Indian Journal of Orthopaedics Surgery

330-334

Authors: Sabary Vaasan L, Raju Karuppal, Sandhya Somasundaran

Introduction: In current scenario, various operative procedures such as submuscular plating, spica casting, external fixation, intramedullary nailing etc available for children having femoral shaft fractures. We aimed to use titanium elastic nails for treating diaphyseal femoral fractures in children, considering the limited evidence of this technique. Our study focused on the efficacy, safety, average length of hospital stay and complications of this method. Materials & Methods: We recruited 20 patients aged 3-13 years with fracture shaft of femur and were treated with stable elastic intramedullary nailing with titanium elastic nails at Government Medical College, Kozhikode from February 2014 to January 2015. Follow ups were carried out at 6, 12 and 24 weeks and there after every 2 months till the fracture union was confirmed. Result: Out of 20 patents, 17 fractures were closely reduced & fixed and in 3 cases, open reduction was done. All the fractures united between 7-12 weeks, with average time of union being 8.3 weeks. All patients had good range of movements except 3 patients who had nail protrusion. The average duration of hospital stay was 7.3 days. Regarding the complications of this technique, limb length discrepancy was the most common complication. Conclusion: It was observed that Elastic Stable Intramedullary Nailing (ESIN) technique is an ideal method for treatment of pediatric femoral shaft fractures. It gives elastic mobility promoting rapid union at fracture site and stability which is ideal for early mobilization. It also has lower complication rate, permits early return to school when compared with other methods of treatment.

339-345

Authors: Siddhartha Sahu, Ipsa Mohapatra, Prachi Sharma.

Osteoporosis an emerging public health problem in developed as well as developing countries, affecting both men and women. Introduction: To estimate the prevalence of osteoporosis and related factors, by using quantitative ultrasound (QUS). Methodology: A cross-sectional study was done among 396 people, measuring their bone mineral density (BMD) by using QUS; after the participants were interviewed using a proforma. Results: Out of the 396 subjects, 198 were males and 198 were females, with a male to female ratio of 1:1; among the males 9.60% had osteoporosis and 44.44% had osteopenia, on the other hand, 11.62% women had osteoporosis and 50.00% had osteopenia. Majority (72.72%) were in the age group of 45 to 54 years. Overall osteopenia was found in 187 (47.22%) and osteoporosis in 42(10.61%); their mean (± SD) age was 52.91 (±9.99) years, with a range of 42 to 88 years. Their mean (± SD) height, weight and body mass index (BMI), important indicators of the nutritional status of the population, were 2.39(± 1.04) m, 63.75(±11.38) kg and 23.98(±3.94), respectively. With increasing age the incidence of osteopenia & osteoporosis were higher; although this was not found to statistically significant. Chi-square analysis showed that educational level, socio-economic status and marital status showed significant associations. Conclusion: This study highlights the prevalence of osteoporosis in Odisha and the urgent need for measures to improve the nutritional status, dietary calcium intake and thus the bone health of this population.

350-355

Authors: Swarn Gupta, Pradeep K. Singh, Kiran Saoji, Sanjay Deshpande, Sohael Khan.

Introduction: Total hip Arthroplasty is a surgical procedure, which relives pain related to hip joint. The success of Total Hip Arthroplasty is its ability to relieve the pain associated with hip joint pathology, while maintaining the mobility and stability of the hip joint. This study was undertaken to assess the Clinical outcome of the Total hip Arthroplasty in our institution. Material & Methods: Retrospective and prospective study was carried out on 500 patients of Total Hip Replacement. All patients underwent a standard clinical and laboratory evaluation that includes briefly information about age, sex, address, clinical history and routine investigation which were done pre operatively. X-Ray of hip joint with AP view was done. Pre-op Range of Motion, deformities and its values were recorded for the study by clinical evaluation and Modified Harris hip scoring was done preoperatively and postoperatively with follow up at 4 weeks, 6 months, 1 year and at yearly intervals. Results: This study was conducted on patients with age ranging from 20 to 75 years with a mean age of 40.50 ±12.15 years at the time of surgery. The main indication for surgery was AVN in 360 patients (72%). The mean total pre-operative harris hip score score was 49.74. The maximum score being, 73 and the minimum, being 37. Post operatively the total mean score was 85.12, with the 65 being the minimum and 96 being the maximum. The most common complication was stress shielding (24%). Acetabular component loosening was seen in 2% cases and femoral stem loosening was found in 12% cases. Calcar resorption was present in 8% cases. Conclusion: In conclusion, Total hip Arthroplasty with or without cement gives good clinical and functional outcomes and is determined by multiple factors, like indication for total hip Arthroplasty, placement of prosthesis, and the operative technique. The results of the procedure must be evaluated in long-term studies. Our study suggests that the Total Hip Replacement can provide satisfactory clinical outcomes after short term duration of follow-up.

