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  Citation statistics : Table of Contents
   2014| January-February  | Volume 48 | Issue 1  
    Online since January 21, 2014

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Orthobiologics and platelet rich plasma
Mandeep S Dhillon, Prateek Behera, Sandeep Patel, Vijay Shetty
January-February 2014, 48(1):1-9
DOI:10.4103/0019-5413.125477  PMID:24600055
Orthobiologics have evolved to the extent that they significantly influence modern orthopedic surgical practice. A better understanding of the role of various growth factors and cells in the process of tendon healing, ligament repair, cartilage regeneration and bone formation has stimulated focused research in many chronic musculoskeletal ailments. Investigators have published results of laboratory as well as clinical studies, using orthobiologics like platelet rich plasma, stem cells, autologous conditioned serum etc., with variable results. However, a clear consensus over the best orthobiologic substance and the method of preparation and usage of these substances is lacking. Much of the confusion is due to the fact that studies ranging from RCTs to case reports present variable results, and the interpretations are wide-ranging. We have reviewed the available orthobiologics related data with a focus on platelet rich plasma in orthopedic conditions.
  13 5,285 624
Minimally invasive plate osteosynthesis for distal radius fractures
Xu-ming Wei, Zhen-zhong Sun, Yong-jun Rui, Xiao-Jun Song
January-February 2014, 48(1):20-24
DOI:10.4103/0019-5413.125483  PMID:24600058
Background: Fractures of distal radius are common injury in all age groups. Cast treatment with or without close reduction is a viable option. However, the results are often unsatisfactory with restricted function. The open reduction and internal fixation often results in extensive soft tissue dissection and associated high rates of infection and delayed/nonunion. The distractor/external fixator have reported good functional and anatomical results but the incidence of pin traction infection nerve injury and cosmedic deformity are high. We introduced a modified operative technique for minimally invasive plate osteosynthesis (MIPO) for distal radial fracture and evaluated the functional outcomes and complications. Materials and Methods: 22 distal radial fractures (10 left, 12 right) were treated using the MIPO technique and two small incisions with a palmar locking plate from August 2009 to August 2010. The wrist function was assessed according to Dienst wrist rating system, and postoperative complications were recorded. Results: According to Dienst wrist rating system, 13 patients showed excellent results, 6 cases showed good results and 3 patients had moderate results. No patient had poor results. Thus, the excellent and good rate was 86.4%. One patient had anesthesia in the thenar eminence and this symptom disappeared after 3 months. One patient had delayed healing in the proximal wrist crease. Two patients had mild pain on the ulnar side of the wrist and two patients had limited wrist joint function. Conclusion: The MIPO technique by using two small palmar incisions is safe and effective for treatment of distal radial fractures.
  6 2,832 413
Outcome of Schatzker type V and VI tibial plateau fractures
Tul B Pun, Vignesh P Krishnamoorthy, Pradeep M Poonnoose, Anil T Oommen, Ravi J Korula
January-February 2014, 48(1):35-41
DOI:10.4103/0019-5413.125490  PMID:24600061
Background: Schatzker type V and VI tibial fractures are complex injuries, usually treated with open reduction and internal fixation (ORIF) using dual plates or ring fixators. ORIF has the advantage of not requiring pin tract care, but has a higher infection rate, especially in open fractures. We have combined the advantages of these two methods to treat these difficult fractures. Materials and Methods: Ten Schatzker type V and 11 Schatzker type VI fractures were treated between 2006 and 2010. ORIF with dual plates was performed, only if there was marked articular displacement (> 2 mm) in a closed fracture. All other fractures including open fractures and closed fractures with soft tissue compromise or minimal articular displacement were treated with ring fixators. The outcomes were analyzed and documented using the Honkonen and Jarvinen subjective, clinical, functional, and radiological criteria and the Western Ontario and McMaster Universities Arthritis Index (WOMAC). Results: Nine closed fractures with marked articular displacement (> 2 mm) were treated with dual plates. Eight closed fractures with minimal articular displacement (< 2 mm) and poor skin condition and four open fractures were treated with ring fixators. The mean follow-up period was 2 ½ years. The mean postoperative knee flexion was 128°. All patients could walk, jump, and climb steps. 90% could squat, though only 50% could duck walk properly. Radiologically, 85% had a plateau tilt of less than 5°, 92% had an articular step of less than 2 mm, and a residual articular widening of less than 5 mm. There were no major infections. Two patients had minor pin tract infections and two requested that their plates be removed subsequently. Conclusion: The protocol used to treat Schatzker type V and VI tibial plateau fractures has had excellent results and we suggest that all open fractures be treated with ring fixators and that ORIF should be done only for closed fractures with marked displacement.
