Indian Journal of Orthopaedics Surgery

1-5

Authors: Amr I. Zanfaly, Adel Abdel Azim

Background: Management of idiopathic osteonecrosis of the femoral head with arthritis in the young age group is controversial. Total hip replacement is considered the gold standard for management of arthritic hip. However, the longevity of the prosthesis and the number of future revisions are still the main source of concern about total hip replacement in this age group. The use of ceramic on ceramic bearing couples improved the longevity of the prosthesis. Patients and methods: In the period from June 2010 – to December 2012, 18 patients (22 hips) with idiopathic osteonecrosis of the femoral head were treated by cement less ceramic on ceramic total hip replacement. This study was done at Zagazig university hospitals. The mean age was 29.5 years old. There were 14 males and 4 females. The mean follow up period was 48.4 months. All cases had idiopathic osteonecrosis of the femoral head stage III and IV according to Ficat classification. The functional results were evaluated according to Harris hip score. The radiological results of the femoral and acetabular components following surgery were evaluated according to the criteria of Lins et al and Engh et al., respectively. Results: The mean Harris hip score improved from 39.36 (range 30-56) preoperatively to 89.59 (range 68-96) in the final controls (p<0.001). Fourteen cases had excellent score, four good, three fair, and one patient had poor score. Patients in the zone from good to excellent represented about 80% from total number of cases. Radiolucency was observed around two acetabular components at 36 months follow-up, it was mildly progressive at 60 months follow-up in one case and the other one developed loosening at 48 months follow up for whom, revision was done at 50 months. Two stems were associated with a radiolucent line at 48 months follow-up. Their progression was not sufficient to conclude that there was any loosening at 60 month follow-up. Conclusion: The results of cementless total hip replacement with ceramic on ceramic bearing surfaces are promising for young patients with idiopathic osteonecrosis of the femoral head at 5 years follow up. Longer - term follow up is recommended.

11-18

Authors: Madhukar. K.T, Debasubhra Mitra, Abhey Wasdev, Susmita Bhattacharya

The likelihood of experiencing an episode of low back pain increases with age, and 85% of people will have at least one episode in their lifetime. Prevalence of low back pain is next only to headache. Total 50 patients (28 male and 22 female) who met the inclusion and exclusion criteria underwent epidural steroid injection. Patient pain scaling is done before performing the procedure, after 48 hours, after 2 weeks, after 3 months of the procedure. The proposed pain scale to be used is Numerical Rating Scale. Out of total 50 patients, after 48 hours it was found 30 patients had mild pain (NRS 1-3 ),18 patients moderate pain (NRS 4-6) and 2 patient continued to have severe pain (NRS 7-10). After 2 weeks it was found 24 patients to be mild pain, 24 patients with moderate pain and 2 patient with severe pain. After 3 months it was found 14 patients had mild pain, 32 patients had moderate pain and 4 patients had severe pain. The effect of epidural steroid injection decreases with time. The local effect of steroids has been shown to last at least 2 to 3 weeks at a therapeutic level. Epidural Steroid Injection is a safe, effective, & economical treatment modality for LBP. It reduces the period of hospitalization, analgesic intake & facilitates the institution of early rehabilitative programs.

27-34

Authors: Arpit Tiwari, Rahul Sinha,, Mustafa Johar, Akanchha

Background: Proximal humerus fractures account for approximately 4-5% of the fracture attendance at the hospital. The management of proximal humeral fractures has always been an enigma because of numerous muscles attachment and paucity of space for fixing the implant. The objective of the present study was to compare different modalities of fixation in proximal humerus fractures. Methods: This is a retrospective study done on 112 patients of acute proximal humerus fractures treated surgically. Follow up was done for 12 months and results were analysed using Neer’s scoring system. Results: Radiological union occurred at average time of 10.1 weeks. As per Neer's scoring system, 36% patients had excellent results while 31% patients had satisfactory results. They were all pain free and successfully returned to their pre-injury work. 25% patients had unsatisfactory and 8% failure result. 2 patients required revision surgery. Conclusion: Treatment options depend on fracture pattern, bone quality, patient's goals and surgeon’s familiarity with the technique. Patients who have two part greater tuberosity avulsion fracture are best treated by closed reduction and percutaneous screws fixation. Patients who have metaphyseal comminution and/or three-part fracture with appreciable displacement of the greater tuberosity are more appropriately treated by open reduction and Internal fixation with a plate.

