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   Table of Contents - Current issue
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September-October 2016
Volume 50 | Issue 5
Page Nos. 453-579

Online since Wednesday, August 31, 2016

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EDITORIAL  

Highlights of this issue p. 453
Ish Kumar Dhammi, Rehan Ul Haq
DOI:10.4103/0019-5413.189611  
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REVIEW ARTICLE Top

Surgical stabilization for open tibial fractures in children: External fixation or elastic stable intramedullary nail - which method is optimal? p. 455
Rohan A Ramasubbu, Benjamin M Ramasubbu
DOI:10.4103/0019-5413.189613  
Background: Management of open tibial fractures is well documented in adults, with existing protocols outlining detailed treatment strategies. No clear guidelines exist for children. Surgical stabilization of tibial fractures in the pediatric population requires implants that do not disrupt the open epiphyses (growth plate). Both elastic stable intramedullary nails and external fixation can be used. The objective of this study was to identify the optimal method of surgical stabilization in the treatment of open tibial fractures in children. Materials and Methods: MEDLINE and Embase were searched from their inception to March 2014 using the following advanced search terms (Key words): “open tibia fracture,” “fracture fixation,” “external fixation,” “intramedullary,” and “bone nail.” Only studies in English and pertaining to children with open fractures treated with elastic stable intramedullary nails or external fixation between 1994 and 2014 were included. Twelve clinical studies were critically appraised. Results: Due to a paucity in the literature coupled with a nonsystematic presentation of results, it proved to be very difficult in extracting relevant results from the studies. This was further added by a variation in outcome measures. Consequently, the results we obtained were difficult to draw conclusions from. Conclusion: There is no conclusive evidence or best practice guidelines for their management. Thus, as is highlighted in this study, more research is needed to determine the optimum treatment strategy for this common pediatric injury. The existing literature is of poor quality; consisting mainly of retrospective reviews of patients' medical records, charts, and radiographs. Carefully designed, high-quality prospective cohort studies utilizing a nationalized multi-hospital approach are needed to improve understanding before protocols and guidelines can be developed and implemented.
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ORIGINAL ARTICLES Top

Minimal invasive transforaminal lumbar interbody fusion versus open transforaminal lumbar interbody fusion p. 464
Arvind G Kulkarni, Hussain Bohra, Abhilash Dhruv, Abhishek Sarraf, Anupreet Bassi, Vishwanath M Patil
DOI:10.4103/0019-5413.189607  
Background: The aim of the present prospective study is to evaluate whether the touted advantages of minimal invasive-transforaminal lumbar interbody fusion (MI-TLIF) translate into superior, equal, or inferior outcomes as compared to open-transforaminal lumbar interbody fusion (O-TLIF). This is the first study from the Indian subcontinent prospectively comparing the outcomes of MI-TLIF and O-TLIF. Materials and Methods: All consecutive cases of open and MI-TLIF were prospectively followed up. Single-level TLIF procedures for spondylolytic and degenerative conditions (degenerative spondylolisthesis, central disc herniations) operated between January 2011 and January 2013 were included. The pre and postoperative Oswestry Disability Index (ODI) and visual analog scale (VAS) for back pain and leg pain, length of hospital stay, operative time, radiation exposure, quantitative C-reactive protein (QCRP), and blood loss were compared between the two groups. The parameters were statistically analyzed (using IBM®SPSS®Statistics version 17). Results: 129 patients underwent TLIF procedure during the study period of which, 71 patients (46 MI-TLIF and 25 O-TLIF) fulfilled the inclusion criteria. Of these, a further 10 patients were excluded on account of insufficient data and/or no followup. The mean followup was 36.5 months (range 18-54 months). The duration of hospital stay (O-TLIF 5.84 days + 2.249, MI-TLIF 4.11 days + 1.8, P < 0.05) was shorter in MI-TLIF cases. There was less blood loss (open 358.8 ml, MI 111.81 ml, P < 0.05) in MI-TLIF cases. The operative time (O-TLIF 2.96 h + 0.57, MI-TLIF 3.40 h + 0.54, P < 0.05) was longer in MI group. On an average, 57.77 fluoroscopic exposures were required in MI-TLIF which was significantly higher than in O-TLIF (8.2). There was no statistically significant difference in the improvement in ODI and VAS scores in MI-TLIF and O-TLIF groups. The change in QCRP values preoperative and postoperative was significantly lower (P < 0.000) in MI-TLIF group than in O-TLIF group, indicating lesser tissue trauma. Conclusion: The results in MI TLIF are comparable with O-TLIF in terms of outcomes. The advantages of MI-TLIF are lesser blood loss, shorter hospital stay, lesser tissue trauma, and early mobilization. The challenges of MI-TLIF lie in the steep learning curve and significant radiation exposure. The ultimate success of TLIF lies in the execution of the procedure, and in this respect the ability to achieve similar results using a minimally invasive technique makes MI-TLIF an attractive alternative.