  4 5,637 370
Microendoscopic lumbar discectomy: Technique and results of 188 cases
Arvind G Kulkarni, Anupreet Bassi, Abhilash Dhruv
January-February 2014, 48(1):81-87
DOI:10.4103/0019-5413.125511  PMID:24600068
Background: Discectomy performed open or with an operating microscope remains the standard surgical management. Tubular retractor system is being increasingly used. Potential benefits include less muscle and local damage, better cosmesis, decreased pain and operative time and faster recovery after surgery. We have evaluated the outcome of micro endoscopic discectomy (MED) utilizing tubular retractors in terms of safety and efficacy of the technique. Materials and Methods: 188 consecutive patients who underwent surgery for herniated disc using the tubular retractors between April 2007 and April 2012 are reported. All patients had a preoperative MRI (Magnetic Resonance Imaging) and were operated by a single surgeon with the METRx system (Medtronic, Sofamor-Danek, Memphis, TN) using 18 and 16 mm ports. All patients were mobilized as soon as pain subsided and discharged within 24-48 hours post surgery. The results were evaluated by using VAS (Visual Analog Scale 0-5) for back and leg pain and ODI (Oswestry Disability Index). Patients were followed up at intervals of 1 week, 6 weeks, 3 months, 6 months, 12 months and 2 years. Results: The mean age of patients was 46 years (range 16-78 years) and the sex ratio was 1.5 males to 1 female. The mean followup was 22 months (range 8-69 months). The mean VAS scale for leg pain improved from 4.14 to 0.76 ( P < 0.05) and the mean VAS scale for back pain improved from 4.1 to 0.9 ( P < 0.05). The mean ODI changed from 59.5 to 22.6 ( P < 0.05). The mean operative time per level was about 50 minutes (range 20-90 minutes). Dural punctures occurred in 11 (5%) cases. Average blood loss was 30 ml (range 10-500 ml). A wrong level was identified and later corrected in a case of revision discectomy. Four patients with residual disc-herniation had revision MED and three patients with recurrent disc herniation later underwent fusion. One patient had wound infection which needed a debridement. Conclusion: MED for herniated discs effectively achieves the goals of surgery with minimal access. The advantages of the procedure are cosmesis, early postoperative recovery and minimal postoperative morbidity.
  4 2,904 215
Effects of Sox9 gene therapy on the healing of bone-tendon junction: An experimental study
Zhiqi Zhu, Aixi Yu, Ming Hou, Xiaoqing Xie, Peng Li
January-February 2014, 48(1):88-95
DOI:10.4103/0019-5413.125521  PMID:24600069
Background: Sox9 is an operon that positively regulates the transcription of type II collagen. The generation of type II collagen plays a critical role in the healing process of the bone-tendon junction (BTJ). Materials and Methods: Sox9 was injected into an established bone-tendon healing model in order to observe its effect on the healing by determining the biomechanical properties of the BTJ. In addition, the recombinant adenovirus Sox9 was used to transduce the animal model samples and in vivo observations of the effect of the adenovirus-mediated Sox9 transduction as well as its promotion of the healing properties were made. Results: Sox9 was not only able to promote the healing, but also increased the biomechanical strength. The recombinant Sox9 delivered by adenoviral vector can be expressed at a high level in the damaged tissues of the bone-tendon junction, which can stimulate the production of type II collagen and improve the healing of the BTJ. Conclusions: Based on the results of this study, we considered that gene therapy may be applicable in the healing process of the bone-tendon junction.