42-47

Authors: Shamim Ahmad Bhat, Raja Rameez, Adnan Zahoor, Tabish Tahir, AsifNazir Baba, Khurshid Ahmad Kangoo

Supracondylar fractures of humerus are common skeletal injuries in paediatric age group comprising 50-60% of elbow injuries. They are often associated with complications and are very notorious for neurovascular injuries between 5 to 10 years of age. Our objective was to evaluate the functional outcome with closed reduction and percutaneous cross k wire fixation. 60 patients of Gartland type III fractures admitted and treated in our hospital were taken for study. The results were assessed as per FLYNN CRITERIA. There were 48 excellent, 6 good,4 fair and 2 poor results. Fair results were due to poor compliance to follow up and postoperative rehabilitation. There were 8 cases with pintract infection, 2 with elbow stiffnes and 1 with cubitusvarus. Closed reduction and percutaneous K wire fixation is very effective and minimally invasive way of treatment of displaced supracondylar humerus fractures. Crossed K wire seems biomechanically better way of stability of fracture reduction.

52-63

Authors: Anubhav Sharma, Pradeep K Singh, Sohael M Khan, Shounak Taywade, Ankit Chintawar, Sparsh Naik

Background: Back pain has been known since the start of written history, probably the first report of back pain and sciatica can be found in an ancient text, the so-called Edwin Smith Surgical Papyrus presumably written around 1550 B.C.1 Although backache (with or without sciatica) is a benign often self -limiting condition (Macnab). 2 The cost of both time lost from work (with loss of productivity) and medical care, as well as the cost of litigation and disability claims, make back pain an industry unto itself. Purpose: The main purpose of this study was to evaluate the clinical, radiological outcome of the lumbar disc patients managed surgically and to compare the results of different surgeries performed. Methods: This study was prospective, non-randomized, cohort study it was carried out in the Department of Orthopaedics, Acharya Vinoba Bhave Rural Hospital, Wardha, between August 2013 – 2015. Patients with more than 18 years were included with persistent bothersome sciatic pain, despite conservative management for a period of 6-12 weeks. All the patients with progressive neurological involvement during a period of conservative treatment. All the patients with cauda equina syndrome or impending cauda equina syndrome. Results: Out of total 67 patients the mean age was 49.85±8.75 years ranging from 40 to 72 years. Male gender was predominantly forming 66% of the sample size whereas 34% of females. All the patients had radicular pain, 26 out of 67 patients had left sided radiculopathy and right-sided radiculopathy was observed in 21 patients whereas 20 patients had bilateral radiculopathy. After MRI 34 patients had extrusion of disc, whereas 17 patients showed sequestrated disc, protrusion of disc was observed in 12 patients, whereas disc bulge was observed in 4 patients. 42% of patients were operated by laminectomy, 33 % patients were operated by microscopic discectomy and minimum 25% of patients were operated with microendoscopic discectomy. L4-L5 level was the most common level to get involved. Mean Pre-operative VAS score for male patients was 6.64 and female patients was 6.78, which was reduced to 3.14 and 3.48 respectively after 6 months of operative management. Mean Pre-operative Oswestery score for male patients was observed to be 44.05 and female patients was 44.87, which was reduced to 24.95 and 27.83 respectively after 6 months of operative management. Complications in all three surgeries were observed. Conclusion: Minimally invasive techniques in all areas of surgery have gained momentum in recent years. Spinal surgery has been no exception. Unfortunately, minimally invasive techniques have often been equated with minimally effective procedures. We understand that the micro endoscopic discectomy and microscopic discectomy techniques are superior to the standard discectomy technique for the treatment of single level lumbar disc herniation’s with regard to pain relief, clinical outcome and functional outcome, volume of blood loss, systemic repercussions, and duration of hospital stay. However, technical expertise and learning curve of the technique could be the limitation. Minimally invasive surgeries are cost-effective treatment for lumbar herniated discs. Results and complications were comparable with those associated with standard discectomy techniques. Patient satisfaction was high, and a cost savings was realized.