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Transforaminal lumbar interbody fusion using one diagonal fusion cage with unilateral pedicle screw fixation for treatment of massive lumbar disc herniation p. 473
Chang-Qing Zhao, Wei Ding, Kai Zhang, Jie Zhao
DOI:10.4103/0019-5413.189595  
Background: Large lumbar or lumbosacral (LS) disc herniations usually expand from the paramedian space to the neuroforamen and compress both the transversing (lower) and the exiting (upper) nerve roots, thus leading to bi-radicular symptoms. Bi-radicular involvement is a statistically significant risk factor for poor outcome in patients presenting with far lateral or foraminal disc herniation after facet preserving microdecompression. There is evidence showing that patients suffering from large lumbar disc herniations treated with interbody fusion have significant superior results in comparison with those who received a simple discectomy. We report our experiences on managing large LS disc herniation with bi-radicular symptoms by transforaminal lumbar interbody fusion (TLIF) using one diagonal fusion cage with unilateral pedicle screw/rod fixation. Materials and Methods: Twenty-three patients who suffered from single level lumbar or LS disc herniation with bi-radicular symptoms treated with unilateral decompression and TLIF using one diagonal fusion cage with ipsilateral pedicle screw/rod fixation operated between January 2005 and December 2009, were included in this study. Operation time and blood loss were recorded. The pain and disability status were pre- and postoperatively evaluated by the visual analog score (VAS) and Oswestry Disability Index (ODI). Interbody bony fusion was detected by routine radiographs and computed tomography scan. Adjacent segment degeneration was detected by routine radiographs and magnetic resonance imaging examination. Overall outcomes were categorized according to modified Macnab classification. Results: The patients were followed up for an average of 44.7 months. Pain relief in the VAS and improvement of the ODI were significant after surgery and at final followup. No severe complications occurred during hospital stay. Interbody bony fusion was achieved in every case. No cage retropulsion was observed, while 3 cases experienced cage subsidence. Adjacent segment degeneration occurred at 3 discs cephalic to the fusion segment at followup. No patients underwent revised surgery. Overall outcome was excellent in 5 patients (21.7%), good in 13 (56.5%), fine in 4 (17.5%), and poor in 1 (4.3%). Conclusions: TLIF using one cage with ipsilateral pedicle screw/rod fixation is an effective treatment option for massive lumbar or LS disc herniation with bi-radicular involvement.
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Risk factors for early redislocation after primary treatment of developmental dysplasia of the hip: Is there a protective influence of the ossific nucleus? p. 479
Atul Bhaskar, Hardik Desai, Gaurav Jain
DOI:10.4103/0019-5413.189610  
Background: Re-dislocation after primary treatment of developmental dysplasia of the hip is a serious complication. We analyzed the various risk factors that contribute to re-dislocation, and whether the bony ossific nucleus (ON) confers increased stability against re-dislocation. Materials and Methods: Fifty-five children (60 hips) were classified into three treatment groups: Closed reduction (CR) in 15 children (17 hips), open reduction (OR) in 26 children (28 hips), and OR with bony surgery (ORB) in 14 children (15 hips). The mean age at initial treatment was 16 months (range 6–36 months). Fifty-one hips and 9 hips were Tonnis Grade 4 and 3, respectively. The mean preoperative acetabular index (AI) was 44.82° (range 32°–56°) for the study group. At initial treatment, bony ON was absent in 8 hips and present in 52 hips. Results: No hip developed stiffness and pain after primary treatment. Although the AI index, Tonnis grade, and absence of ossific nucleus were higher in the re-dislocated groups, this was not statistically significant. Excluding the re-dislocations, four children had a fair outcome, 11 had good outcome, and 36 had excellent outcome as per McKay's criteria. In the CR group (17 hips), two children (2 hips) with absent ON had re-dislocation. In the OR group (28 hips), three re-dislocations were seen (three children) at 3, 5, and 7 months, respectively. Two of these had an absent bony ON. In the ORB group (15 hips), one late sub-luxation occurred in a child with absent ON. The mean preoperative AI for the re-dislocated and located group was 44.66° (range 42°–48°) and 44.53° (range 39°–56°), respectively. The postoperative AI was 34.53. Conclusion: The experience of the treating surgeon and technical factors play an overwhelming role in preventing early dislocation. The absence of ON should perhaps alert the surgeon for enhanced spica care, postoperative splinting, and meticulous intra-operative management.
