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   Table of Contents - Current issue
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September-October 2017
Volume 51 | Issue 5
Page Nos. 485-629

Online since Friday, September 8, 2017

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EDITORIAL  

Upsurge of sports injuries and their treatment p. 485
Raju Vaishya, Ish Kumar Dhammi
DOI:10.4103/ortho.IJOrtho_431_17  
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SYMPOSIUM - SPORTS INJURY Top

Comparison of outcomes of two femoral fixation devices in hamstring anterior cruciate ligament reconstruction p. 487
Miguel Angel Sanchez-Carrasco, Juan Francisco Abellán, Salima Qudsi-Sinclair, Guadalupe Ruiz-Merino, Francisco Javier Carrillo-Juliá, David Bo-Rueda
DOI:10.4103/ortho.IJOrtho_13_16  
Background: Tear of the anterior cruciate ligament (ACL) is a common ligamentous injury of the knee. Reconstruction of this ligament is often required to restore functional stability of the knee. Outcome of ACL reconstruction is significantly affected by how the graft is fixed to the bone. This study is to determine if there is a different clinical outcome after cortical versus cortical-cancellous suspension femoral fixation in hamstring based anterior cruciate ligament (ACL) reconstruction. Materials and Methods: This is a retrospective comparative study conducted between 2006 and 2010. We enrolled patients who underwent arthroscopic ACL reconstruction. Sixty two patients met inclusion criteria and 41 agreed to come for followup assessment. Median age was of 28 years (range 18–39 years). Demographic baseline profile of both groups was similar. The femoral fixation devices were cortical (n = 16) and cortical-cancellous suspension techniques (n = 25). The average period of evolution at the time of assessment was 40 months (range 12-72 months). The patients were examined according to Lachman test (using Rolimeter knee tester), anterior drawer test, pivot shift test, International Knee Documentation Committee questionnaire, and Tegner-Lysholm knee scoring scale. Results: The objective evaluation of the patients (Lachman test) showed better results in terms of stability in the group of patients who underwent the cortical-cancellous suspension method. These differences were not reflected in the assessment of activity level (Tegner-Lysholm), where both groups showed the same results. Conclusions: ACL reconstruction with both cortical and cortical-cancellous suspension femoral fixation techniques show the same clinical results at medium long followup. However, cortical-cancellous fixations seem to provide greater stability to the reconstruction.
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Current concepts in the management of patellar instability p. 493
Michael S Laidlaw, David R Diduch
DOI:10.4103/ortho.IJOrtho_164_17  
Patellar instability is a common presenting clinical entity in the field of orthopedics. This not only can occur from baseline morphologic variability within the patellofemoral articulation and alignment, but also from traumatic injury. While conservative management is many times employed early in the treatment course, symptomatic patellar instability can persist. This article reviews the available indexed published literature regarding patellar instability. Given the debilitating nature of this condition and the long term sequelae that can evolve from its lack of adequate recognition and treatment, this article details the most current methods in the evaluation of this entity as well as reviews the most up-to-date surgical treatment regimens that are available to address this condition.
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The top 10 most cited Indian articles in arthroscopy in last 10 years Highly accessed article p. 505
Raju Vaishya, Mohit Patralekh, Abhishek Vaish, Amit Kumar Agarwal, Vipul Vijay
DOI:10.4103/ortho.IJOrtho_168_17  
The interest in the field of arthroscopy is increasing globally and exponentially in the recent past, including in India. Clinicians interested in this area of super specialization have started publishing their research work in reputed journals in this field. The publication from Indian authors is contributed equally by both the teaching government institutions and nonteaching private hospital specialists. The contributions by the Indian teaching institutes have predominantly Indian authors only, whereas those from the private sectors usually have an association with the foreign authors in their research and publications. The publications with higher hierarchy and level of evidence (1 and 2) are associated with greater citations. In addition, the publications in high-impact, reputed journals attract more citations and therefore it is recommended that the “good” scientific research work should preferably be submitted to these journals to create greater impact and awareness about ones' research and publication.
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Current concepts in the diagnosis and treatment of shoulder impingement p. 516
Bijayendra Singh, Nik Bakti, Abhinav Gulihar
DOI:10.4103/ortho.IJOrtho_187_17  
Subacromial impingement syndrome (SIS) is a very common cause of shoulder pain in the young adults. It can cause debilitating pain, dysfunction, and affects the activities of daily living. It represents a spectrum of pathology ranging from bursitis to rotator cuff tendinopathy which can ultimately lead to degenerative tear of the rotator cuff. Various theories and concepts have been described and it is still a matter of debate. However, most published studies suggest that both extrinsic and intrinsic factors have a role in the development of SIS. The management is controversial as both nonoperative and operative treatments have shown to provide good results. This article aims to provide a comprehensive current concepts review of the pathogenesis, etiologies, clinical diagnosis, appropriate use of investigations, and discussion on the management of SIS.
