Indian Journal of Orthopaedics Surgery

Page No. 6-11

Authors: Arpit Tiwari, Piyush Rajesh, RS Saluja

Background and Objectives: 107 Metacarpal fractures in 81 patients were treated in Index Hospital, Indore from January 2015 to June 2016, with the objective of studying clinically and radiologically, the incidence, mechanism of injury, types of fracture and various treatment aspects. Results were compared to assess the efficacy of different treatment modalities and compare their functional outcomes of the metacarpal fractures of hand. Materials and Methods: 107 metacarpal fractures in 81 patients were enrolled from January 2015 to June 2016. The treatment modalities were broadly categorized into two groups, Group A consisted of conservative treatment, and Group B consisted of surgical treatment. Group A included 38 fractures treated with cock-up splint (n=33) and thumb spica(n=5), while 69 fractures were treated in Group B, which included closed or open reduction (OR) and internal fixation (IF) with K-wires (n=52), OR and IF with miniplate and screws (n=17). Total active range of motion as Suggested by the American society for surgery of hand and Gingrass’s criteria were used for functional assessment and to assess the efficacy of conservative and surgical modalities for metacarpal fractures of the hand. Results: Final evaluation of the patients done at the end of three months. The excellent to good results seen in Group A and B were 76.3% and 89.9%, respectively. Six Complications were seen in Group A, which included four cases with malunion and two cases with stiffness. Four complications were seen in Group B, which included two cases with stiffness and one each of pin tract infection and operative wound infection. Conclusion: Conservative treatment is an inexpensive method, particularly suitable for stable fractures, and in patients who are poor candidates for surgery. Surgical modalities have distinct advantage of stable fixation but with added risk of stiffness. Both conservative and Surgical modalities have good efficacy when used judiciously, Single fractures have shown better grade of total active range of motion compared to multiple fractures. Treatment objective may be compromised if post-treatment physiotherapy and rehabilitation using systemic protocol is not followed.

Page No. 18-22

Authors: Lamture Deepak R, Burande VG

Introduction: Non-union is a serious complication of fracture. Management of non-union has remained a constant challenge. The associated bone defect, shortening, deformity and infection complicate the management. Present study was designed to assess the utility of various available modalities of treatment for non-union in long bones. Material and Methods: 59 patients of non-union of long bones admitted in orthopaedic ward during the period of January 2009 to 2011 were included in a prospective study. Maximum patients 25 (45.45%) were having non-union of tibia followed by femur seen in 12 (21.81%). Detailed history, clinical and radiological examination was conducted. Diagnosis was confirmed and suitable plan of treatment was formulated and undertaken. Results: Results were excellent to good in 59.24% of cases, satisfactory in 37% and poor in 3.7% of cases. Conclusion: Incidence of non-union is increasing gradually. Two commonest bones involved are tibia and femur. Open reduction and internal fixation after freshening of bone ends and autologous bone grafting is the commonest mode of treatment in non-union management.

Page No. 27-30

Authors: Lokesh Gudda Naik, Krishna Sudhakar Badgire, Gaurav Mahesh Sharma, Faisal Qureshi

Introduction: Peritrochanteric fractures comprise of fractures of trochanter, subtrochanteric region and basi-cervical fractures and are the commonest fractures encountered. Patients with unstable intertrochanteric fractures need immediate mobilization to avoid serious complications. Material and Methods: 43 patients with unstable intertrochanteric fractures were randomized and operated using the cemented bipolar prosthesis between September 2011 and August 2013. The inclusion criteria were patients more than 65 years of age, unstable intertrochanteric fracture (Type III and type IV as per Evans classification). Patients with polytrauma and medically unfit patients were excluded from the study. Results: Mean age was 76.65± 5.48 years. The most common mechanism of injury was domestic fall comprising of 87%. The average duration of surgery from the time of injury was 3.5±1.3 days. The average surgical duration was 03.5 mins. The average duration of stay in hospital was 8.4±1.68 days. Final results were calculated using the Harris Hip score with 97% cases as excellent and good while 3% had fair results respectively. Follow-up was done at 1, 3, 6, 12 and 24 months. Conclusion: Cemented bipolar hemiarthroplasty in unstable intertrochanteric fractures has an advantage of stable adequate fixation with early return to activities of daily living, thus preventing serious life threatening complications.

