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  Citation statistics : Table of Contents
   2005| October-December  | Volume 39 | Issue 4  
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Giant cell tumors of lower end of the radius : Problems and solutions
IK Dhammi, AK Jain, Aditya V Maheshwari, MP Singh
October-December 2005, 39(4):201-205
Background: Giant cell tumors of bone are aggressive, potentially malignant lesions. Juxtaarticular giant cell tumours of lower end radius are common and present a special problem of reconstruction after tumor excision. Out of the various reconstructive procedures described, use of nonvascularised fibular autograft has been widely used with satisfactory functional results. Methods: Sixteen patients with a mean age of 20.2 years, with either Campanacci grade II or III histologically proven giant cell tumours of lower end radius were treated with wide excision and reconstruction with ipsilateral nonvascularised proximal fibular autograft. Host graft junction was fixed with intramedullary nail in 12 cases and DCP in last 4 cases. Wrist ligament reconstruction and fixation of the head of fibula with carpal bones using K-wires and primary cancellous iliac crest grafting at graft host junction with DCP was done in last 2 cases. Results: The follow up ranges from 2 - 5 years (mean 3.5 years). At last follow up, the average combined range of motion was 110° with range varying from 60-125°. The average grip strength was 39% in comparison to the contralateral side (range 21-88%). The average union time was 8 months (range 4-12 months). Sound union occurred in 5 months, where DCPs were used. There were 5 nonunions, one resorption of graft, 10 wrist subluxations (2 painful), one recurrence, 3 superficial infections, one wound dehiscence and one amputation. There was no case of graft fracture, metastasis, death or significant donor site morbidity. A total of 10 secondary procedures were required. Conclusions: Enbloc resection of giant cell tumours of lower end radius is a widely accepted method. Reconstruction with nonvascularised fibular graft, internal fixation with DCP with primary corticocancellous bone grafting with transfixation of the fibular head and wrist ligament reconstruction minimizes the problem and gives satisfactory functional results.
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Complications of resection and reconstruction in giant cell tumour of distal end of radius - An analysis
SK Saraf, SC Goel
October-December 2005, 39(4):206-211
Background: The bulk of literature on the subject focuses on the resection of the tumor followed by reconstruction using autologous fibula, however, papers analyzing the failures of this procedure are scanty. The aim is to analyze the various factors responsible for the failures. Methods: Study included 42 patients of aggressive GCT of distal radius, resected and reconstructed using nonvascularised autologous fibula. Host graft junction was fixed using screws (6), intramedullary nail (21) and plate (15). The minimum follow-up was 2 years or till a complication occurred requiring second surgery. Result: The major complications were recurrence in 6 cases (spillage of tumor tissue in 3, poor biopsy site 2, recurrence along the nail tract one case); failure of host graft union in 8 cases due to inadequate contact at host graft junction, poor implant selection, inadequate immobilization and infection; significant instability at wrist in 6 cases due to poor stabilization at carpo fibular junction in addition to inherent instability due to poor congruity between fibulocarpal articulations. Conclusion: Reconstruction of distal end of radius using auto fibula has much higher complication rates than usually believed. A meticulous planning and its execution is must to minimize the problems. Use of dynamic plate for host graft junction and fixation of fibular head to adjacent ulna/carpal bones improves the results.
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Noncemented total hip replacement in various disorders of the hip
BK Dhaon, Anuj Jaiswal, Vishal Nigam, Vineet Jain
October-December 2005, 39(4):225-227
Background: Noncemented total hip arthroplasty has emerged as effective option in various disorders of hip in young patients and those with good bone stock. Method: Between 1992 and 2002, 34 patients underwent 47 uncemented total hip replacements. Preoperative and postoperative Harris hip scores were compared. Patients were followed up for a minimum period of 2 years and maximum of 10 years. Result: Mean Harris hip score improved from preoperative mean of 36.6 to 89 after average follow up of 5.7 years. Forty one hips had excellent or good result and one had poor result. There was no case of femoral stem failure and one case of acetabular component failure. Conclusion: Noncemented total hip arthroplasty gives excellent results in disabling disorders of the hip.