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Iliotibial band syndrome following hip arthroscopy: An unreported complication p. 486
Roberto Seijas, Andrea Sallent, Maria Galan, Pedro Alvarez-Diaz, Oscar Ares, Ramon Cugat
DOI:10.4103/0019-5413.189596  
Background: Hip arthroscopy is considered a safe procedure, considering the relatively low rate of complications. Despite several complications have been described following this surgical procedure, the present event has not yet been described. The purpose of the present study is to report an unpublished complication following hip arthroscopy, after reviewing 162 hip arthroscopies and finding iliotibial band syndrome (ITBS) in the knee during followup. Materials and Methods: A retrospective review of 162 hip arthroscopies performed between September 2007 and June 2011 was carried out, evaluating patients who presented ITBS during followup. Indication for hip arthroscopy was failure of conservative treatment in patients with symptomatic femoroacetabular impingement. Results: During a minimum followup of 2 years, nine patients (5.5%) developed ITBS. All patients were diagnosed with ITBS within the first 45 postoperative days. Conservative treatment was successful in 6 patients while 3 had to undergo surgery. The increased internal rotation, synovitis and increased adduction of the hip can be attributed as predisposing factors to the development of ITBS. Conclusions: This is a newly described observation within followup of hip arthroscopy. These findings may help orthopedic surgeons when planning rehabilitation after hip arthroscopy, including stretching exercises to prevent this syndrome.
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Delay in surgery predisposes to meniscal and chondral injuries in anterior cruciate ligament deficient knees p. 492
Ravi Gupta, Gladson David Masih, Gaurav Chander, Vikas Bachhal
DOI:10.4103/0019-5413.189606  
Background: Despite improvements in instability after anterior cruciate ligament (ACL) reconstruction, associated intraarticular injuries remain a major cause of concern and important prognostic factor for long term results as it may lead to osteoarthritis. Delay in ACL reconstruction has been in variably linked to increase in these injuries but there is lack of consensus regarding optimal timing of reconstruction. The goal of this study was to investigate delay in surgery and other factors, associated with intraarticular injuries in ACL deficient knees. Materials and Methods: A total of 438 patients (42 females; 396 males) enrolled for this prospective observational study. The average age of patients was 26.43 (range 17–51 years) years with a mean surgical delay of 78.91 (range 1 week - 18 years) weeks after injury. We analyzed the factors of age, sex, surgical delay, instability, and level of activity for possible association with intraarticular injuries. Results: Medial meniscus injuries had a significant association with surgical delay (P = 0.000) after a delay of 6 months. Lateral meniscus injuries had a significant association with degree of instability (P = 0.001). Medial-sided articular injuries were significantly affected by age (0.005) with an odds ratio (OR) of 1.048 (95% confidence interval [CI] of 1.014–1.082) reflecting 4.8% rise in incidence with each year. Lateral-sided injuries were associated with female sex (P = 0.018) with OR of 2.846 (95% CI of 1.200–6.752). The level of activity failed to reveal any significant associations. Conclusion: Surgical delay predicts an increase in medial meniscal and lateral articular injuries justifying early rather than delayed reconstruction in ACL deficient knees. Increasing age is positively related to intraarticular injuries while females are more susceptible to lateral articular injuries.
