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   Table of Contents - Current issue
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March-April 2019
Volume 53 | Issue 2
Page Nos. 221-379

Online since Friday, February 22, 2019

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EDITORIAL  

Evidence-based medicine: Hype or reality? Highly accessed article p. 221
Mandeep S Dhillon
DOI:10.4103/ortho.IJOrtho_54_19  
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ORIGINAL ARTICLES: TRAUMA Top

Fixation of the various coronal plane fracture fragments, including the entire coronoid process, in patients with mayo type IIB olecranon fractures - Four methods for fixation p. 224
Soo Min Cha, Hyun Dae Shin
DOI:10.4103/ortho.IJOrtho_42_17  
Background: We introduce several methods for fixation of unique Mayo type II olecranon fractures with the coronal plane fragment (CPF) including the entire coronoid process and report the radiological and clinical results through a case series. Materials and Methods: 12 patients were operated using this method with a mean age of 44 years. CPFs were fixed with concurrent fixation by a locking plate screw for the olecranon in three patients (method 1), cerclage wiring in six patients (method 2), a mini plate in two patients (method 3), and a double-locking plate (method 4) in one patient. We accessed the fragment through an additional medial coronoid approach after identifying the olecranon fragment through a dorsal approach (methods 1–3). In method 4, the CPF was fixed through a dorsal approach between the comminuted metaphyseal fragments. Results: With the exception of one patient with delayed union, all patients had achieved union at 3-month followup. The mean flexion extension arc was 125°. The mean pronation/supination was 72.5°/71.7° (range, 60-80°/60-80°). The mean visual analog scale score for elbow pain was 0.92 (range, 0-2), and the mean Mayo Elbow Performance Score was 86.7 (range, 80-90). The mean Disabilities of the Arm, Shoulder, and Hand score was 10.2 (range, 4-14). There were no major complications. Conclusion: A thorough preoperative understanding of the fragment patterns and preparation of tools for adequate reduction and fixation are necessary for satisfactory clinical and radiological outcomes. However, further comparative trials of conservative management versus surgery for CPF fixation, and any differences in outcomes according to the CPF fixation options, are required.
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Extra articular distal femoral fractures in the elderly treated with retrograde nailing using a spiral-locking blade system p. 232
Prashanth D'sa, Saravana Vail Karuppiah
DOI:10.4103/ortho.IJOrtho_590_17  
Background: The number of elderly patients sustaining long bone fractures is increasing with the rise of elderly population in the western world. Management of distal femur fractures is particularly difficult due to osteoporosis and other associated comorbidities. The key to management would be by surgical stabilization, which allows early mobilization. This study was devised to look into the radiological outcome and complication rate in a series of elderly patients who were treated with retrograde nail using spiral locking blade system for extra articular distal femur fractures. Materials and Methods: This is a retrospective study of patients who have undergone retrograde nailing with spiral-locking blade for distal femoral fractures (extra articular) above the age of 70 years in a major trauma center from 2001 to 2015. Notes were assessed for postoperative complications; time to union and final postoperative followup radiographs were assessed for alignment using a scoring system. Results: Forty one patients with an average age of 80 years and an average followup period of 9 months were included. The mean radiological score at final followup was 10.34 (range 8–12), with no significant shortening in any of the patients. Thirty patients had excellent radiological score (>10) and 11 patients scored good (8–9). The difference in time to union between Group 1 – simple fracture pattern (3.42 months) and Group 2 – complex comminuted fracture pattern (4.74 months) was not statistically significant (P = 0.072). There were five delayed unions but no cutout or metal work failure. Conclusion: The retrograde femoral nail with distal spiral-locking blade system can be a good surgical option for the treatment of extra articular distal femoral fractures in the elderly with the possibility of early weightbearing.
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Antibiotic cement spacer and induced membrane bone grafting in open fractures with bone loss: A case series p. 237
Srinivas Kasha, Sameer Singh Rathore, Hemanth Kumar
DOI:10.4103/ortho.IJOrtho_110_17  
Background: Open fractures are a difficult entity, often complicated by infection and nonunion. Bone loss in such fractures adds to the complexity. Conventional techniques of bone defect management are mainly directed toward fracture union but not against preventing infection or joint stiffness. In this case series, we evaluated Masquelet's technique for management of open fractures with bone loss. Materials and Methods: Twenty seven open fractures with bone defect, which presented within 3 days of trauma were planned for treatment by Masquelet's technique. Followup ranged from 21 to 60 months. Results: Average length of bone defect was 6 cm. Radiological union was obtained at a mean of 280 days since first stage of surgery. Time for union was not related to the size of defect. Union was faster in metaphyseal region (265.6 ± 38.8 days) as compared to diaphysis (300.9 ± 58.6 days). No patient had residual infection after stage 1. All the patients were able to mobilize with full weight bearing after radiological union with a satisfactory range of motion of adjacent joints. Conclusion: This technique can be routinely applied in compound fractures with bone loss with good results. Chances of infection are reduced using antibiotic cement spacer as an adjunct to thorough debridement. Induced biomembrane revascularizes the graft. Union can be expected in most of the cases, however, long time to union is a limitation. Technique is cost-effective and does not require special training or instrumentation. Although it is a two-stage surgery, requirement of multiple surgeries, as may be needed in conventional methods, is avoided.
