.004). Union time and mean LEFS was better in hypertrophic nonunion. Smoking caused a delayed union (P = 0.001). No association between union rate and co-morbidities like diabetes, hypertension and others. Union time and LEFS was better in patients who diant have any associated limb injuries (P - 0.029 and 0.042 respectively). Union time and LEFS was comparable in the groups who had open and closed injuries. Patients with primary oblique and transverse fracture pattern had better union time and LEFS than comminuted and segmental patterns. Type of augmentation (wave/DCP) had no association between the union time and LEFS (P - 0.114 and 0.760).

Conclusion: Exchange nailing and augmentation plating had earlier union than patients who underwent augmentation plating alone. Type of augmentation device is not an issue. There is a definitive correlation between the alignment parameters and functional outcome in treatment of nonunion. Co-morbidities have no bearing on union time.

Keywords: Fracture femur, nonunion femur, diaphysis, augmented plating, exchange nailing, bone grafting

Abstract ID: 1259

A prospective comparative study of outcomes of percutaneous crossed versus lateral pinning in the treatment of displaced supracondylar fractures of humerus in children

Nirav Patel, Paresh Patil, Pravin Patil, Himanshu Kulkarni, Aayush Lal

Krishna Institue of Medical Sciences, Karad, Maharashtra, India

Introduction: Displaced supracondylar fractures of humerus is one of the most common fractures in paediatric age group with preferred treatment being closed reduction with percutaneous K-wire fixation. This study compares whether lateral pin construct alone can provide same stability like medial and lateral pin fixation, and prevent iatrogenic ulnar nerve injury.

Materials and Methods: This is a prospective comparative randomized controlled trial. 60 patients of closed displaced supracondylar fractures, aged between 3 and 12 years were enrolled for the study and randomly divided into two groups, A and B. For each group of 30 patients, they were assigned treatment of crossed pinning and lateral pinning respectively. The outcome was evaluated on basis of pain, motion, stability and function according to Mayo's elbow score and followup was maintained for a period of 24 months. The statistical analysis of data was done.

Results: After assessing 30 patients in each group we found out that mean mayo score was 98.5 in cross pinning group and 96.83 in lateral pinning group. This difference was statistically not significant (P - 0.296).

Conclusion: The lateral pinning grossly swollen elbows in which medial epicondyle was barely palpable with increased risk of ulnar nerve injury during placement of medial pin. However both the methods offer consistently satisfactory functional and cosmetic results.

Keywords: Supracondylar fracture humerus, pinning, ulnar nerve

Abstract ID: 1420

A comparative study of management of fracture shaft of humerus by dynamic compression plate and interlock nailing

Sarvesh Sawant, Vilas Jog, Sanjay Patil

Bharati Vidyapeeth Medical College, Pune, Maharashtra, India

Introduction: Fracture of the shaft of humerus is a common occurrence and there is a debate regarding the choice of operative intervention in humeral shaft fractures that require surgical intervention which include intramedullary nailing (IMN) and dynamic compression plate (DCP). The aim of this study is to find the difference between the functional outcome of the DCP and the IMN in diaphyseal fractures of the humerus in adults.

Materials and Methods: This was a prospective randomized controlled trial of 30 patients. Mean age of patients was 38.5 years. All patients had closed fractures without any prior radial nerve injury. Mean duration of followup was 18 months. All patients with diaphyseal fractures of the humerus were treated with either using DCP or with IMN. They were followed up regularly every 2 weeks until radiological union. The time taken for radiological union in the two groups was compared. After satisfactory radiological union, the functional outcome was assessed by the "Disabilities of Hand, Shoulder and Elbow (DASH) Questionnaire".

Results: There was no statistically significant difference in the two groups with respect to age, mode of injury, side of injury and AO type. The average age of patients in our study was 37.28 years. Primary radial nerve palsy was seen in 3 patients (6.66%), out of which 2 patients recovered completely. The functional outcome was better in DCP compared to interlocking nailing which was statistically significant (P = 0.024). The average time taken for union in the DCP group was 16.06 weeks and in the interlocking group it was 14.05 weeks. The average time for union in all the 30 patients was 15.05 weeks. Two fractures (6.66%) treated with DCP remained ununited. The functional outcome was excellent in 10 patients (8 in the DCP and 2 in the interlocking), good in 12 patients (6 in the DCP and 6 in the interlocking), fair in 6 patients (2 in DCP and 4 in interlocking) and poor in 2 patients (1 in DCP and 1 in interlocking). The complications associated with interlocking group were more than the DCP group.

Conclusion: Both the modalities of treatment are good as far as union of the fracture is concerned, but considering the number of complications and functional outcome, we opine that dynamic compression plating offers better result than interlock nail with respect to pain and function of the shoulder joint.

Keywords: Humerus fracture, interlock nailing, dynamic compression plate

Abstract ID: 1838

Nonunion humeral diaphyseal fractures treated with ilizarov ring fixator

Naveen Chandra

Srujan Ortho and Accident Care, Khammam, Telangana, India

Introduction: Nonunion in diaphyseal fractures of the humerus can be treated by various modalities, but with history of multiple surgeries, osteoporosis, atrophy and joint contractures is further challenging. We are presenting a prospective study wherein the outcome of the treatment of nonunion of diaphyseal fractures of the humerus by Ilizarov's method was analyzed.

Materials and Methods: 30 patients with diaphyseal nonunion of the humerus were treated by Ilizarov's external fixator. These included nonunion after plating (n = 6), intramedullary nailing (n = 14) and conservative methods (n = 10). In post surgical infected nonunion (n = 16), the implants were removed, debridement done, bone fragments were docked application of ring fixator and compression. In aseptic nonunion (n = 14), accordion maneuover was followed as the standrd protocol. Early shoulder and elbow physiotherapy was instituted. The apparatus was removed after clinical and radiological union and the results were assessed for bone healing and functional status.

Results: Fracture union was achieved in all the 30 cases. Pin site infection was seen in 3 cases (10%). The bone healing results were excellent in 25 cases (83.33%) and good in 5 cases (16.66%). The functional results were found to be excellent in 23 cases (76.68%), good in 4 (13.33%) and fair in 3 cases (10%).

Conclusion: Ilizarov's method is an excellent option for treatment of septic and aseptic nonunion of diaphyseal fractures of the humerus as it addresses all the problems associated with nonunion of the humerus like infection, deformity and joint stiffness.

Keywords: Humerus diaphyseal fractures, nonunion, infected nonunion, ilizarov

Abstract ID: 1748

A comparative study between intramedullary nailing with fibular plating and intramedullary nailing without fibular plating in distal tibial-fibular fractures

Rajarshi Roy, Tulasidas Bhattacharyya

Gauhati Medical College and Hospital, Guwahati, Assam, India

Introduction: Nailing of the distal third of the tibia carries some risk of instability and malalignment due to widening of the medullary canal distal to the isthmus for which fibular fixation has been suggested. There is an ongoing debate about the necessity of fibular fixation and also dearth of conclusive studies. So this study deals with comparison between intramedullary tibial nailing with or without fibular plating in such fractures.

Materials and Methods: The study is a prospective randomised control trial of 40 cases (22 male and 18 female) of closed distal third tibial - fibular fractures of age 18-60 years who underwent intramedullary tibial nailing either with fibular plating or without fibular plating (20 in each group), conducted for a period of 18 months with a minimum followup period of 6 months. The functional results were evaluated using American Orthopaedic Foot and Ankle Society (AOFAS) score system.

Results: Mean time to union was 18.5 weeks. Mean AOFAS score in nailing with fibular plating group was 82.5 while that in nailing without fibular plating group was 81.1 (P 0.19). Infection occured in one case of fibular plating group.

Conclusion: There is little difference between intramedullary nailing with fibular plating and intramedullary nailing without fibular plating in terms of final functional outcome.

Keywords: Fracture tibia, fracture fibula, distal third, fibular fixation, tibial nailing

Abstract ID: 1749

A prospective randomised clinical trial of management of tibial plafond fractures by delayed distal tibial plating with primary fibular plating and without primary fibular plating

Nayanmoni Dutta, Tulasi Das Bhattacharyya,

Partha Sarathi Chakraborty

Gauhati Medical College and Hospital, Guwahati, Assam, India

Introduction: Fractures of the tibial plafond are among the most challenging of orthopaedic problems due to subcutaneous distal segment. Currently staged treatment with primary stabilization with minimal internal fixation followed by delayed medial tibial plating is gaining support. We studied comparison between primary external fixation with or without fibular plating followed by distal tibial plating.

Materials and Methods: 40 consecutive closed plafond fractures treated with external fixator with fibular plating (20 cases) and without fibular plating (20 cases) followed by distal tibial plating in all. The mean age of the patients at the time of the operation was 32 years (range: 18-60 years). Mean operative time was 7 days (range 5-12 days). All patients followed up to a period of mean 18 months (range 12-24 months). The functional results were evaluated using American Orthopaedic Foot and Ankle Society (AOFAS) score system.

Results: Mean time to union was 13.5 weeks. Mean AOFAS score in with fibular plating group was 84.5 while that in without fibular plating group was 80.1 (P 0.20). Complication: 4 superficial, 1 deep wound infection, 2 hardware prominence, 2 nonunion and 1 malunion.

Conclusion: There is little difference between with or without fibular plating in terms of final functional outcome.

