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Bone and joint tuberculosis -Guidelines for management
TK Shanmugasundaram
July-September 2005, 39(3):195-198
  62,211 2,614 1
Clubfoot: Etiology and treatment
Ashish Anand, Debra A Sala
January-March 2008, 42(1):22-28
DOI:10.4103/0019-5413.38576  PMID:19823650
Congenital talipes equinovarus is the commonest congenital anomaly with an incidence of one to two per 1000 live births. Over the centuries it has been treated by various modalities, but the dilemma facing the surgeon has been a strong tendency to relapse. With the use of the Ponseti technique, the number of patients who undergo soft tissue release has decreased. This technique probably represents a panacea for the treatment of this unsolved mystery.
  46,384 2,259 5
Management of fracture neck of femur
Hardas Singh Sandhu
April-June 2005, 39(2):130-136
  39,627 3,683 2
Distal radioulnar joint injuries
Binu P Thomas, Raveendran Sreekanth
September-October 2012, 46(5):493-504
Distal radioulnar joint is a trochoid joint relatively new in evolution. Along with proximal radioulnar joint , forearm bones and interosseous membrane, it allows pronosupination and load transmission across the wrist. Injuries around distal radioulnar joint are not uncommon, and are usually associated with distal radius fractures,fractures of the ulnar styloid and with the eponymous Galeazzi or Essex_Lopresti fractures. The injury can be purely involving the soft tissue especially the triangular fibrocartilage or the radioulnar ligaments.The patients usually present with ulnar sided wrist pain, features of instability, or restriction of rotation. Difficulty in carrying loads in the hand is a major constraint for these patients. Thorough clinical examination to localize point of tenderness and appropriate provocative tests help in diagnosis. Radiology and MRI are extremely useful, while arthroscopy is the gold standard for evaluation. The treatment protocols are continuously evolving and range from conservative, arthroscopic to open surgical methods. Isolated dislocation are uncommon. Basal fractures of the ulnar styloid tend to make the joint unstable and may require operative intervention. Chronic instability requires reconstruction of the stabilizing ligaments to avoid onset of arthritis. Prosthetic replacement in arthritis is gaining acceptance in the management of arthritis.
  36,639 960 -
Ganga hospital open injury severity score - A score to prognosticate limb salvage and outcome measures in Type IIIb open tibial fractures
S Rajasekaran
January-March 2005, 39(1):4-13
Background: Gustilo's grade IIIB classification includes a wide spectrum of injuries and is limited by high inter and intra observer error rates. Methods: A trauma score for grade IIIB open tibial fractures was devised to assess injury to three components; the covering tissues, musculotendinous units and bone with the severity scale in each category from one to five. Seven co-morbid conditions known to influence the prognosis were each given a score of two and summed up. Results : Ninety six consecutive Grade IIIB open injuries of tibia were prospectively evaluated. At 3-5 year follow up, of the 88 available, final score was less than five in 6 patients (Group I), between six and ten in 48 (Group II), eleven to fifteen in 29 (Group III) and above 16 in five (Group IV). All patients in Group IV and one in Group III with score of fifteen underwent amputation. There was a significant difference (p less than 0.001) between the three groups in the requirement for flap (16.7,75&100 percent), time for union (16.3,24.9 & 46.9), incidence of deep infection (0,22.9 & 60.7 percent), number of surgical procedures (1.2,3.1 & 6.3) and inpatient days (12.5,22.6 & 59.4). A score of greater than three in any one component required special skills in management and interfered with healing of other structures. Conclusion: The scoring system was easy to apply and had a high degree of interobservor aggreement rate. This comprehensive score reliably prognosticates both limb salvage and outcome measures in severe open injuries of tibia.