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Current concepts in the management of shoulder instability p. 524
Suresh Srinivasan, Radhakant Pandey
DOI:10.4103/ortho.IJOrtho_224_17  
Shoulder instability ranges from subtle instability to frank dislocation. Our understanding on the subject is getting better. Patient lifestyle, increased awareness/expectations, better availability of information, improved imaging modalities, and increased awareness about the previously less known concepts in instability all add to the challenges of managing the problem. History and clinical examination without over reliance on imaging remain essential. We used Embase, PubMed, Medline, CINAHL, Cochrane Library, Scottish Intercollegiate Guidelines Network and Google Scholar search for published literature in English. We used various combinations of the keywords, namely, human shoulder instability, sports injuries, dislocation, surgery, latarjet, glenohumeral, glenoid, and arthroscopy from 1980 to March 2017. The systematic search captured 310 publications. After applying initial exclusion criteria, 41 abstracts were assessed for eligibility. Of these, we selected 20 full-text articles with the majority of focus primarily on surgical management of traumatic shoulder instability. A tailor-made approach for the management of the individual patient is essential and should involve shared decision making. In this article, we have tried to simplify and present the current evidence in the management of traumatic shoulder instability, particularly in sportsperson.
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Current concepts in sports injury rehabilitation p. 529
Himmat Dhillon, Sidak Dhilllon, Mandeep S Dhillon
DOI:10.4103/ortho.IJOrtho_226_17  
In the modern era, rehabilitation after sports injury has become a domain for specialists, and its evolution has necessarily brought together the sports physiotherapist, the sports physician, and the orthopedic surgeon. The changing profile of sports related injury, as well as limited availability of facilities for rehabilitation in many areas of India, is a matter of concern. Elite sportspersons have some protection, but the average athlete is often left to fend for himself. Key factors in successful sports injury rehabilitation protocols are the application of modern rehabilitation protocols under appropriate supervision, appropriate and well timed surgical interventions, and judicious and need based use of pharmaceutical agents. Modern rehabilitation protocols emphasize teamwork and proper rehabilitation planning, and the rehabilitation team has to be lead by a trained sports physiotherapist, with an understanding of the protocols and interventions required at various stages. Injury specific rehabilitation protocols are being practiced worldwide but need to be introduced according to the nature of the sport as well as available facilities. Even in India, sports physicians are increasingly joining specialist rehabilitation teams, and they can help with medication, nutritional supplements, and specialized tests that could improve injury understanding. Inputs from surgeons are mandatory if surgical interventions have been performed. What is often missing in the underdeveloped world is psychological support and a clear understanding by the athlete of his/her rehabilitation protocols. World over, the primary aims are safe return to sports and minimizing reinjury on return to sport; this involves rehabilitation in stages, and current methodology clearly demarcates acute and chronic phases of injury. Close coordination with trainers and coaches is mandatory, and all need to understand that the reconditioning phase is crucial; skill assessment before progression has now become a specialized domain and needs to be introduced at all levels of the sport. A key factor in all sports injury rehabilitation protocols is injury prevention; this involves data maintenance by teams or trainers, which is still not fully developed in the Indian context. The injury and subsequent problems need to be comprehended both by athletes and their coaches. The current review is an attempt to clarify some of the issues that are important and routinely used world over, with the aim to improving rehabilitation after sports even in the underdeveloped world.
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Practice guidelines for the management of multiligamentous injuries of the knee p. 537
Ankit Goyal, Milind Tanwar, Deepak Joshi, Deepak Chaudhary
DOI:10.4103/ortho.IJOrtho_228_17  
Background: Multiligamentous injuries of knee remain a gray area as far as guidelines for management are concerned due to absence of large-scale, prospective controlled trials. This article reviews the recent evidence-based literature and trends in treatment of multiligamentous injuries and establishes the needful protocol, keeping in view the current concepts. Materials and Methods: Two reviewers individually assessed the available data indexed on PubMed and Medline and compiled data on incidence, surgical versus nonsurgical treatment, timing of surgery, and repair versus reconstruction of multiligamentous injury. Results: Evolving trends do not clearly describe treatment, but most studies have shown increasing inclination toward an early, staged/single surgical procedure for multiligamentous injuries involving cruciate and collateral ligaments. Medial complex injuries have shown better results with conservative treatment with surgical reconstruction of concomitant injuries. Conclusion: Multiligamentous injury still remains a gray area due to unavailability of a formal guideline to treatment in the absence of large-scale, blinded prospective controlled trials. Any in multiligamentous injuries any intervention needs to be individualized by the presence of any life- or limb-threatening complication. The risks and guarded prognosis with both surgical and non-surgical modalities of treatment should be explained to patient and relations.