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Management of unstable spinal fractures with segmental spinal instrumentation (VSP System) : Results at 5 year follow up
Dipankar Sen, DK Patro
October-December 2005, 39(4):232-236
Background: Pedicle screw instrumentation has been widely used for spinal stabilisation following spinal injury with variable results. The controversial points associated with spinal injury are effects of canal compromise and decompression on neurological status. Methods: Thirty four patients of unstable thoraco-lumbar fracture with or without neuro-deficit were treated by decompression and stabilisation with VSP system and followed up for 22 - 39 months (mean 29 months). The results were evaluated by neurological recovery (ASIA score), pain relief, loss of surgical correction and functional rehabilitation (FIM score). Results: We achieved a mean post-operative correction of the kyphotic deformity by 14 degrees and an average gain of 30.2% in the canal diameter by decompression. However no correlation was established between degree of canal compromise before or after the surgery with the final neurological outcome. Conclusion: Although the infrastructure for spinal injury management in developing countries is inadequate in many aspects, we find that it is still possible to achieve results, which are comparable with standard literature by adequate decompression and stabilisation followed by appropriate rehabilitation according to the social and cultural demands of the patients.
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Transient osteoporosis of hip-A case report
Puneet Gupta, Sansar Sharma, Vineeta Gupta, Daljeet Singh, Atul Agarwal, V Chauhan
October-December 2005, 39(4):257-259
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Proximal femoral epiphysiolysis in an adult-A case report
B Pasupathy, M Natarajan, A Sivaseelam, R Selvaraj, IS Sudarshan
October-December 2005, 39(4):260-261
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Acute compartmental syndrome developing during knee arthroscopy-A case report
B Dinakar, Ajit Kumar
October-December 2005, 39(4):262-263
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Outcome measures of bipolar hip arthroplasty for atraumatic hip disorders - A preliminary report
Baldev G Dudani, Dinesh Thawrani, Shivanand Chikale
October-December 2005, 39(4):212-217
Background: Bipolar hip arthroplasty was devised for fracture neck femur in elderly patients. Subsequently, indications have been expanded to include conditions affecting acetabulum like rheumatoid arthritis, osteoarthritis and avascular necrosis of femoral head. Materials and methods: We have studied the results of bipolar hip arthroplasty in 38 such patients, with severely involved acetabulum due to rheumatoid arthritis, avascular necrosis of femoral head and primary osteoarthritis. Acetabulum was reamed to get a tight 'equatorial' or 'rim' fit of the prosthesis. Prosthesis selected was 1 mm bigger than the maximum size of reamer used. Cement was used in femur whenever there was marked osteoporosis or wide medullary canal. Post operatively all patients were regularly screened for pain, range of movement, protrusio acetabuli, loosening / sinking of prosthesis and radiographic assessment of movement in the two bearings of prosthesis. Results: Overall results achieved were good to excellent in 80% of patients. Conclusions: The ultimate outcome is comparable to total hip arthroplasty. The added advantage is of low cost, simplicity of procedure and easy future revision.
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Bipolar arthroplasty in non-infective hip arthritis
Vikas Singh, KR Patond
October-December 2005, 39(4):218-220
Background: Hip arthroplasty is the most commonly performed adult reconstructive hip procedure. Not all the patients have extensive deformities of both the femoral head and acetabulum, for which a dual-assembly total hip prosthesis is required. The bipolar arthroplasty as used today has rather specific indications; but a young patient with an avascular head is considered the best candidate. Method: Thirty five bipolar arthroplasties were performed in 29 patients using Talwalkar's bipolar prosthesis for non-infective hip arthritis and the patients were evaluated using Harris Hip Score. Twenty four hips in 21 patients (mean age = 36.17 years) could be followed up for inclusion in this study. Results: At an average follow up of 3.5 years, HHS on an average increased by 43.50; from preoperative 39.58 to post­operative 83.08. Good-to-excellent results were obtained in 19 (excellent- 11; good- 8) hips. Anterior thigh pain, hip pain, deep infection, longitudinal split of femoral shaft and death was seen in one case each. Conclusion: We conclude that bipolar arthroplasty is a simple, reliable, viable and a cost-effective; primary surgical treatment modality in non-infective hip arthritis for young to middle aged patients, especially in our scenario where funds for the operative procedure, prosthesis as well as adequate infrastructure for the hospital are, by and large, limited.