Page No. 36-42

Authors: Rohit Bhandari, Ratnakar Ambade, NS Dhaniwala, Sanjay Deshpande, Pradeep K. Singh

Background: Conservatively treated fractures of the humeral diaphysis have a high rate of union with good functional results. The aim of the current study was to study the outcome of diaphyseal fractures of humerus treated with functional brace. Materials and Methods: Twenty Seven diaphyseal fractures of humerus were included in this study. The functional brace was applied after the swelling subsided under image intensifier. Bracing was continued for a longer or shorter duration based on each individuals’ clinical and radiological finding and progress of healing. Patients were instructed in the performance of pendulum exercises immediately after the application of the initial cast or splint, and the exercises were continued after brace application. Results: Total 27 patients of mean age 34.14 years, were treated with functional brace. The mean union time was 11.23 weeks. 96.3% patients had union and satisfactory functional results. 3.7% had non-union. The average varus- valgus deformity was 9.3 degrees in our study. The average Antero Posterior deformity was of 6.33 degrees. Average shortening was of 5.55 mm. The brace was removed at an average period of 11.23 weeks. 92.59% patients had near normal – shoulder and elbow range of motion. Conclusion: The treatment of diaphyseal fracture of humerus with functional brace gives credence to our long-held hypothesis that micro motion at the fracture site is an important factor in osteogenesis. The final angular deviations are cosmetically and functionally acceptable. It remains the treatment of choice, as it offers high union rate and good functional results.

Page No. 46-53

Authors: Mahesh Kumar NB, Ullas Mahesh, Santosh Kumar

Background & objectives: In elderly, the Intertrochanteric fractures are one of the most common fractures of the hip out of which more than 50% are unstable. Internal fixation is optimal for it fractures which are very challenging. Evolution of intramedullary devices is a result of dissatisfaction with the extra medullary devices in it unstable fractures our main aim was to compare the effectiveness & drawbacks of short Pfn vs long Pfn in the management of It fractures Materials and methods: This study was randomised, time bound, hospital based study conducted in a tertiary hospital, between Sept 2013- Sept 2015. The study included 40cases of unstable it fractures of Group A were operated with short PFN which fitted into the inclusion criteria & group B patients were operated with long Pfn, intraoperative parameters post-operative data & events were noted. Radiological assessment for progression & time of union, fracture alignment & implant related complications were analysed. All patients were accessed in immediate post op, 12 days, 1 month, 3months, 6months & at 1 year with Harris hip score. After data collection, data entry was done in excel worksheet. Data analysis was done with help of SPSS software version 23. Result: In our study the most common case of IT fracture was a trauma following a fall seen in 57 cases of the 80 cases studied accounting for 71% of the cause of injury, the mean intraoperative blood loss in the long Pfn group was 344.5 ml & the short PFN group was 133.5 ml, P value equals 0.0001 this difference is considered statistically significant. The quality of reduction in the short PFN group was significantly lesser than the long PFN group. The post operative complication in the short PFN group was significantly lesser than the long PFN group. The number of cases with limb shortening were more in the short PFN group than the patients in whom long PFN was used. The mean time of union in the short PFN group was 10.05 weeks and the long PFN group was 21.10 weeks. The two- tailed P value equals 0.0217 by conventional criteria, this difference is considered to be statistically significant. The mean lower extremity functionally scale. In the short PFN group was 63.95 & the long PFN group was 67.50. The two tailed P value equals 0.0114 statistically significant. Interpretation & conclusion: Short Proximal Femoral Nail provides good fixation for unstable IT fractures, if proper preoperative planning , good reduction & surgical technique are followed , leading to high rate of bone union & soft tissue damage especially for Asian patients with relatively small femora.

