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   2011| March-April  | Volume 45 | Issue 2  
    Online since February 26, 2011

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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.
  21,652 893 3
Synovial chondromatosis of the elbow in a child
Rishi Narasimhan, Stuart Kennedy, Sandeep Tewari, Deeksha Dhingra, Ibrahim Zardawi
March-April 2011, 45(2):181-184
DOI:10.4103/0019-5413.77141  PMID:21430876
Synovial chondromatosis is cartilaginous metaplasia of mesenchymal remnants of synovial tissue of the joints. Its main characteristic is the formation of cartilaginous nodules in the synovium and inside the articular space (loose bodies). It usually presents between the third and fifth decades and is rare in children. It presents as a mono-articular pathology affecting large joints such as the knee, hip, and elbow. The main symptoms are pain, swelling, and limitation of movements in the affected joint. Diagnosis is made by panoramic radiographs, computed tomography scan, and mainly magnetic resonance imaging and on surgery. The authors describe of synovial chondromatosis presenting in the elbow of an 11 year-old girl which is unreported to the best of our knowledge.
  13,894 128 1
Direct repair of lumbar spondylolysis by Buck's technique
S Rajasekaran, M Subbiah, Ajoy Prasad Shetty
March-April 2011, 45(2):136-140
DOI:10.4103/0019-5413.77133  PMID:21430868
Background: The lesion in spondylolysis is a nonunion that follows a fatigue fracture of pars interarticularis. Direct repair of the pars defect is a logical alternative to fusion as it helps to preserve the motion segment and prevents abnormal stresses at the adjacent levels. The purpose of the study is to analyze the clinical and radiological results of direct screw osteosynthesis of the pars defect by the Buck's method in patients with symptomatic spondylolysis with or without grade 1 spondylolisthesis. Materials and Methods: Nine patients (six males, three females, mean age 24 years) with symptomatic spondylolysis with or without grade 1 spondylolisthesis and a normal disc in magnetic resonance imaging (MRI), who failed conservative treatment, underwent surgery between January 2000 and April 2009. Of them five patients had bilateral lysis at one level, one had bilateral lysis at three levels and two levels each and two had unilateral lysis at one level. Direct pars repair by the Buck's method with internal fixation of the defect using 4.5 mm cortical screws and cancellous bone grafting was done. The mean follow-up period was 45 months. MacNab criteria were used to evaluate the postoperative functional outcome. Healing of the pars defect was assessed by plain radiographs and computed tomography (CT) scan. Results: Spondylolysis was bilateral in seven and unilateral in two patients. Two patients had associated grade 1 spondylolisthesis. The mean operative time was 58 minutes (range 45 - 75 minutes) and blood loss was 98 ml (50 - 140 ml). Although radiological fusion was observed in all patients at a mean follow-up of 45 months (range 9 to 108 months), the functional outcome was excellent in two patients and good in five, with one fair and one poor result. The overall result of the procedure was satisfactory in 78% (7/9) of the patients. The two patients with associated grade 1 spondylolisthesis had fair and poor results. No complications were encountered in the perioperative or postoperative period. Conclusions: In carefully selected patients, direct repair of the pars defect by the Buck's technique of internal fixation and bone grafting was a safe and effective alternative to fusion in younger patients with symptomatic spondylolysis, without associated spondylolisthesis, who failed conservative management.
  11,153 205 3
Bicondylar tibial fractures: Internal or external fixation?
Gunasekaran Kumar, Nicholas Peterson, Badri Narayan
March-April 2011, 45(2):116-124
DOI:10.4103/0019-5413.77130  PMID:21430865
Bicondylar fractures of the tibia, representing the Schatzker V and VI fractures represent a challenging problem. Any treatment protocol should aim at restoring articular congruity and the metaphyseo-diaphsyeal dissociation (MDD)-both of these are equally important to long-term outcome. Both internal and external fixations have their proponents, and each method of treatment is associated with its unique features and complications. We review the initial and definitive management of these injuries, and the advantages and disadvantages of each method of definitive fixation. We suggest the use of a protocol for definitive management, using either internal or external fixation as deemed appropriate. This protocol is based on the fracture configuration, local soft tissue status and patient condition. In a nutshell, if the fracture pattern and soft tissue status are amenable plate fixation (single or double) is performed, otherwise limited open reduction and articular surface reconstruction with screws and circular frame is performed.