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Preoperative magnetic resonance imaging evaluation of semitendinosus tendon in anterior cruciate ligament reconstruction: Does this have an effect on graft choice? p. 499
Mutlu Cobanoglu, Ferit Tufan Ozgezmez, Imran Kurt Omurlu, Ilhan Ozkan, Sevki Oner Savk, Emre Cullu
DOI:10.4103/0019-5413.189612  
Background: Anterior cruciate ligament (ACL) reconstruction with ST autograft is sometimes unsuccessful because of harvested thin graft. Magnetic resonance imaging (MRI) can be a useful tool to evaluate the thickness of the graft. This study is performed to evaluate whether there is any correlation between diameters and cross-sectional area (CSA) of the semitendinosus tendon (ST) on the preoperative magnetic MRI and the diameter of the 4-stranded ST autograft in ACL reconstruction. Materials and Methods: Seventy patients who underwent single-bundle ACL reconstruction with 4-stranded ST for full-thickness ACL ruptures were included in this study. Anteroposterior (AP) and mediolateral (ML) diameters of ST at the levels of the joint line (JL) and femoral physeal line (PL), and also CSA at these levels were measured on T2-weighted fat-suppressed MRI examinations. The data obtained were compared with intraoperatively measured diameters of 4-stranded ST autograft. Correlations between variables were evaluated using Spearman's rho. Receiver operating characteristic and area under the curve statistics were used to evaluate the cut-off value for the correlation between 4-stranded ST graft diameter of 8 mm and CSA (mm2) on MRI. Results: On MRI measurements, no correlation was found between AP diameters at the level of the JL and 4-stranded ST diameter (P = 0.180). However, correlations were found between diameter of 4-stranded ST and ML diameter at the level of JL (P = 0.003) and PL (P = 0.002), AP diameter at the level of the PL (P = 0.009), CSA at the level of the JL (P < 0.001) and at the level of PL (P < 0.001). Correlation between the diameter of 4-stranded ST and CSA at both levels was more significant than that between AP-ML diameters of ST and diameter of autograft. The cut-off value for the 8 mm diameter CSA of 4-stranded ST was 5.9 mm2 at the JL and 8.99 mm2 at the PL. Conclusion: Preoperative MRI evaluation of CSA at the JL of the ST is a reliable parameter to predict graft size. Other graft alternatives should better be considered if the CSA of ST is <5.9 mm2 at the level of the JL.
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Single-bundle versus double-bundle anterior cruciate ligament reconstruction: A comparative study with propensity score matching p. 505
Jeong-Ku Ha, Dhong-Won Lee, Jin-Goo Kim
DOI:10.4103/0019-5413.189605  
Background: Numerous studies have elucidated the functional anatomy and biomechanics of the anterior cruciate ligament (ACL), as a result, double-bundle (DB) ACL reconstruction has received much attention and has become a popular choice because it gives better rotational stability. Many other studies, however, found no differences with respect to stability, and/or other clinical outcomes between the DB and single-bundle (SB) techniques. There is still not enough evidence as to whether the anatomical DB anterior cruciate ligament reconstruction (ACLR) is superior to anatomical SB reconstruction. The purpose of this study is to compare various clinical and functional outcomes between SB and DBACLR at 2 years followup. Materials and Methods: Medical records of patients with ACLR available for at least 2 years followup were reviewed retrospectively. 191 patients (164 males and 25 females) for SB and 48 patients (40 males and 8 females) for DB were selected using the inclusion and exclusion criteria. The mean age of SB and DB was 29.9 and 24.8 years, respectively. Propensity score (PS) was calculated based on age, sex and Tegner activity score and 48 patients in each group were matched by the PS. Lysholm score, International Knee Documentation Committee (IKDC) subjective knee score and Tegneractivity score were investigated. Functional performance tests, isokinetic muscle strength test with Biodex system, pivot shift test and KT-2000 arthrometer test were performed. Results: At 2 years followup, there were no significant differences between SB and DB group in Lysholm score (92.9 vs. 90.6, P = 0.224), IKDC subjective knee score (88.7 vs. 87.0, P= 0.524), Tegner activity score (7.3 vs. 8.0, P = 0.059). No significant differences were also found in all functional performance tests, isokinetic muscle strength tests in 60° and 180°/s, KT-2000 arthrometer test and pivot shift test (P > 0.05). Conclusions: There were no significant differences of clinical and functional outcomes between SB and DB ACLR at 2 years followup.
