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   2009| April-June  | Volume 43 | Issue 2  
    Online since May 2, 2009

 
 
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SYMPOSIUM
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 18,156 836
The science of electrical stimulation therapy for fracture healing
Paul RT Kuzyk, Emil H Schemitsch
April-June 2009, 43(2):127-131
DOI:10.4103/0019-5413.50846  PMID:19838360
This article is a brief review of the basic science research conducted in the field of electrical stimulation for fracture healing. Direct electrical current, capacitive coupling, and inductive coupling have been studied as potential techniques to enhance fracture healing through the proliferation and differentiation of osteogenic cells. These techniques are particularly appealing as they offer a potential minimally invasive solution to the difficult clinical problem of delayed fracture healing and nonunion. Basic science studies have shown conclusively that electrical stimulation techniques lead to bone cell proliferation and have attempted to elucidate the intracellular processes by which this bone cell proliferation occurs. Further basic science and clinical research is required to enhance the effectiveness of this therapy for the treatment of fracture nonunions.
  18 6,494 442
Electrical stimulation: Nonunions
Bauke W Kooistra, Anil Jain, Beate P Hanson
April-June 2009, 43(2):149-155
DOI:10.4103/0019-5413.50849  PMID:19838363
The current paper attempts to provide an overview on the currently available fundamental, preclinical, and clinical evidence on the biologic rationale and therapeutic efficacy of electrical stimulation devices applied in patients with long-bone nonunions. Electrical stimulation (ES) involves the generation of an electrical or electromagnetic current through the ununited fracture. Such currents, which are present in physiologically healing bone, provide stimuli that favor a healing response to bone cells. These stimuli include the enhancement of transmembrane and intracellular calcium-mediated signal transduction and an increased synthesis of paracrine and autocrine growth factors by osteoblasts. Favorable healing union rates, ranging from 43% to 90%, as found by several clinical case series, have prompted the orthopedic community to, at least partially, adopt ES for the treatment of long bone nonunions. Nonetheless, randomized controlled trials have not provided definitive evidence of ES causing nonunions to heal more often than sham devices. This impediment is probably formed by small sample sizes, lack of consistency regarding the definition of union and nonunion, and variability in ES current used.
  16 4,108 353
Low-intensity pulsed ultrasound: Fracture healing
Raman Mundi, Stephen Petis, Roopinder Kaloty, Vijay Shetty, Mohit Bhandari
April-June 2009, 43(2):132-140
DOI:10.4103/0019-5413.50847  PMID:19838361
Annually, millions of people across the world are inflicted with bone fracture injuries. Untimely healing is a significant burden in terms of socioeconomic costs, personal costs, and patients' quality of life. Low-intensity pulsed ultrasound (LIPUS) has gained much attention as a potential adjunctive therapy for accelerating fresh fracture healing, but its efficacy remains controversial. This paper is presented in two parts a literature review followed by a systematic review. The literature review highlights the physiology of fracture healing and the influence LIPUS exerts on cells and molecules involved in this healing process. In part two, we present a systematic review of randomized controlled trials (RCTs) assessing the clinical effectiveness of LIPUS in accelerating the time to fracture healing. The electronic databases we searched for the systematic review are as follows: MEDLINE (from 1996 to November 2008), EMBASE (from 1996 to November 2008), and Healthstar (from 1966 to October 2008). A two-step screening process was used to assess the eligibility of studies yielded by our search. The first step was a review of titles and abstracts for the selection of studies that met the following criteria: (i) inclusion of skeletally mature patients with a fresh fracture, (ii) a minimum of two treatment arms with at least one arm receiving LIPUS treatment and another arm receiving placebo, (iii) random allocation of patients to the different treatment arms, (iv) radiological assessment of time to fracture healing, and (v) publication in the English language. In the second step, selected articles were reviewed in full text. Eligible trials were all scored independently by two reviewers for methodological reporting quality using the 15-item CLEAR NPT checklist (Checklist to Evaluate the Report of a Nonpharmacological Trial). We identified a total of seventy seven studies, nine of which met our inclusion criteria after the initial screening. Of these nine trials, seven were included for the final review. The types of fractures studied among these seven trials included lateral malleolar, radial, and tibial fractures. Three of the seven trials found that LIPUS significantly reduces healing time compared to placebo, whereas the other four did not find a statistically significant difference. There is a substantial level of inconsistency in the findings of several RCTs evaluating the efficacy of LIPUS as an adjunct for fracture healing. Although LIPUS has proven to be effective in certain trials for accelerating fracture healing, no definitive statement can be made regarding its universal use for all fracture types and methods of fracture care. Future high-quality RCTs with larger sample sizes may help to elucidate the specific indications that warrant or dismiss the need for LIPUS therapy.