  10,009 584 3
Nerve reconstruction: A cohort study of 93 cases of global brachial plexus palsy
Anil Bhatia, Ashok K Shyam, Piyush Doshi, Vitrag Shah
March-April 2011, 45(2):153-160
DOI:10.4103/0019-5413.77136  PMID:21430871
Introduction: Brachial plexus injury leading to flail upper limb is one of the most disabling injuries. Neglect of the injury and delay in surgeries may preclude reinnervation of the paralysed muscles. Currently for such injuries nerve transfers are the preferred procedures. We here present a series of 93 cases of global brachial plexus palsy treated with nerve transfers. Materials and Methods: Ninety-three cases of global palsies out of 384 cases of brachial plexus injury operated by the senior surgeon (AB) were selected. Age varied from 4 to 51 years with 63 patients in 20 to 40 age group and all patients having a minimum follow up of at least 1 year post surgery ranging up to 130 months. The delay before surgery ranged from 15 days to 16 months (mean 3.2 months). The aim of the surgery was to restore the elbow flexion, shoulder abduction, triceps function and wrist and finger flexion in that order of priority. The major nerve transfers used were spinal accessory to suprascapular nerve, intercostal to musculocutaneous nerve and pectoral nerves, contralateral C7 to median and radial nerves. Nerve stumps were used whenever available (30 patients). Results: Recovery of ≥ grade 3 power was noted in biceps in 73% (68/93) of patients, shoulder abduction in 89% (43/49), pectoralis major in 100% (8/8). Recovery of grade 2 triceps power was seen in 80% (12/16) patients with nerve transfer to radial nerve. Derotation osteotomies of humerus (n=13) and wrist fusion (n=14) were the most common secondary procedures performed to facilitate alignment and movements of the affected limb. Better results were noted in 59 cases where direct nerve transfers were done (without nerve graft). Conclusion: Acceptable function (restoration of biceps power ≥3) can be obtained in more than two thirds (73%) of these global brachial plexus injuries by using the principles of early exploration and nerve transfer with rehabilitation.
  7,381 271 5
The basic science of peri-implant bone healing
Paul RT Kuzyk, Emil H Schemitsch
March-April 2011, 45(2):108-115
DOI:10.4103/0019-5413.77129  PMID:21430864
Given the popularity of cementless orthopedic implants, it is imperative for orthopedic surgeons to have a basic understanding of the process of peri-implant bone healing. Contact and distance osteogenesis have been used to explain peri-implant bone healing. In contact osteogenesis, de novo bone forms on the implant surface, while in distance osteogenesis, the bone grows from the old bone surface toward the implant surface in an appositional manner. Contact osteogenesis may lead to bone bonding if the surface of the implant displays the appropriate surface topography. The early stage of peri-implant bone healing is very important and involves the body's initial response to a foreign material: protein adsorption, platelet activation, coagulation, and inflammation. This results in the formation of a stable fibrin clot that is a depot for growth factors and allows for osteoconduction. Osteoconduction is the migration and differentiation of osteogenic cells, such as pericytes, into osteoblasts. Osteoconduction allows for contact osteogenesis to occur at the implant surface. The late stage of healing involves the remodeling of this woven bone. In many respects, this process is similar to the bone healing occurring at a fracture site.
  6,071 272 18
Pseudoaneurysm of the anterior tibial artery: A rare complication of proximal tibial steinman pin insertion
Tarun Suri, Vineet Dabas, Sumit Sural, Anil Dhal
March-April 2011, 45(2):178-180
DOI:10.4103/0019-5413.77140  PMID:21430875
An anterior tibial artery pseudoaneurysm is a rare and unexpected complication of Steinmann pin insertion. We describe the case of an 18-year-old boy, who sustained such an injury to the anterior tibial artery during this procedure. Diagnosis was confirmed on a magnetic resonance (MR) angiogram. Aneurysmal sac excision with lateral repair of the vessel wall was performed. Postoperatively, a good flow was documented on a follow-up MR angiogram. This case highlights a major and unexpected complication of a so-called minor procedure. Too posterior a pin placement in the proximal tibia should be avoided to prevent such injuries.