Keywords: Fibular fracture, tibial p plafond fractures, fibular plating, external fixator

Abstract ID: 1506

Predictors of functional outcomes of ankle fractures treated by internal fixation

Rizwan Basha, Dheenadhayalan

Ganga Hospital, Coimbatore, Tamil Nadu, India

Introduction: The functional outcomes of management of ankle fractures depend on achieving anatomical joint congruity, rigid fixation with minimal soft tissue damage. We analysed the functional outcome of ankle fractures which were treated by internal fixation.

Materials and Methods: A prospective clinical, radiological and functional outcome analysis of 98 consecutive ankle fractures treated by internal fixation was performed. At minimum 1 year followup, the radiological and functional outcome were analysed. Radiological parameters studied were medial clear space (≤4 mm), talocrural angle (83 ± 4), Dime sign and Shentons line of the ankle (these were used to assess optimal fibular length). Tibiofibular overlap (≥10 mm), tibiofibular clear space (≤5 mm) and talar tilt (<2) were used to assess syndesmotic widening. Functional outcome was assessed with Olerud and Molander Scoring System. Maximum score is 100 (score of 91-100 was considered 'excellent', 61-90 'good', 31-60 'fair', and <30 'poor'). Fractures were classified based on AO classification and Lauge-Hansen system.

Results: Of the 98 cases majority of fracture patterns were supination adduction (32%) and AO 44 B 2(30%). The mean age was 47.81 years and male to female ratio was 69:29. Mean functional outcome score was 77.96. Twenty four had excellent outcome, 56 had good outcome and 16 had fair outcome and 2 had poor outcome. Fibular length was not maintained in 9 patients. Effect of fibular length on outcome was significant (P 0.000). Five patients had syndesmotic widening, this had a significant effect on the outcome (P 0.019). Patients with maintained fibular length and without syndesmotic widening had better outcome. Twenty eight cases had open fracture. Type of injury (closed or open) had significant effect on outcome (P 0.020). Patients with open injury had poorer outcome when compared to patients with closed injury. Patients with associated injuries and comorbid conditions had poorer outcome.

Conclusion: Outcome is mainly dependent on intraoperative achievement of all radiological parameters (medial clear space [≤4 mm], talocrural angle [83 ± 4], negative Dime sign, maintained Shentons line of the ankle, tibiofibular overlap [≥10 mm], tibiofibular clear space [≤5 mm] and Talar tilt [<2]). In our experience from this study we recommend to confirm under fluoroscopic guidance that all the radiological parameters are achieved before shifting the patient out of operation theatre, to prevent complications and to have better functional outcome.

Keywords: Ankle fracture, internal fixation, radiological parameters

Abstract ID: 1139

Distal radius fracture treated with external fixator: A series of 27 cases

Shivam Anand, Ajoy Kumar Manav, Arjun Singh, Manibhushan Prasad Singh, Kumar Shashikant

Patna Medical College, Patna, Bihar, India

Introduction: Distal radius fractures are one of the most primitive and common fractures to be described. Severely comminuted distal radius fractures are still challenging despite refinements in treament options.

Materials and Methods: This is a prospective study in which 27 patients of distal radius fractures were admitted in casualty depatrment from May 2012 to April 2014. Adult patients with severely comminuted distal radius fractures were treated with simple external fixator (radial distractor: Orthofix) or hybrid treatment (external fixator with K-wires). Unilateral or bilateral unstable fracture of distal radius, comminuted fractures, intraarticular fractures and open fractures were included in this study. Simple two part fracture, die-punch fracture and pahtological fractures were excluded from this study.

Results: Main out come measures were, time and rate of union at the fracture site, evalution using Gartland and Werlry scoring system and complicaions if any. All patients tolerated external fixator well. There was no evidence of ulnar prominence in any case. Pain was completely absent in 23 patients, while in 2 patients pain was present only on strenuous exercise which resolved with physiotherapy. In 2 patients pain was frequently present along with stiffness of wrist. Pin tract infection was present in 3 cases which was managed with proper antibiotics and analgesics. Infection disappeared with treatment within few weeks of removal of pin. Grip strengh ranged from 30% to 100% of contralateral side. Dorsiflexion of wrist ranged from 30° to 80° - 90% of normal. Palmar flexion ranges from 40° to 80°. Supination flexion ranges from 30° to 80° (average 75°) 85% of normal. Pronation flexion ranges from 50° to 95° (average 85°) 90% of normal. Motions of shoulder and elbow was normal in all patients. Intrinsic tightness and motion of MCP joint was observed in 10 patients which resolved after physiotherapy.

Conclusion: External fixator is a simple and inexpensive method based on the principle of ligamentotaxis for treatment of difficult unstable distal radius fractures. It becomes especially important in polytrauma cases. The results are quite satisfactory and we recommend its use in properly selected cases of distal radial fractures.

Keywords: Distal radius fracture, unilateral fixator, functional evaluation, ligamentotaxis

Abstract ID: 1917

Management of Gustilo-Anderson's grade IIIb open fractures and infective nonunions of tibia with limb reconstruction system

PSB Sreenivasulu*, Ashok Reddy Pedaballe, G Gireesh, Musham Suresh, Ch. Vamshi Krishna

Narayana Medical College, Nellore, Andhra Pradesh, India

Introduction: Management of Gustilo-Anderson's grade IIIb open fractures of long bones and infected gap nonunions is a challenging task to orthopedic surgeons due to infection and bone loss. LRS is a good implant of choice compared to simple external fixator and ilizarov fixator. Disadvantages of ilizarov fixator are poor patient compliance, inconvenience and difficulty in frame construction.

Materials and Methods: We conducted a study on 18 patients with grade IIIb open tibial fractures and infected gap nonunion patients treated by LRS. It is a prospective study conducted between June 2011 and December 2013, average limb length discrepancy in cases of gap nonunion was 4 cm. All cases were treated with LRS after thorough wound debridement and fracture end freshening. Ten cases required corticotomy and lengthening. Two cases underwent LRS removal and internal fixation because of increased duration of treatment and complete cure of infection. Average duration of treatment was 8 months. Functional outcome was evaluated using a criteria suggested by Karlstorm and Olerud.

Results: Fifteen out of 18 patients had good results according to K and O criteria. Two patients underwent internal fixation after removal of LRS because of prolonged treatment time and complete control of infection. In one patient LRS was removed because of pin tract infection.

Conclusion: LRS is an uniplanar compliant implant of choice in treating Gustilo-Anderson's grade IIIb compound fractures and infected nonunions of Tibia. Bone loss can be corrected by neo-histiogenesis.

Key words: Compound fractures, LRS, nonunion

Abstract ID: 1945

Comparative study of the management of sub-trochanteric fractures of femur (Sensheimer II-IV) with proximal femoral nail and dynamic hip screw

B Mohammed Ghouse*, Y Thimma Reddy, S Sreenivasa Reddy, M Lakshminarayana, N Ravi Kiran

Govt. Medical College, Anantapur, Andhra Pradesh, India

Introduction: Incidence of subtrochanteric fractures is on rise and pose challenge to the treating surgeon in terms of achieveing appropriate reduction and stable fixation. Closed insertion techniques, shorter lever arm mechanism decreasing the tensile strain on the implant and increased purchase of the proximal fragment are the added advantages of proximal femoral nail over dynamic hip screw with eccentric cantilever mechanism in subtrochanteric fractures. The aim of this study was to analyze retrospectively the results of subtrochanteric fractures (Sensheimer II-IV) treated with this proximal femoral nail (PFN) and dynamic hip screw (DHS).

Materials and Methods: The present study was carried out in Osmania General Hospital, Hyderabad, from July 2011 to July 2014. The study consisted a total of 50 adult patients of sub-trochanteric factures of femur, who are treated with PFN (n = 25) and DHS (n = 25). The inclusion criteria of study are Seinsheimer's type II-IV. Trochanteric fractures with ipsilateral fractures of the both bones of the leg where weight bearing needed to be delayed were not include the study. The average age of the patients ranged from 25 to 55 years.

Results: As per the Harris hip score, 22 out of 25 patients treated with PFN, had excellent to good outcome and 2 patients had fair results and 1 patient with poor outcome as compared to 14 out of 25 patients with excellent to good results, 8 patients with fair results and 3 with poor outcome as treated with that of DHS at their final followup. Two patients treated with PFN had varus reduction and 4 cases treated with DHS had cut through of lag screw. The mean Harris hip score at their final followup was 80.76 with PFN. All the patients were followed for a period of three years.

Conclusion: The advantage of PFN with that of DHS is minimal tissue dissection and blood loss with stable intraosseous fixation. Early ambulation is possible with PFN as there is stable fixation and lesser chance of cut through. From this study, we conclude that PFN is a good implant for the treatment of subtrochanteric fractures of femur compared with that of DHS.

Key words: Dynamic hip screw, proximal femoral nail, subtrochanteric fracture

Abstract ID: 1290

Serum bone specific alkaline phosphatase levels following intramedullary fixation of tibial shaft fractures

Dwivedi D, Kumar S, Jain AK, Puri D, Mehndiratta M

University College of Medical Sciences and GTB hospital, Delhi, India

Introduction: Early detection of delayed union or non-union is not possible by clinico-radiological assessment alone. The current study was undertaken to monitor the fracture healing with serial measurement of serum Bone Specific Alkaline Phosphatse (BAP).