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Patient - implant dimension mismatch in total knee arthroplasty: Is it worth worrying? An Indian scenario p. 512
Jai Thilak, Melvin J George
DOI:10.4103/0019-5413.189618  
Background: The correct sizing of the components in both anteroposterior and mediolateral (ML) dimensions is crucial for the success of a total knee arthroplasty (TKA). The size of the implants selected is based on the intraoperative measurements. The currently used TKA implants available to us are based on morphometric measurements obtained from a Western/Caucasian population. Hence, the risk of component ML mismatch is more common in Asian sub-population, as they are of a smaller built and stature. This study aims to look into the following aspects agnitude of the ML mismatch between the femoral component and the patient's anatomical dimension, evaluation of gender variations in distal femur dimensions, and gender-wise and implant-wise correlation of ML mismatch. Materials and Methods: Intraoperatively, the distal femoral dimensions were measured using sterile calipers after removing the osteophytes and compared with the ML dimension of the implant used. ML mismatch length thus obtained is correlated with the various parameters. Results: Males showed larger distal femoral dimensions when compared to females. Males had larger ML mismatch. None of the implants used perfectly matched the patient's anatomical dimensions. Patients with larger mismatch had lower scorings at 2 years postoperative followup. Conclusion: Implant manufacturers need to design more options of femoral implants for a better fit in our subset of patients. The exact magnitude of mismatch which can cause functional implications need to be made out. The mismatch being one of the important factors for the success of the surgery, we should focus more on this aspect.
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Epidemiology of knee osteoarthritis in India and related factors p. 518
Chandra Prakash Pal, Pulkesh Singh, Sanjay Chaturvedi, Kaushal Kumar Pruthi, Ashok Vij
DOI:10.4103/0019-5413.189608  
Background: Among the chronic rheumatic diseases, hip and knee osteoarthritis (OA) is the most prevalent and is a leading cause of pain and disability in most countries worldwide. Its prevalence increases with age and generally affects women more frequently than men. OA is strongly associated with aging and heavy physical occupational activity, a required livelihood for many people living in rural communities in developing countries. Determining region-specific OA prevalence and risk factor profiles will provide important information for planning future cost effective preventive strategies and health care services. Materials and Methods: The study was a community based cross sectional study to find out the prevalence of primary knee OA in India which has a population of 1.252 billion. The study was done across five sites in India. Each site was further divided into big city, small city, town, and village. The total sample size was 5000 subjects. Tools consisted of a structured questionnaire and plain skiagrams for confirmation of OA. Diagnosis was done using Kellgren and Lawrence scale for osteoarthritis. Results: Overall prevalence of knee OA was found to be 28.7%. The associated factors were found to be female gender (prevalence of 31.6%) (P = 0.007), obesity (P = 0.04), age (P = 0.001) and sedentary work (P = 0.001). Conclusions: There is scarcity of studies done in India which has varied socio geographical background and communities. We conducted this study for analyzing the current prevalence of OA in different locations. This study has evidenced a large percentage of population as borderline OA; therefore, it depends mainly on the prevention of modifiable risk factors to preserve at ease movement in elderly population through awareness programs.
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Reconstruction of Kuwada grade IV chronic achilles tendon rupture by minimally invasive technique p. 523
Xudong Miao, Yongping Wu, Huimin Tao, Disheng Yang, Lu Huang
DOI:10.4103/0019-5413.189599  
Background: Transfer of a flexor hallucis longus (FHL) tendon can not only reconstruct the Achilles tendon but also provide ischemic tendinous tissues with a rich blood supply to enhance wound healing. This retrospective study aims to investigate clinical outcomes in patients who underwent repair of Kuwada grade IV chronic Achilles tendon rupture with long hallucis longus tendons harvested using a minimally invasive technique. Materials and Methods: 35 patients who were treated for Kuwada grade IV Achilles tendon injuries from July 2006 to June 2011 were included in this retrospective study. The age ranged between 23 and 71 years. The duration from primary injury to surgery ranged from 29 days to 34 months (mean value, 137.6 days). All 35 patients had difficulties in lifting their calves. Thirty two were followed up for a mean 32.2 months (range 18–72 months), whereas three were lost to followup. Magnetic resonance imaging (MRI) showed that the tendon rupture gap ranged from 6.0 to 9.2 cm. During surgery, a 2.0 cm minor incision was made vertically in the medial plantar side of the midfoot, and a 1.5 cm minor transverse incision was made in the plantar side of the interphalangeal articulation of the great toe to harvest the FHL tendon, and the tendon was fixed to the calcaneus with suture anchors. Postoperative appearance and function were evaluated by physiotherapists based American Orthopedic Foot and Ankle Society-ankle and hindfoot score (AOFAS-AH), and Leppilahti Achilles tendon ratings. Results: Results were assessed in 32 patients. Except for one patient who suffered complications because of wound disruption 10 days after the operation, all other patients had primary wound healing, with 28 of 32 able to go up on their toes at last followup. The AOFAS-AH score was increased from preoperative (51.92 ± 7.08) points to (92.56 ± 6.71) points; Leppilahti Achilles tendon score was increased from preoperative (72.56 ± 7.43) to (92.58 ± 5.1). There were statistically significant differences. The result of the total excellent and good rate was 93.8% (30/32). MRI of Achilles tendon showed even signal without evidence of tear or cystic degeneration. Conclusion: Reconstruction of a chronic Achilles tendon rupture with an FHL tendon harvested using a minimally invasive technique showed good outcomes.