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Comparison of angle of femoral anteversion after total hip replacements through the anterior and posterior approaches
PS Maini, Gagan Chadha, Naveen Talwar, Kiran Ramesh
October-December 2005, 39(4):221-224
Background: Excessive anteversion or retroversion of femoral component may cause arthroplasty to become unstable. Method: In this study, we calculated the anteversion angle of the femoral neck in thirty non operated (control) hips on both sides by biplanar roentgenography and using the average angle obtained as standard, compared the anteversion angle of the femoral component in thirty patients (both males and females) who had undergone total hip arthroplasty (cemented or uncemented) through anterior and posterior approaches. Results: The average femoral anteversion angle in hips that had undergone total hip replacement through the posterior approach was 18.18 degrees which closely paralleled that of the controls which was 16.31 degrees suggesting that the operating surgeon had a better control over femoral neck anteversion through the posterior approach than the anterior approach in which the average anteversion angle was 9.3607degrees. Conclusion: Operating surgeon had a better control on femoral neck anteversion through the posterior approach as he can position the femoral neck in significantly lesser degrees of anteversion.
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Management of subtrochanteric fractures with a sliding hip screw-plate device
M Shantharam Shetty, M Ajith Kumar, SS Ireshanavar
October-December 2005, 39(4):237-239
Background: Subtrocahnteric fractures pose a problem in management. Methods: Twenty three subtrochanteric fractures were treated with sliding screw plate. Russell-Taylor Type II fractures were 78% and Type I were 22%. Results: Union was achieved in 21 patients. Fractures with medial cortical comminution were most unstable and were at great risk of complication. Conclusion: The sliding screw plate device is a reliable method of achieving union in subtrochanteric fractures in Russell Taylor type II fractures.
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Modification of Baksi sloppy hinge elbow to minimize the stresses at the humeral bone cement interface- An early experience
DP Baksi
October-December 2005, 39(4):240-243
Background : Baksi sloppy hinge elbow is an all metal prosthesis having 7 0 - 10 0 varus - valgus inherent laxity at the hinge section with minimal motion bearing contact area. Due to the presence of laxity at it's hinge section, any strain on the prosthesis dissipates primarily to the surrounding soft tissues thus protecting the cement bone interfaces. However, from our long term clinical experiences on the use of our sloppy hinge design since 1984 and the knowledge of literature review of the results of using other semi­constrained (sloppy) or unconstrained designs, it was observed that radiolucency or loosening at the bone-cement interface occurred mainly around the humeral stem in the long run due to the continued effect of rotational torque of forearm and hand. Hence, an attempt in the improvement of the design concept is being made. Methods : In this respect one flange each of one cm height and breadth and three mm thickness has been incorporated on either sides of the shank of humeral stem of the sloppy hinge at medio­lateral (coronal) plane which will be seated in the corresponding longitudinal groove cut on either side of humeral shaft extending from its transverse cut end to become single assembly during the rotation of humerus. Results : The preliminary results of clinical application of the modified sloppy hinge elbow in ten cases are found satisfactory. Conclusion : The cyclical compression and distraction forces during flexion and extension of the elbow will be distributed over the larger bony area of lower end of humerus where flanges of the humeral shank being seated. The rotational torque effect of forearm and hand particularly with the arm in abduction will be minimised at the humeral bone cement interface as the humerus and the prosthetic stem act as a single assembly by the snugly fitting of the prosthetic flange in the humural shaft
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Treatment of congenital club foot with Ponseti method
RA Agrawal, MS Suresh, Rajat Agrawal
October-December 2005, 39(4):244-247
Introduction: Idiopathic congenital talipes equinovarus (Club Foot) is a complex deformity that is difficult to correct. The goal of treatment is to reduce or eliminate its four components so that the patient has a functional, pain free, plantigrade foot, with good mobility and without calluses, and does not need to wear modified shoes. Material and Methods: We have treated 41 patients with 60 idiopathic clubfoot deformity using Ponseti method of management. The severity of foot deformity was assessed according to the grading system of Dimeglio et al. Results: The mean number of casts that were applied to obtain correction was six (range four to nine casts). Tenotomy was done in 58 feet. Fifty eight feet had good results.Two patients developed recurrence of the deformity due to non-compliance of the use of orthrotics. Conclusion: The Ponseti method is a safe and effective treatment for congenital idiopathic clubfoot and radically decreases the need for extensive corrective surgery. Non compliance with orthotics has been widely reported to be the main factor causing failure of the technique.