  14 12,288 532
Low-intensity pulsed ultrasound: Nonunions
Bernadette G Dijkman, Sheila Sprague, Mohit Bhandari
April-June 2009, 43(2):141-148
DOI:10.4103/0019-5413.50848  PMID:19838362
Nonunions occur in 5-10% of fractures and are characterized by the failure to heal without further intervention. Low intensity pulsed ultrasound therapy has been developed as an alternative to surgery in the treatment of nonunions. We describe a systematic review on trials of low-intensity pulsed ultrasound therapy for healing of nonunions. We searched the electronic databases Medline and the Cochrane library for articles on ultrasound and healing of nonunions published up to 2008. Trials selected for the review met the following criteria: treatment of at least one intervention group with low intensity pulsed ultrasound; inclusion of patients (humans) with one or more nonunions (defined as "established" or as a failure to heal for a minimum of eight months after initial injury); and assessment of healing and time to healing, as determined radiographically. The following data were abstracted from the included studies: sample size, ultrasound treatment characteristics, nonunion location, healing rate, time to fracture healing, fracture age, and demographic information. We found 79 potentially eligible publications, of which 14 met our inclusion criteria. Of these, eight studies were used for data abstraction. Healing rates averaged 87%, (range 65.6%-100%) among eight trials. Mean time to healing was 146.5 days, (range 56-219 days). There is evidence from trials that low-intensity pulsed ultrasound may be an effective treatment for healing of nonunions. More homogeneous and larger controlled series are needed to further investigate its efficacy.
  14 5,512 421
ORIGINAL ARTICLES
The effect of post-operative immobilization on short-segment fixation without bone grafting for unstable fractures of thoracolumbar spine
SH Lee, DS Pandher, KS Yoon, ST Lee, Kwang Jun Oh
April-June 2009, 43(2):197-204
DOI:10.4103/0019-5413.41870  PMID:19838371
Background: Controversy regarding the fixation level for the management of unstable thoracolumbar spine fractures exists. Often poor results are reported with short-segment fixation. The present study is undertaken to compare the effect of fixation level and variable duration of postoperative immobilization on the outcome of unstable thoracolumbar burst fractures treated by posterior stabilization without bone grafting. Patients and Methods: A randomized, prospective, and consecutive series was conducted at a tertiary level medical center. Thirty-six neurologically intact (Frankel type E) thoracolumbar burst fracture patients admitted at our institute between February 2003 and December 2005 were randomly divided into three groups. Group I ( n = 15) and II ( n = 11) patients were treated by short-segment fixation, while Group III ( n = 10) patients were treated by long-segment fixation. In Group I ambulation was delayed to 10th-14th postoperative day, while group II and III patients were mobilized on third postoperative day. Anterior body height loss (ABHL) percentage and increase in kyphosis as measured by Cobb's angle were calculated preoperatively, postoperatively, and at follow-up. Denis Pain Scale and Work Scales were obtained during follow-up. Results: Mean follow-up was 13.7 months (range 3-27 months). At the final follow-up the mean ABHL was 4.73% in group I compared with 16.2% in group II and 6.20% in group III. The mean Cobb's angle loss was 1.8 in group I compared with 5.91 in group II and 2.3 in group III. The ABHL difference between groups I and II was significant ( P = 0.0002), while between groups I and III was not significant ( P = 0.49). Conclusion: The short-segment fixation with amenable delayed ambulation is a valid option for the management of thoracolumbar burst fractures, as radiological results are comparable to that of long-segment fixation with the advantage of preserving maximum number of motion segments.