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Augmentation plate fixation for treating subtrochanteric fracture nonunion p. 246
Yu Cheng Lo, Yu Ping Su, Cheng Pu Hsieh, Chun Hsiung Huang
DOI:10.4103/ortho.IJOrtho_476_17  
Background: The treatment of subtrochanteric fracture nonunion is challenging. Although revision with either an intramedullary or extramedullary device had been advocated with acceptable results, complications that require secondary procedures still arise. The use of an intramedullary device with augmentation plate fixation is a well-known approach for femoral or tibial diaphyseal nonunion. However, this approach has not previously been reported for subtrochanteric fracture nonunion. Materials and Methods: A series of 21 cases of subtrochanteric fracture nonunion treated with an intramedullary device in combination with augmentation side plating were collected and retrospectively reviewed after an average of 18 months of followup. Fourteen patients with a prior well-fixed intramedullary device were treated with side plating and bone grafting. Seven patients underwent revision nailing in addition to side plating and bone grafting. Results: All fractures united well without major complication. The average time to union was 7.1 months. Conclusion: The use of an intramedullary device with augmentation plate fixation is a reliable and decisive procedure for treating subtrochanteric fracture nonunion that produces satisfactory results with a low complication rate.
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Outcome of locked compressive nailing in aseptic tibial diaphyseal nonunions without bone defect p. 251
Cengiz Aldemir, Fatih Duygun
DOI:10.4103/ortho.IJOrtho_449_17  
Background: Treatment of tibial diaphyseal nonunions are rather difficult. Plate-screw, intramedullary nailing and external fixation are the methods used for treatment. The aim of this study is to evaluate the treatment results of aseptic diaphyseal nonunions following tibia fractures by intramedullary compressive tibia nailing (IMCN) with or without bone graft. Materials and Methods: Twenty eight patients who had aseptic tibial nonunion without bone defects operated between 2005 and 2015 were included in the study. The mean age of our patients was 36.4 years (range 20–56 years). There were 22 males and 6 females. Fifteen of the patients exhibited hypertrophic nonunion and thirteen exhibited atrophic nonunion. The average time between fracture occurrence and presentation to our department was 1.6 years (range 1–20 years). All patients underwent fibular osteotomy by removal of a 2 cm bone block from the middle one-third of the fibulas. In all cases, IMCN was applied following the reaming procedure, then maximum bone contacts were achieved manually between proximal and distal bone fragments afterward, and dynamic compressive fixation with 1 mm of compression was performed by a single rotation of the compression screw at the top of the nail. Direct X-ray images were assessed according to the Rust criteria, and functional outcomes were assessed according to the Johner–Wrush criteria. Finite-element analysis was performed for 1 mm of compression. For statistical analysis, Fisher's exact test, Pearson's Chi-square test, and Mann–Whitney U-test were used. Results: Union was achieved in all patients. Radiological union was obtained at an average of 15.5 ± 1.86 weeks. Functional results were found to be good or excellent in 25 (89.2%) patients and average or poor in 3 (10.8%) patients. One patient developed skin necrosis at the wound site, which was treated with rotational flap and skin graft. None of the patients developed implant failure, thromboembolism, deep-vein thrombosis, or infection. Conclusions: The use of compressive intramedullary nailing with or without bone graft is an effective method for the treatment of tibial nonunion.
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Arthroscopic assessment of cartilage healing status after treatment of tibial plateau fracture p. 257
Kwang Won Lee, Dae Suk Yang, Jae Yeon Hwang, Kap Jung Kim, Won Sik Choy
DOI:10.4103/ortho.IJOrtho_190_17  
Background: There are a few reports on the healing status of the cartilage after the treatment of tibial plateau fracture. In this study, we analyzed the healing status of articular cartilage using second-look arthroscopy with clinical and radiological results from patient's in schatzker Type I, II, and III tibial plateau fracture. Materials and Methods: 43 patients operated between January 2011 and December 2013 were included in this retrospective study. Radiological evaluation was performed by comparing simple radiographs from the preoperative, postoperative, and final followup period. Clinical evaluations were performed using the Knee Society Knee Score (KSKS) and the Knee Society Functional Score (KSFS). Moreover, second-look arthroscopic evaluation was performed during implant removal, and cartilage healing status was classified according to the International Cartilage Repair Society grading system (ICRS). Results: In all 43 patients, bony union was achieved with a mean duration of 13.7 weeks. The degree of cartilage healing was poor when the step-off was high (P = 0.016). Furthermore, even in cases with satisfactory step-off <2 mm, there was no case with complete cartilage healing. Between ICRS grade and clinical results, the respective Pearson coefficient for KSKS and KSFS were r = −0.62 and r = −0.59 indicating mean statistically significant negative correlations (P = 0.001). Conclusion: Even though step off was reduced anatomically and clinical outcome was excellent or good, there was not always complete cartilage healing in a followup on second-look arthroscopy. Therefore, we focused on not only radiologic and clinical outcome but also the actual status of cartilage with second-look arthroscopy.