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Patella height changes post high tibial osteotomy p. 545
Siew Ghim Gooi, Chloe Xiao Yun Chan, Melvin Kian Loong Tan, Andrew Kean Seng Lim, Kandiah Satkunanantham, James Hoi Po Hui
DOI:10.4103/ortho.IJOrtho_214_17  
Background: Medial opening wedge high tibial osteotomy (HTO) is a well-described treatment in early medial compartmental osteoarthritis of the knee. However, two undesirable sequelae may follow –patella baja and changes in the posterior tibial slope (TS). Materials and Methods: We conducted a retrospective study in patients who underwent HTO in our center between September 2009 and February 2017. Preoperative and 6-week postoperative long-leg weight bearing films and lateral knee radiographs were assessed. Pre- and postoperative radiological measurements include the Caton-Deschamps Index (CDI), the mechanical axis deviation (MAD), and the posterior TS. Independant t-test and Pearson correlation test were performed. Results: A total of 106 knees were recruited. The mean age was 48.8 ± 10.8 years. 66 (62.3%) and 40 (37.7%) knees were from males and females, respectively. The mean pre- and postoperative measurements was (−9.70° ± 3.67° to 0.08° ± 2.80°) (−varus; +valgus) for the MAD, (7.14° ± 1.78° to 8.72° ± 3.11°) for posterior TS, and (0.93° ± 0.084° to 0.82° ± 0.13°) for CDI (P ≤ 0.001 for all). The association between patella height change and the level of osteotomy (supra-tubercle vs. infra-tubercle) was statistically significant (P < 0.001). A supra-tubercle osteotomy cut significantly lowering patella height (P = 0.011). There was otherwise no statistically significant correlations between patella height changes and the correction angle (P = 0.187) or posterior TS change (P = 0.744). Conclusions: A medial opening wedge HTO above the tibial tubercle was significantly associated with lowering patella height or reducing CDI postoperatively. Based on our results, we would recommend the use of an infra-tubercle osteotomy during the corrective surgery to prevent the complication of patella baja.
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Knee dislocations in sports injuries p. 552
Dinshaw N Pardiwala, Nandan N Rao, Karthik Anand, Alhad Raut
DOI:10.4103/ortho.IJOrtho_229_17  
Knee dislocations are devastating when they occur on the athletic field or secondary to motor sports. The complexity of presentation and spectrum of treatment options makes these injuries unique and extremely challenging to even the most experienced knee surgeons. An astute appreciation of the treatment algorithm is essential to plan individualized management since no two complex knee dislocations are ever the same. Moreover, attention to detail and finesse of surgical technique are required to obtain a good functional result and ensure return to play. Over the past 10 years, our service has treated 43 competitive sportsmen with knee dislocations, and this experience forms the basis for this narrative review.
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Management of anterior cruciate ligament injury. What's in and what's out? Highly accessed article p. 563
Benjamin Todd Raines, Emily Naclerio, Seth L Sherman
DOI:10.4103/ortho.IJOrtho_245_17  
Sports medicine physicians have a keen clinical and research interest in the anterior cruciate ligament (ACL). The biomechanical, biologic, and clinical data researchers generate, help drive injury management and prevention practices globally. The current concepts in ACL injury and surgery are being shaped by technological advances, expansion in basic science research, resurging interest in ACL preservation, and expanding efforts regarding injury prevention. As new methods are being developed in this field, the primary goal of safely improving patient outcomes will be a unifying principle. With this review, we provide an overview of topics currently in controversy or debate, and we identify paradigm shifts in the understanding, management, and prevention of ACL tears.
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Meniscal preservation is important for the knee joint p. 576
Shantanu Sudhakar Patil, Anshu Shekhar, Sachin Ramchandra Tapasvi
DOI:10.4103/ortho.IJOrtho_247_17  
Native joint preservation has gained importance in recent years. This is mostly to find solutions for limitations of arthroplasty. In the knee joint, the menisci perform critical functions, adding stability during range of motion and efficiently transferring load across the tibiofemoral articulation while protecting the cartilage. The menisci are the most common injury seen by orthopedicians, especially in the younger active patients. Advances in technology and our knowledge on functioning of the knee joint have made meniscus repair an important mode of treatment. This review summarizes the various techniques of meniscus tear repair and also describes biological enhancements of healing.
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Role of high tibial osteotomy in cartilage regeneration – Is correction of malalignment mandatory for success? p. 588
Matthew Dhanaraj Thambiah, Melvin K L Tan, James H P Hui
DOI:10.4103/ortho.IJOrtho_260_17  
Malalignment of the knee can cause debilitating symptoms such as pain, resulting in a decline in function and mobility. Surgical options that exist to address this problem include realignment osteotomies and joint replacements. Realignment osteotomies are the more appropriate options in certain patient populations, especially with regard to age and level of activity. Since a high tibial osteotomy (HTO) was first used to manage malalignment of the knee and osteoarthritis, different techniques involving the use of specialized implants have been developed and further refined to good effect. There has also since been much research into the field of cartilage restoration techniques, both as a standalone treatment option and as an adjunct to a realignment osteotomy. This review attempts to detail the origin and the evolution of HTO, particularly in regard to combining this tried and tested procedure with adjunct cartilage restoration techniques, and the overall patient outcomes. A literature search on PubMed was performed, and articles pertaining to the outcomes of the use of an HTO and cartilage restoration techniques were reviewed. The literature in this field indicates good outcomes in terms of objective measurements of cartilage regeneration (such as arthroscopic visualization and magnetic resonance imaging evaluation) and subjective patient outcome scoring systems (such as the International Knee Documentation Committee and Lysholm scores) with a realignment osteotomy alone, and studies have shown that patient outcomes can be further improved with the use of a cartilage restoration procedure as an adjunct.
