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   Table of Contents - Current issue
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May-June 2019
Volume 53 | Issue 3
Page Nos. 381-488

Online since Thursday, April 18, 2019

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EDITORIAL  

Formatting references for scientific manuscripts Highly accessed article p. 381
Srinivas BS Kambhampati, Lalit Maini
DOI:10.4103/ortho.IJOrtho_197_19  
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ORIGINAL ARTICLES: SHOULDER Top

Clinical and structural outcomes after arthroscopic repair of medium- to massive-sized delaminated and nondelaminated rotator cuff tears p. 384
Vivek Pandey, CJ Joseph, Naveen J Mathai, Kiran KV Acharya, Lakshmikanth H Karegowda, W Jaap Willems
DOI:10.4103/ortho.IJOrtho_440_18  
Introduction: Current evidence is controversial about the outcomes after the repair of the delaminated versus nondelaminated rotator cuff tears. The objective of this study was to evaluate the factors affecting delamination of the cuff and clinical and structural outcomes after en masse arthroscopic repair of delaminated versus nondelaminated cuff of varying sizes. Materials and Methods: A total of 233 patients with full-thickness posterosuperior cuff tears were divided in two groups: Group 1: Delaminated tears (n = 131) and Group 2: Nondelaminated tears (n = 102) of medium, large, and massive sizes. Both groups were evaluated by clinical scores (Constant–Murley [CM], American shoulder and elbow score [ASES]) and ultrasonography (USG), at a minimum followup of 2 years. Results: The mean followup was 45.47 months. There was a weak but statistically significant linear correlation (P = 0.02) between the increasing size of tear and delamination, whereas increasing age and duration of symptoms did not correlate with increasing tendency of delamination. Final followup USG analysis revealed that there was no significant difference (P = 0.55) between healing rates of Group 1 and Group 2. Further taking various tear sizes into account, USG revealed no significant difference between the healing rates of two groups. The mean overall final postoperative CM and ASES scores of two groups did not show any significant difference (CM; P = 0.36, ASES; P = 0.4). However, the clinical outcome was significantly better in the completely healed group as compared to partially healed or retear group. Conclusions: A weak linear correlation between delamination and increasing size of the tear was noted. Although overall structural and clinical outcome is no different between two groups, the clinical outcomes of completely healed tear are better than partially healed ones. Level of Evidence: Level III, Retrospective comparative.
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Relation between hypertrophy of teres minor muscle and external rotation lag sign in patients with rotator cuff pathology p. 392
Sandeep Vella, A Srinivasa Rao
DOI:10.4103/ortho.IJOrtho_259_18  
Background: The purpose of this study was to determine the compensatory hypertrophy of the teres minor (TM) muscle in rotator cuff tears (RCTs) and also the relation between hypertrophy of TM muscle and external rotation lag sign (ERLS). Methods: In the period between June 2017 and April 2018, forty patients with RCTs of the shoulder joint came to our institution. We determined the ERLS of all the RCT patients along with the TM occupation ratio in the magnetic resonance imaging (MRI) scan and correlated them together. The normal mean of TM occupational ratio was calculated from ten patients who have undergone MRI scan for other causes but with normal rotator cuff muscles. Results: In our study, the mean TM occupational ratio of 10 normal rotator cuff patients was 0.277. Of 40 rotator cuff pathology patients, the mean occupational ratio of the TM in RCTs is 0.359. Sixteen of the 40 patients had ER lag positive and the remaining 24 patients had ER lag negative. Those who were ER lag negative have an TM occupational ratio >0.401. A positive correlation was found between hypertrophy of TM and ERLS. Conclusion: ERLS will be negative in patients with hypertrophy of TM in the setting of posterosuperior cuff tears. There is a strong correlation between cuff tears and hypertrophy of TM muscle, which helps in better prognosis and functional outcome of the patients treated with surgical intervention.