  30,754 2,290 -
Management of avascular necrosis of femoral head at pre-collapse stage
Ramesh Kumar Sen
January-March 2009, 43(1):6-16
DOI:10.4103/0019-5413.45318  PMID:19753173
In osteonecrosis the success of interventions that forestall or prevent femoral head collapse and maintain hip function would represent a substantial achievement in the treatment of this disease. A review of recent literature regarding bisphosphonate, anticoagulant, and vasodilators and biophysical modalities have demonstrated efficacy in reducing pain and delaying disease progression in early stage osteonecrosis. Though it has been considered still insufficient, to support their routine use in the treatment or prevention of osteonecrosis of the hip. Core decompression with modification of technique is still one of the safest and most commonly employed procedures with evidence based success in the pre-collapse stage of AVN of femoral head. The additional use of bone morphogenic protein, and bone marrow stem cells may provide the opportunity to enhance the results of core decompression. At present, the use of large vascularised cortical grafts, the other surgical procedure with high success rate is still not common due to technical difficulty in surgery. Likewise osteotomies are also not getting common as arthroplasty is getting more acceptable, so is awaited without any intermediate big surgical interventions.
  31,102 1,940 27
Intertrochanteric fractures
GS Kulkarni, Rajiv Limaye, Milind Kulkarni, Sunil Kulkarni
January-March 2006, 40(1):16-23
  27,589 2,317 5
Subchondral stress fracture of femoral head in a healthy adult
Ashish Anand, A RaviRaj, Gautam Kodikal
October-December 2010, 44(4):458-460
DOI:10.4103/0019-5413.67125  PMID:20924491
Subchondral fracture of the femoral head is an uncommon entity and usually occurs as an insufficiency fracture associated with poor bone quality or as a fatigue fracture in young military recruits. This condition should be considered in the differential diagnosis of acute hip pain in young patients along with transient osteoporosis and avascular necrosis of the hip. We report a case of acute onset hip pain in an asymptomatic healthy adult in which the diagnosis was made by magnetic resonance imaging and the patient responded well to conservative treatment.
  24,423 184 1
Surgical approach for high-energy posterior tibial plateau fractures
Shu-Qing Wang, You-Shui Gao, Jia-Qi Wang, Chang-Qing Zhang, Jiong Mei, Zhi-Tao Rao
March-April 2011, 45(2):125-131
DOI:10.4103/0019-5413.77131  PMID:21430866
Background: High-energy fractures of posterior tibial plateau always need surgical treatment. Generally, posterior fragments of these fractures could not be exposed and reduced well in conventional anterior approaches. Although a posterolateral/posteromedial approach to manage posterior tibial plateau fractures can achieve satisfactory results, there are few presentations concerning the treatment of these high-energy injuries based on posterior approaches combined with anterior approach if necessary. Materials and Methods: Ten cases of posterior tibial plateau fractures from high-energy injuries were retrospectively reviewed and followed up for mean 26.5 months (range 14-45 months). A posterolateral/posteromedial approach was adopted primarily to fix main fragment in posterior tibial plateau, and intraoperative assessment of the stability of knee was done. An anterior approach was added if required. Results: Posterolateral approach was employed in seven cases, posteromedial in three, and additional anteromedial in three, and anterolateral in two cases. The average time to union of all 10 fractures was 3.7 months (range 3-5.5 months). Nine patients had satisfactory articular reduction. The range of motion of the knee averaged 2° of extension to 110.5° of flexion. No patient complained of knee instability. The average postoperative HSS score at the final followup was 92.70. Conclusions: High-energy fractures of posterior tibial plateau could be well treated based on posterior approaches combined with necessary anterior approach if required.