  9 4,298 243
Functional outcome of corpectomy in cervical spondylotic myelopathy
Kanishka E Williams, Rajesh Paul, Yashbir Dewan
April-June 2009, 43(2):205-209
DOI:10.4103/0019-5413.50855  PMID:19838372
Background : Cervical spondylotic myelopathy (CSM) is serious consequence of cervical intervertebral disk degeneration. Morbidity ranges from chronic neck pain, radicular pain, headache, myelopathy leading to weakness, and impaired fine motor coordination to quadriparesis and/or sphincter dysfunction. Surgical treatment remains the mainstay of treatment once myelopathy develops. Compared to more conventional surgical techniques for spinal cord decompression, such as anterior cervical discectomy and fusion, laminectomy, and laminoplasty, patients treated with corpectomy have better neurological recovery, less axial neck pain, and lower incidences of postoperative loss of sagittal plane alignment. The objective of this study was to analyze the outcome of corpectomy in cervical spondylotic myelopathy, to assess their improvement of symptoms, and to highlight complications of the procedure. Materials and Methods: Twenty-four patients underwent cervical corpectomy for cervical spondylotic myelopathy during June 1999 to July 2005.The anterior approach was used. Each patient was graded according to the Nuricks Grade (1972) and the modified Japanese Orthopaedic Association (mJOA) Scale (1991), and the recovery rate was calculated. Results: Preoperative patients had a mean Nurick's grade of 3.83, which was 1.67 postoperatively. Preoperative patients had a mean mJOA score of 9.67, whereas postoperatively it was 14.50. The mean recovery rate of patients postoperatively was 62.35% at a mean follow-up of 1 year (range, 8 months to 5 years).The complications included one case (4.17%) of radiculopathy, two cases (8.33%) of graft displacement, and two cases (8.33%) of screw back out/failure. Conclusions: Cervical corpectomy is a reliable and rewarding procedure for CSM, with functional improvement in most patients.
  9 6,474 370
SYMPOSIUM
The science of ultrasound therapy for fracture healing
Gregory J Della Rocca
April-June 2009, 43(2):121-126
DOI:10.4103/0019-5413.50845  PMID:19777126
Fracture healing involves a complex interplay of cellular processes, culminating in bridging of a fracture gap with bone. Fracture healing can be compromised by numerous exogenous and endogenous patient factors, and intense research is currently going on to identify modalities that can increase the likelihood of successful healing. Low-intensity pulsed ultrasound (LIPUS) has been proposed as a modality that may have a benefit for increasing reliable fracture healing as well as perhaps increasing the rate of fracture healing. We conducted a review to establish basic scince evidence of therapeutic role of lipus in fracture healing. An electronic search without language restrictions was accomplished of three databases (PubMed, Embase, Cinahl) for ultrasound-related research in osteocyte and chondrocyte cell culture and in animal fracture models, published from inception of the databases through December, 2008. Studies deemed to be most relevant were included in this review. Multiple in vitro and animal in vivo studies were identified. An extensive body of literature exists which delineates the mechanism of action for ultrasound on cellular and tissue signaling systems that may be related to fracture healing. Research on LIPUS in animal fracture models has demonstrated promising results for acceleration of fracture healing and for promotion of fracture healing in compromised tissue beds. A large body of cellular and animal research exists which reveals that LIPUS may be beneficial for accelerating normal fracture healing or for promoting fracture healing in compromised tissue beds. Further investigation of the effects of LIPUS in human fracture healing is warranted for this promising new therapy.