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Evaluation of functional outcome of arthroscopic rotator cuff repair using southern california orthopedic institute technique p. 396
Nilesh Kamat, Ankur Parikh, Parth Agrawal
DOI:10.4103/ortho.IJOrtho_444_17  
Background: The number of anchors and modality of fixation to be used has been a point of debate in the arthroscopic management of rotator cuff repair. Southern California Orthopedic Institute (SCOI) technique has shown better anatomical healing of tendons using single-row anchors. In this study, we evaluated the functional outcomes of arthroscopic rotator cuff repair using the SCOI technique, in Indian population. Materials and Methods: Thirty two patients (16 males and 16 females) were included in the study, and underwent an arthroscopic repair of small-to-medium-sized rotator cuff tear, at a single institution, for 12 months. Postoperatively, patients were evaluated using UCLA score and Constant-Murley score, and range of motion was analyzed and documented using photographs. Results: Mean age was 57.06 years, and the most common cause of cuff tear was a traumatic degeneration. Mean UCLA score improved from preoperative 8.75 to postoperative 31.79, at 12 months, with the P < 0.001. Similarly, mean Constant-Murley score improved from preoperative 20.66 to postoperative 81.31, at 12 months, with P < 0.001. Conclusion: We conclude that the SCOI single-row technique proves to be a good and effective modality of treatment in the arthroscopic management of small-to-medium-sized rotator cuff tears. In Indian population, considering cost-effectiveness, single-row repair of rotator cuff tears using SCOI technique can be an interesting option in its management.
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ORIGINAL ARTICLES: HIP Top

Efficacy of different posterior capsulotomies on dislocations in hip hemiarthroplasty: T-shaped capsulotomy versus longitudinal capsulotomy p. 402
Ahmet Yilmaz
DOI:10.4103/ortho.IJOrtho_255_18  
Background: Dislocation following hip hemiarthroplasty is one of the leading reasons necessitating a resurgery. Many studies suggested that the type of the surgical approach is the main cause for dislocation. However, no consensus has been reached yet regarding the type of the surgical approach. In this prospective clinical study, we aimed to compare the efficacy of two different capsulotomy techniques on dislocations, applied during hip hemiarthroplasties performed through the posterior approach. Materials and Methods: We investigated the dislocation rates in 287 patients (aged 65 and above) who underwent cemented bipolar hemiarthroplasty for displaced femoral neck fractures through the posterior capsular approach using two different capsulotomy techniques between 2009 and 2016. Patients were followed up for 12 months after hemiarthroplasty. Patients were evaluated in two groups; on whom hemiarthroplasty was performed as longitudinal (146 patients) and as T-shaped capsulotomy (141 patients). Results: Posterior dislocations occurred in seven (5%) patients who underwent hemiarthroplasty with T-shaped capsulotomy. No dislocation was observed in 146 patients who underwent hip hemiarthroplasty through posterior longitudinal capsulotomy. The difference between the two study groups was statistically significant (P < 0.007). Conclusion: Capsule integrity can be achieved through a strong capsule repair which is possible through hemiarthroplasty with longitudinal capsulotomy. Longitudinal capsulotomy is an effective technique in preventing dislocations following hip hemiarthroplasty.