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Efficacy and safety of tranexamic acid for controlling bleeding during surgical treatment of intertrochanteric fragility fracture with proximal femoral nail anti-rotation: A randomized controlled trial p. 263
Xiangping Luo, Shunqing He, Zhaowei Lin, Zhian Li, Chao Huang, Qi Li
DOI:10.4103/ortho.IJOrtho_401_17  
Background: Intertrochanteric fragility fracture (IFF) treated with proximal femoral nail anti-rotation (PFNA) is associated with significant hidden blood loss and high blood transfusion rate. The purpose of the present study was to evaluate the efficacy and safety of tranexamic acid (TXA) in reducing blood loss in these patients. Materials and Methods: Consecutive eligible patients were recruited and randomly assigned to a TXA group or a control group. The TXA group received 15 mg/kg body weight of TXA intravenously 15 min before incision and the same dose 3 h later. The control group received 100 mL of saline intravenously 15 min before incision. The efficacy outcomes included the total perioperative blood loss, postoperative transfusion rate, postoperative hemoglobin level, and length of the hospital stay. The safety outcomes were the incidence of thrombotic events and the mortality rate within 6 weeks after surgery. Results: We had 44 patients in the TXA group and 46 patients in the control group for the final analysis. The TXA group had significantly lower total perioperative blood loss than the control group (384.5 ± 366.3 mL vs. 566.2 ± 361.5 mL; P < 0.020). Postoperative transfusion rate was 15.9% in the TXA group versus 36.9% in the control group (P = 0.024). Each group had one patient with postoperative deep venous thrombosis. In the control group, three patients had cerebral infarction, and one patient died within 6 weeks after the operation. Conclusion: Intravenous TXA is effective in reducing total perioperative blood loss and transfusion rate in IFF treated with PFNA. No increased risk of thrombotic events was observed with the use of TXA; however, this study was underpowered for detecting this outcome. Further research is necessary before TXA can be recommended for high-risk patients.
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ORIGINAL ARTICLES: KNEE Top

Is achieving high flexion necessary for satisfaction after total knee arthroplasty in Indian patients? p. 270
Ashutosh Purushottam Mavalankar, Shubha Rani
DOI:10.4103/ortho.IJOrtho_268_17  
Background: Total knee arthroplasty (TKA) is a very successful operation for the treatment of end-stage arthritis of the knee joint. In spite of improvement in surgical technique, implant design, postoperative pain management, and rehabilitation, some patients are not satisfied with the outcome of the surgery. It is believed that high-flexion (H-F) activities such as cross-legged sitting and squatting are necessary for satisfaction after TKA in Indian patients due to cultural and social reasons. This has led to the development and marketing of implant designs allowing H-F after TKA without strong evidence in the literature. Materials and Methods: We carried out a retrospective study to determine the level of satisfaction in 74 patients operated for 120 TKA over a 5 year period. This was determined on the basis of a satisfaction questionnaire which included questions to assess satisfaction regarding pain relief and ability to perform routine daily activities and high knee flexion activities such as squatting and cross-legged sitting. Results: Out of a total of 74 patients, 69 patients were overall satisfied with their TKA. Out of these, only 5 patients could squat or sit in a cross-legged position. Majority of the patients were satisfied with the pain relief and improvement in their capacity to work provided by TKA. Conclusions: Ability to perform H-F activities after TKA is not a necessary prerequisite for satisfaction in Indian patients. Implant designs allowing H-F should be used in a selected group of patients with good preoperative knee flexion and specific requirements.
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Femoral component alignment with a new extramedullary femoral cutting guide technique p. 276
Ming-Chou Ku, Wei-Jen Chen, Chien-Sheng Lo, Chang-Han Chuang, Zih-Ping Ho, Atul Kumar
DOI:10.4103/ortho.IJOrtho_119_17  
Background: Intramedullary (IM) or extramedullary (EM) mechanical guides are used as alignment tools during total knee arthroplasty (TKA) surgery. The EM guide is less invasive; however, the IM mechanical guide is the preferred option since it has shown superior outcomes in several studies. Picture archive and communication system (PACS) images, if available, are extensively used for preoperative planning and intraoperative guidance. This retrospective study compared TKA outcomes using the conventional IM guide and a new EM technique which uses PACS image for preoperative and intraoperative assessment bone resection. To the best of our knowledge, this is the first study with the new EM technique. Materials and Methods: The study was performed on 205 knees (190 patients) for TKA from 2011 to 2013. The perioperative blood loss and the postoperative alignment angles were assessed for both mechanical guides. The angles were measured on the radiographs of the patient. The blood loss was assessed by the blood accumulated in the hemovac drain during the surgery and until 3 days after the surgery. Results: The new EM guide provided similar postoperative alignment as that obtained with the IM guide. Conclusion: The EM-guided method for femoral bone cutting using PACS films in TKA is as good as the IM method. The additional advantages of less injury to the bone and less fat emboli load to the cardiopulmonary system with the EM method makes it an attractive choice for routine, especially in the elderly and/or simultaneous bilateral, TKA in hospitals without modern computer-assisted navigation systems.
