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   Table of Contents - Current issue
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November-December 2019
Volume 53 | Issue 6
Page Nos. 679-787

Online since Monday, October 7, 2019

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EDITORIAL  

Heralding change: The evolution of the IJO in 2019 Highly accessed article p. 679
Murali Poduval, Lalit Maini
DOI:10.4103/ortho.IJOrtho_555_19  PMID:31673165
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ORIGINAL ARTICLES: KNEE Top

Chondromalacia patella among military recruits with anterior knee pain: Prevalence and association with patellofemoral malalignment Highly accessed article p. 682
Meltem Ozdemir, Rasime Pelin Kavak
DOI:10.4103/ortho.IJOrtho_655_18  PMID:31673166
Background: The aim of this study was to investigate the frequency of chondromalacia patella (CMP) and to evaluate its relation with trochlear morphometric and patellofemoral alignment measurements as well as with edema in superolateral region of Hoffa's fat pad (SHFP) in military recruits with anterior knee pain (AKP). Materials and Methods: Knee magnetic resonance imaging examinations of 288 military recruits with AKP were retrospectively evaluated. Patellar cartilage lesions were graded using modified Noyes system. Quantitative measurements of trochlear morphology (sulcus angle, trochlear sulcus depth, and lateral trochlear inclination [LTI]) and patellofemoral alignment (patellar translation [PT], lateral patellofemoral angle (LPA), Insall-Salvati index, and tibial tuberosity-trochlear groove distance) were made. The SHFP region was assessed for the presence of edema. Mean values of measurements in knees with and without CMP and in knees with early and advanced stage CMP were compared. Results: We found CMP in 169 (58.7%) patients. Patients with CMP demonstrated a significantly greater sulcus angle (P = 0.012), smaller LTI (P = 0.004), greater PT (P = 0.01), smaller LPA (P = 0.036), greater Insall-Salvati ratio (P = 0.034), and higher incidence of SHFP edema (P = 0.001) compared to those without CMP. While none of the measurements were associated with the severity of cartilage damage, the incidence of SHFP edema was significantly correlated with the severity of CMP (P = 0.001). Conclusion: CMP is a common disorder among military recruits with AKP. Patellofemoral malalignment is an important contributory factor in the development of CMP, and the presence of edema in SHFP may be a strong indicator of underlying severe CMP in this population.
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Monofilament cerclage wiring fixation with locking plates for distal femoral fracture: Is it appropriate? p. 689
Sung Hyun Lee, Young Chae Choi, Suc Hyun Kweon
DOI:10.4103/ortho.IJOrtho_269_18  PMID:31673167
Purpose: We aimed to determine the efficacy of cerclage wiring by comparing the clinical and radiological results between internal fixation with locking plates after distal femoral fracture reduction with or without cerclage wiring. Materials and Methods: One hundred and one patients who received open reduction internal fixation for distal femoral fractures of oblique, spiral, and spiral wedge type between 2007 and 2014 were reviewed retrospectively. Only locking plate fixation was performed in 46 patients, and locking plate fixation with additional cerclage wiring was performed in 55 patients (Group CW). Demographic, clinical, and radiologic factors were evaluated in both the groups. Age, gender, bone mineral density, bone graft, and the presence of concomitant fractures were measured as demographic factors. The range of motion of knee joint, Lysholm knee score, visual analog scale score, procedure time, and C-arm time were measured as clinical factors preoperatively and at the final followup. We also evaluated the duration of bone union and knee joint alignment radiologically. Results: There were no demographic differences between the two groups. Furthermore, there were no statistically significant differences between the two groups in terms of clinical and radiological parameters. However, the procedure time used was significantly longer in Group LP than in Group CW (108.4 vs. 95.2 min; P= 0.027). The C-arm time was longer in Group LP (2.8 vs. 1.2 s; P= 0.017). Conclusions: Open reduction and locking plate fixation with additional cerclage wiring is a useful method for the reduction of complicated distal femoral fractures, without increased complications such as nonunion. Level of Evidence: Level III, retrospective cohort design, treatment study.