  5,893 123 6
Tranexamic acid for control of blood loss in bilateral total knee replacement in a single stage
Mandeep S Dhillon, Kamal Bali, Sharad Prabhakar
March-April 2011, 45(2):148-152
DOI:10.4103/0019-5413.77135  PMID:21430870
Background: Tranexamic acid (TEA) reduces blood loss and red cell transfusions in patients undergoing unilateral total knee arthroplasty (TKA). However, there is not much literature regarding the use of TEA in patients undergoing bilateral TKA in a single stage and the protocols for administration of TEA in such patients are ill-defined. Materials and Methods: We carried out a case control study evaluating the effect of TEA on postoperative hemoglobin (Hb), total drain output, and number of blood units transfused in 52 patients undergoing bilateral TKA in a single stage, and compared it with 56 matched controls who did not receive TEA. Two doses of TEA were administered in doses of 10 mg / kg each (slow intravenous (IV) infusion), with the first dose given just before tourniquet release of the first knee and the second dose three hours after the first one. Results: A statistically significant reduction in the total drain output and requirement of allogenic blood transfusion in cases who received TEA, as compared to the controls was observed. The postoperative Hb and Hb at the time of discharge were found to be lower in the control group, and this result was found to be statistically significant. Conclusion: TEA administered in patients undergoing single stage bilateral TKA helped reduce total blood loss and decreased allogenic blood transfusion requirements. This might be particularly relevant, where facilities such as autologous reinfusion might not be available.
  5,593 309 20
Outcome of mears procedure for Sprengel's deformity
Atul Rajeshwar Bhasker, Sachin Khullar, Mohamed Habeeb
March-April 2011, 45(2):132-135
DOI:10.4103/0019-5413.77132  PMID:21430867
Background: Sprengel's shoulder is characterized by scapular maldescent and malposition, causing restriction of shoulder and cervical spine movements. It is associated with a variety of other congenital anomalies. Various surgical procedures have been described to treat this anomaly with no consensus as to the surgical procedure of choice. We report the results of the Mears procedure in the treatment of Sprengel's shoulder. Materials and Methods: Seven children between the age group of two and six years were treated for Sprengel's deformity, with omovertebral bar, and other congenital anomalies. The Cavendish score and Rigault radiological score were used to assess the severity of the deformity, and the position of the scapula relative to the cervical spine, respectively. The Mears procedure involved scapular osteotomy, par tial scapular excision, and release of a long head of triceps. Clavicular osteotomy was done only in two cases to decrease the risk of traction injury to the brachial plexus. Postoperatively, the patients were immobilized in a shoulder sling and range of motion exercises were started as early as possible. The patients were followed regularly at six weeks, three months and regularly at six-months interval. Results: The mean improvement in flexion and abduction was 45 ° (40 - 70 ° ) and 50 ° (40 - 70 ° ), respectively, which was the combined glenohumeral and thoracoscapular movement. The cosmetic and functional improvement by this procedure was acceptable to the patients. Minor scar hypertrophy was seen in two cases. Conclusion: The Mears procedure gives excellent cosmetic and functional results. This procedure addresses the functional aspect of the deformity and is much more acceptable to the patient and parents.