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Epidemiology of revision total knee arthroplasty: A single center's experience p. 282
Vikas Kulshrestha, Barun Datta, Gaurav Mittal, Santhosh Kumar
DOI:10.4103/ortho.IJOrtho_127_17  
Background: There has been a gradual increase in the revision TKA (RTKA) workload due to expanding indications of total knee arthroplasty (TKA), coupled with improving patient longevity. Western countries are already looking at their data on RTKA to plan for the future heath care needs of these patients. Limited data is available on RTKA from developing countries. Our study attempts to fill this gap in knowledge. Materials and Methods: We prospectively documented details of all RTKA performed at our centre for a period of six years (2011-16). We recorded the volume, causes and time to failure from index surgery of all RTKA and further recorded microbiological pattern in septic failures. We looked at the proportion of each cause of failure and time from index surgery. Results: Of the 5068 TKA procedures performed from January 2011 to December 2016, 201 (4%) were first-time revisions. The predominant cause of revisions was prosthetic infection (61%) followed by aseptic loosening (18%) and instability (7%). In the early, mid term, and late-failure groups, prosthetic infection remained the main cause of failure. In 47% of the septic revisions, the offending organisms could be identified and of those identified most (67%) were Gram-negative. Conclusion: The volume of first-time RTKA procedures (4%) at our center remained low compared with that of the Western countries. In Western countries, the incidence of late aseptic failures was higher than that of early-septic failures, whereas in our study, revisions were more commonly performed in the early-failure group (48%) and most failures were due to prosthetic infection (61%).
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New instrumentation improves patient satisfaction and component positioning for mobile-bearing medial unicompartmental knee replacement p. 289
Rajesh Malhotra, Vijay Kumar, Naman Wahal, Arnaud Clavé, James A Kennedy, David W Murray, Hemant Pandit
DOI:10.4103/ortho.IJOrtho_172_17  
Background: The Oxford unicompartmental knee replacement (OUKR) has achieved excellent functional outcomes and long term survivorship in many single center and single surgeon series. However, in national registries, the failure rates are up to three times higher than total knee replacement. This is at least in part due to difficulty experienced by low-volume surgeons in implanting the prosthesis accurately. A new instrumentation system (Microplasty) was introduced to help surgeons achieve better component positioning, however, it is not known whether the new instruments achieve that goal. This study investigates whether the new system achieves better component positioning and whether it improves the clinical outcomes when compared to the existing instruments. Materials and Methods: This retrospective cohort study compared 50 consecutive OUKR implanted using the conventional Phase 3 instrumentation with 100 consecutive OUKR implanted using the new Microplasty instrumentation. Component orientation was measured on postoperative radiographs, and the percentage outside the recommended range was identified. Intraoperative data and retrospectively collected clinical data were also analyzed. Results: Femoral component alignment improved significantly, and there were no outliers in the Microplasty group. Although there were fewer tibial component alignment outliers with Microplasty, the difference was not significant. The intraoperative incidence of tibial recut, patient satisfaction and patient expectations was significantly better in the Microplasty group. The Oxford Knee Scores were also better with Microplasty, however, the difference was not significant. Conclusion: Microplasty instrumentation helps the surgeon achieve optimal component positioning and reduces the need for tibial recut. The clinical outcomes are also better with the Microplasty instrumentation.
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Double bundle versus single bundle reconstruction in the treatment of posterior cruciate ligament injury: A prospective comparative study p. 297
Mai Xu, Qiliang Zhang, Shiyou Dai, Xueren Teng, Yuxin Liu, Zhenhua Ma
DOI:10.4103/ortho.IJOrtho_430_17  
Background: The debate continues regarding the best way to reconstruct posterior cruciate ligament (PCL). The objective of this study was to compare the knee stability and clinical outcomes after single and double bundle (SB and DB) PCL reconstruction. Materials and Methods: A total of 98 patients with PCL injury were enrolled for PCL reconstruction with four-strand semitendinosus and gracilis tendon autograft in the SB technique (n = 65) or two-strand Achilles allograft in the DB technique (n = 33). Each bundle fixation was achieved by the means of femoral Endo Button CL and tibial bioabsorbable interference screw. Demographic data, knee stability, and clinical outcomes were collected for analysis. Results: The SB and DB groups showed comparable demographic data. After a minimum followup interval of 24 months, the data of 59 patients in the SB group and 30 patients in the DB group were analyzed. There was no statistical difference between the SB and DB group in terms of both knee stability and clinical outcomes (P > 0.05). Conclusions: Compared with the SB technique, the DB technique did not exhibit any superiority in knee stability or clinical outcomes.