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Transportal anterior cruciate ligament reconstruction with quadrupled hamstring tendon graft: A prospective outcome study p. 600
Chandan Kumar, Anil Kumar Gupta, Santosh Kumar Singh, Rohit Jain
DOI:10.4103/ortho.IJOrtho_57_17  
Background: Anterior cruciate ligament (ACL) reconstruction has been one of the most commonly performed procedures throughout the world. Unsatisfactory outcome with conventional ACL reconstruction has been attributed to nonanatomic graft placement. Researchers have advised placing the graft in the native footprint of ACL to avoid nonanatomic graft placement. The goal of this study was to analyze the outcome of anatomic single bundle ACL reconstruction using transportal technique. Materials and Methods: This was a prospective outcome study conducted on 85 consecutive patients of ACL reconstruction of which 62 patients met inclusion and exclusion criteria and were analyzed for final results. All the patients underwent ACL reconstruction by quadrupled hamstring tendon graft using transportal technique and the accessory anteromedial (AAM) portal for femoral tunnel creation. The graft was fixed with endobutton on femoral side and bioabsorbable screw on the tibial side. Patients were evaluated for range of motion, International Knee Documentation Committee (IKDC) score, and Lysholm scores at a minimum followup period of 2 years. The mean pre- and postoperative scores were compared using Wilcoxon signed-rank test. Results: The mean Lysholm and IKDC scores improved significantly (P < 0.0001) from preoperative value. According to IKDC score, 90.3% (n = 56) were either normal or near normal at final followup. According to Lysholm score, 75.8% of patients had excellent and 13.3% had good results. Preoperatively, pivot shift was present in 85.5% (n = 53) of patients which reduced to 4.8% (n = 3) postoperatively. Infection and knee stiffness occurred in two patients, and femoral tunnel blowout and graft re-rupture occurred in one patient each. Conclusion: Anatomic ACL reconstruction by AAM portal is a reproducible technique which gives good clinical outcome at short-term followup.
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Anterior cruciate ligament injury, reconstruction, and the optimization of outcome p. 606
James Philip Bliss
DOI:10.4103/ortho.IJOrtho_237_17  
Anterior cruciate ligament reconstruction (ACLR) provides an established surgical intervention to control pathological tibiofemoral translational and rotational movement. ACLR is a safe and reproducible intervention, but there remains an underlying rate of failure to return to preinjury sporting activity levels. Postoperative pathological laxity and graft reinjury remain concerns. Previously, unrecognized meniscal lesions, disruption of the lateral capsule, and extracapsular structures offer potential avenues to treat and to therefore improve kinematic outcome and functional results, following reconstruction. Addressing laterally based injuries may also improve the durability of intraarticular ACLR. Improving the anterior cruciate ligament (ACL) graft replication of the normal ACL attachment points on the femur and the tibia, using either double bundle or anatomical single bundle techniques, improves kinematics, which may benefit outcome and functionality, following reconstruction.
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Medical attention injuries in cricket: A systematic review of case reports p. 614
Akilesh Anand Prakash
DOI:10.4103/ortho.IJOrtho_338_16  
Background: Cricket, classified as noncontact game, has been shown to be associated with increased incidence of injury. Further the recent consensus update in cricket injury surveillance have updated the injury definitions which includes “Medical Attention” injuries. The purpose of this review was to systematically review the various case reports and studies reporting injuries in the game of cricket that fall under the gambit of medical attention injuries. Materials and Methods: A systematic review was conducted online using PubMed and Google Scholar, as per Preferred Reporting Items for Systematic reviews and Metaanalyses guidelines. Predefined eligibility criteria were applied, and the data thus compiled were analysed. Results: A total of 32 studies reporting 43 players including 42 males and 1 female were included in the review. Bowling injuries were the most commonly reported injury. Impact injury was the most common mode with acute presentation in batting and fielding injury, whereas it was gradual onset mode with chronic presentation in bowling injuries. Head and neck injuries were the most common in batting injuries while extremity injuries were common in fielding and bowling injuries. No injuries were reported in umpires. Conclusion: The evidence provided, although not sufficient for any recommendation, it should alert the physicians and those concerned with the primary care of the cricketers to be vigilant of the eccentricity and severity of the injuries, their atypical presentation, mode, mechanism and trend, thereby being prepared for the unexpected presentations.
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CASE REPORT Top