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The effect of intensive abductor strengthening on postoperative muscle efficiency ands functional ability of hip-fractured patients: A randomized controlled trial p. 407
Sophia Stasi, George Papathanasiou, Efstathios Chronopoulos, Ismene A Dontas, Ioannis P Baltopoulos, Nikolaos A Papaioannou
DOI:10.4103/ortho.IJOrtho_183_18  
Background: Hip fractures are common in the elderly and many patients fail to regain prefracture hip abductor strength or functional status. The purpose of this clinical trial was to compare the effects of an intensive abductor muscle exercise program versus a standard physiotherapy intervention in hip-fractured patients. Materials and Methods: Ninety six femoral neck-fractured patients were randomized into equal-sized groups. A 12-week standard physiotherapy program was implemented in the control group(S-PT) whereas an intensive exercise program, emphasizing on abductors' strengthening, was implemented in the research group(I-PT). Abductors' isometric strength of the fractured hip, abductor ratio% in the fractured compared to contralateral hip, and functional level were assessed at the 3rd (postintervention) and 6th (followup) months. Results: Postintervention, abductors' isometric strength was 35.7% greater (P < 0.0005) and abductor ratio% was 2.5% higher (P < 0.0005) in I-PT group, compared to S-PT group. With regard to functional assessments, I-PT group was 29.1% faster during Timed Up and Go (TUG) test and achieved a 26.7% higher Lower Extremity Functional Scale Greek version's (LEFS-Greek) total score, compared to S-PT group (P < 0.0005). At followup, abductors' isometric strength was 37.0% greater (P < 0.0005) and abductor ratio% was 7.1% higher (P < 0.0005) in I-PT group, compared to S-PT group. In addition, I-PT group was 45.9% faster during TUG test (P < 0.0005) and achieved an 11.2% higher LEFS-Greek total score, compared to S-PT group (P = 0.013). Conclusions: Compared to the standard physiotherapy intervention, the intensive abductor-strengthening program significantly increased both abductors' isometric strength of the fractured hip and abductor ratio% and resulted in patients' enhanced functional level. Clinical Trial Identifier: ISRCTN30713542.
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Outcomes of core decompression with or without nonvascularized fibular grafting in avascular necrosis of femoral head: Short term followup study p. 420
Sumanth Lakshminarayana, Ish Kumar Dhammi, Anil K Jain, Himanshu Bhayana, Sapan Kumar, Rahul Anshuman
DOI:10.4103/ortho.IJOrtho_310_18  
Background: Avascular necrosis (AVN) of the femoral head usually occurs in the third to fifth decade. The treatment options depend on the stage of disease varying from nonoperative treatment to surgical procedure including core decompression (CD) with or without nonvascularized or vascularized fibular graft, muscle pedicle bone grafting, osteotomies, and arthroplasty. Finite life of the total hip arthroplasty (THA) prosthesis limits its use in young adults or in middle aged. In this study, we envisage to evaluate the clinicoradiological outcomes of CD and nonvascularized fibular grafting in early stages of AVN femoral head. Materials and Methods: Our study is longitudinal observational study including 76 hips (46 patients) in the age group of 18–48 years (mean 30.07 years). Ficat and Arlet staging system was used and only early stages, that is, Stage 1 (n = 36 hips) and Stage 2 (n = 40 hips) were included in the study. The cases with traumatic AVN were excluded. All patients in Stage 1 underwent CD (Group 1) and those in Stage 2 underwent CD and fibular grafting (Group 2). Preoperative Harris Hip Score (HHS), visual analog score (VAS), plain radiographs, and magnetic resonance imaging (MRI) were compared with serial postoperative HHS, VAS, plain radiographs, and MRI taken at different intervals. Results: Average period of followup was 53.5 months (44–63 months). Radiological progression was not seen in 55 hips out of 76 hips (72.3%), whereas 21 hips (27.6%) demonstrated signs of progression and collapse. Failure of surgery was defined as progression of the disease, which was 25% (n = 9) in Group 1and 30% (n = 12) Group 2. Median values of HHS at the end of the followup in Group 1 was 77 and in Group 2 was 71.5 compared to the preoperative HHS of 48 and 62 in Group 1 and 2, respectively. Median values of VAS at the end of the followup in Stage 1 was 0 and in Stage 2 was 2 compared to the preoperative VAS of 6 and 8 in Group 1 and Group 2, respectively. Conclusion: CD with or without fibular grafting is effective in preserving the sphericity of the femoral head and to delay the progression of the AVN of femoral head in the early stages, that is, Stage 1 and Stage 2 and aids in the early revascularization of ischemic femoral head and is a useful modality to negate or delay the requirement of THA.