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Lower limb alignment in cerebral palsy
SP Das, D Singh, J Sahoo, SV Prasad, RN Mohanty, SK Das
October-December 2005, 39(4):248-253
Background: Spasticity leading to tightness of muscle is disabling. Muscular activity is used for balance of motion and joint alignment rather than weight bearing. Change of joint position interferes with passage of ground reaction force leading to muscle fatigue. During ambulation center of mass changes beyond its range due to so many causes including abnormal hip, knee, ankle and foot motion leading to high energy expenditure. Methods: Three hundred and sixty five lower limbs in 220 patients were operated by various methods described for hip, knee and ankle joint. Results: Results were excellent to fair in two hundred cases and poor in twenty cases. Conclusion: When cases taken up for surgery are selected with proper and repeated assessment, appropriate surgical procedures are performed in time then results of surgery are best in comparison with any other modalities of treatment and also achieved in a short time
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Hydroxyapatite as a bone graft substitute: Use in cortical and cancellous bone
Sanjay Agarwala, Abhijit Bhagwat
October-December 2005, 39(4):254-256
Background : Autogenous bone is regarded as the best bone graft material. Various grafting materials have been advocated to fill bony defects. Our purpose was to study the utility of amorphous hydroxyapatite as an autogenous bone graft substitute in cancellous and cortical bone. Methods : A prospective study was undertaken over a period of five years. Patients included were those which would otherwise require bone grafting in cancellous and cortical bone fractures (15 in each group). Hydroxyapatite (HA) ceramic blocks of standard size (5mm x10m) were either used alone or mixed with autogenous cancellous graft in metaphyseal locations, along with bone marrow (derived from reaming or drilling) in intertrochanteric regions and mixed with cancellous graft in cortical areas. The results were assessed on standard radiographs. Biopsy of hydroxyapatite regenerated bone was taken at implant removal. Results: In cancellous areas as graft incorporation ensues over months the intrinsic structure of the hydroxyapatite blocks blurred with blunting of the sharp edges (on radiographs). Biopsy confirmed bone in-growth. In cortical areas the blocks did not show evidence of bone in-growth. Conclusion: Hydroxyapatite alone or when mixed with cancellous bone marrow is an effective adjuvant for autogenous bone grafts, especially in cancellous areas of bone. Mixing it with host marrow provides osteoinductive stimulus. It is biocompatible, osteoconductive but not osteogenic.
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Role of SPECT imaging in symptomatic posterior element lumbar stress injuries
UK Debnath, BJC Freeman, M Solaymani-Dodaran, JK Webb
October-December 2005, 39(4):228-231
Background : Diagnosis of stress injuries of spine is very difficult with conventional radiography. Methods : In a observational study, 132 subjects were recruited (between 8 and 38 years of age), who had lumbar spondylolysis or posterior element stress injuries. All these patients underwent clinical examination followed by plain X-rays, planar bone scintigraphy and SPECT (single photon emission computerised tomography). SPECT scans can identify the posterior element lumbar stress injuries earlier than other imaging modalities. As the lesions evolve and the completed spondylolysis becomes chronic, the SPECT scans tend to revert to normal even though healing of the defect has not occurred. The aim of the study was to determine the time lag after which SPECT imaging tends to be negative. We divided the patients into two groups, one SPECT positive group and the other SPECT negative group. Pre treatment background variables such as age, gender, back pain in extension or flexion, sporting activities, time of onset of symptoms, Oswestry Disability Index (ODI) were used in a univariate logistic regression model to find the strong predictors of positive SPECT imaging results. Determinants of positivity versus negativity of SPECT were identified by discriminant analysis using multivariate logistic regression. Results : Seventy nine patients had positive SPECT scans whereas 53 patients had negative SPECT scans. Bilateral increased uptake was more common than unilateral uptake. Increased uptake at the L5 lumbar spine was more common (70%) in SPECT positive group. Low back pain in extension was significantly more common in SPECT positive subjects. Active sporting individuals had higher probability of having a positive SPECT scan. The mean time lag from the onset of low back pain to SPECT imaging was 7 months in SPECT positive group and 25 months in the SPECT negative group. Multivariate analysis predicted that there is a significant difference in positivity of SPECT scans (reduced number of positive results) in subjects who had onset of pain more than six months. Conclusion : SPECT imaging performed within the first six months following the onset of symptoms could predict the mode of treatment in patients with lumbar spondylolysis or posterior lumbar spinal element stress injuries.
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