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   2006| July-September  | Volume 40 | Issue 3  
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Role of ligamentotaxis in management of comminuted intra/juxta articular fractures
RPS Boparai, RS Boparai, Rajesh Kapila, Dilbans Singh Pandher
July-September 2006, 40(3):185-187
Background : Comminuted intra/juxta-articular fractures are the most difficult one's to treat in orthopaedics as far as functional & cosmetic results are concerned. The basic aim of our study was to analyse the efficacy of distractors / external fixator in various forms using principle of ligamentotaxis to achieve a high degree of functional & cosmetic results in these fractures. Methods : This consecutive prospective study comprised of thirty cases of comminuted intra/juxta-articular fractures, varying from grade 0 to grade III B Gustilo & Anderson classification, treated by the principle of ligamentotaxis using distracter / ex fix in its various forms. Results : Average time of union varied from 3 weeks to 20 weeks depending upon the bone involved. Commonest complication was pin tract infection (13), while delayed union (3) and mal­union (one) was also observed. Good range of motion at the involved joint was observed in majority of the cases. As per modified clinical scoring system of Green and O'Brien (1978) excellent to good results were seen in 73.34% cases and fair to poor results in 26.66%. Conclusion : Thus we conclude that ligamentotaxis is an excellent method for the management of comminuted intra/juxta articular fractures. It not only obviates the need of ORIF and/or POP cast but also gives better functional results. It is very useful in compound comminuted fractures around joints where other methods are contraindicated.
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Results of cemented bipolar hemiarthroplasty for fracture of the femoral neck - 10 year study
PS Maini, Navin Talwar, VK Nijhawan, Manish Dhawan
July-September 2006, 40(3):154-156
Background : One of the most common treatments of displaced fracture of femoral neck in elderly is bipolar hemiarthroplasty. Method : Two hundred and seventy patients of displaced fracture of femoral neck were treated by bipolar hemiarthroplasty. The Mean age of the patients at the time of surgery was 69.80 years. Results : Follow up ranged between 12 months and 120 months. There were 8 cases each of acetabular erosion and protrusion with 10 cases of femoral stem loosening. Eight cases had post operative dislocation requiring open reduction. Eighteen patients got revision surgery to total hip replacement. The overall incidence of DVT/PE was 9.9% which declined after regular use of low molecular weight heparin. Eleven patients had post operative infection. There were 54.2 % excellent results, 21.0 % good results, 10.7 % fair and 3.7% poor results. Conclusion : Elderly patients with displaced fracture of neck femur are able to ambulate early after Cemented bipolar hemi arthroplasty. The complication rate is low, the component survival long and pre injury functional status is restored in majority of patients.
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Intraosseous disc prolapse: A diagnostic puzzle
Rajesh Parasnis, Gautam D Talawadekar, KH Sancheti, Shekhar Bhojraj
July-September 2006, 40(3):168-172
Background : Schmorl's node or intraosseous disc prolapse is herniation of the nucleus pulposus material through the vertebral end plates. Presence of Schmorl's nodes as end plate lesions following trauma, tumours and osteoporosis further complicates diagnosis. The present study was done to understand diagnosis and approach to management of symptomatic Schmorl's nodes. Methods : During a period of three years we came across 14 patients who presented with severe back pain. Conventional radiographs, CT Scans and MRI showed the presence of end plate lesions with varied radiological appearance. The first group, comprising of seven patients had lytic lesions without any sclerosis on only one side of the intervertebral disc as seen on the CT scan. The second group comprising of five patients had sclerotic lesions with new bone formation associated with disc space reduction. The two patients in the third group showed a combined lytic and sclerotic lesion without any soft tissue changes. MRI of eleven patients revealed hypointense lesion on T 1 and T 2 weighted images with surrounding zone of hyper intensity on T 2 weighted images. The remaining three patients, did not have this hyper intense zone on T 2 weighted images . In five patients multiple Schmorl's nodes were observed. Diagnosis of symptomatic Schmorl's nodes was mainly done by exclusion. All patients were given rest and anti-inflammatory drugs followed by exercises. Results : The first two groups of patients responded to the treatment and had complete relief of symptoms but both the patients in third group had persistent symptoms. MRI repeated after eight weeks showed an enhancing lesion with prevertebral soft tissue. A transpedicular core biopsy proved the lesion to be tuberculosis in one patient. Anti Koch's therapy was promptly started and follow up study showed resolution of the lesions. At the end of the study period all the patients were asymptomatic and returned to their active profession. Conclusion : The difficulty in diagnosis is attributed to the fact that every person with Schmorl's node is not symptomatic. For accurate diagnosis it is necessary to have high index of suspicion, close follow up and exclusion of other associated conditions. In case of poor response to conservative treatment an alternative diagnosis has to be considered and if required it should be proved or disproved by a biopsy of the lesion (percutaneous or open).