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Cement pedestal spacer technique for infected two-stage revision knee arthroplasty: Description and comparison of complications p. 695
Ahsan Akhtar, Chris Mitchell, Catarina Assis, Farhad Iranpour, Anna Kropelnicki, Robin Strachan
DOI:10.4103/ortho.IJOrtho_90_19  PMID:31673168
Background: Infection following total knee arthroplasty (TKA) is a significant complication, with an incidence of up to 2% in primary TKA and 4%–8% in revision cases. Two-stage revision is the gold standard treatment for long-lasting infections of TKA. The purpose of this study was to describe the cement pedestal spacer technique used in infected two-stage revision knee arthroplasty and compare complications against conventional fixed and mobile cement spacers. Patients and Methods: A retrospective review was conducted in all cases who underwent two-stage TKA revision for infection between 2009 and 2015. These cases were separated into groups depending on the cement spacer utilized (fixed, mobile nonpedestal, and mobile spacers with cement pedestal). The cement pedestal technique involves press fitting a cement cylinder into the femur before definitive spacer insertion. Results: Forty four patients underwent two-stage revision TKA. Fewest complications were observed in the pedestal group, with no spacers having subluxed/tilted. The longest followup was also observed in the pedestal group (mean 52.5 months). Mobile spacers with no cement pedestal displayed the highest reinfection rate (16.7%) and the greatest number of cases with complications (malalignment, subluxation, tilting, and spacer fracture). All patients in the pedestal group were ambulatory after the first-stage revision. Conclusions: The cement pedestal technique minimizes complications by optimizing component positioning and balancing. It also safely extends the indication for an articulated spacer into a set of cases with more extensive bone loss and allows for extended monitoring of inflammatory markers.
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Improved pain and function in knee osteoarthritis with dexamethasone phonophoresis: A randomized controlled trial p. 700
Mohamed Ahmed Said Ahmed, Emad Samuel Boles Saweeres, Nasr Awad Abdelkader, Salwa Fadl Abdelmajeed, Ahmed Roshdy Fares
DOI:10.4103/ortho.IJOrtho_639_18  PMID:31673169
Background: Intraarticular corticosteroid injection is an adjunct to core treatments for relief of moderate-to-severe pain in osteoarthritis (OA) patients. This randomized controlled trial was conducted to determine the effect of dexamethasone phonophoresis (DxPh) on knee OA. Patients and Methods: Forty six female patients with knee OA were randomized into two equal groups. The study group received DxPh over the medial side of the knee, transcutaneous electrical nerve stimulation (TENS), and quadriceps strengthening exercises. Control group received ultrasound therapy and the same TENS and exercise program. Pain was assessed using the visual analog scale (VAS) and the pain subscale of Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pre- and posttreatment. Functional mobility was assessed by the Timed Up and Go (TUG) test, total WOMAC, and the joint stiffness and physical function subscales of WOMAC. The minimal clinically identifiable difference was used to calculate treatment effect sizes of both modalities, which was compared to intraarticular steroid injections. Results: The VAS, TUG, and WOMAC scores improved with both modalities. Pain intensity improved by 50.6%–58.0% in the study group (VAS and pain subscale of WOMAC, respectively) compared to 17.8%–28.6% for the control group. Functional mobility showed a higher rate of improvement in the DxPh group compared to control (37.7 vs. 17.5% for TUG and 53.2 vs. 23.0 and 56.1 vs. 26.4% for the joint stiffness and physical function subscales of WOMAC, respectively). Posttreatment results revealed statistically and clinically significant improvement in pain intensity and functional mobility in the DxPh group. Conclusion: DxPh resulted in a greater improvement in pain and function in patients with knee OA than therapeutic ultrasound combined with exercise and TENS. The effect size of phonophoresis was clinically significant and higher than that reported for intraarticular steroid injection from pooled data in the literature.
