Indian Journal of Orthopaedics Surgery

217-222

Authors: Arjun Ajith Naik, Ashwin Kamath

Lateral epicondylitis which is also known as tennis elbow is a very painful condition which can restrict the daily activities of a person. It can be treated in various modalities out of which local corticosteroid and physiotherapy with analgesics are the common modes which has shown good results in the past. However there exists a conflict between the functional outcome and the efficiency of these two modalities with no definitive conclusion on which is the better among the two. In this study we compare the functional outcome between the two modalities at a follow up of six weeks and found that local corticosteroid injection has proved to give faster relief from symptoms with early return to work. However patients who were treated with analgesics and physiotherapy also showed significant improvement during the course of treatment. This study will help to decide which among the two modalities have a better result and what the management protocol to be followed is

231-235

Authors: Prashant Vilas Bhandari, Punarvasu Rajeev Jagtap, Suyog Prakash Burgute, Vijay Vasant Nemade

Background: Treatment of comminuted avulsion fractures of Anterior Cruciate Ligament (ACL) is challenging. Arthroscopic fixation techniques such as fixation with Screws, staples, k-wires and Sutures are described to achieve this. But in comminuted avulsion fractures of ACL(Meyers and McKeever Type IV), attempts at internal fixation with screws, staples or k-wires often becomes impossible as small fragments of avulsed bone may further shatter while fixing them with implant. Hence we decided to perform arthroscopic reduction and fixation with sutures. Aim of this study is to demonstrate efficacy and benefits of fixation of ACL avulsion fractures with arthroscopic reduction and suture fixation technique. Methods: Patients diagnosed as having comminuted avulsion fractures of ACL and treated at our institute between November 2012 to January 2015 and those who were followed up in Out Patient Department or on telephone up to January 2016 were retrospectively studied. We could trace records of 23 patients who fulfilled our inclusion, exclusion and follow up criteria. Fixation of ACL avulsion fractures was performed with arthroscopic reduction and suture fixation technique. Results: 23 patients with comminuted avulsion fracture of Anterior Cruciate Ligament were studied retrospectively. Postoperatively 17 patients had full range of motion by 8 weeks. The remaining 6 patients had a range of 5 0 to 1100 at the 8 week. This was improved to 5 0 to 1250 till 12 weeks of follow up.19 patients had a negative Lachman test postoperatively, and 4 patients had a grade I Lachman, but with a firm end point. 2 patients had deep vein thrombosis on 3 rd and 5 th post-operative day. These patients were treated with low molecular weight heparin injections subcutaneously for 1 week followed by oral anticoagulants and physiotherapy. At an average of 27 months' follow-up (range, 12 to 39 months), all of the patients were satisfied with their outcome and returned to their pre-injury functional activity. Conclusion: Arthroscopic suture fixation of comminuted avulsion fractures of ACL gives acceptable results and reduces implant related complications

240-245

Authors: Vikram Ashok Rajguru, Swarup-Masih Sohanlal Daniel, Amit Kale

Background: Lower end radius fractures are among the most common fractures of the upper limb and accounts for 15-20% of orthopedic admissions in hospitals. Management these fractures continues to be a therapeutic problem and challenge. Though there are various treatment options described so far; still there is lacunae in the literature, regarding accurate treatment modality, particularly in case of unstable fractures. Various clinical and biomechanical studies have shown the benefits of restoring anatomical reduction. However other studies have demonstrated that restoring normal anatomy does not offer better functional outcomes. While achieving good fracture alignment may be significant, the actual functional importance of anatomical reduction is controversial. The assumption that functional outcome is better by restoration of anatomy is argued. Most orthopaedicians accept the fact that anatomical alignment is preferable, but the threshold for acceptable malunion and the long-term outcome of anatomical reduction on functional outcome and patient related satisfaction remain to be evaluated. The study had been taken up to disclose the correlation between anatomical and functional outcome in these patients with distal radius fracture. Objective: To examine association of radiographic parameters of distal radius fracture and objective (ROM, Grip strength) and subjective (PRWE) functional outcome. Study design and setting: A observational study on management of adult patients with distal radial fractures presenting at Deenanath Mangeshkar Hospital and Research Centre, Pune from October 2013 to December 2015. Patients and methods: This study carried out on the patients with intra-articular and extra-articular fractures of the distal end radius as per selection criteria and after taking a written informed consent. Outcome measures were assessed both objectively and subjectively. Objective assessment included a radiographic score determined by measuring the radial length, radial angle and dorsal angle on wrist radiographs; and the wrist function by measuring the range of motion and hand-grip strength. Subjective assessment was done using wrist pain and disability based on the patient rated wrist evaluation (PRWE) score. Data were analyzed using SPSS v20. Results and analysis: The mean age of our study population (49) was 53 years (20 – 90 years), and 33 patients (67%) were female. Twenty eight fractures (57.1%) were of the dominant hand. Non-operative (14) and operative treatments (35) were used. Majority of patients had a good radiographic score (61%), while 6% had a poor score. Sixty five patients (65%) had a good functional objective score, and 21% had an excellent score. In the subjective assessment of pain and disability, the PRWE score was highest in the 41-60 years age group at 38/100 and least in those at 60 and above years (32/100; p= 0.004). There was a positive correlation (p =0.000) between radiographic assessment and the objective functional assessment in younger age group. There was no correlation between the radiographic score and the subjective assessment (p =0.319). Grip strength was a significant predictor of disability (PRWE score). Conclusion: The majority of the patients had a good radiographic score which correlated positively with the objective functional score, especially in the younger patients; however, a good radiographic score does not seem to positively affect the subjective functional outcome. The patient’s age is an important factor in the overall patient satisfaction regardless of the radiographic and the objective functional scores, hence to be considered during planning of treatment options