  21,899 899 3
The hierarchy of evidence: Levels and grades of recommendation
BA Petrisor, M Bhandari
January-March 2007, 41(1):11-15
DOI:10.4103/0019-5413.30519  PMID:21124676
  20,967 918 17
Comparison of the prognosis among different age groups in elderly patients with hip fracture
Tetsuo Hagino, Satoshi Ochiai, Masanori Wako, Eiichi Sato, Shingo Maekawa, Yoshiki Hamada
January-March 2008, 42(1):29-32
DOI:10.4103/0019-5413.38577  PMID:19823651
Background: The outcome of treatment of hip fractures in different age groups in the elderly population is largely unknown. Hence, we stratified elderly patients with hip fracture into age groups and compared the prognosis in various age groups. Materials and Methods: Among 459 patients with hip fracture treated at our hospital from 1997, 430 patients aged 65 years or above at the time of injury were studied. The patients comprised 98 males and 332 females and the ages at injury ranged from 65 to 103 years (mean 83.4 years). There were 167 cases of femoral neck fracture and 263 cases of trochanteric fractures. Surgery was performed in 383 cases, while 47 cases were treated conservatively. The subjects were classified by age into young-old for those aged 65-74 years (group A, n = 55), middle-old for those aged 75-84 years (group B, n = 172), old-old for those aged 85-94 (group C, n = 180), and oldest-old for those aged 95 years or above (group D, n = 23). The functional and survival prognosis at discharge in each group was investigated. Results: Numbers of patients who were ambulatory at discharge among those ambulatory before injury were 43 of 49 (87.8%) in group A, 113 of 152 (74.3%) in group B, 86 of 138 (62.3%) in group C, and 5 of 14 (35.7%) in group D, showing worse recovery of walking ability as age advanced. Among those ambulatory before injury, 42 patients in group A, 139 patients in group B, 130 patients in group C, and 12 patients in group D underwent surgery and of these patients, 38 patients (90.5%) in group A, 109 patients (78.4%) in group B, 83 patients (63.8%) in group C, and 5 patients (41.7%) in group D were ambulatory at discharge. On the other hand, the numbers of patients who were ambulatory at discharge among those receiving conservative treatment were 5 of 7 (71.4%) in group A, 4 of 13 (30.8%) in group B, 3 of 8 (37.5%) in group C, and 0 of 2 (0%) in group D, showing better walking ability in surgical patients than in conservatively treated patients even in the elderly. There were two in-hospital deaths in group B, 11 in group C, and two in group D. Five of the 15 deaths were inoperable cases due to poor performance status at admission. Conclusion: Walking ability at discharge and survival prognosis worsened as age advanced. On the other hand, since surgical cases achieved better walking ability than conservatively treated cases, efforts should be made to achieve better functional prognosis even in the old-olds, including surgery together with early ambulation and rehabilitation.
  20,369 922 1
Treatment of giant cell tumor of bone: Current concepts
Ajay Puri, Manish Agarwal
April-June 2007, 41(2):101-108
DOI:10.4103/0019-5413.32039  PMID:21139760
Giant cell tumor (GCT) of bone though one of the commonest bone tumors encountered by an orthopedic surgeon continues to intrigue treating surgeons. Usually benign, they are locally aggressive and may occasionally undergo malignant transformation. The surgeon needs to strike a balance during treatment between reducing the incidence of local recurrence while preserving maximal function. Differing opinions pertaining to the use of adjuvants for extension of curettage, the relative role of bone graft or cement to pack the defect and the management of recurrent lesions are some of the issues that offer topics for eternal debate. Current literature suggests that intralesional curettage strikes the best balance between controlling disease and preserving optimum function in the majority of the cases though there may be occasions where the extent of the disease mandates resection to ensure adequate disease clearance. An accompanying treatment algorithm helps outline the management strategy in GCT.
  19,380 1,786 17
Postoperative pyrexia after arthroplasty - when to panic ?
Sanjay Agarwala, Deepak Jain, Abhijit Bhagwat
April-June 2005, 39(2):93-98
Background: Success of arthroplasty is contingent on a clear understanding of the potential complications. Today with improved methods of sepsis control, incidence of joint sepsis has dropped to less than 2%. Despite this fever is still common in the early post-operative period. Methods: We reviewed 184 consecutive hip and knee replacement surgeries for incidence and clinical significance of post-operative fever. The cases were followed up for a period of over 3 to 5 years. Temperature charts up to 6 th postoperative day and all investigations were reviewed to determine the cause of fever. Results: Post operative fever was recorded after 82 procedures (44.6%). The average maximum temperature occurred on post­operative day 1 (98.9 o F). Only 2 TKR got infected. Incidence of fever was higher in TKR as compared to THR. Conclusion: Post-operative fever is common and probably inflammatory. It is not an important predictive factor of joint infection. Work up for joint infection is not indicated unless other corroborative features are present. Aspiration of painful joint is a highly accurate for identifying an infection.
  19,425 331 1
Tuberculosis of lumbar spine
Pravin Kanabar
April-June 2005, 39(2):81-89
  18,514 841 -
Bone stimulation for fracture healing: What's all the fuss?