Materials and Methods: Twenty cases of isolated closed diaphyseal fractures of Tibia in healthy young adults between the ages of 18-45 years were included in the study. The patients having any systemic disease and/or drug intake affecting bone turnover were excluded. All these fractures underwent closed reduction and internal fixation with intramedullary interlocking nail and were followed for 24 weeks. The fracture healing was assessed by local tenderness and ability to bear weight with or without support every 4 weeks. Radiological assessment of fracture healing was done at 4, 8, 12, 18 and 24 weeks. Patients with bridging callus in 3 cortices in anteroposterior and lateral radiograph of fracture site were labelled as united. Serum BAP levels were measured at 0, 4, 8 and 12 weeks (MicrovueTM BAP EIA kit manufactured by Quidel® Corporation, San Diego, USA).

Results: At 12 weeks, eighteen patients were able to bear weight without support and had no local tenderness, two patients started bearing weight without support and demonstrated absence of local tenderness by 24 weeks. At 8 weeks 9 patients had bridging callus seen in 1 cortex whereas one patient had bridging callus in 2 cortices. At 12 weeks 14 patients had bridging callus in 1 cortex, 5 patients in 2 cortices. At 18 weeks 13 patients had radiological union (bridging callus in 3 or 4 cortices), 6 patients had bridging callus in 2 cortices and one patient had bridging callus in 1 cortex. At 24 weeks 18 patients had bridging callus at 3 or 4 cortices and 2 patients had bridging callus in 2 cortices only. Those 2 patients were labelled as delayed union. The patients with bridging callus in at least 1 cortex at 8 weeks had higher levels of BAP when compared to patients with no callus (p=0.004). BAP levels in the 2 cases of delayed union were found to be consistently below the baseline (0 week) at 4, 8 and 12 weeks.

Conclusion: The outcome of the study has revealed that radiological union lagged behind clinical assessment of fracture healing. The levels of BAP were found to be elevated during the course of fracture healing. The absence of rise levels of BAP above the baseline was found in two cases which showed delayed union suggesting that it may be used for monitoring fracture healing.

Keywords: Serum bone specific alkaline phosphatase, fracture union, shaft tibia


Abstract ID: 1697

Indirect spinal canal decompression in thoracolumbar/lumbar burst fractures: A retrospective analysis of 38 cases

Ish Dhammi, AK Jain

University College of Medical Sciences and G.T.B. Hospital, Delhi-110095, India

Introduction: The optimal treatment for thoracolumbar/lumbar burst fractures is still controversial. Short segment fixation and fusion, long segment fixation with short segment fusion, primary anterior decompression with posterior instrumentation either in one stage or 2 stages or posterolateral compression, posterior instrumentation, etc. are used by various studies. However, the goal of treatment is to correct traumatic deformity, spinal column stabilization and canal decompression to provide adequate space for cord to heal. We retrospectively analyzed our such cases treated by indirect reduction of canal through distraction of vertebral column and short segment posterior instrumentation.

Materials and Methods: 38 cases of thoracolumbar and lumbar burst fractures treated by short segment posterior stabilization spanning one level above and one level below using pedicle screws and indirect reduction through distraction were included in study. We excluded patients other than burst fractures, where direct reduction or canal clearance was used, patients in which bone grafting anterior/posterior or posterolateral was used. There were 29 males and 9 females. Mode of trauma was fall from height ( n = 23) and road traffic accident (n-15). The fracture was classified as per Denis Classification. Type A ( n = 12), Type B ( n = 24) and Type D ( n = 2). X-rays were available in all the cases, CT scans in 8 cases and MRI in 29 cases. The D12 ( n = 9), L1 ( n = 8), L2 ( n = 6), L3 ( n = 3) and L4 ( n = 2). The average kyphus angle was 14.1° (range 0°-28°). Average vertebral body height was 60.1%. There were 12 cases of Frankel E (no neurological deficit), 20 were Frankel D, 5 were Frankel C and 1 was Frankel B. All the cases were operated between 2 weeks of trauma. The associated injuries with spine were in 12 cases (Fracture calcneum [ n = 8], fracture tibial condyle [ n = 2], fracture femur [ n = 1] and fracture Hoffa [ n = 1]).

Results: The average followup is 2.8 years (range: 8 months to 8 years). At followup 25 patients had Frankel E grade and 10 patients had Frankel D grade and 4 patients did not had any recovery. The postoperative kyphus angle was −10 (−100 to 120) which was maintained at final followup. Postoperative vertebral height average was 81% (60-88%). There was breakage of screw in one case. There was loosening of rod with coming out of inni in one case. There was superficial infection in five cases which were managed by wound lavage and antibiotics in 2 cases and only antibiotics in 3 cases.

Conclusion: Indirect reduction and short segment stabilization gives satisfactory results.

Keywords: Thoracolumbar fractures, burst fractures, pedicle screw fixation, spine stabilization

Abstract ID: 1357

Evaluation of results of isthmic spondylolisthesis in adults treated by TLIF and cage

Rabindranath Saren, Kiran Kumar Mukhopadhyay

N.R.S. Medical College and Hospital, Kolkata, West Bengal, India

Introduction: Posterior spinal fusion is an established procedure in the management of Isthmic spondylolisthesis not adequately controlled by conservative management. Various techniques of posterior spinal fusion have been tried. Among them TLIF is an newer effective technique and is comparable with any other procedure in term of operative time, blood loss and financial burden to the patient.

Materials and Methods: 20 adult patients with Isthmic spondylolisthesis and back pain or radicular symptoms that have not improved with conservative treatment seen between November 2010 and January 2014 were included in study. Those with other pathological conditions of lumbar spine like trauma, tumour or infection were excluded from the study. It was a prospective study without any control. Patients were examined thoroughly with emphasis on their neurological status. Radiological investigations were done, instrumentation through posterior approach was performed. Patients were followed up at 1 month, 3 months, 6 months, and 9 months, 1 year and thereafter.

Results: Pain relief as assessed by VAS was significant at 6 months There was significant reduction of disability as assessed by postoperative modified ODI. Anterior and posterior bony bridging in 4 patients, Bony continuity between the upper and lower endplates in 3 patients, trabecular structure in the anterior graft in 1 patient, lack of radiolucent lines around the anterior graft in 1 patient, no sign of fusion in 1 patient were noted out of total 10 patients operated.

Conclusion: Clinical outcome of the TLIF was comparable with PLIF or ALIF technique. The postoperative improvement of both the ODI and the VAS values were significant. The radiographic fusion rate was 90%. Advantages of the TLIF technique is avoidance of the anterior approach and its risk of trauma to the spinal cord.

Keywords: Spondylolisthesis, TLIF, PLIF, spinal fusion

Abstract ID: 1021

Analysis of the morphometric characteristics of the thoracic spine in Indian population

Paritosh Gogna, Roop Singh

Pt. B.D. Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India

Introduction: The base line morphometric data of thoracic spine in Indian population are not available. We analyzed it in reference to the musculoskeletal anatomy and biomechanics of the spine. The data was also analyzed in relation to implants and instrumentations available for spinal surgery.

Materials and Methods: CT scans of thoracic spine of patients free from spinal disorders were reviewed in total of 600 vertebrae in 50 patients. Parameters recorded were pedicle width, length and height; transverse pedicle angles; chord length; canal dimensions; body width and height; spinous process angle; transverse process length with help of computer software.

Results: Pedicle width decreased from T1 (9.27 ± 1.01) to T4 (4.5 ± 0.93) and increased to T12 (8.31 ± 1.83); length of pedicle was minimum at T4 (11 ± 1.34) and height increased from T1 (11.23 ± 1.3) to T12 (18.04 ± 1.33). Transverse pedicle angle decreased from T1 (35.4° ± 2.21) to T12 (−9.8° ± 2.39). Chord length was largest at T10 (60.1 ± 3.45). Canal dimensions were narrowest at T4/T5 (20.02 ± 1.23) in anteroposterior and 21.12 ± 1.23 in interpedicular diameters. Spinous process angle increased from T1 (30.11° ± 6.74) to T6 (57.89° ± 9.31) and decreased to (16.21° ± 7.38). Transverse process length increased from T1-T7 (23.54 + 2.12-31.21 + 1.91) and then decreased to T12 (12.11 + 2.3). Body dimensions showed increasing trends from T1-T12.

Conclusions: Most trends in changes of parameters from T1 to T12 can be explained on the basis of local musculoskeletal anatomy and biomechanical stresses. The smallest diameter screw and shortest available screw for adults are not safe in majority of the Indian population in mid-thoracic region.

Keywords: Spine, thoracic, morphometry, CT scan

Abstract ID: 1696

Assessment of lumbar canal dimensions by plain radiograph, CT scan and MRI in symptomatic patients of lumbar canal stenosis with reference to age matched asymptomatic population

Vipin Dalal, Inder Pawar, Sudhir K. Kapoor, Ramavtar, Supreeti Kohli

ESI-PGIMSR, Basaidarapur, New Delhi, India

Introduction: Accurate diagnosis of the clinical syndrome of spinal stenosis is important because of the substantial differential diagnosis and because the range of treatments includes spinal surgery, which is associated with some morbidity and treatment failure in the elderly population. There has not been convincing evidence of a relationship between symptoms or surgical results and any anatomical measure. The poor correlation between radiological manifestations and the clinical picture emphasizes the fact that more studies are required to determine the natural course of this syndrome. Aims and objectives are to assess radiological dimensions of lumbar spinal canal and to find out the critical canal dimensions at which symptoms appear.