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Evaluation of Ponseti method in neglected clubfoot p. 529
Abhinav Sinha, Anil Mehtani, Alok Sud, Vipul Vijay, Nishikant Kumar, Jatin Prakash
DOI:10.4103/0019-5413.189597  
Background: Gentle passive manipulation and casting by the Ponseti method have become the preferred method of treatment of clubfoot presenting at an early age. However, very few studies are available in literature on the use of Ponseti method in older children. We conducted this study to find the efficacy of Ponseti method in treating neglected clubfoot, which is a major disabler of children in developing countries. Materials and Methods: 41 clubfeet in 30 patients, presenting after the walking age were evaluated to determine whether the Ponseti method is effective in treating neglected clubfoot. This is a prospective study. Pirani and Dimeglio scoring were done for all the feet before each casting to monitor the correction of deformity. Quantitative variables were expressed as mean ± standard deviation and compared between preoperative and postoperative followup using the paired t-test. Also, the relation between the Pirani and Dimeglio score, and age at presentation with the number of casts required was evaluated using Pearson's correlation coefficient. No improvement in Dimeglio or Ponseti score after 3 successive cast was regarded as failure of conservative management in our study. Results: The mean age at presentation was 3.02 years (range 1.1 - 10.3 years). The mean followup was 2.6 years (range 2–3.9 years). The mean number of casts applied to achieve final correction were 12.8 casts (range 8 - 18 casts). The mean time of immobilization in cast was 3.6 months. The mean Dimeglio score before treatment was 15.9 and after treatment were 2.07. The mean Pirani score was 5.41 before treatment and 0.12 after treatment. All feet (100%) achieved painless plantigrade feet without any extensive soft tissue surgery. 7 feet (17%) recurred in our average followup of 2.6 years. Conclusions: Painless, supple, plantigrade, and cosmetically acceptable feet were achieved in neglected clubfeet without any extensive surgery. A fair trial of conservative Ponseti method should be tried before resorting to extensive soft tissue procedure.
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Negative pressure wound therapy for Gustilo Anderson grade IIIb open tibial fractures p. 536
Chul Hyun Park, Oog Jin Shon, Gi Beom Kim
DOI:10.4103/0019-5413.189604  
Background: Traditionally, Gustilo Anderson grade IIIb open tibial fractures have been treated by initial wide wound debridement, stabilization of fracture with external fixation, and delayed wound closure. The purpose of this study is to evaluate the clinical and radiological results of staged treatment using negative pressure wound therapy (NPWT) for Gustilo Anderson grade IIIb open tibial fractures. Materials and Methods: 15 patients with Gustilo Anderson grade IIIb open tibial fractures, treated using staged protocol by a single surgeon between January 2007 and December 2011 were reviewed in this retrospective study. The clinical results were assessed using a Puno scoring system for severe open fractures of the tibia at the last followup. The range of motion (ROM) of the knee and ankle joints and postoperative complication were evaluated at the last followup. The radiographic results were assessed using time to bone union, coronal and sagittal angulations and a shortening at the last followup. Results: The mean score of Puno scoring system was 87.4 (range 67–94). The mean ROM of the knee and ankle joints was 121.3° (range 90°–130°) and 37.7° (range 15°–50°), respectively. Bone union developed in all patients and the mean time to union was 25.3 weeks (range 16–42 weeks). The mean coronal angulation was 2.1° (range 0–4°) and sagittal was 2.7° (range 1–4°). The mean shortening was 4.1 mm (range 0–8 mm). Three patients had partial flap necrosis and 1 patient had total flap necrosis. There was no superficial and deep wound infection. Conclusion: Staged treatment using NPWT decreased the risks of infection and requirement of flap surgeries in Gustilo Anderson grade IIIb open tibial fractures. Therefore, staged treatment using NPWT could be a useful treatment option for Gustilo Anderson grade IIIb open tibial fractures.