Galkowski Victoria, Brad Petrisor, Brian Drew, David Dick
April-June 2009, 43(2):117-120
DOI:10.4103/0019-5413.50844  PMID:19838359
Approximately 10% of the 7.9 million annual fracture patients in the United States experience nonunion and/or delayed unions, which have a substantial economic and quality of life impact. A variety of devices are being marketed under the name of "bone growth stimulators." This article provides an overview of electrical and electromagnetic stimulation, ultrasound, and extracorporeal shock waves. More research is needed for knowledge of appropriate device configurations, advancement in the field, and encouragement in the initiation of new trials, particularly large multicenter trials and randomized control trials that have standardized device and protocol methods.
  18,151 836 18
Simultaneously anterior decompression and posterior instrumentation by extrapleural retroperitoneal approach in thoracolumbar lesions
Anil K Jain, Ish Kumar Dhammi, Saurabh Jain, Jaswant Kumar
October-December 2010, 44(4):409-416
DOI:10.4103/0019-5413.69315  PMID:20924482
Background: Anterior decompression with posterior instrumentation when indicated in thoracolumbar spinal lesions if performed simultaneously in single-stage expedites rehabilitation and recovery. Transthoracic, transdiaphragmatic approach to access the thoracolumbar junction is associated with significant morbidity, as it violates thoracic cavity; requires cutting of diaphragm and a separate approach, for posterior instrumentation. We evaluated the clinical outcome morbidity and feasibility of extrapleural retroperitoneal approach to perform anterior decompression and posterior instrumentation simultaneously by single "T" incision outcome in thoracolumbar spinal trauma and tuberculosis. Patients and Methods: Forty-eight cases of tubercular spine (n = 25) and fracture of the spine (n = 23) were included in the study of which 29 were male and 19 female. The mean age of patients was 29.1 years. All patients underwent single-stage anterior decompression, fusion, and posterior instrumentation (except two old traumatic cases) via extrapleural retroperitoneal approach by single "T" incision. Tuberculosis cases were operated in lateral position as they were stabilized with Hartshill instrumentation. For traumatic spine initially posterior pedicle screw fixation was performed in prone position and then turned to right lateral position for anterior decompression by same incision and approach. They were evaluated for blood loss, duration of surgery, superficial and deep infection of incision site, flap necrosis, correction of the kyphotic deformity, and restoration of anterior and posterior vertebral body height. Results: In traumatic spine group the mean duration of surgery was 269 minutes (range 215-315 minutes) including the change over time from prone to lateral position. The mean intraoperative blood loss was 918 ml (range 550-1100 ml). The preoperative mean ASIA motor, pin prick and light touch score improved from 63.3 to 74.4, 86 to 94.4 and 86 to 96 at 6 month of follow-up respectively. The mean preoperative loss of the anterior vertebral height improved from 44.7% to 18.4% immediate postoperatively and was 17.5% at final follow-up at 1 year. The means preoperative kyphus angle also improved from 23.3° to 9.3° immediately after surgery, which deteriorated to 11.5° at final follow-up. One patient developed deep wound infection at the operative site as well as flap necrosis, which needed debridement and removal of hardware. Five patients had bed sore in the sacral region, which healed uneventfully. In tubercular spine (n=25) group, mean operating time was approximately 45 minutes less than traumatic group. The mean intraoperative blood loss was 1100 ml (750-2200 ml). The mean preoperative kyphosis was corrected from 55° to 23°. Wound healing occurred uneventful in 23 cases and wound dehiscence occurred in only 2 cases. Nine out of 11 cases with paraplegia showed excellent neural recovery while 2 with panvertebral disease showed partial neural recovery. None of the patients in both groups required intensive unit care. Conclusions: Simultaneous exposure of both posterior and anterior column of the spine for posterior instrumentation and anterior decompression and fusion in single stage by extra pleural retroperitoneal approach by "T" incision in thoracolumbar spinal lesions is safe, an easy alternative with reduced morbidity as chest and abdominal cavities are not violated, ICU care is not required and diaphragm is not cut.