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Morphometric study of lower end femur by using helical computed tomography p. 304
Bhanu Awasthi, Sunil Kumar Raina, Vivek Negi, Narvir Singh Chauhan, Sandeep Kalia
DOI:10.4103/ortho.IJOrtho_136_17  
Background: A mismatch between the prosthesis size and bone may result in a number of complications. Keeping this in view, it is essential to analyze the morphological differences of the knee observed across various ethnic groups to improve the performance of total knee arthroplasty (TKA). The current study was aimed at studying the computed tomography (CT) profile of distal femur in Indian population and evaluates it morphologically. Materials and Methods: This descriptive study was conducted on 62 patients presenting to the Department of Orthopedics in a tertiary care center in rural north-west India for features suggestive of osteoarthritis and trauma of knee from September 17, 2015 to September 16, 2016. Helical CT of both knees was done, and the data were analyzed using Statistical Package for Social Sciences Version 17.0 statistical significance was assessed with the help of t-test and the value of P < 0.05 was considered to be statistically significant. Results: The mean mediolateral (ML) value in male patients was 72.74 ± 4.45 while the mean ML value in female patients was lower (63.59 ± 2.61). The mean anteroposterior (AP) value in male patients was significantly (statistically) higher (49.62 ± 3.86) in comparison to mean AP value in female patients (45.11 ± 4.4). The mean anterior lateral condylar height (ALCH) value in male patients was higher (17.53 ± 2.72) in comparison to mean ALCH value in female patients (14.63 ± 3.42). Conclusions: The current study highlights the need to develop components and implants for use in TKA and fractures of distal femur keeping the age- and sex-specific anatomical features of people of different ethnic origins in view.
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ORIGINAL ARTICLES: SPINE Top

The use of preoperative and intraoperative pavlov ratio to predict the risk of postoperative C5 palsy after expansive open-door laminoplasty for cervical myelopathy p. 309
Bingjin Wang, Weifang Liu, Zengwu Shao, Xianlin Zeng
DOI:10.4103/ortho.IJOrtho_217_17  
Background: No standard preoperative preventive measure has been established to decrease the occurrence of C5 palsy after expansive open-door laminoplasty. The aim of this study is to establish a reliable measured parameter in predicting the risk of the postoperative C5 palsy. Materials and Methods: A total of 276 patients receiving posterior open-door laminoplasty for cervical spinal stenotic myelopathy were studied. The patients were divided into two groups according to the preoperative Pavlov ratio (Group A: Pavlov ratio <0.65 and Group B: Pavlov ratio ≥0.65). Correlations between the occurrence of postoperative C5 palsy and Pavlov ratio were analyzed, and Group A was further tested. The surgical procedures, clinical symptoms, and Pavlov ratio were described. Results: The patients with Pavlov ratio <0.65 had a higher risk of developing postoperative C5 palsy (P < 0.05, odds ratio [OR] = 2.91). No significant difference was found in gender, age, etiology, type of operation, and pre- and postoperative Japanese Orthopaedic Association scores between patients with and without postoperative C5 palsy. The cutoff (1.01) of receiver operating characteristic curve of the postoperative Pavlov ratio of the Group A was calculated. The postoperative Pavlov ratio ≥1.01 of the patients in Group A was a significant risk factor of the development of postoperative C5 palsy (P < 0.01, OR = 10.83). Conclusions: The preoperative Pavlov ratio <0.65 at the C5 level was more likely to develop the postoperative C5 palsy. When the preoperative Pavlov ratio is <0.65, the postoperative Pavlov ratio ≥1.01 at the C5 level is a reliable predictor for the development of postoperative C5 palsy. Pavlov ratio may be one of the reasons for postoperative C5 palsy.