  3 1,551 72
Outcome of percutaneous continuous drainage of psoas abscess: A clinically guided technique
Bharat R Dave, Ranganatha Babu Kurupati, Dipak Shah, Devanand Degulamadi, Nitu Borgohain, Ajay Krishnan
January-February 2014, 48(1):67-73
DOI:10.4103/0019-5413.125506  PMID:24600066
Background: Percutaneous aspiration of abscesses under ultrasonography (USG) and computer tomography (CT) scan has been well described. With recurrence rate reported as high as 66%. The open drainage and percutaneous continuous drainage (PCD) has reduced the recurrence rate. The disadvantage of PCD under CT is radiation hazard and problems of asepsis. Hence a technique of clinically guided percutaneous continuous drainage of the psoas abscess without real-time imaging overcomes these problems. We describe clinically guided PCD of psoas abscess and its outcome. Materials and Methods: Twenty-nine patients with dorsolumbar spondylodiscitis without gross neural deficit with psoas abscess of size >5 cm were selected for PCD. It was done as a day care procedure under local anesthesia. Sequentially, aspiration followed by guide pin-guided trocar and catheter insertion was done without image guidance. Culture sensitivity was done and chemotherapy initiated and catheter kept till the drainage was <10 ml for 48 hours. Outcome assessment was done with relief of pain, successful abscess drainage and ODI (Oswestry Disability Index) score at 2 years. Results: PCD was successful in all cases. Back and radicular pain improved in all cases. Average procedure time was 24.30 minutes, drain output was 234.40 ml, and the drainage duration was 7.90 days. One patient required surgical stabilisation due to progression of the spondylodiscitis resulting in instability inspite of successful drainage of abscess. Problems with the procedure were noticed in six patients. Multiple attempts ( n = 2), persistent discharge ( n = 1) for 2 weeks, blocked catheter ( n = 2) and catheter pull out ( n = 1) occurred with no effect on the outcome. The average ODI score improved from 62.47 to 5.51 at 2 years. Conclusions: Clinically guided PCD is an efficient, safe and easy procedure in drainage of psoas abscess.
  2 2,897 149
Diaphyseal femoral fractures below the age of six years: Results of plaster application and long term followup
Nunzio Catena, Filippo M Sénčs, Simone Riganti, Silvio Boero
January-February 2014, 48(1):30-34
DOI:10.4103/0019-5413.125487  PMID:24600060
Background:In children less than 6 years, the treatment of femoral shaft fracture is often non surgical, using closed reduction and casting. The literature reports many experience about this type of trauma but none of these has a long term followup. We present a retrospective study on a group of femoral diaphyseal fractures treated nonsurgically in children up to 6 years of age, with a minimum of 10 year followup. Materials and Methods:48 cases (36 males/12 females) with femoral diaphyseal fractures treated between January 1988 and December 1998 were reviewed. Patients with fractures due to obstetrical trauma and pathologic fractures were excluded. The mean age of the patients was 3.3 ± 1.1 years (range 5 months-6 years). Right side was involved in 21 cases (44%), and left side in 27 cases (56%). In 34 cases (71%), closed reduction was performed and hip spica was applied with the hip and knee flexed to 45΀. In 8 cases (17%), skeletal traction was applied to perform fracture reduction and the traction pin was embedded in plaster while in the remaining 6 cases (12%), the Delitala pressure apparatus was applied after casting. Results:All fractures healed in our study. There were no complications (infection or vascular nervous issues, axial deviations, consolidation delays, or pseudoarthrosis). In 13 cases (27%), followup examinations showed mean lengthening of 1.3 ± 0.75 (range 0.5-2.5 cm) of the fractured lower limb. All these patients were treated with skin traction before treatment and presented with 2.08 ± 0.28 cm mean initial femoral shortening. In 1 case (2%) with 2.5 cm lengthening, epiphysiodesis of the ipsilateral knee was performed. No patients showed prolonged difficulty with gait disorders. Conclusion:On the basis of our results conservative treatment of femoral shaft fractures in children can be considered less invasive and safe procedure.