Materials and Methods: A cross-sectional study (2011-2013) carried out in the Department of Orthopaedics with collaboration of Department of Radiologyat our institute. Symptomatic lumbar canal stenosis (LCS) and normal group with 20 study subjects of age group 45-65 years, underwent plain radiograph, CT and MRI. Lumbar canal dimensions like sagittal canal diameter, inter-pedicular diameter, inter-ligamentous diameter and lateral recess depth of 200 lumbar vertebrae were measured at all lumbar levels (L1-L5) and statistical evaluation using mean, standard deviation (SD), standard error, Student's t-test and ROC curve was done. A P < 0.05 was considered statistically significant.

Results: There were significant differences in sagittal canal dimensions and lateral recess depth of lumbar spinal canal between the 2 groups. The critical canal dimensions at which symptoms of stenosis appear, in reference to antero-posterior diameter of the lumbar spinal canal based on ROC curve were 11.13, 16.34 and 14.99 mm on X-ray, CT and MRI respectively.

Conclusion: We recommend that there is a need for consensus on well-defined, unambiguous radiological criteria to define and characterise lumbar spinal stenosis in order to improve diagnostic accuracy. The results reported in this study can be used as a source for the development of radiological criteria in future.

Keywords: Spine, lumbar canal stenosis, lumbar canal diameters, CT scan

Abstract ID: 1944

A single stage anterolateral decompression and posterior instrumentation by lateral extracavitary approach for tuberculosis of spine

Ashok Reddy Pedaballe, Gopala Krishnaiah Thalluri, VS Ravindranath, Ranjith Kumar Yalamanchili, Ramakrishna Reddy G

Osmania General Hospital, Afzal Gunj, Hyderabad,

Andhra Pradesh, India

Introduction: The surgical treatment of tuberculosis spine has the disadvantage of violating thoracic/abdominal cavities by transthoracic/transdiaphragmatic approaches. Here we describe the procedure and results of lateral extracavitary approach which is used for anterolateral debridement, interbody fusion and fixation with a single mid-line posterior incision without violating thoracic/abdominal cavities.

Materials and Methods: This is a prospective study consisting of 12 (5 male, 7 female) patients with tuberculosis of spine who underwent surgical management under antituberculous drugs (ATT) therapy through lateral extracavitary approach are included in the study. Among them 7 had thoracolumbar, 4 had thoracic and one had lumbar lesion. Nine patients had neurological deficits, number of vertebrae involved ranged between 2 and 4. Average preoperative kyphosisis was 25.5° (range: 17°-37°). Average vertebral height loss was 6.14° (3.1°-9.17°) calculated by surgimap software. Preoperative neurological status in three patients was normal, ASIA grade A in two, grade B in two and grade C in five patients. Surgery was done in prone position, by posterior mid-line incision, followed by pedicle screw placement proximally and distally. After costotransversectomy and hemi laminectomy, a plane was developed between vertebral body and pleural cavity, through which anterior column was debrided and reconstructed with rib grafts ( n = 7), tricortical iliac graft ( n = 4) and bone chips ( n = 1). This study excludes multicentre lesions in the spine, patients with bedsores over the deformity.

Results: Average operating time was 280 min, blood loss was 1250 ml and average followup was 26 months. Neurological status improved to ASIA-E in 10 patients and ASIA-D in two patients at the last followup. Radiological fusion was achieved in all patients. The mean postoperative kyphosis 9.6°. Complications were superficial wound infection ( n = 1), hemothorax ( n = 1) and dural tear (n = 2).

Conclusion: Lateral extracavitary approach is a versatile approach for tuberculosis spine. It allows adequate anterolateral debridement, decompression and posterior instrumented spinal fusion with advantage of single stage posterior only procedure with minimal complications.

Keywords: Extracavitary approach, pedicle screws, tuberculosis spine

Abstract ID: 1122

Correlation of Pre-treatment and post-treatment diffusion tensor imaging parameters with neurological status in pott's spine

Jain N, Jain AK, Kumar S, Saini NS

UCMS & GTB Hospital, Delhi, India

Background: Diffusion Tensor Imaging (DTI) detects alteration of diffusion of water molecules earlier than MRI, hence can detect changes early in disease/cord compression. The DTI observations are not available in pott's spine hence this prospective study to document DTI observations in pott's spine with neurological deficit and find correlation with clinical course.

Materials and Methods: Thirty four (Group A - 16 without deficit , Group B - 18 with deficit) patients of spinal TB diagnosed clinicoradiologically / MRI observations / histopathology / FNAC / TB-PCR were enrolled. DTI was performed before start of treatment and after 6 months. The parameters studied were Fractional anisotropy (FA) , Mean diffusivity (MD) and Tractography. The neurological deficit was graded by Jain and Sinha score. All patients were treated by DOTS , and surgery where indicated (Developing / persistent / progressive paraplegia on treatment, severe paraplegia, unstable vertebral column, severe kyphotic deformity and doubtful diagnosis). Changes in FA and MD at and below the site of lesion (SOL) were compared to above the SOL (control) using the student's t-test . Pre-treatment and post-treatment FA and MD values were also compared. Correlation of DTI parameters ( FA and MD ) with neurological score was done by Pearson correlation coefficient. Subjective assessment of Tractography images was done in relation to the severity of neurological deficit.

Results: The range of FA and MD values above the SOL (control) showed a wider variation in paraplegics as compared to non-paraplegics. The mean average FA was not significantly decreased at the SOL in patients with paraplegia as compared to above the SOL (control). Mean average FA was significantly decreased below the SOL in both groups A and B (p=0.01 , p=0.001) as compared to above the SOL. After treatment, significant decrease (p=0.02) in mean average FA at the SOL compared to pre-treatment was observed. Mean average MD below the SOL was significantly decreased (p=0.04) after treatment as compared to pre-treatment. A moderate positive correlation (r =0.49) between mean average FA and neural score after 6 months of treatment was found. The tractography images were not consistent with severity of paraplegia.

Conclusion: Whole cord diffusion parameters are affected by chronic compression. There are variable effects of epidural collection , inflammatory tissue and fibrin of abcess on FA and MD in TB spine. Tractography was not found to be useful for evaluation of severity of paraplegia.

Keywords: Pott's spine, TB spine, DTI, Diffusion tensor imaging


Abstract ID: 1946

Various modalities of treatment of giant cell tumour in the long bones-our experience

G Veera Reddy, Y Thimma Reddy, M Lakshmi Narayana, N Ravi Kiran, S Sreenivasa Reddy

Osmania General Hospital, Afzal Gunj, Hyderabad,

Andhra Pradesh, India

Introduction: GCT is common osteolytic tumour usually of long bones, locally aggressive and high tendency of local recurrance. This prospective study was conducted to assess the outcome of various modalities of management.

Materials and Methods: This study was conducted between June 2007 and July 2013 in Department of Orthopaedics and Traumatology, Osmania General Hospital, Hyderabad. 20 patients who satisfied the inclusion criteria were included. Eight were males and 12 were females. The mean age group of the study was 30 years. Intralesional (n = 12) and marginal excision (n = 8) followed by bone grafting was the procedure done in stage I and II Enneking type of GCT. In stage II and III wide excision followed by reconstruction with fibular graft was done. They were followed up for an average period of 2 years.

Results: Out of 20 patients, 16 patients underwent procedures like excision with and without bone graft, and four patients underwent Ennekings procedure and reconstruction with fibular graft. The functional outcome was assesed by musculoskeletal tumour society score, (MSTS) score. The MSTS score (26) (86.92%) was achieved for femoral lesions treated with salvage procedures. The least value (22.6) (75.3%) of mean functional score was noted for lesions involving the arm and the shoulder girdle.

Conclusion: It is feasible for a surgeon, in a given set up, to effectively carry out the limb salvage and reconstructive procedures and to get good functional results.

Key words: Ennekings staging, giant cell tumour, MSTS score


Abstract ID: 1602

Analysis of functional outcome following open reduction and internal fixation of late presentation of lateral humeral condyle fracture in children

Thamizharasan Lakshmanan, R. Sivakumar,

P. V. Thirumalamurugan, Singaravelu

Madurai Medical College, Madurai, Tamil Nadu, India

Introduction: Children with lateral humeral condyle fractures often present late due to illiteracy, fond of native treatment. In the past, fixation of delayed presenting lateral humeral condyle fracture was recommended only if lateral humeral condyle physis was open, metaphyseal fragment was large and displacement of fragment was <1 cm from the joint surface. However all delayed presenting lateral condyle humeral fractures even if not in good position can be treated with open reduction and internal fixation and bone grafting. In this study we analysed the outcome following fixation of delayed presenting lateral humeral condyle fractures in children.