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The effect of renal transplantation in end-stage renal failure patients undergoing total hip replacement p. 426
Winston Shang Rong Lim, Kelvin Guoping Tan, Andy Khye Soon Yew, Seng Jin Yeo
DOI:10.4103/ortho.IJOrtho_163_18  
Background: Patients with end-stage renal failure (ESRF) undergoing elective orthopedic surgery generally have higher postoperative morbidity and mortality compared to the general population. Studies on the outcome of ESRF patients undergoing total hip replacement (THR), especially those with a functioning renal transplant, are conflicting. We aim to evaluate the impact of renal transplantation on functional outcome and postoperative complications in patients with ESRF undergoing THR. Materials and Methods: A total of 29 primary THRs were performed in 25 patients with ESRF between 1999 and 2013. There were 12 patients with 14 THRs who had a functioning renal transplant at the time of surgery (transplant group), and 13 patients with 15 THRs who were dialysis dependent with either no or failed prior transplant (nontransplant group). Functional outcome was evaluated with the Oxford Hip Score (OHS) and Western Ontario and McMaster Universities Osteoarthritis Index. Clinical records and followup radiographs were used to evaluate postoperative complications. Results: There is lower mortality rate (P = 0.02) and lower overall complication rate in the transplant group compared to the nontransplant group (relative risk 0.60, 95% confidence interval 0.40–0.91, P = 0.008). The mean increase in OHS postoperatively was greater in the nontransplant group (nontransplant-24.7; transplant-18.7) and trended toward statistical significance (P = 0.06). Conclusion: ESRF patients who undergo THR experience improvements in functional outcome regardless of transplant status. There was no significant difference in postoperative functional outcomes between the two groups of patients, but patients with renal transplants are less likely to experience postoperative complications and have better survival.
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ORIGINAL ARTICLES: KNEE Top

The international knee documentation committee score indicates midterm patient satisfaction with outcomes after meniscal allograft transplantation p. 431
Jeong Ku Ha, Yoon Seok Kim, Min Soo Kwon, Kyu Sung Chung, Sang Bum Kim, Jin Goo Kim
DOI:10.4103/ortho.IJOrtho_244_18  
Background: This study aimed to identify the factors associated with patient satisfaction with the outcome of meniscal allograft transplantation (MAT). Materials and Methods: Patients treated with MAT from March 2006 to May 2009 were asked to complete a five-point Likert scale regarding satisfaction with the outcome of MAT, in addition to the following subjective outcome evaluation forms: the International Knee Documentation Committee (IKDC) subjective forms, Knee Society Score knee and function forms, and Lysholm Knee Scoring Scale. We collected radiologic data using X-ray and magnetic resonance imaging and assessed isokinetic muscle strength test using the Biodex System 3. We investigated whether these parameters were significantly associated with patient satisfaction. Statistical analysis was computed using univariate and multivariable logistic regression. Results: Among the 130 patients who underwent MAT, 49 participated in the interview and were included in this study. The mean followup period was 50.4 months. Mean patient age was 40 (±9) years; 33 were male and 16 were female (33%). The lateral meniscus was transplanted in 13 (27%) patients, while the medial meniscus was involved in 36 (73%) patients. On univariate analysis, sex and isokinetic extension strength deficit at 60° and 180° as well as the IKDC, Knee Society, and Lysholm scores showed significant association with patient satisfaction regarding the outcome. On multivariable logistic regression, only the IKDC score showed a significant association, with P = 0.04. Conclusions: The study results support the importance of patient-reported subjective outcomes in terms of patient satisfaction following a surgical procedure. Regarding MAT, the IKDC outcome score reflects patient satisfaction. Level of evidence: Level III.