  2 1,851 202
Early detection of peroneal neuropathy by ultrasound
Shih-Wei Huang, Wei-Te Wang
January-February 2014, 48(1):104-106
DOI:10.4103/0019-5413.125532  PMID:24600072
A 12 year old boy presented with ankle sprain. The physical examination revealed mild weakness of ankle dorsiflexion. An ultrasound was done for the soft tissues of the ankle. In addition to relative atrophy of the peroneus longus muscle, a compressive common peroneal nerve (CPN) lesion with a synovial cyst at the level of the proximal tibiofibular joint (PTFJ) was accidently found. Since there were features of CPN compression by the synovial cyst, total excision of the cyst was performed. After the operation, muscle strength improved and the neurological deficit subsided. Therefore, the early diagnosis of PTFJ synovial cyst with nerve injury was crucial in order to achieve a better result. The obscure nature of clinical presentations can delay the diagnosis, which may potentially lead to a poor prognosis after treatment in such cases. This report highlights the fact that ankle sprain do need a thorough clinical work up in some cases.
  1 2,809 71
Conservative management of psoas haematoma following complex lumbar surgery
Sandesh Lakkol, Praveen Sarda, Prasad Karpe, Manoj Krishna
January-February 2014, 48(1):107-110
DOI:10.4103/0019-5413.125534  PMID:24600073
We report psoas hematoma communicating with extradural hematoma and compressing on lumbar nerve roots during the postoperative period in a patient who underwent L3/4 level dynamic stabilization and L4/5 and L5/S1 posterior lumbar interbody fusion. Persistent radicular symptoms occurring soon after posterior lumbar surgery are not an unknown entity. However, psoas hematoma communicating with the extradural hematoma and compressing on L4 and L5 nerve roots soon after surgery, leading to radicular symptoms has not been reported. In addition to the conservative approach in managing such cases, this case report also emphasizes the importance of clinical evaluation and utilization of necessary imaging techniques such as computed tomography (CT) scan and magnetic resonance imaging (MRI) scan to diagnose the cause of persistent severe radicular pain in the postoperative period.
  1 2,133 60
Slipped upper femoral epiphysis: Outcome after in situ fixation and capital realignment technique
Sujit Kumar Tripathy, Ramesh Kumar Sen
January-February 2014, 48(1):111-111
DOI:10.4103/0019-5413.125538  PMID:24600074
  1 754 88
"Four quadrant parallel peripheral screw fixation for displaced femoral neck fractures in elderly patients
Sandeep R Biraris, Darius F Soonawalla, Dhiraj V Sonawane, Pradip S Nemade
January-February 2014, 48(1):112-113
DOI:10.4103/0019-5413.125541  PMID:24600076
  1 942 102
Cutaneous hypoesthesia following plate fixation in clavicle fractures
Lushun Wang, Muliang Ang, Keng Thiam Lee, Ganesan Naidu, EBK Kwek
January-February 2014, 48(1):10-13
DOI:10.4103/0019-5413.125478  PMID:24600056
Background: We report the functional impact and natural history of cutaneous hypoesthesia after plate internal fixation for mid shaft clavicle fractures with a horizontal skin incision from year 2009 to 2011. Materials and Methods: 38 patients had complete followup data with an average followup period of 23.2 months (range 8-43 months). The impact of supraclavicular nerve injury was studied by assessment of the incidence, functional impact and natural history of numbness with detailed review of the case records and phone questionnaires. Results: The incidence of postoperative numbness was 55.3% (n = 21). Most patients reported the numbness to be at its worst within the first operative month. At the time of worst numbness, 28.6% (n = 6/21) of patients reported the numbness to be severe while 42.9% (n = 9/21) reported moderate numbness and 28.6% (n = 6/21) reported mild numbness. Fifteen of these patients described increased awareness of numbness during contact with straps or clothes. Two patients were significantly bothered by this numbness; 4 patients stated that it was a moderate bother while 7 patients considered it a mild bother. A total of 8 patients reported that they were not bothered at all by the numbness. An overwhelming majority of affected patients (90.5%, n = 19/21) reported an improvement in the severity of numbness felt over time. At the last followup, the incidence of numbness declined from 55.3% to 36.8% with 7 patients reporting complete resolution of numbness. The numbness however was found to persist in 66.7% of patients. Only 1 patient reported continued severe numbness. The awareness of numbness with straps and clothing was severe in 5 patients. None of the patients were significantly bothered by this numbness. Conclusions: Cutaneous sensory loss is a common occurrence following plate fixation of the clavicle and might have been under reported in the literature. The numbness improves in the vast majority, but commonly persists to some degree for up to 2 years and maybe permanent. However, only a small minority eventually considered the numbness a significant "bother" and to affect them while wearing clothing or when in contact with shoulder straps.