254-258

Authors: Arunodhaya Siddartha, Supreeth Nekkanti, Purushotham Sastry, Seshagiri, Abhilash G

Background: Bicondylartibial fractures are serious injuries and are difficult to manage even for the most experienced trauma surgeons. The soft tissue around proximal tibia demonstrates poor healing response following dissection or manipulation. Hence surgical fixation of these injuries by osteosynthesis has shown mixed results over the years. Case Series: We conducted a prospective study of five consecutive patients of compound proximal tibia bicondylar fractures from January 2013 to June 2016. All of them were compound type 3A or 3B injuries classified according to Gustilo-Anderson grading system of open injuries. ILIZAROV fixator was used for treatment in all the cases. The fixator was kept for an average of twelve to twenty weeks. The patients range of motion and knee society score was recorded at the end of 32 weeks. Results: The average range of movements achieved in the knee joint was105 degrees at the end of eight months. Complications included knee stiffness and pin site infections. Knee stiffness was managed by subjecting the patient to aggressive physiotherapy by continuous passive movements. In one patient manipulation under general anesthesia had to be done. Two patients had pin site infections which were superficial and subsided by antibiotics and daily pin site dressings. The knee society score was excellent in four patients and good in one patient. Conclusion: This case series emphasizes the clinical success and low morbidity to the patient when treated with ILIZAROV fixator. The technique is suited well to manage complex proximal tibia injuries as it provides a stable construct in all the planes. Anatomical reduction of fragments can be achieved by closed reduction using olive wires during ILIZAROV application. This would avoid excessive dissection of soft tissue required during plating.

264-270

Authors: P. Antony Leo Aseer, G. Arun Maiya, M. Mohan Kumar, P.V. Vijayaraghavan

Background: Total knee replacement (TKR) surgery has become the most successful surgery for patients with severe debilitating arthritis. Numerous factors influence the outcomes in TKR Post-operative physiotherapy and rehabilitation greatly influences the outcome of TKR. Despite the high incidence of TKR in recent years there is no post-operative rehabilitation approach being incorporated correctly to address the muscular and functional deficits following surgery. Objective: The main objective of the study is to analyze the effectiveness of structured rehabilitation program on the functional outcome of patients following total knee replacement. Materials & Methods: All patients who were planned to undergo elective primary TKR were recruited. Subjects posted for revision TKR, rheumatoid arthritis posted for TKR, immediate post-operative complications like deep vein thrombosis, signs of infection, TKR for Post-fracture cases were excluded. Eighty subjects enrolled for the study were randomly allocated to control and experimental group using simple random sampling. The control group receives standard care and experimental group receive structured exercise program comprising range of motion, staged training of quadriceps, vastus medialis strengthening exercises, early balance training and functional retraining. Outcomes including pain severity, knee joint mobility, isometric muscle strength, six minute walk test and functional outcome using KOOS scale were measured post-surgery and after 3 months follow up. Results: In experimental group, follow up measures of pain severity (p-.0001), knee joint extension range (p-.0016), isometric strength of hamstrings (p-0008) shows statistically significant results than control group. Whereas, in experimental group, follow up measures of knee flexion range (p-< .0001), isometric strength of quadriceps (p-<.0001), six minute walk test (p-< .0001), functional outcome subscale of KOOS-symptoms and quality of life (< .0001) shows statistical highly significant results than control group. Conclusion: The structured exercise program was effective in improving the primary and secondary outcomes following primary total knee replacement.