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Temporal value of c-reactive protein and erythrocyte sedimentation rate after total knee arthroplasty in patients with elevated preoperative c-reactive protein: A matched-pair analysis p. 437
Seung Ah Lee, Seung-Baik Kang, Chan Yoon, Chong Bum Chang, Moon Jong Chang, Jai Gon Seo
DOI:10.4103/ortho.IJOrtho_96_18  
Background: We aimed to determine whether temporal values of C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) after total knee arthroplasty (TKA) differ between patients with and without elevated preoperative CRP. We hypothesized that temporal pattern of CRP and ESR change would differ between the two groups. Materials and Methods: This retrospective study included 30 TKAs with a diagnosis of osteoarthritis with elevated preoperative CRP (>1 mg/dl) without clinical signs and symptoms of infection before surgery (elevated CRP group). Patients without elevated preoperative CRP were matched in a 1:10 fashion according to age, sex, number of comorbidities and whether TKA was unilateral or bilateral (nonelevated CRP group). The temporal values of CRP and ESR after TKA were compared between the two groups until 2 months after surgery. Results: The mean peak values of CRP and ESR after surgery were similar between the two groups in both unilateral and bilateral TKAs. In the unilateral TKA, mean values of CRP and ESR and the proportions of the knees with normal CRP and ESR at 2 months after surgery were similar in the two groups. However, in the bilateral TKA, mean values of CRP and ESR were higher and the proportions of the knees with normal CRP and ESR at 2 months after surgery were lower in the elevated CRP group compared to the nonelevated CRP group. Conclusions: When performing TKA in patients with elevated preoperative CRP, the fact that the levels of CRP and ESR may not be normalized until 2 months after surgery should be considered during followup.
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Age and body mass index has no adverse effect on clinical outcome of unicompartmental knee replacement - Midterm followup study p. 442
Hemanth Kumar Venkatesh, Shanmuga S Maheswaran
DOI:10.4103/ortho.IJOrtho_230_18  
Introduction: Unicompartmental knee replacement (UKR) is well-established procedure for the anteromedial compartment of knee arthritis with intact anterior cruciate ligament. The significance of age and body mass index (BMI) is not clear in the outcomes of UKR. Our hypothesis was that age and BMI does not affect the clinical and functional outcome following fixed bearing UKR. Materials and Methods: The study cohort of 148 was selected after stringent inclusion criteria and average followup was 5.6 years (range 2–10 years). The fixed bearing Miller Galante UKR procedure was carried out on all patients. Results: In the study cohort of 175, the average age of the cohort was 61.7 years. The sample size aged ≤55 years and aged ≥55 years was 38 and 137, respectively. The mean BMI of the cohort was 29.2 kg/m2 (range: 21–38 kg/m2). The sample size of BMI ≤30 kg/m2 and BMI ≥30 kg/m2 was 117 and 58, respectively. In the cohort group, BMI ≤30 kg/m2 and BMI ≥30 kg/m2, there was no statistically significant difference in the Knee Society Score clinical scores, functional scores, and knee range of motion scores, (P > 0.05). This study infers no statistically significant difference in the clinical and functional outcome between age group ≤55 years and age ≥55 years, (P > 0.05). The failure rates of the group of BMI ≤30 kg/m2 and BMI ≥30 kg/m2 were 4.27% (5 knees) 3.44% (2 knees), respectively. The failure rates in the age group ≤55 years and group ≥55 years were 2 knees (3.44%) and 5 knees (4.27%), respectively. Conclusion: This study confirms that age and BMI does not influence the functional outcome and clinical outcome following fixed bearing UKR.