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Human autologous mesenchymal stem cells with extracorporeal shock wave therapy for nonunion of long bones p. 543
Lei Zhai, Xin-Long Ma, Chuan Jiang, Bo Zhang, Shui-Tao Liu, Geng-Yan Xing
DOI:10.4103/0019-5413.189602  
Background: Currently, the available treatments for long bone nonunion (LBN) are removing of focus of infection, bone marrow transplantation as well as Ilizarov methods etc. Due to a high percentage of failures, the treatments are complex and debated.To develop an effective method for the treatment of LBN, we explored the use of human autologous bone mesenchymal stems cells (hBMSCs) along with extracorporeal shock wave therapy (ESWT). Materials and Methods: Sixty three patients of LBN were subjected to ESWT treatment and were divided into hBMSCs transplantation group (Group A, 32 cases) and simple ESWT treatment group (Group B, 31 cases). Results: The patients were evaluated for 12 months after treatment. In Group A, 14 patients were healed and 13 showed an improvement, with fracture healing rate 84.4%. In Group B, eight patients were healed and 13 showed an improvement, with fracture healing rate 67.7%. The healing rates of the two groups exhibited a significant difference (P < 0.05). There was no significant difference for the callus formation after 3 months treatment (P > 0.05). However, the callus formation in Group A was significantly higher than that in the Group B after treatment for 6, 9, and 12 months (P < 0.05). Conclusion: Autologous bone mesenchymal stems cell transplantation with ESWT can effectively promote the healing of long bone nonunions.
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Retrospective cohort study comparing the efficacy of prednisolone and deflazacort in children with muscular dystrophy: A 6 years' experience in a South Indian teaching hospital p. 551
Harish Petnikota, Vrisha Madhuri, Sangeet Gangadharan, Indira Agarwal, Belavendra Antonisamy
DOI:10.4103/0019-5413.189609  
Background: Muscular dystrophies are inherited myogenic disorders characterized by progressive muscle wasting and weakness of variable distribution and severity. They are a heterogeneous group characterized by variable degree of skeletal and cardiac muscle involvement. The most common and the most severe form of muscular dystrophy is DMD. Currently, there is no curative treatment for muscular dystrophies. Several drugs have been studied to retard the progression of the muscle weakness. There is much controversy about steroid usage in muscular dystrophy with respect to regimen, adverse effects, and whether long term benefits outweigh side effects. This study is to assess steroid efficacy in children with muscular dystrophy. Materials and Methods: All children with diagnosed muscular dystrophy by muscle biopsy, immunohistochemistry and/or genetic test were enrolled in the study. They were started on either prednisolone (0.75 mg/kg/day) or deflazacort 0.9 mg/kg/day based on affordability. All were followed up every 6 months with clinical assessment, quality of life questionnaire and clinical and laboratory assessment of side effects. Outcome measures of children on deflazacort and prednisolone at 1 year followup were summarized as numbers and percentages and were compared using Fisher's exact test. Results: Twenty two children with muscular dystrophy were included (prednisolone group: 10 and deflazacort group: 12). The mean age was 7.7 years at an average followup of 26.4 months. Twenty children were diagnosed to have Duchenne's; one had Becker's muscular dystrophy while one had sarcoglycanopathy by Type 2C. All children from prednisolone group maintained their ambulatory status at 2 and 4 years followups while three on deflazacort lost their ability to walk at an average age of 11.3 years. All activities of daily living were found to be better in prednisolone group. Muscle function and time taken to walk improved in prednisolone group. Weight gain in children on prednisolone was three times more. Conclusions: Prednisolone is more beneficial than deflazacort at doses of 0.75 mg/kg/day and 0.9 mg/kg/day, respectively, however it is associated with adverse effects.