69-76

Authors: Hanumantharaya GH, Kamala GR

Introduction: Avascular necrosis is defined as a group of symptoms, dominated by pain, loss of function and bony collapse caused by anoxemia and other deficiency in arterial nutrition of the head of the femur, prolonged enough to result in the marked degeneration, even necrosis of bone. Methodology: Data collected included: Pre-clinical studies – model of AVN, variety and dosage of SC, histologic and imaging analyses. Clinical studies – study design, classification and etiology of AVN, and treatment protocol. Results: It was also noticed that 9 hips (28.13) with stage III, 8 hips (25%) with stage II and 2 hips (6.25%) associated with stage I disease. There was one hip (3.13) of Stage V and VI each. This was according to classification by Steinberg et al. Conclusion: Thus, a focus on early disease management aimed at joint preservation by preventing or delaying progression is key.

83-87

Authors: Sameer Wooly, Anand Kumar.B.S

Background: Clubfoot occurs approximately 1 in 1000 live births and is one of the most common congenital birth defects. There have been many reports of successful treatment of idiopathic clubfoot with Ponseti method in the western world, but there are only few studies done in the developing country like India. So the present study was undertaken with the following objective. Objective: To evaluate the efficacy of Ponseti method in the treatment of idiopathic clubfoot. Methodology: A study was conducted from August 2013 to August 2014 in our Hospital attached to PESIMSR. 25 patients (36 clubfoot) were evaluated in our study. All patients were treated by manipulation and casting as described by Ponseti. Main outcome measures included in the study were, the degree of correction of the deformity and the effect of different variables in the course of management. Results: In our study, we treated 25 babies with idiopathic clubfoot by Ponseti method, among them 11 had bilateral affection. The mean age of the babies was 14 weeks. Out of the 25 babies, 30 of the 36 feet had deformity of a severe grade i.e., Pirani score of 5. The mean number of casts required was 5.8. Tenotomy was required for 26 feet. The average number of casts required were increased as age of presentation increases indicating increasing difficulty and delay in correction of babies who presented late. The results were excellent in 64% (16 out of 25) and good in 28% (7 out of 25).The average Pirani score for the group at the presentation was 5.47 (4.5 to 6) and the mean Final Pirani score was 0.25 (0 to 0.5) which was statistically significant. Conclusion: Ponseti method is a very safe, efficient and economical treatment for the correction of clubfoot which radically decreases the need for extensive corrective surgery. The results are excellent when treatment begins early.

93-95

Authors: Shirish Virupanna Tumbal

Indian Journal of Orthopaedic Surgery (IJOS) is a peer-reviewed journal with reputable academics and experts as members of its Editorial Board. IJOS publishes information on basic and applied orthopaedics for a worldwide readership. It publishes original research papers, critical reviews dealing with all fields of Orthopaedicsand it addresses the international scientific community. Papers related to orthopaedic science on a worldwide basis are also considered. Special emphasis is given to issues that go beyond the traditional boundaries of anorthopaedic journal.Articles on the state-of-the art of orthopaedic surgeryin different parts of the world, the research activities and medical education in orthopaedic teaching, the role of orthopaedics in society, new findings from the frontiers of current researchare always encouraged.