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Prospective analysis of functional outcome of single-stage surgical treatment for symptomatic tandem spinal stenosis p. 315
Manoj Dayalal Singrakhia, Nikhil Ramdas Malewar, Sonal Deshmukh, Shivaji S Deshmukh
DOI:10.4103/ortho.IJOrtho_316_17  
Background: Tandem spinal stenosis (TSS) is a rare presentation leading to combined clinical features of upper motor neuron and lower motor neuron lesion which includes intermittent neurogenic claudication with or without neurological deficit, progressive gait imbalance and gait disturbances. In literature, there is controversy whether stage surgery or single-stage surgery should be done. Materials and Methods: From June 2009 to November 2016 in a series of 1381 patients who underwent surgery for various degenerative spinal conditions, 82 patients were diagnosed with having symptomatic TSS with an incidence of 5.93%. All patients diagnosed with TSS underwent single-stage surgical intervention by one surgical team. The perioperative factors were recorded for each patient. All patients were evaluated preoperatively and postoperatively at each followup with the modified Japanese Orthopaedic Association (mJOA) score, Nurick's grading, Oswestry disability index (ODI) and Cooper scale. Results: In this study, 82 patients including 70 males and 12 females underwent simultaneous surgical intervention for symptomatic TSS. The mean age of patients was 61.78 ± 10.48 years. There was a significant improvement in mJOA score, Nuricks grading, ODI and Coopers scale postoperatively as compared to preoperative values (P < 0.05). Conclusion: Symptomatic TSS can be safely managed by single-stage surgical intervention with good postoperative results or without a significant increase in complication rates. Single-stage surgical intervention helps to relieve the symptoms of both cervical and lumbar spinal cord compression, avoids the risk of repeated anesthesia, reduce the duration of surgery, repeated hospitalization hence, reducing the cost for hospitalization and also reducing the rehabilitation, recuperation time and early functional recovery justifies single-stage surgical intervention.
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Management of acquired compressive myelopathy due to spinal fluorosis p. 324
Jayprakash V Modi, Kirtan V Tankshali, Zulfikar M Patel, Bhavya H Shah, Abhishek K Gol
DOI:10.4103/ortho.IJOrtho_570_17  
Background: Fluorosis is an endemic disease of India which causes compressive cervical and/or dorsal myelopathy. This study aims to evaluate the role of surgical management in the crippling fluorosis along with evaluation of radiological imaging as screening/diagnosing tool for the disease. Materials and Methods: This is a prospective cohort study of 33 patients operated at tertiary care center having nontraumatic involvement of spinal cord affecting neurology with history, clinical and radiological features (Ossified Posterior Longitudinal Ligament-, Ossified Ligamentum flavum) suggesting fluorosis as the cause of compression. Outcomes were measured in terms of improvement in Nurick grading, Rankins scale, spasticity, Oswestry Disability Index, modified Japanese Orthopaedic Association scores. Results: Spinal fluorosis is a male predominant disease affecting the elderly after years of fluorine intake. Cervical and/or dorsal spine are predominantly involved at multiple levels (>=2). Diagnosis of the disease poses difficulty due to lack of established laboratory parameters with high sensitivity, availability, and lack of awareness among surgeons. Skeletal survey alone has >90% sensitivity for diagnosing the disease. Once evaluated properly, decompression at correctly identified levels invariably improves the spasticity and quality of life immediately post-surgery. At final followup, there was on average improvement of 2 scales in nurick grade, rankins scale and ashworth grading whereas average improvement in ODI, mJOA and dorsal specific mJOA were 52%, 3.17 points and 2.7 points respectively. However, preoperative counselling for “apparent neurological deterioration” in immediate postoperative period is very important. Complications like infection and dural tear have to be prevented with special surgical tactics. Conclusion: Skeletal survey along with computed tomography and magnetic resonance imaging is cost-effective modality for the screening/diagnosis for fluorosis. Once developed, surgery, either curative or palliative, is the best treatment at crippling stage of the disease.
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ORIGINAL ARTICLES: BASIC SCIENCES Top

The “Gastrocnemius–Achilles Tendon–Calcaneus complex”: Different responses after percutaneous versus vulpius achilles tendon lengthening in New Zealand white rabbits p. 333
Federico Canavese, Davide Barbetta, Bartolomeo Canavese, Alain Dimeglio
DOI:10.4103/ortho.IJOrtho_397_17  
Background: This study aimed to describe the clinical, radiological, biomechanical, electromyographic, and histoenzymologic modifications in the “Gastrocnemius–Achilles Tendon–Calcaneus complex” caused by percutaneous Achilles tendon lengthening (PATL) versus Vulpius Achilles tendon lengthening (VATL) in New Zealand White (NZW) rabbits. Materials and Methods: Eight female NZW rabbits were used at 7 months of age. Two rabbits were euthanized before surgery for anatomical dissection, three underwent PATL (two bilateral and one unilateral), and the three others underwent VATL (two bilateral and one unilateral). Clinical examination, biomechanics, electromyography, standard radiographs and magnetic resonance imaging (MRI), and histology and histoenzymology were assessed after surgery. Results: At the end of the experiment, the subjects showed good clinical status but different functional outcomes of surgery: rabbits submitted to PATL developed permanent limp and lost their capacity to jump compared to rabbits submitted to VATL which remained able to ambulate and jump normally. Standard radiographs and MRI showed that PATL led to significantly greater increase in dorsal or anterior flexion of the tibiotarsal angle (TT angle) compared to VATL, whereas electromyographic and histoenzymologic observations of muscle unit showed little or no variation between the two groups of operated rabbits. Conclusions: Although PATL leads to greater improvement in dorsal or anterior flexion (TT angle) of the rabbit ankle compared to VATL, it has negative effects on functional outcome as it reduces the contractile capacity of the rabbit muscle unit, ultimately impairing the ability to ambulate and jump.