  17,065 402 13
Mucoid degeneration of the anterior cruciate ligament: Management and outcome
Vivek Pandey, CPS Suman, Swati Sharma, Sripathi P Rao, KV Kiran Acharya, Charudutt Sambaji
March-April 2014, 48(2):197-202
DOI:10.4103/0019-5413.128765  PMID:24741143
Background: Mucoid degeneration (MD) is a rare pathological affection of the anterior cruciate ligament (ACL). Mucinous material within the substance of ACL produces pain and limited motion in the knee. This series describes the clinicoradiological presentation of patients with mucoid ACL, partial arthroscopic debridement of ACL and outcomes. Materials and Methods: During a period of 3 years, 11 patients were included based upon the clinical suspicion, magnetic resonance imaging (MRI) findings, arthroscopic features and histopathologic confirmation of MD of ACL. Result: Six patients were male and five were female with median age of 40 years (range 21-59 years). All patients complained of knee pain with median duration of 5 months (range 1-24 months). All patients had painful deep flexion with 63.6% (N = 7) reporting trivial trauma before the onset of symptoms. MRI revealed MD of ACL in all with associated cyst in three patients. Partial debridement of ACL was done in ten and complete in one patient. None of them required notchplasty. Histopathology confirmed the diagnosis in all of them. At the mean followup of 13.81 months (range 6-28 months), all patients regained complete flexion and none complained of instability. Conclusion: Prior knowledge of condition with high index of suspicion and careful interpretation of MRI can establish the diagnosis preoperatively. It responds well to partial debridement of ACL and mucinous material without development of instability.
  16,783 524 2
Management of trochanteric Fractures
Sudhir S Babhulkar
October-December 2006, 40(4):210-218
  16,004 1,096 3
Guillain-Barre syndrome: A possibility in a spinal cord injured patient
Yogendrasinh Jagatsinh
July-September 2007, 41(3):239-240
DOI:10.4103/0019-5413.33690  PMID:21139752
A 28-year-old male had paraplegia as a result of fracture dislocation of T12/L1 six years ago. He was functioning independently until four weeks ago, when he started complaining of trunkal paraesthesia which later progressed to include the upper extremities. The initial diagnosis was that of posttraumatic syringomyelia (PTS). While awaiting the MRI scan he developed weakness of upper limbs. The weakness restricted his self-care activities including transfers. The MRI did not show any evidence of syringomyelia. Neurological consultation and assessment yielded provisional diagnosis of Guillain-Barre syndrome (GBS). The patient was treated with immunoglobulins and regained 90% of his previous neurological status. This case is reported to raise awareness among clinicians to include the possibility of the GBS in the differential diagnosis of progressive neurological loss on top of existing neurological deficiency in spinal cord injured patients.
  16,133 342 1
Management of femoral neck fractures in young adults
Thuan V Ly, Marc F Swiontkowski
January-March 2008, 42(1):3-12
DOI:10.4103/0019-5413.38574  PMID:19823648
Femoral neck fractures in young adults are uncommon and often the result of high-energy trauma. They are associated with higher incidences of femoral head osteonecrosis and nonunion. Multiple factors can play a significant role in preventing these devastating complications and contribute to a good outcome. While achieving an anatomic reduction and stable internal fixation are imperative, other treatment variables, such as time to surgery, the role of capsulotomy and the fixation methods remain debatable. Open reduction and internal fixation through a Watson-Jones exposure is the recommended approach. Definitive fixation can be accomplished with three cannulated or noncannulated cancellous screws. Capsulotomy in femoral neck fractures remains a controversial issue and the practice varies by trauma program, region and country. Until there is conclusive data (i.e. prospective and controlled) we recommend performing a capsulotomy. The data available is inconclusive on whether this fracture should be operated emergently, urgently or can wait until the next day. Until there is conclusive data available, we recommend that surgery should be done on an urgent basis. The key factors in treating femoral neck fractures should include early diagnosis, early surgery, anatomic reduction, capsular decompression and stable internal fixation.