102-109

Authors: Maruthi CV, Shivanna

Background & Objectives: Back pain, the ancient curse is now appearing as a modern epidemic. 80% of the population is affected by this symptom at sometime of life. Impairments of the back and spine are ranked as the most frequent cause of limitation of activities in people of all age groups. Lumbar discs are responsible for well over 90% of all organic symptoms attributable to low backache. Here we have done a clinical study, which includes sixty cases of lumbar intervertebral disc prolapse in the age group of 20 to 70 years, irrespective of sex, with clinical symptoms, signs and radiological evidence treated either conservatively or surgically with discectomy in the Department of Orthopaedics at our institute. All cases were followed up and functional results were analysed. The objective was to study the clinical presentation, evaluate outcome of both conservative and surgical management and to compare the results of both modes of treatment. Methods: Out of 60 patients included in the study, 30 were treated conservatively & another 30 underwent laminotomy discectomy in the Department of Orthopaedics at our institute between October 2007 & September 2013. The short-term follow-up results in patients who were followed up for a minimum of 6 months after treatment were evaluated by using the Japanese Orthopaedic Association scoring system through clinical examination and questionnaire. Results: Prevalence of disc prolapse was in age group of 20 to70 years, while peak incidence was between 30-40 years of age. Incidence of disc prolapse in males was almost twice as much as in females (in our series 65% male cases were noted). 56.67% cases had disc prolapse at L4-L5 level, which being the commonest site of disc prolapse followed by L5-S1 of about 41.67% and 1.67% at L3-L4 level. In the short term follow-up of 6 months, the outcome was good in 90% & excellent in 6.67% of surgically treated patients with 3% complication rate. Conservatively treated group of patients showed 46.67% good, 43.33% fair & 10% poor results. Interpretation & Conclusion: Short term outcome of standard discectomy in our study was favourable and comparable to other studies. With the execution of appropriate selection criteria and appropriate pre & post treatment planning, a good to excellent outcome was seen in nearly 97% in surgical study. In conservatively treated group, 90% patients showed fair to good result. Therefore lumbar discectomy is still a simple, safe & effective treatment with rapid relief for patient while conservative treatment if given to properly selected cases also gives effective results. Patients undergoing surgery for lumbar disc herniation achieved greater improvement in outcome than conservatively treated patients.

115-118

Authors: Devendrappa. H, Santosh, Prabhanjan Kumar

Background: Calcaneum fractures account for 2% all fractures. Intra-articular fractures account for approximately 75% of calcaneal fractures and historically have been associated with poor functional outcome. These fractures are uniformly caused by an axial load mechanism, such as a fall from Height or a motor vehicle accident. The current preference in the surgical treatment of calcaneus fractures is open reduction and internal fixation. However, there were some unsatisfactory results from this technique such as flap necrosis, deep infection and non-union. In selected cases, it is possible to obtain reduction with a percutaneous approach with the Essex-Lopresti Technique using an axial pin. The technique of closed reduction and percutaneous fixation was introduced by Westheus and popularized by Gissane. But the credit for describing the technique goes to Essex-Lopresti. The effectiveness of this technique in the restoration of Böhler’s angle and calcaneal height in tongue shaped is well documented. Aim: To evaluate the outcome of Essex Lopresti technique in intraarticular tongue shaped calcaneal fractures. Material and Methods: 20 patients with tongue shaped intraarticular calcaneum fractures were admitted and treated with closed reduction and pin fixation (Essex Lopresti technique) in vijayanagar institute of medical sciences, Bellary. Patients follow up done for 1year. Outcome of the study was evaluated using Creighton Nebraska Health Foundation Assessment sheet for calcaneum fractures. Results: Incidence was common in 30 to 45years old male patient with most common mechanism of injury being fall from height. 20% of the patients were associated with other side communited calcaneum fracture and 30% patient were with other bones fracture. 80% of patient had good results and 20% had fair result with no poor results. Conclusion: Essex Lopresti technique is effective technique for tongue shaped intraarticular calcaneum fractures with excellent outcome and acceptable complications.

124-126

Authors: Ravindra Chauhan, Naveen BM, HS Agarwal

About the Journal Indian Journal of Orthopaedic Surgery (IJOS) is a peer-reviewed journal with reputable academics and experts as members of its Editorial Board. IJOS publishes information on basic and applied orthopaedics for a worldwide readership. It publishes original research papers, critical reviews dealing with all fields of Orthopaedicsand it addresses the international scientific community. Papers related to orthopaedic science on a worldwide basis are also considered. Special emphasis is given to issues that go beyond the traditional boundaries of anorthopaedic journal.Articles on the state-of-the art of orthopaedic surgeryin different parts of the world, the research activities and medical education in orthopaedic teaching, the role of orthopaedics in society, new findings from the frontiers of current researchare always encouraged.