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Intermittent parathyroid hormone injection can decrease femoral head collapse in the vascular deprivation of rat femoral head model p. 340
Chih-Wei Chiang, Wei-Chuan Chen, Chian-Her Lee, Chih-Hwa Chen
DOI:10.4103/ortho.IJOrtho_315_17  
Backgrounds: Intermittent parathyroid hormone (intermittent PTH) injection has been shown to improve osteogenesis. We hypothesized that intermittent PTH injection could stimulate osteogenesis during the early phase of vascular deprivation-induced femoral neck osteonecrosis in a rat model. Materials and Methods: Eighteen Sprague-Dawley rats were divided into three groups (normal saline [CON], PTH 10 μg/kg [PTH-H], and PTH 1 μg/kg [PTH-L]) for 8 weeks by subcutaneous injection. All rats were sacrificed at postoperative 8 weeks, and all underwent a micro-computed tomography (μ-CT) examination for bone quality and quantity evaluation and histomorphometric analysis for microscopic histologic differences. Results: Under μ-CT examination, both the PTH-H and PTH-L groups revealed less bone resorption than the control group. The PTH-H group had a better bone protective effect than the PTH-L group. Bone mineral density was increased in the PTH-H and PTH-L groups compared to the control group. The uninjured left femoral head was enlarged in both PTH groups. The histologic examination showed that both PTH groups had new bone and cartilage formation. The control group had only dead bone without any osteogenesis. Conclusion: Intermittent PTH injection could decrease bone resorption and improve bone density, compared to the control group, in vascular deprivation of the femoral head in a rat model. High-level intermittent PTH injection had a better effect than low-level intermittent PTH injection.
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The effects of nerve and tendon gliding exercises combined with low-level laser or ultrasound therapy in carpal tunnel syndrome p. 347
Zuzanna Bartkowiak, Małgorzata Eliks, Małgorzata Zgorzalewicz-Stachowiak, Leszek Romanowski
DOI:10.4103/ortho.IJOrtho_45_17  
Background: Carpal tunnel syndrome (CTS) is a common medical condition that doctors and physiotherapists come across in clinical practice. There are no explicit recommendations concerning which physical therapy methods should be applied in its treatment; however, there have also been no studies on the effects of combining low-level laser therapy (LLLT) or ultrasound with nerve and tendon gliding exercises. The purpose of this study was to evaluate the therapeutic efficacy of ultrasound and LLLT combined with gliding exercises. Materials and Methods: A total of seventy patients with mild to moderate CTS, divided into two groups, were included in this study. Group 1 received ultrasound treatment, whereas Group 2 underwent LLLT. The treatment lasted 2 weeks (5 sessions/week). In addition, both groups were treated with nerve and tendon gliding exercises three times daily. The clinical evaluation involved an interview on subjective and objective sensory abnormalities, the intensity of pain, the measurement of grip strength, Phalen's test, Tinel's sign, and the Boston Carpal Tunnel Questionnaire. The assessment was performed before and after the treatment. Results: A decrease in sensory impairments, improvement in visual analog scale, hand grip strength and the Boston Questionnaire results were significant in all patients after therapy. No meaningful differences between groups were noted in any of the examined variables after treatment. No adverse effects were observed. Conclusions: The results of this study may suggest the clinical efficacy of LLLT or ultrasound combined with gliding exercises in patients with mild to moderate CTS.
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Ulnar nerve innervation to triceps: A cadaveric study and a technical note on partial triceps to biceps transfer p. 353
Darshan Kumar A Jain, Sathish T Kumar, Naresh Shetty
DOI:10.4103/ortho.IJOrtho_440_17  
Background: The loss of elbow flexion is a routinely encountered problem in clinical practice. There is no literature on ulnar nerve innervation to triceps in addition to the radial nerve which is dual nerve innervation to triceps in the Indian population. We intend to study the incidence of ulnar nerve innervation to the medial head of triceps in Indian population and also the clinical feasibility of transfer of long and medial head of triceps tendon to biceps around the medial aspect of humerus. Materials and Methods: A cross-sectional study was conducted using 32 fresh-frozen skeletally mature cadavers of Indian origin. The possible contribution of the ulnar nerve to medial head of triceps in addition to the radial nerve was recorded. The arm length, the distance where the ulnar nerve pierces the medial intermuscular septum from medial epicondyle; the distance of the ulnar nerve fascicle from the medial epicondyle was also measured. Results: The incidence of ulnar nerve innervation to the medial head of triceps was 43.8%. Mean arm length was 29.13 cm. Mean distance where the ulnar nerve pierced the medial intermuscular septum from medial epicondyle was 9.93 cm. Mean distance of the ulnar nerve branch to the triceps from medial epicondyle was 8.01 cm. Conclusion: This study reveals the presence of dual nerve innervation to triceps in 43.8% of the Indian population. The clinical implication would be to look for the possible contribution of the ulnar nerve fascicle to the medial head of triceps, which will help us to include the medial head along with the long head of triceps while performing partial triceps-to-biceps tendon transfer, and the other use would be as a donor fascicle when performing a nerve transfer.