  1 3,742 137
Glenoid fossa fractures: Outcome of operative and nonoperative treatment
Ramesh K Sen, Sachin Sud, Gaurav Saini, Sushil Rangdal, Radheshyam Sament, Vikas Bachhal
January-February 2014, 48(1):14-19
DOI:10.4103/0019-5413.125480  PMID:24600057
Background: Glenoid fossa fractures are rare injuries having a prevalence of 0.1%. These fractures may be managed operatively if substantially displaced. However, several fractures of glenoid fossa are managed nonoperatively, even if displaced, due to high incidence of associated injuries which may render patient unfi t to undergo major orthopaedic surgery. There is a relative paucity of articles reporting on outcome of treatment of glenoid fossa fractures. We present our experience of treating these injuries over past decade with operative and nonoperative methods. Materials and Methods: 21 patients of glenoid fossa fractures were included in this series with 14 males and 7 females. Patients with displacement of >5 mm who were fi t to undergo surgery within 3 weeks of injury were operated using a posterior Judet's approach. Overall 8 patients with displaced fractures were operated (Group A) while 9 patients with displaced fractures (Group B) and 4 patients with undisplaced fractures (Group C) were managed nonoperatively. Results: The mean age and followup period in this series was 29 years and 7.3 years respectively. In group A, average constant score was 87.25. The least constant score was observed for group B (58.55) while group C had an average constant score of 86. Brachial plexus injury and fracture-dislocations had poorer outcome. Conclusion: Operative treatment for displaced glenoid fractures is a viable option at centers equipped to handle critically ill patients and subset of patients with fracture-dislocation as opposed to fracture alone should always be treated operatively due to persistent loss of function.
  1 3,895 236
Transpedicular curettage and drainage versus combined anterior and posterior surgery in infectious spondylodiscitis
Byung Ho Lee, Jin-Oh Park, Hak-Sun Kim, Hwan-Mo Lee, Byung-Woo Cho, Seong-Hwan Moon
January-February 2014, 48(1):74-80
DOI:10.4103/0019-5413.125508  PMID:24600067
Background: Hematogeneous infectious spondylodiscitis usually occurs in older immunocompromised patients with other comorbidities. They are usually unable to undergo reconstructive anterior and posterior surgeries. Therefore, an alternative, less aggressive surgical method of transpedicular curettage and drainage was suggested. This study was designed to compare the surgical outcomes for the treatment of hematogeneous infectious spondylodiscitis between transpedicular curettage and drainage technique and conventional combined anterior and posterior surgery. Materials and Methods: Between January 2002 and July 2011, 26 patients underwent surgical treatment for hematogeneous infectious spondylodiscitis. The patients were classified into two groups depending on surgical modality: a transpedicular curettage and drainage (TCD) group and a combined anterior and posterior surgery (CAPS) group. Results: The TCD group consisted of 10 patients (mean age 68.0 years), and the CAPS group consisted of 16 patients (mean age 58.4 years).The mean postoperative followup periods were 36.9 (months) in the TCD group and 69.9 (months) in the CAPS group. The operation time was 180.6 ± 33.6 minutes in the TCD group and 332.7 ± 74.5 minutes in the CAPS group (P < 0.05). Postoperative independent ambulation began at postoperative 4.9 ± 2.4 days in the TCD group but at postoperative 15.1 ± 15.3 days in the CAPS group (P < 0.05). The postoperative hospital stays were 19.9 ± 7.8 days in the TCD group and 35.4 ± 33.3 days in the CAPS group (P < 0.05). The level of C-reactive proteins decreased significantly in both groups after surgery (P < 0.05). Conclusion: Transpedicular curettage and drainage technique proved to be a useful technique for treating hematogeneous infectious spondylodiscitis in patients who were in poor heath with multiple comorbidities unable to undergo the conventional combined anterior and posterior surgery in a single day in terms of earlier ambulation, shorter hospitalization and similar clinical success rate.