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Role of arthroscopic surgery in degenerative knees with mechanical symptoms p. 446
Ravi Gupta, Anubhav Malhotra, Aditya Singla, Ashwani Soni, Sudhir Kumar Garg, Dinesh Kumar Walia
DOI:10.4103/ortho.IJOrtho_218_18  
Background: This study was conducted to evaluate functional outcome in patients undergoing/underwent arthroscopic surgery for degenerative knees with mechanical symptoms or acute exacerbation of symptoms, not amenable to conservative measures. Materials and Methods: This was a longitudinal type of study (prospective and retrospective). For the prospective cohort, followup was done at an interval of 2 weeks, 6 weeks, 6 months and 1 year to record visual analog scale (VAS), International Knee Documentation Committee (IKDC), and short form-8 (SF-8) scores. For the retrospective cohort, hospital records were studied to record the preoperative VAS score. Preoperative IKDC and SF-8 scores were recorded at final followup based on recall method (patient's memory). Furthermore, postoperative VAS, IKDC, and SF-8 scores at final followup were recorded. Results: There were a total of 46 knees (28 retrospective and 18 prospective) in 44 patients. The mean age was 52.34 ± 11.73 years. There were 28 female knees and 18 male knees. The mean followup of patients in the retrospective cohort was 55 months (range: 13–126 months), whereas all patients in prospective cohort completed the minimum followup of 1 year. The improvements in VAS, IKDC, and SF-8 were statistically significant. Forty-one cases were successful and five cases were failure. All successful patients (41 cases) said “yes” and all failure cases (05) said “no” to the question-”If given a choice, would you still like to get the same surgery done for the same problem??”. There was one complication deep venous thrombosis. Conclusion: We recommend arthroscopic surgery in patients with degenerative knees, with mechanical symptoms and acute exacerbation of symptoms, not amenable to conservative measures.
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ORIGINAL ARTICLES: TRAUMA Top

Role of fat graft alone versus enriched fat graft with stromal vascular filtrate in painful amputation stump p. 452
Parvesh Malik, Sunil Gaba, Chirag Ahuja, Ratti Ram Sharma, Ramesh K Sharma, N Khandelwal
DOI:10.4103/ortho.IJOrtho_385_18  
Background: Traumatic amputations are very prevalent in today's world. Successful rehabilitation of an amputee largely depends on how well he/she adapt to prosthesis. However, because of poor scar characteristics, these patients often complain of pain while using prosthesis. Autologous fat graft is being vastly used all over the world to improve the scar of various etiologies. However, it has been associated with unpredictable resorption rate. Objectives: We report the results of the study which was done to assess the consequences of fat grafting over scars and to see its effects on pain management in amputated stump and compare the autologous fat graft with stromal vascular filtrate (SVF)-enriched fat graft for scar remodeling and pain modulation on amputation stumps. Materials and Methods: A prospective randomized trial was conducted from July 2014 to December 2015. A group of ten patients, who were unable to wear prosthesis due to painful amputation stump, incorporated in the study and randomly distributed in two groups. Group A of five patients (case group) was treated with autologous fat graft enriched with SVF while Group B (control group) of remaining five patients was treated with fat graft alone. The results were assessed at baseline, at 1 month, and at 6 months postoperatively using patient and observer scar assessment scale (POSAS) score. Magnetic resonance imaging (MRI) was done to compare fat content preoperatively and 6 months postoperatively. Results: All ten patients reported improvement in scar characteristics, most notably in pain in both scales of POSAS score. The improvement was comparable in both groups. However, the fat content in case group was significantly more in comparison to control group when assessed 6 months postoperatively using MRI scan. Conclusion: Autologous fat grafting is a viable and minimally invasive solution for painful amputation stump. Enrichment of fat graft with SVF can enhance its viability over long term. This study was done as a pilot project. Hence, further long term studies with large sample size are needed to ascertain the benefits observed in this study.