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Effectiveness and safety of the combined use of tranexamic acid: A comparative observational study of 1909 cases p. 708
Charles-Herve Vacheron, Pascal Roy, Pierre Yves Petit, James Appery, Michel Fessy, Vincent Piriou, Anthony Viste, Arnaud Friggeri
DOI:10.4103/ortho.IJOrtho_148_19  PMID:31673170
Background: Tranexamic acid (TA) use in lower-limb arthroplasty has been valued in these surgeries high-risk hemorrhagic due to its antifibrinolytic action. The objective of the present study was to determine the effectiveness of the combined intravenous (IV) and intraarticular (IA) administration of TA in lower-limb arthroplasty. Methods: We conduct a prospective observational study between January 1, 2014, and December 31, 2017, including all programmed lower-limb arthroplasties. Patients were divided into four groups: no TA, 15 mg/kg IV TA, 3 g IA TA, and 15 mg/kg IV and 3 g IA. The effect on calculated total blood loss (milliliter of red blood cell [RBC]), hemoglobin, transfusion, and duration of hospitalization was studied after adjustment on age, American Society of Anesthesiologists, surgery, and postoperative curative anticoagulation. Complications related to TA administration were systematically reported. Results: A total of 1909 patients were included – “no TA,” n = 184; “IV,” n = 1137; “IA,” n = 214; and “IV + IA,” n = 374. In the IV + IA group, a decrease in blood loss was observed compared to the no TA group (+220 ml 95% confidence interval [CI] [184; 255] of RBCP < 0.001) and in the IA group (+65 ml 95% CI [30; 99] of RBCP < 0.001). The length of hospital stay of the IV + IA group was shorter compared to the no TA group (hazard ratio [HR] 0.35, 95% CI [0.29; 0.43],P < 0.001) to the IA group (HR 0.57, 95% CI [0.48; 0.69],P < 0.001) and the IV group (HR 0.45, 95% CI [0.39; 0.50],P < 0.001). One case of deep vein thrombosis occurred in the group without TA. Conclusion: Administration of combined TA appears effective and safe; further studies are needed in order to establish a consensual protocol.
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Failure to return to preinjury activity level after hamstring anterior cruciate ligament reconstruction: Factors involved and considerations in goal setting p. 714
Jonathan D Kosy, Jonathan RP Phillips, Adaeze Edordu, Rahul Pankhania, Peter J Schranz, Vipul Mandalia
DOI:10.4103/ortho.IJOrtho_186_18  PMID:31673171
Background: Recent interest in the return to sports, following anterior cruciate ligament reconstruction, has focused on the influence of psychological factors. However, many factors contribute to this endpoint. This study aimed to investigate the ability of nonprofessional athletes to return alongside the reasons for failure. Materials and Methods: We retrospectively studied 101 postreconstruction patients with followup in excess of 12 months. All patients underwent hamstring autograft anterior cruciate reconstruction. The Cincinnati Sports Activity Scale was used to define activity level preinjury, postinjury, and postreconstruction. Structured questionnaires were used to identify factors in those who did not return to the same level. Results: Seventy percent of patients returned to their preinjury activity score. Of the 30% of patients who failed, age, reconstruction type, and associated pathology were unrelated. However, reconstruction within 6 months of injury resulted in increased return to preinjury score (P < 0.05). Failure was associated with continued knee symptoms (57%), lifestyle changes (27%), anxiety (27%), fear (23%), and other musculoskeletal problems (10%). Considerable interplay was found between these factors. Failure to return was associated with increased further surgery, but this was successful in only one-third of patients. Conclusion: Psychological factors are important (and may require targeted input), but return-to-sport is multifactorial. Ongoing symptoms may prompt further surgery, but this is frequently unsuccessful in achieving return. Patient-specific goals should be sought and revisited throughout the rehabilitation program. Acknowledging psychological barriers, in those aiming to return to the same level, may help achieve this goal. In other patients, success may be return to a desired lower level. Understanding the patient's expectations is important in goal setting.