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Infection following implant surgery
SC Goel
July-September 2006, 40(3):133-137
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Management of periarticular fractures of long bones of the lower extremity by hybrid external fixation
Mayil Vahanan Natarajan, Chethan Nagaraj, R Selvaraj, B Pasupathy, Antony Vimal Raj, P Sankarlingam
July-September 2006, 40(3):177-179
Background : Management of periarticular fractures is associated with many complications. Hybrid fixators allows for early partial weight bearing and range of motion exercises at adjoining joints. Furthermore, it promotes callous formation by continuous axial micro movements in the fixation frame. Methods : We have prospectively analyzed the results of hybrid external fixation in the management of periarticular fractures of long bones of the lower extremity in 20 patients accounting for 22 limbs. We treated 19 fractures (18 compound and 1 closed) and three fracture nonunions with this method. The mean age of the patients was 36.5 years. In 12 patients hybrid fixation was the primary procedure while in 8 patients hybrid fixation was done following initial emergency AO Uniplanar external fixation. Fourteen patients required subsequent surgeries such as bone grafting and soft tissue cover. Results : The mean follow up of our patients was 13.2 months (5 - 25 months). We achieved excellent results in 10 fractures, good in 4 fractures, fair in 3 fractures and poor results in 3 fractures. Two patients were lost to follow up. Bony union was achieved in 18 of the fractures. A short-term acceptable result was achieved in 17 cases. Conclusion : Hybrid external fixation is a very effective and useful treatment modality in the management of fractures close to a joint providing excellent to good results. It combines the advantages of both Ilizarov and AO external fixators. It is minimally invasive, modular and yet efficient in promoting massive new proliferative callus formation at the fracture site.
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Epidemiology of golf related musculo-skeletal injuries
Mandeep S Dhillon, Sanjay Singh, Himmat Singh Dhillon, Jaspal S Sandhu
July-September 2006, 40(3):188-190
Background : Golfing has become an increasingly popular sport enjoyed by both men and women. Although the game is not viewed as hazardous, golfers do sustain injuries connected with the game. However, golf injuries have received little attention in the literature and there is no study from Asia. Methods : A prospective study was undertaken to analyze the incidence, cause and type of injury among amateur golfers. Open ended questionnaires were sent to 1000 golfers; 240 responded (Av age 51 years, 200 males and 40 females). The respondents played an average of 2 rounds per week. Results : One hundered and ten (46%) responders had sustained one or more orthopaedic injuries. Both among men and women, the lower back was the most common site of injury followed by shoulder and dorsal spine. There was a difference in the injury pattern in skilled and relatively unskilled players. Lack of warm up, excessive practice and improper swing mechanics were the most common causes. Conclusion : Golf injuries perhaps could be prevented or reduced by proper technique, controlled practice routines, physical conditioning and pre-play stretching exercises. The most important factor in this playing population seems to be prevention.
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Displaced intra-articular fractures of calcaneum
KP Srivastava
July-September 2006, 40(3):147-153
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Osteonecrosis : Early diagnosis, various treatment options and outcome in young adults
Sushrut Babhulkar
July-September 2006, 40(3):138-146
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Results of treatment of clubfoot by Ponseti's technique in 40 cases : Pitfalls and problems in the Indian scenario
Atul Bhaskar, Shraddha Rasal
July-September 2006, 40(3):196-199
Background : Though described long back, there has been a renewed interest towards Ponseti method of conservative treatment of clubfoot recently. Methods : Forty children with idiopathic clubfeet were treated by Ponseti technique. The median age at presentation was 9 days. Twenty-six children with bilateral and 12 children with unilateral clubfeet were graded by the Pirani method at the commencement of treatment and then at the final follow-up. Feet were graded as excellent if the Pirani score was zero, fair, if the sum of mid-foot and hind-foot score was one or less and poor, if the score was more than one. Thirty four children need a heel cord tenotomy and all children received conventional ankle-foot orthosis (AFO) and foot-abduction orthosis (FAO) to maintain correction. Results : Twenty-eight children had excellent correction, four had a fair outcome and eight cases had relapse in their deformity. Poor splint compliance and fitting along with incomplete correction of the deformity were identified as the chief causes leading to a poor result. Conclusion : A strict protocol and parent education can improve the outcome for all cases with the Ponseti technique. Key-words: Clubfoot; Congenital talipes equinovarus; Ponseti technique.