Materials and Methods: We selected 18 children with fracture of lateral condyle of humerus presenting >3 weeks after injury. This prospective study was conducted between June 2011 and November 2013. The mean followup period was 1 year 2 months. The age of the children ranged from 4 years to 13 years with mean age 7 years at the time of surgery. Eighteen children presented between 4 weeks to 3 years post injury. Fourteen were male and 4 were female. There were 15 Milch's type II fracture and 3 Milch's type I fractures. Fifteen fractures were of Jakob's stage III and 3 were of stage II. In all 18 delayed presenting lateral humeral condyle fractures open reduction and internal fixation with k-wires and bone grafting was done. Outcome was analysed based on Modified Functional Rating Index of Broberg and Morrey and based on modified Aggarwal's criteria.

Results: All 18 children achieved fracture union with mean time of 8 weeks. Fifteen children had improvement in range of elbow movements, 2 had no loss of movement and 1 had loss of range of movements but without pain. There was no worsening of carrying angle. Based on modified functional rating index of Broberg and Morrey thirteen children had excellent result and five had good result. Based on modified Aggarwal's criteria 8 children had excellent result, 3 had good, 2 had fair, and 5 had poor results.

Conclusion: Open reduction and internal fixation and bone grafting is recommended for fixation of all delayed presenting lateral humeral condyle fracture in children. K-wire stabilization is sufficient enough in maintaining reduction. Osseous union can be achieved in all delayed presenting lateral humeral condyle fracture and the united fracture provides bony buttress thereby cubitus valgus can be prevented. By limiting the soft tissue dissection and early mobilization loss of elbow movements can be prevented.

Keywords: Fracture lateral condyle, children, K-wire, functional assessment

Abstract ID: 1750

A comparative study between titanium elastic nailing and dynamic compression plating in paediatric femoral shaft fractures

Kartikey Mishra, Pradip Kumar Baruah, Tulasidas Bhattacharyya

Gauhati Medical College and Hospital, Guwahati, Assam, India

Introduction: The purpose of this study is to compare the results of compression plating and flexible intramedullary nailing for paediatric femoral shaft fractures. Compression plate fixation provides rigid anatomic fixation but requires extensive dissection. Fixation with flexible intramedullary nailing is safe and effective alternative treatment method especially in simple transverse and short oblique fractures.

Materials and Methods: It is a randomised control trial of 40 paediatric closed femoral shaft fracture cases between 6 and 12 years of age which were treated with either flexible intramedullary nailing or compression plating (20 in each group) conducted for period of 18 months with a minimum followup period of 1 year after index operation. The healing time and the operation time were compared between two groups with non parametric statistical tests.

Results: Average operation time was significantly shorter in the flexible intramedullary nailing group (P 0.03). Fracture treated with compression plate fixation had an average healing time of 4.3 months and that for titanium elastic nails was 3.8 months. No significant difference was observed in the healing time between the two groups (P 0.06).

Conclusion: The result of this study suggests that flexible intramedullary nailing of the femoral shaft fractures in patients over 6 years of age provides better results than plating.

Keywords: Femoral shaft fracture, TENS, children, dynamic compression plate

Abstract ID: 1502

Surgical and functional outcomes of tens nailing in long bones of children

RS Bajoria

G R M C, Gwalior, Madhya Pradesh, India

Introduction: In present scenario there has been increasing trend towards surgical intervention in long bones of children especially femur and tibia. Conventional methods like spica casting, traction, plating, external fixation remains controversial. Intramedullary fixation by tens/enders nailing is simple, minimally invasive and gives excellent results with minimal complications. Hence titanium elastic nailing is gaining popularity as a methods of fixation in these fractures.

Materials and Methods: We are presenting a series of 44 cases of femur and tibia managed by TENS and Enders nailing and results were compared with 40 cases managed by other methods like external fixation, Thomas, cast/Spica application etc. Study was conducted in department of orthopedics, G R Medical College, Gwalior from 2006 to 2014. 28 cases were of transverse and 16 cases of oblique/spiral fracture pattern. 32 boys and 12 girls of age 6 to 15 years were evaluated. Patients were followed clinically and radiologically for a minimum period of 1 year. Average followup period was 2 year.

Results: Final results were evaluated using the Flynn's scoring criteria. This system based on leg length inequality, malalignment, pain and minor and major complications. 26 (60%) patients had excellent, 13 (30%) satisfactory and 5 (10%) poor functional results. Knee stiffness and mild infection at entry point was seen in some cases. No limb length disparity or deformity was found.

Conclusions: Titanium and flexible nails are easy to use with minimally invasive technique with high rate of excellent to good results. This system also prevents damage to distal femoral epiphysis and possible shortening in future and avoids all complications seen with other conventional methods.

Keywords: Femur fracture, children, TENS, Enders

Abstract ID: 1384

Surgical management of Sprengel shoulder using modified Woodward procedure: A case series

Ishan Shevate, Sandeep Patwardhan, Ashok Shyam, Parag Sancheti

Sancheti Institute, Pune, Maharashtra, India

Introduction: Sprengel shoulder is a rare congenital anomaly (incidence 1:1,00,000) in which asymmetry of shoulder, neck deformity, restriction of shoulder movements and cosmetic appearance are major concerns. Here we present the results of deformity correction with modified Woodward's procedure.

Materials and Methods: The modified Woodward's procedure was performed on 28 patients (19 females; 9 males) with Sprengel deformity in age group from 4 to 11 years. The mean age of presentation was 6.3 years. Preop assessment with Cavendish grading showed 8 patients with grade II/III and 4 patients with grade IV. In addition to Cavendish scale shoulder asymmetry; scapular elevation and medialisation were evaluated. Modified Woodward procedure included resection of omovertebral band/bone, detachment of trapezius, rhomboids with mobilization of scapula to reach normal level. A wire loop was passed from inferior angle of scapula to the skin. Postoperatively arm to chest strapping was given for 3 weeks; gradual shoulder mobilization was carried out thereafter. Removal of ethibond stay suture or button was done at 6 weeks and supervised physiotherapy was given.

Results: Followup duration was 16 month (range: 12-20 months). Modified Woodward's procedure led to excellent cosmetic correction in all the cases. Average translocation of 2.8 cm was gained. Mean preoperative shoulder elevation was 4.41 cm which improved to 0.7 cm. Shoulder abduction range improved 35% on average (from preoperative mean of 110° to postoperative mean of 150°). One patient developed neuropraxia of axillary nerve; one patient developed pressure sore which was used to hold inferior angle of scapula but none of these required any active management.

Conclusion: The modified Woodward procedure offers improvement of shoulder abduction and cosmetic appearance for patients with minimal morbidity.

Keywords: Shoulder, Sprengel shoulder, modified Woodward

Abstract ID: 1859

Correction of angular deformities of knee in children using guided growth technique by eight plates

BM Lohith, Purushotham Lal, Ramachandra

Sparsh Hospital, Bengaluru, Karnataka, India

Introduction: Angular deformities of the knee, a common problem in the early years of life are frequently encountered in paediatric orthopaedics not only because of very high incidence of these deformities but also because of major parental concern in the present highly demanding sports oriented society. The purpose of this study is to discuss the role of 8-plate hemi-epiphysiodesis to correct angular deformities of the knee joint and to compare our results with published data. This technique has rapidly gained popularity, but there is scant literature with regard to its effectiveness.

Materials and Methods: We had total of 25 children with total 45 knees having varus or valgus angular deformities, of which 20 were bilateral and 5, were unilateral. Patients were seen in outpatient department of Sparsh Hospital. All the patients were symptomatic and were followed for 6 months to observe progression or regression of the deformity. Those children without any spontaneous improvement with growth remaining of at least 12 months were selected for the present study. Study was prospective as well as retrospective in nature from 2009 to 2013.

Results: In our study we studied the cases from 3 to 13 years of age group. The mean preoperative genu valgum deformity was 19.79 degrees with range from 13° to 35° and genu varum deformity was 17.29° (9-25°). There were total four cases with complications. 91.1% of the deformed knees were corrected fully at the mean final followup period of 27 months, neutralizing the mechanical axis and correction of the deformity. The rate of correction was slower in the pathological group than in the idiopathic group. The degree per month of correction was also slower in the pathological group than in the idiopathic group.

Conclusion: 8-plate is technically simple and potent tool to correct genu valgum and varus deformities around knee in children without need for osteotomies in many children. We consider the eight-plate the best solution for the treatment of pediatric angular deformities, due to idiopathic or underlying pathological condition. Rebound deformity, although uncommon and unpredictable, can safely be managed by repeated guided growth with the eight-plate. Medical management along with hemiepiphysiodesis using growth plate gives good out come in case of metabolic conditions like rickets. Based on the low complication rate, patient acceptance, and the rapidity of improvement, this technique should be used as treatment of choice.

Keywords: Angular deformity, guided growth technique, knee joint

Abstract ID: 1774

Assessment of outcome of percutaneous needle tenotomy of quadriceps in the management of congenital dislocation of knee

Raja Bhaskara Kanakeshwar, Sandeep Patwardhan, Ashok Shyam, Parag Sancheti

Sancheti Institute of Orthopaedics and Rehabilitation, Pune, Maharashtra, India

Introduction: Management of congenital knee dislocation (CDK) depends on severity and flexibility of the deformity. Various modalities of treatment ranging from serial cast, open quadricepsplasty and minimally invasive quadricepsplasty are being described. We describe percutaneous needle tenotomy of quadriceps for treatment of flexible CDK and present the results of our retrospective case series.