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No difference in outcome of anterior cruciate ligament reconstruction with “bone–patellar tendon-bone versus semitendinosus-gracilis graft with preserved insertion:” A randomized clinical trial p. 721
Ravi Gupta, Anil Kapoor, Ashwani Soni, Sourabh Khatri, Gladson David Masih, Mukta Raghav
DOI:10.4103/ortho.IJOrtho_214_19  PMID:31673172
Background: The type of graft for anterior cruciate ligament (ACL) reconstruction is still a topic of debate and there is still no clear consensus on the ideal graft for ACL reconstruction. Purpose: This study was conducted to compare the outcome of ACL reconstruction surgery between hamstring tendon graft and bone–patellar tendon-bone (BPTB) graft. Materials and Methods: One hundred and sixty professional athletes were enrolled in the study. They were divided into two groups by computerized randomization. In Group I, ACL reconstruction was done using BPTB graft, and in Group II, ACL reconstruction was done using semitendinosus gracilis graft with preserved tibial insertion (STGPI). Postoperatively, patients were assessed for knee stability, Lysholm score, and WOMAC score. Results: Mean KT-1000 side-to-side difference at 1 year was 2.31 ± 1.68 mm in BPTB cohort and 2.52 ± 1.6 mm in STGPI cohort (P = 0.4); and at 2 years, it was 1.98 ± 1.62 mm in BPTB cohort and 2.23 ± 1.6 mm in STGPI cohort (P = 0.4). Mean Lysholm score at 2 years was 96.1 ± 5.81 in STGPI cohort and 97.3 ± 4.62 in BPTB cohort (P = 0.15). Mean WOMAC score at 2 years was 3.3 ± 2.76 in STGPI cohort and 2.84 ± 2.21 in BPTB cohort (P = 0.25). Graft rupture rate was 3.75%; 3 patients in each group had graft rupture. Kneeling pain was present in 15% (12/80) of patients with BPTB graft whereas none of the patients in STGPI cohort had kneeling pain. Conclusion: There was no difference between two grafts in term of knee stability, visual analog scale score and functional outcome. However, hamstring tendon graft is associated with less donor site morbidity.
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Measurement of the whole and midsubstance femoral insertion of the anterior cruciate ligament: The comparison with the elliptically calculated femoral anterior cruciate ligament footprint area p. 727
Genki Iwama, Takanori Iriuchishima, Takashi Horaguchi, Shin Aizawa
DOI:10.4103/ortho.IJOrtho_434_18  PMID:31673173
Purpose: The purpose of this study was to measure the detailed morphology of the femoral anterior cruciate ligament (ACL) footprint. The correlation and the comparison between the measured area and the area which mathematically calculated as elliptical were also evaluated. Materials and Methods: Thirty nine nonpaired human cadaver knees were used. The ACL was cut in the middle, and the femoral bone was cut at the most proximal point of the femoral notch. The ACL was carefully dissected, and the periphery of the ACL insertion site was outlined on both the whole footprint and the midsubstance insertion. Lateral view of the femoral condyle was photographed with a digital camera, and the images were downloaded to a personal computer. The area, length, and width of the femoral ACL footprint were measured with Image J software (National Institution of Health). Using the length and width of the femoral ACL footprint, the elliptical area was calculated as 0.25 π (length × width). Statistical analysis was performed to reveal the correlation and the comparison of the measured and elliptically calculated area. Results: The sizes of the whole and midsubstance femoral ACL footprints were 127.6 ± 41.7 mm[2] and 61 ± 20.2 mm[2], respectively. The sizes of the elliptically calculated whole and midsubstance femoral ACL footprints were 113.9 ± 4.5 mm[2] and 58.4 ± 3 mm[2], respectively. Significant difference was observed between the measured and the elliptically calculated area. In the midsubstance insertion, significant correlation was observed between the measured and the elliptically calculated area (Pearson's correlation coefficient = 0.603, P= 0.001). However, no correlation was observed in the whole ACL insertion area. Conclusion: The morphology of the femoral ACL insertion resembles an elliptical shape. However, due to the wide variation in morphology, the femoral ACL insertion cannot be considered mathematically elliptical.