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Antegrade Rush nailing for fractures of humeral shaft- an analysis of 200 cases with an average follow up of 1 year
WG Gadegone, Yogesh Salphale
July-September 2006, 40(3):180-182
Background : The incidence of humeral fracture has significantly increased during the recent times due to the rising age of the population and the number of automobile accidents. In order to achieve a stable fixation and early mobilization, numerous surgical implants have been devised. Method : We carried out a prospective analysis of the data of 200 consecutive patients who had closed fractures of the humeral shaft treated with ante-grade closed Rush nails at our institute. Patients with preoperative radial nerve injury were excluded from this study. In 186 patients we achieved close to anatomic reduction of the fracture fragments. In 14 patients we had to resort to limited open reduction. Results : Fracture united in 186 of 188 patient followed up for one year. Complications occurred in 26 patients. We strongly advise a careful surgical technique and modification as per the individual fracture pattern to reduce the complications. Conclusion : Osteosynthesis with multiple Rush nails features the advantages of rotational stability of the head-neck fragment to the diaphysis, an unreamed implantation technique without any special instruments, the speed of execution and minimal economic burden so important for the developing country like ours.
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Correction of post-traumatic kyphosis using intermediate facet joints as fulcrum in dorso-lumbar spine injuries
Amit Agrawal, M Shantharam Shetty, JP Shetty, U Srikrishna, Swapnil S Nagvenkar
July-September 2006, 40(3):164-167
Background : Post traumatic kyphotic deformity are managed by different methods. Posterior stabilization of dorso-lumbar fractures with transpedicular screws and rods using intermediate facets as fulcrum can restore body height. Methods and material : In a retrospective clinical study 6 consecutive patients with complete or incomplete neurological deficits as a result of the dorso-lumbar fractures were included. Local kyphosis was measured as the angle between the upper and lower end plates of the collapsed vertebrae preoperatively, postoperatively and at the last follow-up visit. The neurological condition of the patients was recorded in the pre-op and follow up period according to Frankel grading systems. Stabilization with pedicle screw fixation and posterior fusion with autogenous bone chips were done after decompression in all 6 patients included in this study. The outcome of the study was evaluated with regard to the correction of kyphotic deformity and increase in vertebral body height after adequate neural canal decompression and fusion. Results : Of the 6 patients 4 were Frankel A and 2 Frankel C pre-operatively. Three patients sustained wedge fracture and three sustained burst fracture. The most commonly affected vertebra was L 1 with 4 cases followed by L 2 . The preoperative mean kyphotic angle was 23.3° (17°-28°), and was corrected to 15.8 (12° - 22°) with a correction rate of 32.3% (21.4 - 43.5 %) in the post-operative period and this correction was improved at three months follow up and the final correction was measured to be 46.3% (22.7-59.0 %). Serial postoperative radiographic follow­up assessment showed maintenance of kyphotic correction. Minimum correction of body height was .05 cm (correction rate­1.8%) and maximum correction was .65 cm (correction rate­28.9%) in post-operative period with a mean of 0.29 cm (correction rate-13.1%). Conclusions : Preserved the intermediate articular processes can be used as fulcrum to reduce the kyphosis that can be maintained as they provides continuous support and traction.
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Charnley-Hasting bipolar modular replacement option for intracapsular fracture neck femur
Sanjay Agarwala, Abhijit Bhagwat
July-September 2006, 40(3):157-159
Background : The consensus of treating a transcervical fracture neck femur in elderly is on replacement surgery. A total arthroplasty is not always the answer especially in patients where stability and mobility need to be balanced especially in patients who cannot comprehend the required changes in the life style & restriction in activity. The traditional method would be a hemiarthroplasty with Austin Moore's or Thompsons prosthesis. Both are in the long term associated with loosening, acetabular erosion, pain and loss of mobility. Method : The present study involves 106 patients who underwent 108 surgeries with a hybrid system of Charnley stems and Hastings bipolar shells, for transcervical fracture neck femurs. Results : Over all 78% had excellent to good results at three­year follow up. Conclusion : The advantage of the system is in the modularity obtained from the different sized Charnley stems, Hasting shell which are available in increments of 1mm allow exact matching of the head and the ease with which the system can be converted to Charnleys low friction Arthroplasty without replacing the stems.
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The role of Esmarch bandage and percutaneous cannulated cancellous screws in tibial condylar fracture
Kiran Shete, Parag Sancheti, Rutuj Kamdar
July-September 2006, 40(3):173-176
Background : Proximal tibial fractures involving the condyles are often a matter of debate with regards to surgical management. The purpose of this study was to evaluate the efficacy of using closed reduction with an eschmarch bandage, gentle hammering, and use of percutaneous cannulated cancellous screws for fixation and buttressing the fracture, as a treatment modality for specific tibial condyle fractures. Methods : We evaluated 90 closed upper end tibia fractures, Schatzker types I, III, and IV, treated with closed reduction using an esmarch bandage and minimally invasive percutaneus fixation with cannulated cancellous screws. Results : We achieved excellent results in 33.3% of the cases, good result in 50%, a fair result in 13.3 %, and a poor result in 3.3 % cases. Conclusion : This minimally invasive modality of treatment of upper end tibia fractures gives satisfactory results. The use of esmarch bandage and gentle hammering to help achieve acceptable reduction has the advantage of being relatively simple and easily reproducible, without the use of any expensive extra medical equipment. The percutaneous fixation with cancellous screws has minimal morbidity. Thus, this is a good modality of treatment of tibial condlyle fractures of Schatzker types I, III and IV.