Materials and Methods: This was a retrospective study of 16 patients (26 knees) with flexible CDK. Twelve patients with bilateral and four with unilateral deformities. None of the patients were syndromic and all procedures were done within 8 weeks of age. All patients were treated with percutaneous quadriceps tenotomy using wide bore needle. The outcome was measured using knee evaluation score and complications in view of extensor lag, instability and knee flexion deformity.

Results: The mean preoperative hyperextension was 40° (30-70°). All patients achieved >90° flexion intraoperatively. The mean knee flexion at walking age was 135° (130-140°). Knee evaluation score showed good results in nine patients and fair results in three patients. There was no extensor lag, knee flexion deformity or infection. One patient of anterior instability had ACL aplasia which was documented on MRI.

Conclusions: Percutaneous needle tenotomy of quadriceps is an effective, simple and safe procedure for flexible, non syndromic CDK presenting early. It avoids complications associated with open surgical procedure and cause less extensor scarring. However its effectiveness in stiff/hyperlax and variants associated with syndromes is yet to be determined.

Keywords: Congenital dislocation knee, quadriceps, tenotomy, percutaneous

Abstract ID: 1936

The obstetric elbow in neonate

Arvind Bodla, Aluka Sundeep Kund Reddy, Khaleelulla SDGK, B Raja Ramesh, Ranjith K Yalamanchili

Osmania General Hospital, Afzal Gunj, Hyderabad,

Andhra Pradesh, India

Introduction: The obstetric elbow in neonate is a complete distal humeral epiphyseal separation which is similar to elbow dislocation a rare injury in neonates, which is difficult to recognize and diagnose clinically. A complicated delivery of an infant causing abnormal traction pull over the elbow can result in a traumatic separation of the distal epiphysis from metaphysis, resulting in pseudo paralysis of child`s limb. Evaluation with X-ray is challenging and gives appearance of dislocation, until capitellar ossification centre appears. Traumatic separation of the distal epiphysis may be missed in maternity wards and not diagnosed until the patient is discharged from hospital.

Materials and Methods: We report five such uncommon cases over 4 years, in which a fracture separation of the distal humeral epiphysis was diagnosed in a newborn after thorough clinical examination, by ultrasonography and MRI. A clear delineation of the injury was provided as birth time injury during emergency section after retrospective questioning. Clinical features included swelling of the elbow, crepitus and restricted movements of elbow, but could not conclude a final diagnosis. X-rays revealed postero-medial displacement of radius and ulna in relation to humerus with decreased joint space when compared to normal elbow. Ultrasonography and MRI revealed distal humerus epiphysis posterior displacement when compared with normal joint. In doubtful cases (n = 9), MRI gives definitive diagnosis with good visualization of the cartilage and bone than ultrasound in newborns. Posterior triceps splitting approach with 2 cross K-wire fixation was performed in all five cases, nerve was not visualized.

Results: The physeal separation was treated by open reduction and internal fixation with Kirschner wires. A 2 years followup observation revealed a good clinical recovery, anatomical radiological alignment, with excellent functional outcome without any clinical deformity and neurodeficit.

Conclusion: Attention to the radiographic relationship of the ulna and humerus and an appropriate index of suspicion are the key to early diagnosis. We recommend ultrasound and MRI to be included as diagnostic tools in doubtful elbow injuries in neonates. Open reduction followed by Kirschner wire pinning, gives good functional results.

Key words: Distal humerus, epiphyseal injury, epiphyseal separation humerus, magnetic resonance imaging, neonate, Kirschner wire

Abstract ID: 1495

Correlation of pirani score and foot bimalleolar angle in the treatment of idiopathic congenital talipes equino varus by ponseti method in infants

Anshuman R, Singh MP, Jain AK,

UCMS & GTB Hospital , Delhi, India

Background: Foot bimalleolar angle(FBM) drawn on podogram provides an objective evidence of clubfoot deformity and its clinical improvement /deterioration . Pirani score has been used extensively to evaluate severity of clubfoot deformity. This study aims to correlate Pirani score and FBM angle to assess severity of deformity and correction achieved.

Material and Method: Thirty five feet with idiopathic congenital talipes equinus varus deformity less than one year were prospectively treated from Nov 2012 to April 2014. CTEV (secondary with neuromuscular origin) were excluded. The deformity was evaluated by Pirani score. They were placed in three groups i.e. group one (Pirani 0.5-2.0), group two (Pirani 2.5-4) and group three (Pirani 4.5-6). FBM angle was drawn on podogram. The weekly plasters were applied using Ponseti method. Pirani scoring and FBM angle were measured each week. Percutaneous tenotomy of the Achilles tendon was performed if residual equinus was observed after complete correction of adduction and varus deformity or when 15° of dorsiflexion. Follow up was done at 3rd month and at 6th month and final result was evaluated at 6th month.

Results: With every treatment week Pirani score decreased and became 0 when foot was corrected completely (corrected foot is one having no equinus, varus and full hindfoot mobility). Mean FBM angle at the start of treatment was 65.89(±5.312) .Mean foot bimalleolar angle of the group three was 66.16, of group two was 73.02 and of group one was 80.61. It increased with gradual correction of deformity until it became normal (Normal FBM angle = 820- 840). At the 3rd month and 6th month both Pirani score and FBM angle were normal. Each week and at the end of the study, of the whole data, correlation between Pirani score and FBM angle was found out using pearson's correlation, spearman's correlation test, Tukey's test and ANOVA and correlation was found to be stastically significant (p value <0.05)

Conclusion: Pirani score decreases and Foot bimalleolar angle increases with the clinical correction of foot. Pirani scoring and Foot bimalleolar angle correlated to each other in relation to the severity of deformity and correction achieved. Foot bimalleolar angle provides an objective evidence of clubfoot deformity, improvement or deteoriation.

Keywords: CTEV, Clubfoot, foot bimelular angle, Pirani

Upper Limb

Abstract ID: 1528

A prospective comparative study of three treatment modalities for idiopathic adhesive capsulitis of shoulder

Hemant Kumar Pippal, Manoj Kumar

Maulana Azad Medical College, New Delhi, India

Introduction: There is quasi-scientific belief of subsequent generations of clinicians after Codman, that idiopathic frozen shoulder recovers fully. There is paucity of high level of evidence in the literature in favour of one or more treatment modalities for idiopathic adhesive capsulitis. Capsular release and intraarticular steroid injections have emerged as effective treatment modalities over the years. In the light of above present study has been designed to prospectively test the relative efficacy of arthroscopic capsular release and intraarticular steroid injections, compared to a control arm.

Materials and Methods: This prospective comparative study was conducted on 30 consecutive patients of both sexes, 40-75 years of age, presenting with adhesive capsulitis. Patients with significant injury, any surgical procedure to ipsilateral shoulder or arm within past 2 years and uncontrolled diabetes were excluded from the study. Patients were divided in to three groups for conservative, arthroscopic capsular release and intraarticular steroid injection. Pre and postoperative range of motion (ROM) were recorded and shoulder rating questionnaire (SRQ) was filled. ROM and SRQ improvements were compared 6 months after the initiation of therapy and compared for statistical significance.

Results: All the groups showed improvement in range of motion in most of the patients. Mean improvements in ROM and post treatment SRQ score in three groups, was compared using independent sample t-test for statistical significance (P < 0.05). Apart from significant improvement in external rotation movement in ACR group when compared to conservative management we did not find any significant difference in the outcome of these three groups. SRQ of all the three groups were comparable at the time of initiation of study and post treatment SRQ were also not much different in the three groups. We found a higher percentage of patients associated with diabetes mellitus (66.6%) as compared to the one reported in the literature 20-40%.

Conclusions: Passive restriction of external rotation has been found to be the most reliable clinical sign for the diagnosis of idiopathic adhesive capsulitis in the present study. A clinical sense has emerged from the present dissertation that most patients, if first put on conservative line of treatment will respond favorably. However, there remains a miniscule of patient population of recalcitrant idiopathic adhesive capsulitis who will benefit by intraarticular steroid or arthroscopic capsular release.

Keywords: Shoulder, adhesive capsulitis, arthroscopy, steroid

Abstract ID: 1261

Evaluation of the treatment of the frozen shoulder by hydrolic capsular distension followed by physiotherapy and its comparison with only physiotherapy

Mandar Shaha, Pradeep Kulkarni, Ravindra Gunaki, Pravin Patil, Nirav Patel

Krishna Institute of Medical Sciences, Karad, Maharashtra, India

Introduction: Although many treatment options have been advocated for the self limiting disease of the frozen shoulder, there is no robust evidence of the superiority of one over other. This study intended to evaluate the outcome of hydrolic capsular distension followed by physiotherapy and its comparison with only physiotherapy regime in treatment of frozen shoulder.

Materials and Methods: In this randomized prospective study we have studied total 50 cases within the age group of 40-70 years with idiopathic frozen shoulder. They were divided into two groups of 25 patients each. Patients in the first group were treated with shoulder joint capsular distension using normal saline and steroid under local anesthesia at outpatient department followed by physiotherapy and the patients in second group were treated with physiotherapy only. The aim was to obtain earlier pain relief and earlier relief from functional disability. Shoulder pain and disability index (SPADI) score was used as a tool for evaluation and comparison.

Results: In our study we have found that at the end of 3 weeks all the patients in the first group treated with capsular distension H and physiotherapy showed excellent range of motion and pain relief. While most of the patients in the only physiotherapy group had less improvement in range of motion at the end of 3 weeks (P value).