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CASE REPORTS: KNEE Top

Arthroscopic excision of angio-fibro-lipomatous hamartoma of the knee: A rare case report p. 732
Silvampatti R Sundararajan, Ramakanth Rajagopalakrishnan, Shanmuganathan Rajasekaran
DOI:10.4103/ortho.IJOrtho_330_18  PMID:31673174
Angio-fibro-lipomatous hamartoma is a benign adipose tissue tumor very rarely seen in musculoskeletal distribution, and its incidence in the knee joint has never been reported. The patient in our case presented with knee pain of 2 years' duration, following blunt trauma. Preoperatively, veno-lymphatic malformation/hemangioma was considered as the diagnosis. Only after arthroscopic excision biopsy, histopathological examination, retrospective radiological analysis, and a review of literature, we were able to diagnose this rare condition. The histopathological picture of this benign adipose tissue tumor contained a mixture of mature adipose tissue and fibrous and vascular tissues. Here, in this case report, we discuss about PTEN gene causing PTEN hamartoma of soft tissue and angiolipoma presentations and its variants.
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ORIGINAL ARTICLES: MISCELLANEOUS Top

Short term results of a new comprehensive protocol for the management of congenital pseudarthrosis of the Tibia p. 736
Sandeep Vijaykumar Vaidya, Alaric Aroojis, Rujuta Mehta, Mandar Vikas Agashe, Arjun Dhawale, Ankita Vijay Bansal, Kailash Sarathy
DOI:10.4103/ortho.IJOrtho_155_19  PMID:31673175
Background: Treatment of Congenital Psuedarthrosis of Tibia (CPT) often poses significant challenges due to difficulty in achieving union and subsequent complications like refractures, implant failures, etc. Our new comprehensive protocol is aimed at achieving crossunion between the tibia and fibula. Aims and objectives: The aim of the present study is to evaluate the short-term results of our new protocol and to compare the results with our previously used techniques. Materials and Methods: 10 patients with mean age 2.35 years (1 to 6.5 years) who were treated by our new comprehensive protocol were included in Group A, and 11 patients with mean age 2 years (1 to 5.5 years) who primarily underwent intramedullary rodding with bone graft were included in Group B. The new comprehensive protocol consisted of pre-operative Zolendronate infusion, surgery consisting of intramedullary fixation of tibia supplemented with Ilizarov ring fixator and bone grafting aimed at achieving tibia-fibula cross-union. Retrospective evaluation of serial radiographs was performed and outcomes with respect to union and subsequent complications were analysed. Results: 10/10 (100%) patients in Group A united, whereas union was achieved in only 8/11 (72%) patients in Group B. The index surgery was successful in achieving union in all 10 patients in Group A, whereas in Group B 2.25 (1 to 4) surgeries were needed to achieve union. The time to union was significantly shorter in Group A (4.68 months) as compared to Group B (30.88 months). The cross sectional area of union was significantly greater in Group A (3.82 cm2) as compared to Group B (1.18 cm2). One patient in Group A needed a subsequent corrective osteotomy for tibial valgus, and one patient underwent tibia lengthening; whereas in Group B, two patients needed corrective osteotomes for residual malaligments. Conclusion: Our study demonstrates that the new comprehensive protocol is extremely effective for achieving sound union in Congenital Pseudarthrosis of Tibia.