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Hyaluronic acid-based mesh add-on iliac autograft improves bone healing and functional outcomes in atrophic nonunion of clavicular midshaft: A 2-year followup p. 459
Mustafa Caglar Kir
DOI:10.4103/ortho.IJOrtho_702_17  
Background: Atrophic nonunion may frequently be seen after clavicular midshaft fractures. Despite a variety of surgical options, clavicular nonunion cases are associated with impaired bone healing. The aim of current study was to evaluate efficacy of perioperatively administered hyaluronic acid (HA)-based mesh in patients with atrophic midshaft clavicular nonunion managed with iliac wing autograft and plate fixation. Materials and Methods: This retrospective clinical study investigated 44 patients with atrophic midclavicular nonunion who underwent open reduction plate fixation with iliac wing autografts. Patients were divided into two groups as those managed with iliac wing autograft and anatomical locking plate (ALP) fixation alone and those managed with add-on perioperative HA-based mesh, i.e., Group 1 (n = 24) and Group 2 (n = 20), respectively. Age, duration till to surgery, fracture healing time, length of gap, and length of injured and contralateral clavicle were also invastigated. The 2-year Disabilities of the Arm, Shoulder and Hand (DASH) and Constant scores were evaluated. Kolmogorov–Smirnov test, Mann–Whitney U-test, and Spearman's correlation test were used to assess variables. Results: Patients' age, followup time, and duration till surgery were similar between two groups. The study groups did not significantly differ in terms of postoperative clavicular length, as measured relative to unaffected side. Mean duration of the fracture healing was significantly shorter in Group 2 compared to that in Group 1. Mean postoperative 2-year Constant score was statistically higher in Group 2 compared to that of Group 1. In addition, Group 2 had also significantly higher DASH score than that of Group 1. Conclusions: HA-based mesh application added on the iliac wing autografting with ALP fixation may be an efficacious alternative for atrophic nonunion of clavicular midshaft.
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Lateral clavicle fractures with coracoclavicular ligament disruption (Neer's Type IIB): Review of literature and a new technique for all-suture fixation p. 465
Praveen Sarda
DOI:10.4103/ortho.IJOrtho_485_18  
Background: All-suture fixation for the treatment of Neer's Type IIB lateral clavicle fractures by coracoclavicular (CC) ligament reconstruction has become popular in the past decade. Results of modified under-coracoid-around-clavicle (UCAC) technique are reported in this paper. Methodology and Results: Nineteen consecutive patients with minimum 6-month followup (FU) were identified. Average FU was 23 months (6–47 m), mean age was 38 years (16–81), and male-to-female ratio was 2:1. The time to surgery varied from 4 days to 12 weeks. Two patients had primary lateral end excision; of the rest, all but one healed fully. Average time to regain full range of motion was 4 weeks; postoperative Oxford Shoulder Score at 6 months was 43. All the patients returned to their previous occupation. One patient showed mild osteolysis on the last X-rays. There were no cases with infections or stiffness. Discussion: CC ligament reconstruction converts the unstable Type IIB fracture into stable Type I; therefore, it is unnecessary to fix the distal fragment separately. Standard plating procedures are technically challenging due to small lateral fragment and frequently require a second operation for implant removal. The cost of commercially available implants vary from ≤750 to ≤1450. This technique is quick, easy to perform, provides good primary stability, and comparable union rates with other techniques at an implant cost of <£120. Conclusion: This is a reproducible and efficient technique that provides comparable results with other established procedures at a fraction of the cost of the next cheapest implant. It is recommended for the treatment of displaced Type II clavicle fractures. Level of Evidence: Level IV.
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Fixation of posterior tibial plateau fracture with additional posterior plating improves early rehabilitation and patient satisfaction p. 472
Shivam Sinha, Mahipat Singh, Shyam K Saraf, Amit Rastogi, Alok K Rai, Tej Bali Singh
DOI:10.4103/ortho.IJOrtho_295_18  
Introduction: Posterior tibial plateau fractures (PTPF) are difficult to manage because of options of multiple approaches, paucity of implants, and lack of ideal construct for fixation. We investigated the benefits of using posterior approach and buttress plate for fixation of the posterior tibial condylar fractures in terms of the fracture healing rate, clinico-radiological, perioperative morbidity, and patient-related outcomes and compared them in those who achieved acceptable reduction without posterior stabilization. Patients and Methods: Seventy two patients with posterior tibial plateau fractures were prospectively followed after random allocation into two Groups A and B. Thirty eight patients of Group A (dual plating) were managed with stabilization of posterior fragment with Lobenhoffer approach in addition to anterolateral plating. Thirty four patients of Group B (single plate) were managed with isolated anterolateral plating after reducing the PTPF. Twelve patients lost to follow-up and sixty patients were available (thirty in either group) for final assessment. Followup was done by clinical examination, radiographs and computed tomography scan, fracture union, articular continuity, and deformities around the knee. Subjective outcome assessment was done with the International Knee Documentation Committee (IKDC) 2000 and Knee Society Score (KSS). Results: At 1-year followup, the two groups did not differ in time of fracture union. IKDC and KSS were significantly better in dual-plating group (P < 0.001). Mean operative time and blood loss were more in dual-plating group (A). The mean hospital stay and complications did not show significant differences. Conclusion: Addition of posterior approach for stabilization of the posterior fragment in posterior tibial plateau fractures achieves early and improved knee functions, good range of movements, minimal deformities, and pain scores by the time fracture unites. However, peri-operative morbidity, Extra implant costs and increased operative time are its disadvantages.