Keywords: Shoulder, adhesive capsulitis, hydrolic capsular distension, physiotherapy

Abstract ID: 1286

Outcome of Zancolli's Lasso procedure for paralytic claw hand due to Hansen's disease in improvement of deformity, grip strength and range of motions

M Mallesh, Suresh, Suryakanth Kalluraya, Virendra Bhasme, Sateesh Kalagi

Karnataka Institute of Medical Sciences, Hubli, Karnataka, India

Introduction: Leprosy, commonly seen in India affects the ulnar nerve causing claw hand. Many procedures for the correction of clawing like extensor bypass surgery, Palmaris Longus tail graft, extensor carpi radialis graft etc. gives good results with increasing power and motion functions of hand but needs meticulous surgery, extensive institutional post operative re-education, training and otherwise results in stiff fingers. Current study with Zancolli's Lasso procedure was done in need for a simple surgery and easy postoperative physiotherapy with good results in peripheral centers of India.

Materials and Methods: 15 patients with ulnar claw hand secondary to leprosy were selected between the period of January 2013 to January 2014 in our hospital. Patients with simple claw hand with mobile fingers and positive Bouvier phenomenon were included. Disease was controlled by anti leprosy treatment with MDT for minimum of 6 months. Flexor Digitorum Superficialis Lasso transfer was done with postoperative physiotherapy. Method of assessment included preoperative and postoperative assesment of range of motions, deformity and grip strength which was measured with hand dynamometer. Also angle of unassisted extension of PIP joint with MCP joint held at 90° flexion was measured with goniometer.

Results: The mean post operative grip strength improvement was 30% in 3 months and 46% in 6 months. Mean rate of improvement of active extension lag was 35% overall. Patients with less extensor lag had more improvement compared with patients with more extensor lag. Sixty per cent of patients had good deformity correction, 26.6% fair and 13.3% showed poor results. One patient had superficial skin complication and one patient developed parasthesia of medial aspect of ring finger probably due to injury to digital nerve during surgery which recovered subsequently.

Conclusion: Zancolli's Lasso procedure for ulnar claw hand is a simple surgery which can be performed even in a peripheral centre with good results. It requires little re education, training and physiotherapy. This procedure was more successful in restoring grip strength. Early surgery and less extensor lag gives excellent results.

Keywords: Hansen's disease, claw hand, Zancolli's procedure

Abstract ID: 1201

Three finger hand: Functional and cosmetic outcome

KN Jayakrishnan, Ashwath Acharya, Anil Bhat

Kasturba Hospital, Manipal, Karnataka, India

Introduction: To assess patient satisfaction, functional and cosmetic outcome of single digit ray amputation in hand.

Materials and Methods: Between 2001 and 2013, 48 patients who underwent primary or secondary single ray amputation were retrospectively reviewed. Subjective assessment of function was done with DASH score and result assessment scale (RAS). Grip, pinch strength and range of motion and sensibility assessed. Patient's non injured hand was used as control. Patients were assigned to groups like primary/secondary, transposition/non-transposition, border/central, replantation/no-replantation.

Results: The study had 48 patients with 23 primary and 25 secondary ray amputations. 23 border digits and 25 central digits were amputated. 8 of the 25 central digit amputations underwent transposition of adjacent digit. Time of assessment was from 1 to 104 months. Average loss of grip was found to be 44% of contralateral normal hand and average loss of pinch strength was 29%. Average DASH score was 20 and RAS score 3.5. 18 of the 48 patients had full range of motion of the remaining digits. 10 patients had decreased sensibility and neuroma in webspace. 83% patients rated the cosmetic results as excellent or good. All patients had an average total time off work of 16 weeks. 34 of the 48 returned to preinjury occupation. No statistically significant differences were observed in hand function among paired factors like trauma versus tumor, border versus central digit, dominant versus non dominant and male versus female, transposition versus non transposition. Poor functional outcome was noted in patients undergoing multiple surgeries, associated injury to adjacent digits, soft tissue defect requiring local/abdominal flap and it was statistically significant.

Conclusion: Single ray amputation is a viable immediate salvage procedure and a reasonable later reconstructive option to improve hand function after irretrievable digit dysfunction and gives excellent functional and cosmetic results. Primary ray amputations are better than secondary ray amputations. Transposition of adjacent digit for central ray amputation gives good cosmetic outcome. Index ray amputation was the least disabling in our study. Affection of neighbouring digits was associated with greater loss of grip and pinch strength and prolonged time off work. Ray amputation should be considered when managing patients with soft tissue tumours with metastatic potential or malignant tumours of hand, due to low recurrence rates after surgery. However radiotherapy can lead to poor functional outcome.

Keywords: Finger amputation, ray amputation, DASH

Abstract ID: 1487

Staged reconstruction of extensor tendons in zone 4, 5, 6 with post traumatic dorsal composite tissue loss

Prajwal Mane, Anil Bhat, Ashwath Acharya

Kasturba Hospital, Manipal University, Manipal, Karnataka, India

Introduction: Crush Injuries of hand area is major industrial problem and its management demands skills not only in surgery but also combined contributions from physiotherapy and rehabilitation programs. Little has been described in literature in the management especially, of patients with dorsal composite tissue loss including extensor tendons.

Materials and Methods: Between January 2010 and 2013 we treated 36 patients with crush injuries involving dorsal composite tissue loss. Six of them had loss of extensor tendons in the zones 4, 5 and 6. All of them underwent staged reconstruction by abdominal flap cover and subsequently extensor tendon reconstruction by fascia lata graft. Mobilization and splinting was followed under a hand therapist between each of the stages. At 1 year of followup, a detailed evaluation was done to assess hand function.

Results: Grip and pinch strengths were restored to an average of 53% of the opposite side. There was no extensor lag or subluxation. There was swan neck deformity involving the Index finger in one of the patients. All the patients were satisfied and four returned back to their work.

Conclusion: Staged reconstruction of extensors of the hand with dorsal composite tissue loss in zone 4, 5 and 6 with fascia lata tendon graft gives gratifying results restoring optimum function of hand.

Keywords: Hand, industrial injury, crush injury

Abstract ID: 1560

Assessment of hand function in closed small bone fractures treated by open reduction and internal fixation by mini fragment plate or closed pinning:

A randomized controlled trial

Rohit Pandey, Nishant Soni

UCMS and GTB Hospital, Delhi, India

Introduction: Hand fractures are the most common fractures of upper extremity. There is no study in literature which clearly gives advantage of one method of surgical fixation of fracture over the other in small tubular bones of hand comparing wider outcome measures. Hence the study "Assessment of hand function in closed small bone fractures treated by open reduction and internal fixation by mini fragment plate or closed pinning: A randomized controlled trial" was done.

Materials and Methods: A randomized controlled trial between closed reduction and percutaneous Kirschner wire fixation under image intensifier or open reduction and internal fixation with mini fragment plates (AO) by standard techniques was conducted from November 2012 to April 2014. Total 32 patients with 16 in each group. Inclusion criteria were adult in age group 16-60 years, fresh (3 days) closed fractures of metacarpals and phalanges, shaft fractures of metacarpal and phalanges. Exclusion criteria were pathological fracture, presence of any major systemic illness, malignancy which precludes the treatment of small bone fractures of hand within described time frame or operative intervention, patient on drugs which affects fracture healing like steroid, anticancer drugs, polytrauma patients, extensive communition of the metacarpal or phalanx detected pre or intraoperatively, dislocations at either end of the fractured bone, parents/guardians/patients not willing to participate in study. Outcome evaluated in terms of - time to union of fracture in each individual group, radiological angulations in coronal and/or sagittal plane, Degree of strength achieved measured with dynamometer, DASH Scoring, range of motion of each digit.

Results: There was no significant difference in both the groups in terms of return to full hand function. Union was seen in both groups at 6 and 12 weeks. Radiological angulation in both coronal and sagittal plane was found to be dependent upon initial angulation of the fracture and fracture type more in K wire patients than plating. DASH score was significantly different at 6 weeks. Total range of motion was comparable.

Conclusion: No modality was found to be superior to other for fixation of small bone fractures of hand. Results were comparable in both the groups. However K wire fixation results were slightly better than plating group in terms of early DASH score and grip strength after fixation.

Keywords: Fracture metacarpal, fracture phalanges, mini plates, K-wires, DASH

Abstract ID: 1757

Management of chronic acromioclavicular joint dislocation with modified Weaver-Dunn procedure combined with acromioclavicular joint augmentation

Jagan MR Velpula, P Gajula, D Narender, B Mohammad Ghouse, Ashvin Pimpalnarker

10 Badgerdale Way, Littleover, Derby, DE23 3ZA, England, UK

Introduction: Treatments of chronic acromioclavicular joint dislocation are complicated. Many procedures have been described in the past for the management. Treatment modalities have changed with increasing understanding of the nature of the problem, patient expectations and the biomechanics of the joint.

The aim of the study was to assess the functional outcome of the chronic AC joint dislocations treated by modified Weaver-Dunn procedure combined with acromioclavicular joint (AC joint) augmentation.