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Functional outcome of bell tawse procedure for the management of chronic unreduced monteggia fracture-dislocation in children p. 745
EG Mohan Kumar, GM Yathisha Kumar, Mohammed Noorudheen
DOI:10.4103/ortho.IJOrtho_47_19  PMID:31673176
Aim of Study: Unreduced or missed Monteggia fracture-dislocation after 4 weeks is a common presentation in a tertiary care center. The aim of this study is to study the functional outcome of Bell Tawse procedure for the management of chronic unreduced Monteggia fracture-dislocation in children. Materials and Methods: In this retrospective study with prospective data collection, 17 children were treated with open reduction of the radial head and annular ligament reconstruction (Bell Tawse) combined with ulnar osteotomy. The cases were classified based on Bado's classification. The minimum period of followup was 14 months and maximum followup was 18 months with the mean period of followup of 16.2 months. Preoperative and postoperative Mayo Elbow Performance Index (MEPI) scores were calculated. We also compared the preoperative and postoperative Kim's elbow functional scores. Results: At the final followup, the radial head was maintained in a completely reduced position in 16 children. Mean preoperative MEPI score was 76.76 and mean postoperative score was 91.11, which was statistically significant (P < 0.001). Mean preoperative Kim's score was 76.94 and mean postoperative score was 91.35, which was also statistically significant (P < 0.001). One girl had a mild subluxation of the radial head at 1-year followup. The ulnar osteotomy was united in all 17 children, and none of them required secondary procedures. We have not identified any complications such as compartment syndrome, infection, posterior interosseous nerve palsy, avascular necrosis of the radial head, or loss of range of motion. Conclusion: We recommend ulnar osteotomy, open reduction of the radial head, and annular ligament reconstruction in children with unreduced Monteggia fracture-dislocation before long term complications sets in.
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Demographic Study of Orthopedic Trauma among Patients Attending the Accident and Emergency Department in a Tertiary Care Hospital p. 751
Rajesh Kumar Rohilla, Sumit Kumar, Roop Singh, Ashish Devgan, Hari Singh Meena, Varun Arora
DOI:10.4103/ortho.IJOrtho_161_19  PMID:31673177
Background: Trauma causes a major burden on the health system and economy of the country. A better understanding of the epidemiology of trauma can be of great help in planning preventive and curative strategies. Materials and Methods: A total of 4834 patients of trauma presenting during 1 year were included in this observational study. Demographic profile and other related criteria were noted, and data were statistically analyzed. Results: Male to female ratio was 5:1; most affected age group was 25–44 years in males and 45–64 years in females; 23.2% were illiterate; and professionals and students were most commonly affected. Road traffic accident (RTA), fall, and assault were the three most common causes; two wheelers were the most common accident causing vehicle. Nearly 17.7% were below poverty line and 67.6% reached hospital within 12 h. Medicolegal cases were 29.7%; only 29.3% reached hospital by ambulance and 3.72% were hemodynamically unstable. Only 3.6% received prehospital care and 16.23% were under alcohol influence. About 23.18% of RTA victims were pedestrians; city roads were the most common accident site. Head injury (25.85%) was the most common associated injury. Fractures were most common in hand (9.72%). The injury severity score (ISS) and New ISS were worse in the patients who were not using seat belt/helmet or were under influence of alcohol. The rate of death and associated injuries was also higher in this group. Conclusion: Trauma is a major preventable cause of mortality and morbidity mainly affecting the productive age group of the society.