  9 4,443 475
Global burden of trauma: Need for effective fracture therapies
George Mathew, Beate P Hanson
April-June 2009, 43(2):111-116
DOI:10.4103/0019-5413.50843  PMID:19838358
Orthopedic trauma care and fracture management have advanced significantly over the last 50 years. New developments in the biology and biomechanics of the musculoskeletal system, fixation devices, and soft tissue management have greatly influenced our ability to care for musculoskeletal injuries. Many therapies and treatment modalities have the potential to transform future orthopedic treatment by decreasing invasive procedures and providing shorter healing times. Promising results in experimental models have led to an increase in clinical application of these therapies in human subjects. However, for many modalities, precise clinical indications, timing, dosage, and mode of action still need to be clearly defined. In order to further develop fracture management strategies, predict outcomes and improve clinical application of newer technologies, further research studies are needed. Together with evolving new therapies, the strategies to improve fracture care should focus on cost effectiveness. This is a great opportunity for the global orthopedic community, in association with other stakeholders, to address the many barriers to the delivery of safe, timely, and effective care for patients with musculoskeletal injuries in developing countries.
  7 3,479 367
Extracorporeal shockwave therapy: A systematic review of its use in fracture management
BA Petrisor, Selene Lisson, Sheila Sprague
April-June 2009, 43(2):161-167
DOI:10.4103/0019-5413.50851  PMID:19838365
Extracorporeal shockwave therapy is increasingly used as an adjuvant therapy in the management of nonunions, delayed unions and more recently fresh fractures. This is in an effort to increase union rates or obtain unions when fractures have proven recalcitrant to healing. In this report we have systematically reviewed the English language literature to attempt to determine the potential clinical efficacy of extracorporeal shockwave therapy in fracture management. Of 32 potentially eligible studies identified, 10 were included that assessed the extracorporeal shockwave therapy use for healing nonunions or delayed unions, and one trial was included that assessed its use for acute high-energy fractures. From the included, studies' overall union rates were in favor of extracorporeal shockwave therapy (72% union rate overall for nonunions or delayed unions, and a 46% relative risk reduction in nonunions when it is used for acute high-energy fractures). However, the methodologic quality of included studies was weak and any clinical inferences made from these data should be interpreted with caution. Further research in this area in the form of a large-scale randomized trial is necessary to better answer the question of the effectiveness of extracorporeal shockwave therapy on union rates for both nonunions and acute fractures.
  7 4,714 316
CASE REPORTS
Disc prolapse and cord contusion in a case of Klippel-Feil syndrome following minor trauma
Amit Agrawal, Arvind M Badve, Nikhil Swarnkar, Kaustubh Sarda
April-June 2009, 43(2):210-212
DOI:10.4103/0019-5413.50857  PMID:19838373
Klippel-Feil syndrome (KFS) is defined as congenital fusion of two or more cervical vertebrae and patients with KFS are frequently asymptomatic. However, these patients are especially prone to cervical cord injury after a minor fall or a major traumatic episode. We report an unusual case of KFS where the patient had disc prolapse between two Klippel-Feil segments and discuss the difficulties in the management of this case.
  6 2,556 196
SYMPOSIUM
Pulsed electromagnetic stimulation in nonunion of tibial diaphyseal fractures
Anil Kumar Gupta, Kailash Prasad Srivastava, Sachin Avasthi
April-June 2009, 43(2):156-160
DOI:10.4103/0019-5413.50850  PMID:19838364
Background: Nonunion of long bones is a difficult clinical problem and challenges the clinical acumen of surgeons. Multiple surgical or nonsurgical modalities have been used to treat nonunions. Noninvasive pulsed electromagnetic stimulation is an entity known to affect the piezoelectric phenomenon of bone forming cells. We conducted a study on 45 long-bone fractures of tibia treated by pulsed electromagnetic stimulation, which are analyzed and reported. Materials and Methods: A total of 45 tibial fractures with established atrophic nonunion were enrolled between 1981 and 1988. All the patients had abnormal mobility and no or minimal gap at fracture site with no evidence of callus formation across the fracture site. The patients' age ranged between 24 and 68 years; 40 were men and 5 were women. All patients having evidence of infection, implant in situ , and gap nonunions were excluded from study. Pulsed electromagnetic stimulation was given using above-knee plaster of Paris cast (0.008 Weber/m 2 magnetic field was created for 12 h/day). The average duration for pulsed electromagnetic stimulation (PEMS) therapy was 8.35 weeks, with the range being 6-12 weeks. The cases were evaluated at 6 weeks and subsequently every 6-weekly interval for clinical and radiological union. The withdrawal of therapy was decided as per clinicoradiological evidence of union. Results: All but three patients showed evidence of union. About 35% (n = 16) cases showed union in 10 weeks, and 85% (n = 38) cases showed union in 4 months. The average duration of therapy using PEMS was 8.350.48 weeks, and the average duration of immobilization was 3.02 0.22 months. Three cases that did not show evidence of union were poorly compliant for the apparatus of PEMS. Conclusion: PEMS is a useful noninvasive modality of treatment for difficult nonunion of long bones.