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CASE REPORTS Top

Proximal femoral erosion: A sequelae of psuedoaneursym formation following operative fixation of an intertrochanteric neck of femur fracture p. 479
Surjit S Lidder, Daniel J Epstein, Victoria Courtice, Marc D George
DOI:10.4103/ortho.IJOrtho_139_18  
A 72-year-old male sustained a left intertrochanteric neck of femur fracture following a fall. He underwent operative fixation with a dynamic hip screw and was discharged home. Fifteen months later, the patient presented again with ongoing left thigh pain and swelling. A pelvic radiograph showed scalloping of the medial proximal femoral cortex. Further investigation revealed a left profunda femoris artery pseudoaneurysm. Vascular injury during operative fixation of intratrochanteric fractures is a rare complication, which may be missed due to a delayed presentation. Treating physicians should be mindful of late presentations of vascular injury following the surgical fixation of proximal femoral fractures.
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Late-onset paraplegia in old healed spinal tuberculosis due to traumatic fracture of fusion mass – A rare case report p. 482
J Naresh Babu, Viswanadha Arun Kumar
DOI:10.4103/ortho.IJOrtho_275_18  
The natural healing of spinal tuberculosis occurs by spontaneous fusion of vertebral bodies with or without kyphotic deformity. Late-onset paraplegia secondary to the fracture of fusion mass in tuberculosis is one of the rare conditions which have not been extensively reported. A 56-year-old male patient sustained road traffic accident was diagnosed with a fracture of fusion mass in already healed tuberculosis. He was presented with weakness in both the lower limbs with ASIA-C grading of spinal cord injury. He was treated with posterior instrumented stabilization and decompression. The patient recovered well postoperatively and had regained his complete power of both lower limbs. Late-onset paraplegia in old healed spinal tuberculosis is a well-known entity that may be caused due to transaction of the cord by a bony ridge or when the formed granulation or fibrous tissue constricts the cord. Fusion mass fractures are not very uncommon in conditions such as ankylosing spondylitis or diffuse idiopathic skeletal hyperostosis. Traumatic fractures tend to occur at the adjacent vertebral bodies to the fused ones as the biomechanical stress at the junctional site is far higher than at the center of the fused mass. In healed spinal tuberculosis, resultant deformity would be kyphosis. The angle of kyphosis is directly proportional to the resulting neurological deficit. Fractures of fused mass in healed tuberculosis are similar to the fractures in other ossifying bone lesions. The purpose of this article is to document the rare possibility of late-onset paraplegia in uninstrumented old healed spinal tuberculosis with kyphotic deformity, due to the fracture of fusion mass as seen in ankylosing spondylitis.
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PROFILE Top

Legend of Indian Orthopedics: Prof. (Dr.) Bimalendu Das p. 486
Raju Vaishya, Ved Prakash Middha
DOI:10.4103/ortho.IJOrtho_480_17  
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OBITUARY Top

Prof. HKT Raza (1956-2019) p. 488
Jamal Ashraf
DOI:10.4103/0019-5413.256523  
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