Page No. 59-61

Authors: Madhukar KT, Harsh Tiwari, Cheemala Vikram

Missed injuries is defined as an injury found after the initial complete patient assessment and diagnostic studies that was directly related to the traumatic event and was identified after first 24 hours following admission. Even though not frequently life-threatening, they may result in significant long-term disability. The aim of this study was to define the incidence of missed orthopaedic injury for adult major trauma patients and to examine the details of missed injuries in order to identify and make comment on potential risk factors for missed injury. 671 admissions in orthopaedics indoor patients in a rural tertiary care centre for the period of 10 months from 1st January 2016 to 31st October 2016 were included for study. 18 patients were identified with delayed diagnoses of the injury. Patients with a decreased level of consciousness or head injury, with intubation/sedation or with alcohol or drug intoxication are unable to give a good history, cooperate with physical exam or identify sources of pain are the main risk factors for missed injuries. Other factors for missing an injury include Inadequate Clinical Assessment, Misinterpretation of Studies and Late Presentation of Observable Findings. Repeated assessments, both clinical and radiological, are mandatory to diminish this problem. In initial evaluation, one still has to treat the greatest threat to life before complete diagnosis of all injuries, but alertness to evolving injuries must remain in mind throughout the patient’s hospital stay.

Page No. 69-72

Authors: Ravikumar TV, Sathish Kumar T, Vinay Jain K, Mahesh M

Study Design: Prospective longitudinal study Objective: The aim of our study article was to find the factors related to successful outcomes with clinical factors like level, side of disc herniation and type of herniation in patients undergoing the microscopic discectomy. Methods: One hundred and seven patients between the ages of 20 years to 45 years, who have undergone single-level lumbar micro discectomy in our institution, operated by a single surgeon were taken in to the study and were followed prospectively for 2-years period. Patients with failed conservative management either with rest, physical therapy and epidural/transforaminal steroid infiltration were included with in the age group of 20-45 years. Pre and Postsurgical visual analog scale, pre and post Prolo score, patient satisfaction and return to duty along with the need of additional surgery and neurological recovery were noted in relation with the level of the disc herniation, side of disc herniation and the type of disc herniation stenosis. Results: Patients with L5-S1 Disc herniation had better Visual Analog Scale score compared to L4-L5 level. Sequestered disc herniation had better clinical outcomes than other types. Patients with L5-S1 Disc herniation had better Visual Analog Scale score compared to L4-L5 level. Sequestered disc herniation had better clinical outcome compared to contained discs. During the final follow up, patient’s return to unrestricted duty was seen in 85%, 10% in restricted duty and 5% have changed their previous profession. Conclusion: Microscopic discectomy is a well-known procedure for the lumbar disc herniations and one of the most common spinal procedure performed in today’s world. Patients with L5-S1 disc herniation had better Visual Analog Scale score and Prolo score compared to L4-L5 level. Sequestered disc herniation had better clinical outcomes. Patient with left side disc herniation had better outcomes and lesser complication rates. This factor might be due to predominant right handedness with better instrument guidance and root retraction during the surgical procedure.

Page No. 78-83

Authors: Mayank Patel, Jayant Sharma, Sunil Jakhar

Introduction: Comminuted of articular surfaces and metaphyseal region, extensive soft tissue injuries, infection and risk of compartment syndrome are the challenging factor for management of proximal bicondylar Tibial fractures. Various modalities like cast, traction or open reduction and internal fixation using single to dual plating available for treating such type of fractures. We study the results of dual locking plate and buttress plating in management of proximal Tibial Schatzker V and VI tibial plateau fracture by using minimally invasive surgical technique. Method: The study was conducted on 30 patients admitted in the department of orthopaedics at Unique super specialty centre, Indore with diagnoses of Tibial plateau fractures (Schatzker classification type 5 and 6) treated with minimally invasive bicondylar fixation. The patients were followed up for a minimum period of six months and clinical and radiological progression of fracture union with the functional outcome was studied by using knee society score. Result: 2 patients out of 30 were lost follow up and 20 patients showed excellent results while 8 patients had good to fair and none with poor result. The average time for radiological union was 12 weeks. Conclusion: The results of the study concluded that by using minimal invasive technique of bi condylar fracture fixation are excellent without any major complication