  6 4,103 293
CASE REPORTS
Primary aneurysmal bone cyst of patella
N Somasekhar Reddy, Venkata Reddy Sathi
April-June 2009, 43(2):216-217
DOI:10.4103/0019-5413.50859  PMID:19838375
O0 f all the aneurysmal bone cysts (ABC) occurring in the body, less than 1% are seen in the patella. We report here, a 27-year-old woman with Stage III ABC of patella. Curettage, chemical and thermal cautery of the bed followed by autogenous bone grafting of the defect was done. At two-year follow up, there was a suspicion of lucency in the middle of the patella. However a repeat curettage revealed only fibrous tissue. Now at four years of follow up, the bone graft remained well incorporated. Patient has mild anterior knee pain on stair climbing but regained normal knee function.
  5 3,113 168
Neglected dorsal dislocation of the scaphoid
Rajkumar S Amaravati, MJ Saji, HP Rajagopal, Gururaj
April-June 2009, 43(2):213-215
DOI:10.4103/0019-5413.50858  PMID:19838374
Isolated dislocation of the scaphoid is very rare. A 45-year old male, industrial worker reported two and half months after injury with wrist pain and swelling on the dorsum of left wrist. He was diagnosed as neglected dorsal dislocation of scaphoid. Proximal row carpectomy with capsular interposition was done stabilizing the distal carpus on the radius using Kirschner wires. At-12 months follow-up the patient had good wrist function and was satisfied with the outcome of the treatment. We hereby report this neglected dorsal dislocation of scaphoid in view of rarity and discuss the various options for management.
  4 3,228 209
EDITORIAL
Bone stimulators: Beyond the black box
Mohit Bhandari, Anil K Jain
April-June 2009, 43(2):109-110
DOI:10.4103/0019-5413.50842  PMID:19838357
  4 3,280 432
SYMPOSIUM
Economic evaluation of bone stimulation modalities: A systematic review of the literature
Melissa L Button, Sheila Sprague, Osama Gharsaa, Sandra LaTouche, Mohit Bhandari
April-June 2009, 43(2):168-174
DOI:10.4103/0019-5413.50852  PMID:19838366
Various bone stimulation modalities are commonly used in treatment of fresh fractures and nonunions; however, the effectiveness and efficiency of these modalities remain uncertain. A systematic review of trials evaluating the clinical and economical outcomes of ultrasounds, electrical stimulation, and extracorporeal sound waves on fracture healing was conducted. We searched four electronic databases for economic evaluations that assessed bone stimulation modalities using ultrasound therapy, electrical stimulation, or extracorporeal shock waves. In addition, we searched the references and related articles of eligible studies, and a content expert was contacted. Information on the clinical and economical outcomes of patients was independently extracted by reviewers. Fourteen studies met the inclusion criteria; therefore, very limited research was found on the cost associated with treatments and the corresponding outcomes. The data available focus primarily on the efficacy of newly introduced treatment methods for bone growth, but failed to incorporate the costs of implementing such treatments. One economic analysis was identified that assessed different treatment paths using ultrasound. A total cost savings of 24-40% per patient occurred when ultrasound was used for fresh fractures and nonunions (grade C recommendation). The results suggest that the ultrasound is a viable alternative for bone stimulation; however, the impacts of the other modalities are left unknown due to the lack of research available. Methodological limitations leave the overall economic and clinical impact of these modalities uncertain. Large, prospective, randomized controlled trials that include cost-effectiveness analyses are needed to further define the clinical effectiveness and financial burden associated with bone stimulation modalities.