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Postero-medial release in clubfoot - A retrospective study of causes of failures
AV Sanghvi
July-September 2006, 40(3):191-195
Introduction : Postero-medial release is the most common surgical procedure used to correct the deformity of clubfoot. It has been seen that despite a good correction immediately following the surgery, the long-term results are not satisfactory. Material and methods : A retrospective study was carried out in a total number 52 clubfeet in 36 patients treated by postero­medial release to assess the causes of failures. The mean duration after surgery was 5.1±1.2 years, mean age at operation was 1.1±0.5 years and mean age of patient at final follow up was 6.9±2.1 years. The results were plotted and compared with different variables. Results : The results were successful in 36 and failure in 16 patients. A significantly high failure rate of 80% was found when postero-medial release was done after 3 years of age as a sole procedure as compared to 25.5% only if age was less than 3 years (p<0.05). The patient compliance to follow bracing protocol showed significantly high failure rate of 52.4% in non-compliant patients versus 16.1% in compliant patients (p<0.05). A significantly high failure rate was also seen when bracing was not continued beyond 3 years after surgery (p<0.05). Neurological clubfoot had a significantly high failure rate (80%) compared to idiopathic clubfoot (25.5%) (p<0.05). A significantly high failure rate was also noted when infection and skin necrosis lead to skin grafting or flap coverage as compared to those healed with dressings alone (p<0.05). Conclusion : Postero-medial release achieves best results in patients of less than 3 years of age and patients with compliance for bracing for at least up to 3-4 years following surgery and idiopathic clubfoot. Infection in clubfoot does not increase the failure rate unless it is severe enough to require plastic coverage. Any deviations from the above significantly increase the chances of failure of the procedure and hence can be labeled as the causes of failures of postero-medial release.
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Retrograde interlocking nailing in diaphyseal fractures of humerus
RK Goyal, Harish Chandra, KK Pruthi, A Kumar
July-September 2006, 40(3):183-184
Background : Retrograde interlocking nailing for humeral fracture is technically difficult but has advantage of sparing the involvement of rotator cuff and subacromial bursa. Methods : A total number of 12 cases (9 closed, 3 compound - Grade I and II), having diaphyseal fractures of upper (3 cases) and middle third (9 cases ) of humures were treated by retrograde interlocking nailing. Out of 12 cases, 11 were fresh and 1 was old fractures. Cases were followed up for 3 year. Results : Excellent results were seen in 8, good in 3 and fair in one case ( delayed union). One case developed elbow stiffness, whereas none developed shoulder stiffness. Conclusions : Apart from the overall advantages of conventional locked nailing technique, retrograde locked nailing has additional advantage of sparing the rotator cuff and subacromial bursa, thus prerserving the shoulder functions.
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Bone and Joint Decade (BJD) 2000 - 2010
Satish Goyal
July-September 2006, 40(3):200-201
  2,561 187 -
A reliable and simple method for identifying at start patients with tuberculosis of the spine suitable for ambulatory chemotherapy
K Sriram, PR Somasundaram, R Parthasarathy, V Chandrasekaran
July-September 2006, 40(3):160-163
Background : Ambulatory chemotherapy is very effective in the treatment of spinal tuberculosis, involving vertebral bodies, without paraplegia. However, some patients with thoracic disease could develop worsening of kyphosis. It would be helpful to predict which patients were unlikely to develop severe kyphosis. Methods : Step-wise discriminant analysis on the 10-year data of 79 patients treated with ambulatory chemotherapy showed that the angle of kyphosis on admission and the site of the lesion were associated with an angle of 50 0 or less at 10 years. An equation based on these factors was evolved to give a discriminant function (D) value. Results : Of 51 patients with an angle of 50˚ or less at 10 years, 47 had a D value of 0.499 or less, giving a predictive accuracy of 92%. Of 28 patients who had an angle of more than 50˚ at 10 years, 5 had a D value of 0.499 or less (false-negativity of 18%). Considering the initial angle, which was much more important (p<0.0001) than the site of the lesion (P<0.03), 46 of the patients with an angle of 50˚ or less at 10 years had an initial angle of 30˚ or less (predictive accuracy of 90%); 3 of the patients who had an angle of more than 500 at 10 years had an initial angle of 30˚ or less (false-negativity of 11%). Conclusion : If the angle of kyphosis on admission is 300 or less, ambulatory chemotherapy could be confidently prescribed. The method is reliable and simple.
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