Material and Methods: We treated 54 patients with chronic AC joint dislocation (grade 2-4) by modified Weaver-Dunn procedure with additional AC joint augmentation. This is a prospective study in active sports persons. We used tight rope system in 20 patients, Mersilene tape in 22 patients and no. 5 Ethibond in 12 patients. All patients were subjected to active shoulder physiotherapy. The study excludes fractures around the AC joint and shoulder joint.

Results: Mean followup was 20 months (range: 16-30 months), mean age of the patients was 35 years, and male to female distribution was 8:1. We assessed them clinically and radio logically during their followup. All patients were back to their occupation. 80% (n = 43) are back to their pre injury sporting activity level. The mean disabilities of the arm, shoulder and hand (DASH) score was 10.2 pts. One (n = 1) patient had a failure of augmentation.

Conclusion: Our study shows that chronic symptomatic AC joint dislocations, (Rockwood types III-V) managed with modified Weaver-Dunn procedure with augmentation are showing good short term results. Significant improvement in the patient satisfaction assessed by early return to work (sporting activity) and radiological restoration of the normal anatomy of the AC joint.

Keywords: AC joint dislocation, outcome, Weaver-Dunn

Foot and Ankle

Abstract ID: 1543

Early results of Ponseti method for treatment of relapsed idiopathic clubfoot

Suresh Chand, Anil Mehtani

Lady Hardinge Medical College, Delhi, India

Introduction: There have been several reports of successful treatment of idiopathic clubfoot with Ponseti method, the use of this method for treatment of relapse cases has rarely been reported. This study evaluates the early results of Ponseti method when used for treatment of relapsed idiopathic clubfoot.

Materials and Methods: 110 idiopathic clubfeet (75 children) presenting with relapse before skeletal maturity were managed with Ponseti method (62 feet were in >2 years age group, 7 feet had previous non-Ponseti surgical treatment). The severity of deformity was classified according to grading system of Pirani and Dimeglio et al. Pattern of relapse, number of casts and any additional procedures required during treatment were recorded along with any complication or re-relapse.

Results: The mean age at presentation with relapse was 35 months. The mean followup time was 10 months. Noncompliance to FAB was present in 95 clubfeet. Equinus was the most common deformity that relapsed followed by adduction, varus and cavus respectively in various combinations with or without dynamic supination. Correction was achieved with a mean of 4.7 casts. PCT was required in 48 feet whereas TATT was added to PCT in 17 feet. 4 feet required percutaneous plantar fasciotomy for cavus correction. 2 feet required TAL. 1 feet required posterior capsular release and 2 feet required calcaneal osteotomy. During followup 17 feet (15.5%) had re-relapse which was managed again in similar way with Ponseti method.

Conclusion: Our early term results support the use of the ponseti method for the management of relapsed clubfoot deformity including post surgical relapses. However, longer followup will be necessary to assess the risk of re-relapses and the potential need for corrective surgery in these relapse cases especially post surgical relapses and in older age group.

Keywords: Idiopathic clubfoot, relapsed CTEV, Ponseti method


Abstract ID: 1468

A demographic study of the musculoskeletal manifestations in human immuno deficiency virus infection

B Vijayeswar Reddy, Ashwath Acharya, Anil K Bhat

Kasturba Medical College, Manipal, Karnataka, India

Introduction: The spectrum of musculoskeletal involvement in HIV infected patients and their pattern of presentations to an orthopedic surgeon was studied.

Materials and Methods: This is a case series of 1621 HIV reactive patients who were evaluated for musculoskeletal involvement from 2009 to 2013. The demography and spectrum of presentations were analysed based on patient records with specific ICD codes for musculoskeletal manifestations.

Results: Out of 1621 patients, 120 patients with established musculoskeletal disorders were observed (7.4%). Seventy two were males and 48 were females (M/F 3:2) with majority in the age group of 30-50 years. The spectrum was grouped into neoplasms, infections, myopathies, rheumatologic/inflammatory. Neoplasms included skeletal metastasis (23), non Hodgkins lymphoma (19), multiple myeloma (2). Infections were Potts spine (20), septic arthritis (5), pyoderma (1), necrotising fascitis (4) and osteomyelitis (1). Myalgia was present in 48 patients (40%) along with myositis (7) and pyomyositis (6). Rheumatological disorders were polyarthralgia/arthritis (20), synovitis (4), flare up of rheumatoid arthritis (4), reactive arthritis (5), systemic lupus erythematosus (1) and discoid lupus erythematosus (1). Avascular necrosis of femoral head was seen in one patient.

Conclusion: Myalgia was the commonest symptom in 40% patients along with arthralgia/arthritis in 16.6% patients. NHL was the most common neoplasm associated with HIV apart from secondaries in bone. Infections in HIV may arise in superficial soft tissue, muscles, joints and marrow cavity. Awareness of musculoskeletal manifestations in HIV patients will help Orthopaedic surgeons in differential diagnosis of an unusual clinical presentation.

Keywords: HIV infection, musculoskeletal effects, demographic study

Abstract ID: 1631

Prospective study of effectiveness of platelet rich plasma (PRP) in treatment of early osteoarthritis knee

Siddharth Sharma, Virender Gautam, Lalit Maini

Maulana Azad Medical College, New Delhi, India

Introduction: Current trend of osteoarthritis has been shown to involve patients as early as 40 years of age, in this group the treatment modalities are further limited. Most management options provide only symptomatic relief do not address disease process. PRP is proposed to be a disease modifying modality which repairs and restores the normal cartilage in early stages of OA. The aim of our study was to prospectively monitor the therapeutic role of platelet rich plasma (PRP) in early stages of osteoarthritis.

Materials and Methods: In the study fifteen patients of either sex aged 35-70 years with the diagnosis of Kellgren Lawrence Grade 1 or 2 OA knee were included in the study and were selected according to inclusion and exclusion criteria. The baseline details of all patients were noted on a pre designed performa. Patients were given single autologous PRP injection (prepared from an in-house centrifugation machine) intraarticularly in the knee under strict aseptic precautions. The patients were then followed up at a period of 1 month for 6 months and patients were analyzed on basis of WOMAC Knee score.

Results: Results of our study revealed 52% improvement in symptom score during 1 st month and continued till 3 months, the stiffness score improved to 14% till 1 st month and maximum effect at 3 months 51.8%, pain score improved by 50% during first 2 months, functional score improved by 34.5% during first 3 months and total score improved by 30% during first 3 months. The analysis revealed that a significant and continuous improvement in all parameters of WOMAC score was observed in the patients injected with PRP and showed dramatic improvement during 1 st month which continued to improve till 3 months followed by some recurrence or worsening till 6 months but it never reverted to pre injection level.

Conclusion: The result of our study supports the effectiveness of PRP injection for relieving pain and improving knee function in OA knee. Improvement in symptoms was noted by 1 month after PRP injection which continued to improve over next 2 months followed by some recurrence or worsening till 6 months but never reached the pre injection level. Some improvement persisted till 6 months after PRP injection.

Keywords: Platelet rich plasma, osteoarthritis knee, cartilage repair

Abstract ID: 1894

Modified Thompsons quadricepsplasty to treat extension contracture of the knee following surgically treated supracondylar fractures of femur

Srinivas Balagani

MNR Medical College and Hospital, Hyderabad, Andhra Pradesh, India

Introduction: Quadricepsplasty is a technique devised to release extra articular adhesions or contractures which prevent useful flexion of the knee. Thompsons quadricepsplasty results in varied knee flexion with severe extension lag whereas Judets quadricepsplasty allows controlled sequential release of adhesions with no extension lag but modified Thompsons quadricepsplasty offers an advantage of Z-plasty of quadriceps along with sequential release of adhesions in patients with more severe extension contracture of the knee.

Materials and Methods: 4 cases of extension contracture of knee following surgically treated supracondylar fractures with intraarticular extension of femur which were fixed internally with locking distal femoral plates and screws were selected and their range of flexion was recorded, that varied from 0° to 20°. Interval between internal fixation of fracture to quadricepsplasty varied from one and half to 2 years. Initially repetitive manipulations under general anaesthesia were tried, when there was no improvement in knee flexion, quadricepsplasty was considered. Incision was made over the previous scar which was extended distally anterolateral to the knee, knee joint was exposed by lateral parapatellar incision, medial and lateral retinacula were released, intra articular adhesions between tibial and femoral condyles were released then 45° passive knee flexion was achieved. Supra patellar gutter adhesion and patello femoral adhesions were released, then 70° of passive knee flexion was acheived. Vastus muscles and rectus femoris were elevated extra periosteally and fibrotic muscle excised, multiple transverese incisions were made over tensor fascialata which gave 90 degrees of passive knee flexion. Z plasty of quadriceps muscle was performed which gave 140° of passive knee flexion at the end then implants were removed. Patients were put on CPM from immediate postoperative period and supervised physiotherapy was done.

Results: Postoperative knee flexion acheived varied from 90° to 110° at the end of 2 years followup. Extension lag varied from 10° to 20°.

Conclusion: (1) Patient education regarding physiotherapy plays a significant role in determining surgical outcome. (2) Eventhough extension lag is the main disadvantage of Z-plasty, the flexion acheived at the end is more compared to Judets quadricepsplasty or Thompsons quadricepsplasty. (3) The amount of blood loss and length of incision are less as compared to Judets quadricepsplasty. (4) Extension lag produced is less as compared to Thompsons quadricepsplasty.

Keywords: Quadricepsplasty, knee contracture, supracondylar fracture femur

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