  4 3,190 205
ORIGINAL ARTICLES
Dynamic osteosynthesis by modified Kuntscher nail for the treatment of tibial diaphyseal fractures
Wasudeo M Gadegone, Yogesh S Salphale
April-June 2009, 43(2):182-188
DOI:10.4103/0019-5413.48824  PMID:19838368
Background: We evaluated a series of diaphyseal fractures of the tibia using low-cost, Indian-made modified Kuntscher nail (Daga nail) with the provision of distal locking screw for the management of the tibial diaphyseal fractures. Materials and Methods: One hundred and fifty one consecutive patients with diaphyseal fractures of tibia with 151 fractures who were treated by Daga nail were enrolled. One of the patients who had died because of cancer, and the two patients who were lost to follow-up at 3 months were excluded from the study.Therefore data of 148 patients with one hundred and fortyeight fractures is described. One hundred twenty closed fractures, 20 open Grade I fractures, and eight open Grade II fractures as per Gustilo and Anderson classification were included in this study. One hundred fourteen men and 34 women, with a mean age of 38.4 years, were studied. The result were analysed for Surgical time, duration of hospitalisation, union time, union rate, complication rate, functional recovery and crutch walking time. The fractures were followed at least until the time of solid union. Results: The follow-up period averaged 15 months (range, 6-26 months). Union occurred in 140 cases (94.6%). The mean time to union was 13 weeks for closed fractures,17.8 weeks for Grade I open fractures, and 21.6 weeks for Grade II open fractures. Compartment syndrome occurred in two patients. Superficial infection occurred in five cases of Grade I and II compound fractures. Three closed fractures and one case of Grade I compound fracture required bone grafting for delayed union. Two cases of Grade II compound fracture with nonunion required revision surgery and bone grafting. Twelve cases resulted in acceptable malalignment due to operative technical error. In four cases, the distal screw breakage was seen, but none of these complications interfered with fracture healing. Recovery of joint motion was essentially normal in those patients without knee or ankle injury. Conclusion: Unreamed distally locked dynamic tibial nailing (modified Kuntscher nail/Daga nail) can produce excellent clinical results for diaphyseal tibial fractures. It has the advantages of technical simplicity, minimal cost, user-friendly instrumentation, and a short learning curve.
  3 4,819 392
Distraction histiogenesis for treatment of Kienbock's disease: A 2- to 8-year follow-up
DS Meena, Narender Saini, Vishal Kundanani, Lokesh Chaudhary, Dinesh Meena
April-June 2009, 43(2):189-193
DOI:10.4103/0019-5413.50854  PMID:19838369
Background: Distraction histiogenesis is known to enhance vascularity and stimulate new tissue formation. Its use in Kienbock's disease is not reported in the literature, so we proposed to study the outcome after distraction histiogenesis in treating this condition. Materials and Methods: This prospective study comprised of six patients (two male and four female) with mean age 18.16 years (range 21-35 years) with clinicoradiologically diagnosed Lichtman stage II (n = 3) and stage III (n = 3) Kienbock's disease with a mean duration of symptoms 6.67 months. The ulnar variance was neutral in two and was negative in four patients treated with the application of Joshi external stabilization system (JESS) across the wrist. The gradual distraction was done at a rate of 0.5 mm/day. After the distraction of 5-7 mm, the distractors were kept static for 3 weeks. The wrist was mobilized by using hinged distractors for next 3 weeks. Later short cockup splint was used for further 4 weeks. At the end of minimum 2 years, an assessment was done on the basis of relief of symptoms, ability to perform activities of daily living, range of movement at wrist, grip strength, and on radiology (change in the density of bone and C:MC ratio i.e ratio of carpal height to third metacarpal height) . Results: The mean follow-up was of 4.5 years (range 2-8 years). The average duration of treatment was 5.3 months (range 4.5-6 months), and the duration of distraction (both static and hinged) was 8 weeks. Clinically all the patients were relieved of the symptoms with an increase in the range of wrist movement (ulnar deviation increased from 20.8 o to 29.5 o , radial deviation from 17.5 o to 21 o , dorsiflexion from 37.5 o to 52.5 o , and palmer flexion from 38.3 o to 47.5 o ). At the last follow-up, activities of daily living were not affected, and all the patients were on their previous jobs without any fresh complaints. The average grip strength increased to 73-86% of normal. Radiologically the C:MC ratio (ratio of carpal height to third metacarpal height) did not show any significant improvement, but the density of lunate decreased. Conclusion: Distraction histiogenesis when used in Lichtman stage II and III with negative or neutral ulnar variance gives good symptomatic relief, allowing return to normal activities. This study has also shown that reparative process is possible in avascular bone by distraction. The authors recommend further research in this modality of treatment.