Page No. 87-92

Authors: Neelanagowda V.P. Patil, Anand Patil, Shankar H. Bellad, Rahul Uttamrao Kamble, Veereshpattan Shetty

Background: Supracondylar fractures of humerus is one of the most common injuries in children. It requires great attention while treating as it is associated with neuro-vascular complications pre-operatively and intra-operatively. The aim of this study was to compare the functional outcomes of closed reduction and open reduction with cross-pinning percutaneous fixation in Gartland Type II and III supracondylar humeral fracture extension type. Methods: In this prospective study, 120 children with type II and type III Gartland fracture extension type were treated with percutaneous k-wire fixation, between July 2009 to March 2016. 62 cases treated with closed reduction with cross pinning which formed group A and open reduction with cross pinning fixation were performed in 58 patients which formed group B. Result: According to the Flynn’s criteria group A showed 96.8% of satisfactory results and group B showed 96.6% of satisfactory results. The duration of surgery in group A was on an average 20 minutes (16 to 24 minutes) and in group B was on an average 39 minutes (35-45 minutes). There were 6 cases (10.34%) of delayed wound healing in Group B which were due to the soft tissue edema. There was 1 case of ulnar nerve neuropraxia in group A. We did not come across any case of pin tract infection. Conclusion: Supracondylar fractures in children are difficult to treat because of its associated complications in fracture reduction. Various studies are there with different methods of fixation done for this fracture, but there is no clear consensus regarding the ideal treatment. In our study with open versus closed pinning for supracondylar fracture, we found no significant difference in final functional outcome after the study.

Page No. 100-104

Authors: Mukesh Kumar, Vinod Padmanabhan

Aims & Objectives: To know the functional outcome of Primary TKR in Severe fixed flexion deformity of knee compared with TKR in knees without fixed flexion deformity (FFD). Materials & Methods: This is a prospective study of the patients with severe flexion deformity and without FFD of knees underwent primary TKR between 2009-2014. Total of 45 knees were taken for the study with 22 with FFD of more than 30 degree and 23 were without FFD which were kept as a control. This study includes both inflammatory and non-inflammatory arthritis. Results: Primary TKR in FFD - Average FFD was 46 degree, Pre-operative average KSS-pain score was 28 and functional score was 12, post operatively KSS pain score was 83.2 and function score was 78.3. There was significant difference in pain score and patient’s satisfaction in patients with inflammatory arthritis (though the number were less) than non-inflammatory arthritis. The postoperative KSS- pain and functional score, in patients with no FFD was comparable with patients with FFD and there was no significant difference. Conclusion: Patients with severe FFD knees perform same as patients with knees without FFD. Finally, patient with severe FFD and Inflammatory arthritis are happier than patient without FFD knees in midterm follow up. Level of Evidence: II

Page No. 108-110

Authors: Shuaib Ahmed, Prashant Acharya, Arjun Naik, Terence D’souza

Introduction: Chronic foot pain and swelling can pose difficulty in arriving at a diagnosis and appropriate treatment often resulting in inferior outcome. Materials and methods: A 45 year patient with chronic foot pain was evaluated clinically and underwent blood investigations which showed elevated serum uric acid levels (9.1mg/dl). Ankle plain radiograph showed arthritic changes. All of these were pointing towards a differential diagnosis. Synovial biopsy report showed chronic gouty arthritis of foot. Discussion: Chronic midfoot pain and swelling being a diagnostic dilemma must have a panel of differential diagnoses before arriving at a provisional diagnosis. Conclusion: Having known the unusual presentations of gout a thorough evaluation of patient presenting with chronic midfoot pain and swelling should be done