  14,818 1,428 20
Bioabsorbable implants in orthopaedics
MS Dhillon, AV Lokesh
October-December 2006, 40(4):205-209
  14,549 1,111 1
Intertrochanteric fractures in elderly high risk patients treated with Ender nails and compression screw
Sidhartha Gangadharan, MR Nambiar
July-September 2010, 44(3):289-291
DOI:10.4103/0019-5413.65154  PMID:20697482
Background: Ender and Simon Weidner popularized the concept of closed condylocephlic nailing for intertrochanteric fractures in 1970. The clinical experience of authors revealed that Ender nailing alone cannot provide secure fixation in elderly patients with osteoporosis. Hence we conducted a study to evaluate the efficacy of a combined fixation procedure using Ender nails and a cannulated compression screw for intertrochanteric fractures. Materials and Methods: 76 patients with intertrochanteric fractures were treated using intramedullary Ender nails and cannulated compression screw from January 2004 to December 2007. The mean age of the patients was 80 years (range 70-105 years).Using the Evan's system of classification 49 were stable and 27 unstable fractures. Inclusion criteria was high risk elderly patients (age > 70 years) with intertrochanteric fracture. The exclusion criteria included patients with pressure sores over the trochanteric region. Many patients had pre-existing co-morbidities like diabetes mellitus, hypertension, COPD, ischemic heart disease, CVA and coronary artery bypass surgery. The two Ender nails of 4.5mm each were passed across the fracture site into the proximal neck. This was reinforced with a 6.5 mm cannulated compression screw passed from the sub trochanteric region, across the fracture into the head. Results: The mean follow-up was 14 months (range 9-19 months) Average time to fracture union was 10 weeks (range 6-16 weeks). The mean knee ROM was 130o (± 5o). There was no case of nail penetration into hip joint. In five cases with advanced osteoporosis there was minimal migration of Ender nails distally. Conclusions: The Ender nailing combined with compression screw fixation in cases of intertrochanteric fractures in high risk elderly patients could achieve reliable fracture stability with minimal complications.
  14,404 1,235 1
Cervical spinal cord injury in playing golf - A Case Report
Y Jagatsinh, S Quadri
October-December 2006, 40(4):273-273
  15,075 441 -
Epidemiology of hip fracture: Worldwide geographic variation
Dinesh K Dhanwal, Elaine M Dennison, Nick C Harvey, Cyrus Cooper
January-February 2011, 45(1):15-22
DOI:10.4103/0019-5413.73656  PMID:21221218
Osteoporosis is a major health problem, especially in elderly populations, and is associated with fragility fractures at the hip, spine, and wrist. Hip fracture contributes to both morbidity and mortality in the elderly. The demographics of world populations are set to change, with more elderly living in developing countries, and it has been estimated that by 2050 half of hip fractures will occur in Asia. This review conducted using the PubMed database describes the incidence of hip fracture in different regions of the world and discusses the possible causes of this wide geographic variation. The analysis of data from different studies show a wide geographic variation across the world, with higher hip fracture incidence reported from industrialized countries as compared to developing countries. The highest hip fracture rates are seen in North Europe and the US and lowest in Latin America and Africa. Asian countries such as Kuwait, Iran, China, and Hong Kong show intermediate hip fracture rates. There is also a north-south gradient seen in European studies, and more fractures are seen in the north of the US than in the south. The factors responsible of this variation are population demographics (with more elderly living in countries with higher incidence rates) and the influence of ethnicity, latitude, and environmental factors. The understanding of this changing geographic variation will help policy makers to develop strategies to reduce the burden of hip fractures in developing countries such as India, which will face the brunt of this problem over the coming decades.
  14,810 387 109
Cervical spine trauma
Joel A Torretti, Dilip K Sengupta
October-December 2007, 41(4):255-267
DOI:10.4103/0019-5413.36985  PMID:21139776
Cervical spine trauma is a common problem with a wide range of severity from minor ligamentous injury to frank osteo-ligamentous instability with spinal cord injury. The emergent evaluation of patients at risk relies on standardized clinical and radiographic protocols to identify injuries; elucidate associated pathology; classify injuries; and predict instability, treatment and outcomes. The unique anatomy of each region of the cervical spine demands a review of each segment individually. This article examines both upper cervical spine injuries, as well as subaxial spine trauma. The purpose of this article is to provide a review of the broad topic of cervical spine trauma with reference to the classic literature, as well as to summarize all recently available literature on each topic. Identification of References for Inclusion: A Pubmed and Ovid search was performed for each topic in the review to identify recently published articles relevant to the review. In addition prior reviews and classic references were evaluated individually for inclusion of classic papers, classifications and previously unidentified references.
  13,985 1,149 9
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