  3 3,124 263
SYMPOSIUM
Fracture healing in India: Available therapies, indications, and protocols
Michel Saccone, Anil K Jain
April-June 2009, 43(2):175-181
DOI:10.4103/0019-5413.50853  PMID:19838367
The availability of fracture healing therapies to the general public is limited in India. The infrastructure of the health system in India, involving both public and private sectors, does not provide adequate opportunity for rural and low-income inhabitants to access needed care. Also the lack of funding from the government and the overall lack of physicians place a large strain on the system. This paper will take an in-depth look at the state of the current health care system and how it affects bone stimulation therapy in India. The Indian Journal of Orthopaedics was used as a reference for the bone stimulation therapies currently utilized in India. A general search of the therapies and technologies was performed to determine protocols and indications. A table of fracture healing therapies and technologies was composed which provides a description of each therapy, as well as its specific indications and protocols. This information was then used by the authors to hypothesize the most feasible methods of fracture healing to meet the Indian demographic. Based on an assessment of the health system of India, the most practical methods of bone stimulation therapy were determined. It was also determined that nearly all forms of therapy could be made available if sufficient resources were set aside for it. Bone stimulation therapy in India remains a large void in the health care system.
  3 2,817 454
CASE REPORTS
Acetabular revision using a total acetabular allograft
Rajesh Malhotra, Vijay Kumar
April-June 2009, 43(2):218-221
DOI:10.4103/0019-5413.50860  PMID:19838376
The most challenging aspect of an acetabular revision is the management of severe bone loss, which compromises implant fixation and stability. We present a case of failed acetabular revision with extensive bone loss (Paprosky Type 3b) in a 50-year-old woman with rheumatoid arthritis, which was treated using total acetabular allograft. At a follow-up of 1 year and 3 months, the allograft had united with the host bone. This is the first report of the use of a total acetabular allograft for revision total hip arthroplasty in India. The total acetabular allograft allows the placement of the component closer to the normal hip center, provides initial stability for the acetabular component, and restores bone stock to the host pelvis.
  1 2,787 231
ORIGINAL ARTICLES
Molecular studies of achondroplasia
Risha Nahar, Renu Saxena, Sudha Kohli, Ratna Puri, Ishwar Chandra Verma
April-June 2009, 43(2):194-196
DOI:10.4103/0019-5413.50856  PMID:19838370
Background: Achondroplasia (ACH) is the most frequent form of short-limbed dwarfi sm, caused by mutations in the FGFR3 gene. It follows an autosomal dominant inheritance, though most cases are sporadic. The molecular techniques are the only available methods to confi rm the diagnosis of a skeletal dysplasia. Clinical and radiological features are only suggestive and not confi rmatory. The present study was conducted to fi nd out how often the clinical diagnosis of achondroplasia is verifi ed on molecular studies. Materials and Methods: From 1998 through 2007, we carried out molecular analysis for the two common mutations in the FGFR3 gene in 130 cases clinically suspected to have ACH. Results: A diagnostic mutation was identifi ed in 53 (40.8%) cases. The common mutation (1138G>A) was present in 50 (94.7%) of the positive cases, while the rare 1138 G>C substitution was found in three (5.3%). Conclusion: This study shows that confi rmation of clinical diagnosis of ACH by molecular genetic testing is essential to distinguish it from other skeletal dysplasias, to plan therapeutic options, and to offer genetic counseling. Management (medical and surgical) in patients confi rmed to have ACH, is briefl y discussed.
  1 4,356 267
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