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ORIGINAL ARTICLES: HAND Top

Transplantation of a free vascularized joint flap from the second toe for the acute reconstruction of defects in the thumb and other fingers p. 357
Jihui Ju, Lei Li, Ruixing Hou
DOI:10.4103/ortho.IJOrtho_200_17  
Background: This study aimed to evaluate a novel surgical method for the acute reconstruction of defects in the thumb and other fingers by transplanting a free vascularized joint flap from the second toe and to determine its clinical curative effects. Materials and Methods: A free vascularized joint flap from the second toe was transplanted to reconstruct a complete defect of the thumb and other fingers accompanied by the loss of the proximal finger in 10 patients. Of these patients, three had their thumbs reconstructed with a free vascularized joint flap from the second toe and with the proximal interphalangeal joint flap, one had a thumb reconstructed with a free vascularized joint flap from the second toe, and six had their finger defects reconstructed with the proximal interphalangeal joint flap. The toes of the metatarsophalangeal joint were amputated at the foot donor site. All patients underwent one-stage emergency surgery. Results: The composite tissue flaps, replanted thumbs, and fingers survived well in all 10 cases. Follow-up visits were conducted for 6–28 months, with an average of 9 months of follow-up. The transplanted bone joints healed over a period of 6–16 weeks. Bone nonunions and refractures did not occur, and the walking function of the foot donor site was not visibly affected. Conclusion: A free vascularized joint flap from the second toe can be transplanted to repair defects in the thumb and other fingers. This technique can be applied to recover the appearance and function of fingers.
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ORIGINAL ARTICLES: PAEDIATRICS Top

Results of supracondylar “V” osteotomy for the correction of genu valgum deformity p. 366
Rahul Ranjan, Alok Sud, Rajesh Kumar Kanojia, Lakshay Goel, Suresh Chand, Abhinav Sinha
DOI:10.4103/ortho.IJOrtho_547_17  
Background: Medial close wedge, lateral open wedge, dome and “V” osteotomies are the commonly to correct the genu valgum (GV) deformity. However, the ideal method for the correction of coronal plane deformity is controversial. This prospective study is to evaluate the functional and radiological result of supracodylar “V” osteotomy to correct GV deformity. Materials and Methods: “V” osteotomy was done in all patients with clinically significant GV deformity and was fixed with crossed K-wires. Weight-bearing mobilization was started after radiological union. Patients were evaluated for correction in different clinical and radiological parameters. The function of the knee was assessed by Bostman's score. The subjective score was used to assess the parent's satisfaction after the procedure. Results: 187 limbs with genu valgum deformity (47 males and 71 females) were included in this study. We observed a significant improvement in the mean intermalleolar distance, clinical and radiological tibiofemoral angle and lateral distal femoral angle, from 17.3 to 3.9 cm, 23.8°to–4.5°, 25.6° to 6.1°, 76.6° to 88.4°, respectively. The mean Bostman score improved from 20.6 to 28.1. The parent's satisfaction assessed subjectively was 95.3 points. Conclusion: This osteotomy along with the fixation with K-wires is a safe, effective, reproducible technique with a short learning curve and a procedure requiring no repeat surgery for implant removal, with good functional results, and without major complications.
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CASE REPORT Top

Concurrent index-to-little finger dorsal dislocations of the carpometacarpal joints with carpal bone fractures p. 374
Ki-Tae Na, Sang-Uk Lee, Sun-Young Joo, Jin-Young Nho
DOI:10.4103/ortho.IJOrtho_550_17  
A 32-year-old man presented with simultaneous dorsal dislocations of the index-to-little finger carpometacarpal (CMC) joint with carpal bone fractures. Closed reduction was unsuccessful even after general anesthesia. During open dorsal approach, we found interposed joint capsule in the CMC joints and after removal of the joint capsule open reduction was easily achieved. We placed four Kirschner wires through the CMC joint. Furthermore, the fractured dorsal fragments of the trapezoid and hamate were fixed with mini screw in each. During 1-year followup, the patient showed good recovery and no evidence of posttraumatic arthritic changes in plain X-ray. We recommend to fix the dorsal fragment of the carpal bone with screws as well as the transarticular fixation of the CMC joint in case of concurrent CMC joint fracture-dislocation of all four fingers.
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LETTER TO EDITOR Top

Three-dimensional-printed polyether ether ketone implants for orthopedics p. 377
Abid Haleem, Mohd Javaid, Abhishek Vaish, Raju Vaishya
DOI:10.4103/ortho.IJOrtho_499_18  
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