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Radiologic and histological observations in experimental T1–T12 dorsal arthrodesis: A qualitative description of T1-T12 segment and other body parts involved, between prepubertal age and skeletal maturityxs p. 558
Federico Canavese, Alain Dimeglio, Davide Barbetta, Marco Galeotti, Bartolomeo Canavese, Fabio Cavalli
DOI:10.4103/0019-5413.189600  
Background: This experimental study provides a qualitative description and the morpho-structural features of the fusions taking place in the thoracic spine between prepubertal age and skeletal maturity. There is a lack of informations regarding the influence of partial or total dorso-thoracic vertebral arthrodesis on the development of the thoracic cage as well as its potential effects on different intra and extra-thoracic organs. This study admits the hypothesis that vertebral arthrodesis may have influence on other body areas and so, it intends to verify the possible secondary involvement of other body parts, such as intervertebral discs, cervical and thoracic spinal ganglia, sternocostal cartilage, ovaries and lungs. Materials and Methods: Fifty-four female New Zealand white rabbits were submitted to dorsal arthrodesis. The radiologic imaging and light microscopy histological pictures were taken and studied in all. Computed tomography (CT) scan measurements were performed in operated and sham operated rabbits at different time. Similarly, histological specimens of intervertebral discs, cervical and thoracic spinal ganglia, sternocostal cartilage, ovaries and lungs were analyzed at different times. The study ended at the age of 17–18 months. Results: Most rabbits had formed a fusion mass, which was only fibrous at first, then osteofibrous and finally, in the older subjects, structured in lamellar-osteon tissue. Intervertebral foramens were negatively involved in vertebral arthrodesis, as shown by CT scans. Intervertebral discs showed irregular aspects. The increase of atresic follicles and the reduction of primordial follicles in operated rabbits led to the hypothesis of a cause-effect relationship between arthrodesis and modified hormonal status. Dorsal root ganglia showed microscopic alterations in operated rabbits especially. Conclusions: The process of fusion mass and bone formation, associated with the arthrodesis, involves at different degrees of the vertebral bodies, discs and intervertebral foramens, ganglia and spinal nerve roots.
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CASE REPORTS Top

Life-threatening paraspinal muscle hematoma after percutaneous vertebroplasty p. 567
Chang-Hoon Jeon, Nam-Su Chung, Jae-Heon Lee, Han-Dong Lee
DOI:10.4103/0019-5413.189601  
Bleeding and hematoma formation is rarely reported in percutaneous vertebroplasty procedure. An 84 year old male presented with a large paraspinal muscle hematoma after a percutaneous vertebroplasty. The patient had neither any prior bleeding disorder nor any anticoagulant treatment. Vital signs of the patient were unstable, and his hemoglobin level decreased daily. After a month of conservative treatment, including transfusion, cryotherapy, pain control and bed rest, his hemoglobin level remained stable and he showed relief from pain. Four months later, hematoma resolved spontaneously and he could walk without back pain.
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Posterior dislocation of hip with ipsilateral intertrochanteric fracture: A report of two cases p. 571
Rehan Ul Haq, Jaswant Kumar, IK Dhammi, Anil K Jain
DOI:10.4103/0019-5413.189614  
Posterior dislocations of the hip are known to be associated with fractures of the femoral head, neck, shaft, or posterior acetabular wall. However, its association with ipsilateral intertrochanteric fracture has only been anecdotally described in the English literature. We report two such cases managed by open reduction (OR) of the hip and internal fixation (IF) of the intertrochanteric fracture. The first case was a 26-year-old male who was managed by OR of the hip with IF of the intertrochanteric fracture with a dynamic hip screw and had a good functional result at 1-year followup. The second case was a 36-year-old female who was also managed by OR of the hip with IF of the head fragments with Herbert screw and IF of the intertrochanteric fracture with a dynamic condylar screw. The patient had a fair, functional result at 1-year followup. With the increase in high energy trauma, these fracture patterns have become more common, and there is an urgent need to review the existing classifications so that these fractures are better categorized, and treatment guidelines defined.
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LETTERS TO EDITOR Top

What is indexing? p. 577
BV Murlimanju, Latha V Prabhu, MD Prameela, Mangala M Pai, Vasudha V Saralaya
DOI:10.4103/0019-5413.189598  
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Author's reply p. 578
Ish Kumar Dhammi, Rehan Ul Haq
DOI:10.4103/0019-5413.189603  
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RETRACTION NOTICE Top

Retraction: Hip spica versus Rush pins for management of femoral diaphyseal fractures in children p. 579

DOI:10.4103/0019-5413.189615  
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