  5,592 131 -
Local recurrences after curettage and cementing in long bone giant cell tumor
Kabul C Saikia, Tulsi D Bhattacharyya, Sanjeev K Bhuyan, Bikas Bordoloi, Bharat Durgia, Firoz Ahmed
March-April 2011, 45(2):168-173
DOI:10.4103/0019-5413.77138  PMID:21430873
Background : Giant cell tumor of bone (GCT) is a benign lesion with great propensity for local recurrence. This study aimed to analyse the rates of local recurrence and its possible predisposing factors in Campanacci's Grade III and II GCT of long bones following intralesional curettage and bone cementing. Materials and Methods: 32 cases of either sex with Campanacci's Grade II (n= 14), and Grade III (n=18) with intact articular surface, operated between 1995 and 2007 in form of intralesional curettage and bone cementing were studied. All the cases were followed up for 2.5-12 years (mean, 6.5), after primary treatment. The mean age at operation was 32.4 years (range, 18.5-40 years). The proximal tibia was involved in 13 cases (40.6%), followed by distal femur (n=11)34.4% distal tibia (n=3) 9.4%, proximal femur (n=2) 3.2% and distal radius (n=3) 9.4%. Results: Eleven patients (34.4%) had local recurrence, of which eight were of Campanacci's Grade III. The mean recurrence time was 14 months (range, 3-34 months). The two-year recurrence-free survivorship was 71.9% (n=23/32). Post-recurrence mean follow-up was 4.2 years (range, 2-6.5 years). Conclusion: We observed higher rate of local recurrence with Campanacci's Grade III GCTs. We recommend selective use of this procedure in Grade III lesions, particularly with extensive soft tissue involvement.
  5,405 209 7
Bladder management methods and urological complications in spinal cord injury patients
Roop Singh, Rajesh Kumar Rohilla, Kapil Sangwan, Ramchander Siwach, Narender Kumar Magu, Sukhbir Singh Sangwan
March-April 2011, 45(2):141-147
DOI:10.4103/0019-5413.77134  PMID:21430869
Background: The optimal bladder management method should preserve renal function and minimize the risk of urinary tract complications. The present study is conducted to assess the overall incidence of urinary tract infections (UTI) and other urological complications in spinal cord injury patients (SCI), and to compare the incidence of these complications with different bladder management subgroups. Materials and Methods: 545 patients (386 males and 159 females) of traumatic spinal cord injury with the mean age of 35.4±16.2 years (range, 18 - 73 years) were included in the study. The data regarding demography, bladder type, method of bladder management, and urological complications, were recorded. Bladder management methods included indwelling catheterization in 224 cases, clean intermittent catheterization (CIC) in 180 cases, condom drainage in 45 cases, suprapubic cystostomy in 24 cases, reflex voiding in 32 cases, and normal voiding in 40 cases. We assessed the incidence of UTI and bacteriuria as the number of episodes per hundred person-days, and other urological complications as percentages. Results: The overall incidence of bacteriuria was 1.70 / hundred person-days. The overall incidenceof urinary tract infection was 0.64 / hundered person-days. The incidence of UTI per 100 person-days was 2.68 for indwelling catheterization, 0.34 for CIC, 0.34 for condom drainage, 0.56 for suprapubic cystostomy, 0.34 for reflex voiding, and 0.32 for normal voiding. Other urological complications recorded were urethral stricture (n=66, 12.1%), urethritis (n=78, 14.3%), periurethral abscess (n=45, 8.2%), epididymorchitis (n=44, 8.07%), urethral false passage (n=22, 4.03%), urethral fistula (n=11, 2%), lithiasis (n=23, 4.2%), hematuria (n=44, 8.07%), stress incontinence (n=60, 11%), and pyelonephritis (n=6, 1.1%). Clean intermittent catheterization was associated with lower incidence of urological complications, in comparison to indwelling catheterization. Conclusions: Urinary tract complications largely appeared to be confined to the lower urinary tract. The incidence of UTI and other urological complications is lower in patients on CIC in comparison to the patients on indwelling catheterizations. Encouraging CIC; early recognition and treatment of the UTI and urological complications; and a regular follow up is necessary to reduce the medical morbidity.
  5,147 293 14
Failure of cervical arthroplasty in a patient with adjacent segment disease associated with Klippel-Feil syndrome
Ioannis D Papanastassiou, Ali A Baaj, Elias Dakwar, Mohammad Eleraky, Frank D Vrionis
March-April 2011, 45(2):174-177
DOI:10.4103/0019-5413.77139  PMID:21430874
Cervical arthroplasty may be justified in patients with Klippel-Feil syndrome (KFS) in order to preserve cervical motion. The aim of this paper is to report an arthroplasty failure in a patient with KFS. A 36-year-old woman with KFS underwent two-level arthroplasty for adjacent segment disc degeneration. Anterior migration of the cranial prosthesis was encountered 5 months postoperatively and was successfully revised with anterior cervical fusion. Cervical arthroplasty in an extensively stiff and fused neck is challenging and may lead to catastrophic failure. Although motion preservation is desirable in KFS, the special biomechanical features may hinder arthroplasty. Fusion or hybrid constructs may represent more reasonable options, especially when multiple fused segments are present.