360-365

Authors: Yogesh R. Gaikwad, Vijay V. Nemade, Vijayanad R. Lokhande, Shardul M. Soman, Sandeep D. Shinde

Introduction: Management of chronic osteomyelitis demands prolonged Antibiotic therapy. Antibiotics may be administered systemically or locally. Local antibiotic therapies have definite advantages. In this study we used Indigenous Antibiotic Impregnated malleable PMMA Cement Rod. Aim of this study is to evaluate the efficacy of Indigenous Antibiotic Impregnated Malleable PMMA Cement Rod in the treatment of chronic osteomyelitis of long bones. Methods: This study involved retrospective evaluation of 63 patients of chronic osteomyelitis of long bones treated at our institute between February 2011 to January 2016. All patients with chronic osteomyelitis of long bones with less than 2 cm of sequestrum formation were included in the study. Patients with infected non-union were treated with other modalities of treatment and were excluded from the study. Initially for first three years we treated 33 patients of chronic osteomyelitis of long bones with surgical removal of infected and dead bone and soft tissue followed by local Antibiotics Impregnated PMMA Beads. These patients were considered as Group A. Later since February 2014 we started treating patients with Indigenous Antibiotic Impregnated Malleable PMMA Cement Rod and these patients were considered as Group B. Results: There were 33 patients in group A. 26 patients cured with complete irradication of the infection. Cultures performed on tissue sample taken at the time of Beads removal were negative in these cases. In 9 patients removal of Beads was difficult. 7 patients had persistent pain, swelling and inflammation. On investigations they had raised CRP, Total count and Neutrophillia. They all underwent second surgical procedure - removal of Beads and further treatment with Masquelet technique. One of these 7 patients had pathological fracture which was stabilized with Antibiotic impregnated PMMA intramedullary nail. These 7 cases required 16 to 23 weeks for complete cure of infection. The average time required for complete recovery in Group A patients was 17 weeks. There were 30 patients in group B. All patients were completely cured in a mean time period of 8 weeks (range, 6–11 weeks). No patient required a second surgical procedure to achievecontrol of infection. Tissue samples obtained at the time of Rod removal showed no growth on culture in all these patients. Conclusion: Our study results demonstratesvery effective and complete cure of chronic osteomyelitis in less time period with the use of Indigenous Antibiotic Impregnated Cement Rod technique as against the use of Antibiotic Impregnated Cement Beads.

372-377

Authors: Gaurav Jain, Deven Taneja, Prakash Bangani.

Introduction: Tibial shaft fracture is among the most common long bone fracture encountered, open fractures are more common in the tibia because one third of the Tibial surface is subcutaneous throughout most of its length, and the blood supply to the tibia is more precarious than that of bones enclosed by heavy muscles. Whenever open fractures occur in the tibia they are more commonly type IIIB. Objective: To study delayed union, non-union and infection are relatively common complications of tibial shaft fracture functional outcome & effect of dynamization in closed Intra-medullary Interlocking nailing for closed and open (Gustilo & Anderson Type I to Type IIIb) Tibial diaphyseal fractures. Material and Methods: Total of 56 skeletally mature patients diagnosed as Tibial diaphyseal fracture included closed & open (Gustilo type I to IIIb). Treated with intramedullary interlocking nail. Observation & Results: The age distribution was 42.9% in 21-40 years age group & 41.1% in 41-60 years age group with mean age 39.32 ± 14.85. Majority of fractures occurred in male i.e. 76.8%. Road traffic Accidents were found to be the main culprit as it contributed to 83.9% of total cases, other includes the fall from height (12.5%) & slip at home (3.6%). Among 56 tibia fractures 51.8 % were the lower 1/3rd shaft of tibia. 31.5% were middle 1/3rd shaft of tibia fracture. 1.8% upper 1/3rd shaft of tibia fracture. 8.9% are segmental fracture. In 33 cases which is more commonly i.e. 58.9% & Right side was involved in only 23 cases i.e. 41.1% of total cases. 80.4% of total cases (45) were closed tibia fractures. Dynamization increases the rate of callus formation with mean time to union post dynamization is 6.86 weeks. We evaluated patient using Lysholm score at 3 months and we found that mean Lysholm score was 75.54, which has increased in 6 months to 87.84. At the end of the study we found score further increased to 95.39. Final result in 56 case of tibia shaft fractures treated with intramedullary interlocking nail, 39 case (69.6%) result was “Good to excellent”, in 13 patient (23.2%) results were “Excellent”. 3 patients (5.4%) had “fair to good “result. 1 patient had “fair” result. We found no case with poor results. Conclusion: Dynamization increases the pace of fracture healing in delayed uniting fracture. Intramedullary interlocking nails shows good to excellent results in the treatment of diaphyseal fractures. Distal tibia shaft fracture are more common followed by middle 1/3rd.