Laparoscopic acetabular fracture fixation after three-dimensional modelling and printing p. 620
Can-Jun Zeng, Wen-Hua Huang, Hua-Jun Huang, Zhang-Lin Wu
DOI:10.4103/0019-5413.214215  
Current surgical treatment of acetabular fractures is open reduction and internal fixation and requires a large incision resulting in considerable blood loss and a potentially long duration of recovery. We report a case of an acetabular fracture that received laparoscopic internal fixation after three-dimensional (3D) modelling and printing of the acetabulum. A 43 year old male fell from a height of 3 m resulting in a right acetabulum anterior column fracture. Thin section computed tomography scanning with 0.6 mm increments and subsequent 3D reconstruction was performed, and a 3D model of the acetabulum and fracture was printed. The steel reconstruction plate was prebent in vivo and placed into the optimized position based on the 3D modelling and the optimized insert orientation and measured screw length were determined. The fracture was reduced and the plate placed laparoscopically without complications, and the patient had excellent functional recovery. Acetabular fractures are complex injuries, and while minimally invasive surgical techniques are used in many fields, they are not common for the treatment of acetabular fractures. 3D modelling is commonly used in medicine, and although 3D printing is used in some fields, it has not found widespread use in orthopedics.
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LETTERS TO EDITOR Top

“Decalcified allograft in repair of lytic lesions of bone”: A study to evolve bone bank in developing countries p. 624
SM Ajoy, BN Pushpa
DOI:10.4103/ortho.IJOrtho_514_16  
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Author's reply p. 625
Anil Kumar Gupta, Kumar Keshav, Praganesh Kumar
DOI:10.4103/ortho.IJOrtho_605_16  
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PROFILE Top

Legends in Indian orthopedics: Prof. Amulya Kumar Saha p. 626
Bhavuk Garg, Indrajit Sardar
DOI:10.4103/ortho.IJOrtho_463_17  
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ERRATUM Top

Erratum: Management guidelines for metal-on-metal hip resurfacing arthroplasty: A strategy on followup p. 628

DOI:10.4103/0019-5413.214230  
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Erratum: The history of biomechanics in total hip arthroplasty p. 629

DOI:10.4103/0019-5413.214231  
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