  5,125 62 1
Use of irradiated autologous bone in joint sparing endoprosthetic femoral replacement tumor surgery
Sridhar Vijayan, William Bartlett, Robert Lee, Peter Ostler, Gordon W Blunn, Stephen R Cannon, Timothy WR Briggs
March-April 2011, 45(2):161-167
DOI:10.4103/0019-5413.77137  PMID:21430872
Background: Joint preservation is usually attempted in cases of bone tumors, though insufficient bone following tumour resection may prevent fixation of conventional joint sparing prosthesis. To preserve the hip joint in skeletally immature patients, we have combined autologous proximal femoral irradiation and intercalary re-implantation with custom made distal femoral replacements. Materials and Methods: A retrospective cohort study of four patients (aged 4-12 years); in whom irradiated autologous bone was combined with an extendable distal femoral endoprostheses was performed. There were three cases of osteosarcoma and one case of Ewing's sarcoma. Results: At a mean follow-up of 70.5 months (range 26-185 months), all four patients were alive without evidence of local recurrence. There was no evidence of metastatic disease in three patients while one patient showed chest metastatic disease at presentation. In all cases, the irradiated segment of bone united with the proximal femur and demonstrated bone ongrowth at the prosthetic collar. There were no cases of loosening or peri-prosthetic fracture. One implant was revised after 14 years following fracture of the extending component of the endoprosthesis. Conclusions: We report encouraging results utilizing irradiated autologous proximal femoral bone combined with distal femoral replacement in skeletally immature patients.
  4,757 100 -
Nontraumatic osteonecrosis of the distal pole of the scaphoid
Bhavuk Garg, Himanshu Gupta, Prakash P Kotwal
March-April 2011, 45(2):185-187
DOI:10.4103/0019-5413.77142  PMID:21430877
Post traumatic osteonecrosis of distal pole of scaphoid is very rare. We present a case of 34 years old male, drill operator by occupation with nontraumatic osteonecrosis of distal pole of the scaphoid. The patient was managed conservatively and was kept under regular follow-up every three months. The patient was also asked to change his profession. Two years later, the patient had no pain and had mild restriction of wrist movements (less than 15 degrees in either direction). The radiographs revealed normal density of the scaphoid suggesting revascularization.
  4,034 114 2
Three-minute critical appraisal of a case series article
Kevin Chan, Mohit Bhandari
March-April 2011, 45(2):103-104
DOI:10.4103/0019-5413.77126  PMID:21430861
  3,777 135 13
Correlation between clinical features and magnetic resonance imaging findings in lumbar disc prolapse
Saurabh Jain, Sudhir Kumar
March-April 2011, 45(2):105-105
DOI:10.4103/0019-5413.77127  PMID:21430862
  2,470 264 -
The rational treatment of fractures: Use the evidence with caution
Anil K Jain
March-April 2011, 45(2):101-102
DOI:10.4103/0019-5413.77125  PMID:21430860
  2,523 206 -
Comparison of Ponseti and Kite's method of treatment for idiopathic clubfoot
Ashok K Shyam
March-April 2011, 45(2):188-188
DOI:10.4103/0019-5413.77143  PMID:21430878
  1,897 173 1
Predictors of long-term outcomes with hip resurfacing
Mohit Bhandari, Sarah Culgin
March-April 2011, 45(2):106-107
DOI:10.4103/0019-5413.77128  PMID:21430863
  1,758 83 -
Neglected Musculoskeletal Injuries
Ashok N Johari
March-April 2011, 45(2):190-190
  1,573 186 -
Authors' reply
Raju Rijal, Bikram Prasad Shrestha, Girish Kumar Singh, Mahipal Singh, Pravin Nepal, Guru Prasad Khanal, P Rai
March-April 2011, 45(2):189-189
  1,387 57 -
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