  1 1,495 99
Percutaneous balloon kyphoplasty of osteoporotic vertebral compression fractures with intravertebral cleft
Bao Chen, Shunwu Fan, Fengdong Zhao
January-February 2014, 48(1):53-59
DOI:10.4103/0019-5413.125498  PMID:24600064
Background: Intravertebral cleft is a structural change in osteoporotic vertebral compression fractures (OVCF), which is the manifestation of ischemic vertebral osteonecrosis complicated with fracture nonunion and pseudoarthrosis and appears in the late stage of OVCF. Despite numerous studies on OVCF, few aim to evaluate the clinicoradiological characteristics and clinical significance of intravertebral cleft in OVCF. This study investigates clinicoradiological characteristics of intravertebral cleft in OVCF and the effect on the efficacy of percutaneous balloon kyphoplasty (PKP). Materials and Methods: PKP was performed on 139 OVCF patients without intravertebral cleft (group A) and 44 OVCF patients with intravertebral cleft (group B). The frequency distribution of the affected vertebral body, bone cement infusion volume, imaging manifestation, leakage rate and type, preoperative and postoperative height of the affected vertebral body, visual analog scale (VAS) and Oswestry disability index (ODI) score were evaluated. Results: Significant differences were found in the frequency distribution of the affected vertebral body and bone cement leakage type between the two groups ( P < 0.05). However, differences in bone cement infusion volume and leakage rate ( P > 0.05) were not detected. In both groups, the postoperative height of the affected vertebral body was significantly improved ( P < 0.05). The restoration of vertebral body height in group B was more evident than that in group A ( P < 0.05). The preoperative VAS and ODI scores in group B were significantly higher than those in group A ( P < 0.05). After surgical treatment, pain relief and daily activity function in both groups were significantly improved ( P < 0.05), and no significant difference in postoperative scores was detected between the two groups ( P > 0.05). Conclusion: Intravertebral cleft exhibits specific clinical and imaging as well as bone cement formation characteristics. PKP can effectively restore the affected vertebral body height, alleviate pain, and improve daily activity function of patients.
  1 2,075 109
The efficacy of diagnostic battery in Pott's disease: A prospective study
Manoj Kumar, Raj Kumar, Arun Kumar Srivastva, Vijaya Lakshmi Nag, Narendra Krishnani, Anand Kumar Maurya, Tapan N Dhole, Sunil G Babu
January-February 2014, 48(1):60-66
DOI:10.4103/0019-5413.125503  PMID:24600065
Background: The diagnosis of Pott's disease is mostly based on clinicoradiological observations substantiated by the bacterial culture, staining and histopathology. Since, no single technique is enough to conclude Pott's disease in diagnosis, the present study was undertaken to correlate the clinicoradiological, microbiological, histopathological and molecular method to evaluate the effectiveness in diagnosis of Pott's disease. Materials and Methods: 62 clinicoradiologically suspected cases of Pott's disease were included in this study. The specimens for diagnostic work up were collected either during surgery or by computed tomography guided fine needle aspiration. All these specimens were tested for tuberculosis (TB) through Ziehl-Neelsen (ZN) microscopy, BACTEC culture, histopathology and polymerase chain reaction (PCR). The final diagnosis was established by the results of performed tests and clinicoradiological improvement of cases at the end of 6 months on anti tubercular treatment. Results: Out of 62 cases, 7 were excluded from this study as these were turned out to be neoplastic lesions on histopathology. Amongst remaining 55 cases, the TB was diagnosed in 39 (71%) on histopathology, 37 (67.5%) on PCR, 27 (49%) on BACTEC culture and 20 (36.3%) on ZN microscopy. Ultimately 45 cases were tested as positive and 10 were detected as negative for TB in combination of ZN microscopy, BACTEC culture and histopathology. PCR was positive in 37 of 45 cases and 10/55 cases remained negative. On clinical analysis of these 10 cases, it was noted that these were cases of relapse/poor compliance. The combination of PCR and histopathology was also shown positive for TB in 45 cases. Hence, the PCR showed a fair positive agreement (Κc = 0.63) against the combined results of all performed traditional methods. Conclusions: The combination of PCR and histopathology is a rapid and efficient tool for diagnosis of Pott's disease.