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Surgeon's neck posture during spine surgeries: “The unrecognised potential occupational hazard” p. 758
J Naresh-Babu, Viswanadha Arun-Kumar, D GS Raju
DOI:10.4103/ortho.IJOrtho_677_18  PMID:31673178
Study Design: Observational study. Purpose: The purpose of this study is to analyze the surgeon's neck postures while performing lumbar spinal surgeries. Overview of Literature: Lumbar spinal surgeries are on rising trend, and with increase in number of procedures, the average time spent by a spine surgeon performing surgical procedures is also increasing. The effect of operating posture on the surgeon's neck is largely unknown. From the studies conducted on usage of smartphones, abnormal neck postures, especially the forward head posture (FHP), were found to adversely affect the cervical spine of individuals. The present study analyzes the neck position of spine surgeons during lumbar spine surgeries. Methodology: Sixty video recordings (25 open transforaminal lumbar interbody fusions [TLIFs] and 35 lumbar decompression [LD] procedures – 15 with headlight and 20 with operating microscope) of surgeries performed by three spine surgeons of different heights were analyzed. Running videos of the surgeries were recorded concentrating on the surgeons with reflective markers taped to their surface landmarks corresponding to C7 spinous process, tragus of the ear, and outer canthus of the eye. Video recordings were standardized by a fixed video recorder in the same operating theater. Snapshots from the video were obtained whenever the surgeon changes the position. Head flexion angle (HFA), neck flexion angle (NFA), and cervical angle (CA) were measured and analyzed. Results: During TLIF, HFA and NFA were significantly higher during the phases of decompression and fusion (P < 0.05). The average CA of all surgeons was lower, thereby adversely affecting the cervical spine (20.15° ± 5.05°). During LD, CA showed significant difference between usage of microscope and headlight (P < 0.001). Conclusion: Surgeon's FHP is frequently caused by a compromise between the need to perform surgery with hands, without elevating the arms, and simultaneous control of gaze at surgical field. The usage of microscope was found to reduce the stress on neck while performing surgery.
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Outcomes of balloon kyphoplasty for the treatment of osteoporotic vertebral compression fracture in rheumatoid arthritis: A case–control study p. 763
Kyu-Tae Hwang, Young-Il Ko, Sang Hoon Park, Seung Gun Lee, Chang-Nam Kang
DOI:10.4103/ortho.IJOrtho_405_18  PMID:31673179
Background: Patients with rheumatoid arthritis (RA) have higher rate of osteoporosis and vertebral fracture than individuals without RA. This study aimed to compare the outcomes of balloon kyphoplasty (KP) performed to treat osteoporotic vertebral compression fracture (OVCF) in RA patients with the outcomes in non-RA patients. Materials and Methods: The patients who received KP for OVCF and could be followed up at least 1 year were included in the study. These patients were divided into RA group and non-RA group. For clinical outcomes, the visual analog scale for back pain (VAS-BP) and Korean version of the Oswestry Disability Index (K-ODI) were assessed before and after the procedure and at the 1-year followup. For radiological outcomes, the anterior vertebral height and change in local kyphotic angle were measured. Complications were also examined. Results: Twenty three RA patients (31 vertebral bodies) and 107 non-RA patients (124 vertebral bodies) were analyzed. In two groups, postoperative VAS-BP and K-ODI decreased significantly to similar extents. There was a similar recovery of vertebral height and kyphotic angle in two groups. However, in terms of complications, adjacent segment fracture and recollapse were more frequent in the RA group than in the non-RA group. Conclusions: The use of KP to treat OVCF in RA group exhibited similar outcomes to non-RA group in terms of pain reduction, vertebral height restoration, and kyphosis correction. However, RA group had significantly higher rate of complications involving adjacent segment fracture and recollapse. Therefore, careful followup after KP in patients with RA is required to monitor for high complication rate.