382-385

Authors: Madhukar K. T., Moinuddin Basha K

Introduction: Fractures of the tibia and fibula are relatively common and have been recognized as serious and debilitating injuries for centuries. The primary aim of the study was to compare outcomes in patient with a diaphyseal fracture of tibia managed by intramedullary nailing with intact fibula Vs fracture both bone of the leg. Method: Total of 72 patients were included in this study. They were divided into 2 groups. Group A (12 out of 72) comprised patients with tibial diaphysis fracture alone, and Group B (60 out of 72) was made up of patients with both bone fractures of leg. Reamed intramedullary nailing was done in both Groups. Both the groups were followed up and compared in terms of duration of surgery, the rate of union. Result: The average duration of surgery (group A-108 minutes, Group B-98.6 minutes), the rate of union was longer [20 weeks in group A and 18.2 weeks in group B] in group A. Group A were more proven for union-related problem. In group A, the delayed union was seen in 6 (50%) cases out of which 4 united readily with fibular osteotomy/partial fibulectomy and 2 patients were diagnosed with non-union. In group B, the delayed union was seen only in 4 (6.66%) and none were progressed to non-union. Conclusion: Fracture tibia with intact fibula are more proven for union-related problems when compared to both bone leg fracture. Partial fibulectomy is an effective intervention in the management of delayed union in isolated tibia fracture.

389-393

Authors: Dhammapal S. Bhamare, Abhijeet Shroff, Rahul Madhukar Salunkhe, Sumeet Kumar, Sanjay Deo.

Introduction: Diaphyseal fractures of forearm in children and adolescent are extremely common and there are various treatment modalities available for the same. The aim of the study is to assess the outcome of different techniques in management of non-physeal forearm fractures in children and adolescents, to demonstrate the efficacy and complications of open method and to explore the outline of the demographic data of diaphyseal forearm fractures occurring in children and adolescent. Materials and Methods: 50 patients of age group between 1-15 years were included and were treated and assessed with casting, plating or nailing according to various indications between July 2015 to September 2016. Results: 29 patients were treated with casting, 18 with nailing and 3 with plating. 4 patients failed to follow up after discharge from hospital. Duration of hospital stay, operative time and rate of union were statistically significant in the various groups. Final results analysed by Price et al criteria were statistically not significant. Conclusion: Closed reduction and casting yield excellent to good results and if satisfactory alignment is not achieved, surgeon should proceed for operative treatment. Nailing fixation of an unstable forearm fractures in skeletally immature patients allows early functional treatment with an excellent functional and cosmetic outcome in comparison to plate osteosynthesis. However, studies with larger population and longer follow up period are required for further analysis.

398-401

Authors: Vinod Nair, Prafulla Herode, Amit Chaudhary, Clevio Desouza, Kartikeya Sharma

Introduction: Intraarticular fractures of Calcaneum are not uncommon. Among the tarsal bones calcaneus is most frequently fractured. Calcaneal fractures account for 60% of tarsal bone injuries and 2% of all fractures. Axial loading is most common mode of injury, fall from height causing bilateral calcaneal fractures. Other fractures associated with fall from height have to be excluded such as pelvic and spinal fractures. Material and Methods: This is a prospective study of 20 patients with displaced intraarticular fractures (Type–II Sanders and above) of calcaneum, which were admitted to the hospital and operated with plating and bonegrafting through extensile lateral approach, between September 2013 and February 2016. Result: A total of 20 calcaneal fractures in 24 patients were randomly selected treated by plating for example locking calcaneal plate. Among the 20, there was predominance of right sided fractures. Discussion: Open reduction and internal fixation of displaced intra-articular calcaneal fractures by locking calcaneal plate maintains the joint congruity and decrease the incidence of subtalar arthritis. Although, conservative treatment was considered gold standard previously, there is increase tendency towards internal fixation with excellent results. Surgery for calcaneus fractures should be delayed, ideally for 10-14 days, in the presence of significant edema or fracture blister formation. Conclusion: Based on our small study and results, we conclude that open reduction and internal fixation with locking calcaneal plate is excellent treatment option with good post operative outcome for displaced fracture of calcaneum, as serious complications are not significant.

405-407

Authors: Surath Amarnath, Surath Harsha Vardhan, Mettu Rami Reddy, I. V. Renuka

Introduction: Gout is a disorder of purine metabolism manifested by high serum uric acid levels, recurrent attacks of acute arthritis and deposition of monosodium urate crystals within and around the joints. Peri articular nodules are a challenge to both clinicians and diagnosticians especially if the nodules are large. Case presentation: A 34 year old male patient presented to the orthopedic clinic with a large localized progressive swelling in the region of the first Metatarsophalangeal joint of foot. Magnetic resonance imaging (MRI) revealed a large well-marginated lobulated, diffuse soft mass lesion around the 1st Metatarsophalangeal joint with encasement of surrounding tendons. The differential diagnoses given were synovial sarcoma, giant cell tumor and Pigmented Villonodular synovitis. Excision biopsy was done and histopathology revealed a classical picture of gouty tophus. Subsequently blood chemistry was done and showed marked hyperuricemia (7.8mg/dl). Conclusion: We present a case of gouty tophus masquerading as a soft tissue sarcoma. This case report serves to bring about awareness of an uncommon presentation of a common disease. Extraordinary presentations of gout, in its severe form can mimic a soft tissue tumor.