  1 2,748 233
Ramesh Sen
January-February 2014, 48(1):114-114
  - 693 113
Late recovery in cerebral fat embolism
KP Srikanth, SR Sundararajan, S Rajasekaran
January-February 2014, 48(1):100-103
DOI:10.4103/0019-5413.125527  PMID:24600071
Fat embolism syndrome presenting primarily with cerebral manifestations is rarely reported. We report here two such patients who showed complete recovery following initial deterioration. The aim of these reports is to highlight that prolonged intensive care and good rehabilitation can lead to normal neurologic recovery despite poor clinical picture initially. The importance of adequate oxygenation to prevent secondary brain damage is emphasized during prolonged recovery.
  - 1,966 89
Neglected surgically intervened bilateral congenital dislocation of knee in an adolescent
Jaswant Kumar, Ish Kumar Dhammi, Anil K Jain
January-February 2014, 48(1):96-99
DOI:10.4103/0019-5413.125524  PMID:24600070
Neglected bilateral congenital dislocation of knee is unusual. A 12 year old boy presented with inability to walk due to buckling of the knee. The symptoms were present since the child learnt walking. He preferred not to walk. Bilateral supracondylar femoral osteotomy was done at the age of 6 years. Patient had a fixed flexion deformity of both knees, 30° in the right (range of flexion from 30° to 45°) and 45° fixed flexion deformity in left knee respectively (range of flexion from 45° to 65°) when presented to us. The radiological examination revealed bilateral congenital dislocation of knee (CDK). No syndromic association was observed. He was planned for staged treatment. In stage I, the knee joints were distracted by Ilizarov ring fixators and this was followed by open reduction of both the knee joints in stage II. A bilateral supracondylar extension osteotomy was done 18 months after the previous surgery (stage III). The final followup visit at 4 years the patient presented with range of motion 5-100° and 5-80° on the right and left knee respectively with good functional outcome. The case is reported in view of lack of treatment guidelines for long standing neglected CDK in an adolescent child.
  - 3,055 112
Author's reply
Bhava RJ Satish, Atmakuri V Ranganadham, Karruppasamy Ramalingam, Sujit Kumar Tripathy
January-February 2014, 48(1):113-113
  - 590 46
Author's reply
Sanjay Arora, Vivek Dutt, Thomas Palocaren, Vrisha Madhuri
January-February 2014, 48(1):111-112
  - 588 53
Wasudeo M Gadegone
January-February 2014, 48(1):115-115
  - 532 62
Transfracture abduction osteotomy: A solution for nonunion of femoral neck fractures
Jairamchander Pingle
January-February 2014, 48(1):25-29
DOI:10.4103/0019-5413.125485  PMID:24600059
Background: Nonunion and avascular necrosis (AVN) of the femoral head remains one of the major complications following femoral neck fractures. Despite various surgical techniques and internal fixation devices, the incidence of nonunion and AVN has remained unsolved. Neglected nonunion of femoral neck fracture is common in the developing world. Treatment options include rigid internal fixation with or without bone grafting, muscle pedicle bone graft, valgus osteotomy of the proximal femur with or without bone graft, valgus osteotomy or hip arthroplasty. We conducted a retrospective analysis of cases of nonunion of femoral neck fracture treated by transfracture abduction osteotomy (TFAO). Materials and Methods: Over a period of 35 years (1974-2008), 30 patients with nonunion of femoral neck fractures were treated with TFAO over a period of 35 years (1974-2008), All patients were less than 50 years of age. Absence of clinical and radiological signs of union after four months was considered as nonunion. Patients more than 50 years of age were excluded from the study. Union was assessed at 6 months radiologically. Limb length was measured at six months. The mean duration of femoral neck fracture was 19 months (range 4 months 10 years). Results were analyzed in terms of radiological union at six months. Average followup was five years and six months. Results: Consistent union was noted at the followup after six months in 29 cases. One case was lost to followup after five and one-half months postoperatively. However, the fracture had united in this case at the last followup. Average shortening of the limb at six months was 1.9 cm. Average neck shaft angle was 127° (range 120-145°). Five cases went into AVN but were asymptomatic. Two cases required reoperation due to back out of Moore's pins. These were reopened and cancellous screws were inserted in the same tracks. Conclusions: Consistent union of nonunion femoral neck fracture was noted at the followup after six months in 29 cases. The major drawback of the procedure is immobilization of the patient in the hip spica for eight weeks.