276-279

Authors: Shivanand C Mayi, Sachin Shah, Sadashiv R Jidgekar

Background: In India the estimated geriatric population is going to rise from 8% of total population in 2010 to 19% by 2050. Incidence of osteoporosis and associated fractures will rise in coming years with increasing elderly population. Management of fracture neck of femur and unstable intertrochanteric fractures in osteoporotic bone is challenging in elderly as they are more prone for fracture associated complications like pressure sore, deep vein thrombosis and pneumonia. Aim: The purpose of this study is to evaluate the role of cemented bipolar hemiarthroplasty in management of osteoporotic proximal femoral fractures in elderly people. Patients and Methods: In this prospective study twenty patients with osteoporosis having proximal femoral fractures (fracture neck of femur/unstable intertrochanteric fracture) were treated by cemented bipolar hemiarthroplasty. Patients were followed up at 3 weeks, 3, 6, and 12 months to evaluate the function outcome. Mean age of the patients in this study was 73.84 years. Results: Average duration follow up in this study was 14.63 month. Mean Harris Hip Score in the post-operative period was 42.73±8.78 which improved to 81.57±9.11 at 6 months. Average post-operative mobilization duration was 3.84 day and average hospital stay was 11.31 day. At 1 year follow up 85% patients had excellent to fair outcome and 10% had poor outcome. Conclusion: Treatment of osteoporotic proximal femoral fractures with cemented bipolar hemiarthroplasty gives better functional outcome.

285-288

Authors: Nazmuddin J Jetaji, Kiran S. Belsare, Shyam Thakkar, Prashant N. Gedam, Aseem N. Parekh

The trapeziometacarpal joint is most often affected by primary osteoarthritis or post-traumatic arthritis. The aims and objectives of the study was to evaluate the subjective and objective results of thumb carpometacarpal arthritis treated with Suspension arthroplasty and comparison of the results at our institution with those mentioned in the literature. This is the study of 10 patients who were treated with suspension arthroplasty and followed up postoperatively at six months or more, the average being 14.2 months. The test of significance applied was Wilcoxon signed-rank test. A p-value of < 0.05 was considered as significant. The patients were evaluated after surgery in the terms of Mayo’s wrist score, grip strength, pinch strength and pain. Results: There were 8 females and 2 males, 8 right handed (dominant) and 2 left handed. The average age was 56 yrs with SD of 4.7 yrs. The preoperative Mayo’s wrist score was 44 which increased to 74.5 at the time of the longest follow up. The difference was statististically significant (p-value of < 0.05). The increase in grip strength was impressive and statistically significant. It increased from a preoperative mean of 42% of the opposite hand to 69%. The increase in pinch strength although was less impressive as compared to the grip strength as reflected in the Mayo’s wrist score. It increased from a mean of 45.8% of the opposite hand to 54.7%. VAS scores reduced from mean of 4.8 to 0.2 showing significant reduction in pain at the base of the thumb. Conclusion: Our study highlights the importance of diagnosing and identifying this potentially treatable common condition which is often confused with other differential diagnoses. Ligament reconstruction and tendon interposition is an easy and reproducible technique to restore function and relieve pain in the joint.

293-305

Authors: Ratnakar E Ambade, Karan K Mane

Financial Disclosure: There are no financial relationship for this study to disclose. Study Design: Cross sectional prospective study to evaluate the Clinical findings of lumbar spinal stenosis and correlated to the MRI findings. Objectives: To examine the clinical presentation in lumbar spinal stenosis, also the radiologic features of lumbar spinal stenosis on MRI SCAN and to correlate the both. Summary of Background Data: Several studies have been performed regarding the correlation of clinical findings with the radiologic findings, it is important to find out the sensitivity, efficacy and lapses of both the methods and to formulate an effective diagnostic plan for management of patients with lumbar spinal stenosis specially in a rural setup in Indian population. Methods: Cross sectional prospective study to evaluate the clinical findings of lumbar spinal stenosis and correlated to the MRI findings. Clinical findings which were evaluated included Age, Occupation, Duration of symptoms, claudication distance, clinical level for disc protrusion, motor and sensory deficits, bladder bowel involvement. MRI findings which were noted as related to lumbar spinal stenosis were canal diameter, level of disc protrusion, ligamentum flavum hypertrophy. Results: Many clinical parameters do correlate with the MRI features of lumbar spinal stenosis. This may not be true in all cases and hence clinical parameters are of paramount importance while considering the treatment option for the patient evenly supported by the MRI findings. Conclusion: To conclude with MRI is the modality of choice in patients with lumbar spinal stenosis but needs to be correlated with clinical findings to ascertain or diagnose or classify LSS in terms of severity and before planning for surgical decompression.

310-312

Authors: Jayakrishnan Kelamangalathu Narayana Kurup, Imthias Vazhayil Kottamtavida, Hitesh Hasmukhlal Shah

Kasabach-Merritt Syndrome (KMS) is a rare and life threatening complication presenting as thrombocytopenia with consumptive coagulopathy in patients with large capillary or cavernous hemangioma. It is associated with a mortality of 30-40%[1,2] . We report a case of a 16 year old boy with Klippel-Trenaunay Syndrome (KTS) who sustained a right supra condylar femur fracture complicated by KMS. His thrombocytopenia and coagulopathy was managed followed by rush rodding of femur fracture. The preoperative management of KMS was demanding and needed constant monitoring due to the risk of haemorrhage and thrombosis. This is the first case of surgical management of a long bone fracture complicated by KMS in children to be reported.