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Comparison of magnetic resonance arthrography and wrist arthroscopy in the evaluation of chronic wrist pain in Indian population p. 769
Nishank H Mehta, Bhavuk Garg, Tahir Ansari, Deep N Srivastava, Prakash P Kotwal
DOI:10.4103/ortho.IJOrtho_92_19  PMID:31673180
Background: The purpose of our study was to compare magnetic resonance arthrography (MRA) as a diagnostic modality against the gold standard of wrist arthroscopy in the evaluation of chronic wrist pain. Materials and Methods: Thirty three patients with chronic wrist pain suspected to have ligament injuries of the wrist were prospectively recruited. They underwent MRA examinations followed by wrist arthroscopy. Arthroscopic findings were compared with radiological findings focusing on three important structures – triangular fibrocartilage complex (TFCC), scapholunate ligament (SLL), and lunotriquetral ligament (LTL). Results: For the 17 patients with TFCC tears/perforations on arthroscopy, MRA gave a sensitivity (SEN) = 88%, specificity (SPE) = 87.5%, positive predictive value (PPV) = 88%, and negative predictive value (NPV) = 87.5%. For the 13 patients with SLL tears on arthroscopy, MRA gave SEN = 77%, SPE = 100%, PPV = 100%, and NPV = 87%. For the 7 patients with LTL tears on arthroscopy, MRA gave SEN = 29%, SPE = 100%, PPV = 100%, and NPV = 84%. A composite correlation between findings on MRA and wrist arthroscopy revealed an overall SEN = 73%, SPE = 96%, PPV = 93%, and NPV = 85% for MRA, with overall accuracy = 88%. Conclusions: The presented diagnostic results of MRA are superior to those of magnetic resonance imaging quoted in literature. MRA is a potent tool for evaluating chronic wrist pain but tends to miss lesions of intrinsic carpal ligaments (SLL and LTL) more than TFCC. Wrist arthroscopy may be recommended when the clinical suspicion is strong.
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Evaluation of functional outcome of elbows after resection arthroplasty of failed total elbow replacement p. 776
Ananda Kisor Pal, Debadyuti Baksi, Rahul Mondal, Durgapada Baksi
DOI:10.4103/ortho.IJOrtho_506_18  PMID:31673181
Background: Recovery of elbow function is a challenging problem following resection arthroplasty after failure of total elbow prosthesis. The objective of this study is to evaluate long term functional outcome in a series of such patients. Materials and Methods: Nineteen patients with twenty elbows who had failed total elbow arthroplasty (TEA) following the use of Baksi total elbow prosthesis needed removal of prosthesis during the period from 1978 to 2003. As two patients were lost to followup, 17 patients with 18 elbows (bilateral in one) were included in this study with a mean age of 44.3 years. Nine cases had uncontrolled infection, seven cases of aseptic loosening including one occurred after TEA for bilateral postburns ankylosis, and two had broken humeral stems. After removal of the prosthesis and its adjacent surrounding bone cement, the cut ends of humerus and ulna were approximated with number 5 Ethibond suture. Postoperatively, the elbow was immobilized in a plaster slab in 110° elbow flexion for 6 weeks followed by physiotherapy. The patients were evaluated for 15–19.4 (mean 16.3) years where functional results were compared at 10 years and 15 years following resection arthroplasty. Results: The resected elbow initially remained flail but gradually regained stability, especially in the sagittal plane. Both the groups showed overall improvement from preoperative Mayo Elbow Performance Score (MEPS) 26.5 to postoperative mean MEPS at 10 years (69.6) and at 15 years (70) (P = 0.001). Postoperative mean DASH score was 36.62 at 10 years' and 36.38 at 15 years' followup, suggesting persistence of function of resected elbow in the passage of time. The results were good in 9 (50%), fair in 7 (38.8%), and poor in 2 (11.1%) patients. None had recurrence of infection. Transient ulnar nerve palsy was seen in three patients. Postoperatively, power of Biceps recovered up to Medical Research Council grade 4 and Triceps 2–3. Conclusion: Resection arthroplasty of elbow provided acceptable functional recovery in our series of patients with failed elbow prosthesis.
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The role of transcortical vessels in diaphyseal vascularity p. 785
Adil Asghar
DOI:10.4103/ortho.IJOrtho_276_19  PMID:31673182
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Mobile application for orthopedic disability assessment p. 786
Ankur Agarwal, Shantanu Shah, Sheetal Agarwal
DOI:10.4103/ortho.IJOrtho_203_19  PMID:31673183
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