  - 2,028 311
Outcome of double bundle anterior cruciate ligament reconstruction using crosspin and aperture fixation
Deepak Joshi, Vineet Jain, Ankit Goyal, Vibhu Bahl, Prashant Modi, Deepak Chaudhary
January-February 2014, 48(1):42-48
DOI:10.4103/0019-5413.125493  PMID:24600062
Background: Double bundle anterior cruciate ligament (DBACL) reconstruction is said to reproduce the native anterior cruciate ligament (ACL) anatomy better than single bundle anterior cruciate ligament, whether it leads to better functional results is debatable. Different fixation methods have been used for DBACL reconstruction, the most common being aperture fixation on tibial side and cortical suspensory fixation on the femoral side. We present the results of DBACL reconstruction technique, wherein on the femoral side anteromedial (AM) bundle is fixed with a crosspin and aperture fixation was done for the posterolateral (PL) bundle. Materials and Methods: Out of 157 isolated ACL injury patients who underwent ACL reconstruction, 100 were included in the prospective study. Arthroscopic DBACL reconstruction was done using ipsilateral hamstring autograft. AM bundle was fixed using Transfix (Arthrex, Naples, FL, USA) on the femoral side and bio interference screw (Arthrex, Naples, FL, USA) on the tibial side. PL bundle was fixed on femoral as well as on tibial side with a biointerference screw. Patients were evaluated using KT-1000 arthrometer, Lysholm score, International Knee Documentation Committee (IKDC) Score and isokinetic muscle strength testing. Results: The KT-1000 results were evaluated using paired t test with the P value set at 0.001. At the end of 1 year, the anteroposterior side to side translation difference (KT-1000 manual maximum) showed mean improvement from 5.1 mm ± 1.5 preoperatively to 1.6 mm ± 1.2 ( P < 0.001) postoperatively. The Lysholm score too showed statistically significant ( P < 0.001) improvement from 52.4 ± 15.2 (range: 32-76) preoperatively to a postoperative score of 89.1 ± 3.2 (range 67-100). According to the IKDC score 90% patients had normal results (Category A and B). The AM femoral tunnel initial posterior blow out was seen in 4 patients and confluence in the intraarticular part of the femoral tunnels was seen in 6 patients intraoperatively. The quadriceps strength on isokinetic testing had an average deficit of 10.3% while the hamstrings had a 5.2% deficit at the end of 1 year as compared with the normal side. Conclusion: Our study revealed that the DBACL reconstruction using crosspin fixation for AM bundle and aperture fixation for PL bundle on the femoral side resulted in significant improvement in KT 1000, Lysholm and IKDC scores.
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Protruded and nonprotruded subungual exostosis: Differences in surgical approach
Hakan Basar, Mustafa Erkan Inanmaz, Betül Basar, Emre Bal, Kamil Çagri Köse
January-February 2014, 48(1):49-52
DOI:10.4103/0019-5413.125496  PMID:24600063
Background: In subungual exostosis surgery, repair of the damaged nail bed and surgical excision of the mass without damaging the nail bed is important. The ideal method of surgery is still unclear. This study is done to qualify the effects of different surgical methods on outcome measures in different types of subungual exostosis. Materials and Methods: Fifteen patients, operated with a diagnosis of subungual exostosis between January 2008 and June 2012, were evaluated. Protruded masses were excised with a dorsal surgical approach after the removal of the nail bed and nonprotruded masses were excised through a"fish-mouth" type of incision. Results: The mean age of the patients in protruded subungual exostosis group was 17.3 years (range 13-22 years) and this group consisting of seven female and two male patients. The patients were followed up for a mean of 14.1 ± 4.8 months. The mean age of the patients in the nonprotruded subungual exostosis group was 14.6 years (range 13-16 years) and consisting of six female patients. The patients were followed up for a mean of 11.6 ± 2.9 months. The results were positively affected by changing the surgical approach depending on whether or not the exostosis is protruded from the nail bed. All patients had healthy toe nails in the postoperative period without any signs of recurrence. Conclusions: In patients with a protruded subungual exostosis, the mass should be removed by a dorsal approach with the removal of the nail and injury to the nail bed should be repaired. In patients with a nonprotruded subungual exostosis, the mass should be excised through a "fish-mouth" type incision at the toe tip without an iatrogenic damage.
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