Indian Journal of Orthopaedics Surgery

221-224

Authors: Anil Nayak,Zulfikar Patel,Hriday Acharya*,Dhaval Devani

Introduction: Long bone fracture of forearm is common skeletal injury. The most common causes of such injuries include road traffic accident, fall or direct trauma, amongst the various types of forearm fractures, both-bone diaphyseal forearm fractures in adults are frequently met by the orthopaedic doctors. There are various methods available for fixation of both bone diaphysial fractures like both bone plate fixation, both bone intramedullary nailing and hybrid method with nailing in one of the bones and plating in other. Our aim of the study is which method of fixation is most clinically justifiable in both bone diaphysial fractures amongst all the available choices. Materials and Methods: This is a retrospective study of 200 cases of diaphyseal fractures of radius ulna selected randomly over a period two year from March 2016 to March 2018 conducted at civil hospital Ahmedabad. All patients were followed up for a period 6 months post operatively. Result and Conclusion: After studying result of all four method of fixation hybrid fixation showed good union rate, less chance of infection, less chance of malunion and non union,relatively good stability, less incidence of swelling and better recovery with a less chance of implant removal incidence and failure.

230-233

Authors: Nitin Wale,S Phuljhele,Atin Kundu*,Rajat Banchhor

Introduction: Intertrochanteric hip fractures are common with advancing age. PFN is now increasingly used to fix unstable intertrochantric fractures however it does not fix greater trochanter. Gluteus medius and gluteus minimus attach to greater trochanter, hence abductor weakness is a likely consequence. In this study we measured the incidence of post operative abductor weakness (trendelenberg gait) and result of targeted physiotherapy on it. Materials and Methods: Between September 2014 and august 2016, 45 patients with unstable intertrochanteric fractures underwent proximal femoral nailing in the Department of Orthopaedics Pt. J. N. M Medical College and Dr. B.R.A.M Hospital, Raipur (C.G.). The patients included in this study were more than 18 years of age with unstable fractures classified according to Modified Evans classification type 3, 4 and 5 with the duration of trauma less than 3 weeks. The functional assessment was made using Mckay criteria through analysis of abductor muscle strength. Result: Immediate Postoperative muscle power was Grade 1 (02 pt.), Grade 2 (27 pt.), and Grade 3 (14 pt.). At 6 months follow up only 02 patients had grade 4 power (due to varus malunion) rest all had muscle power Grade 5. In this study we found that only 2 out of 45 patients (4.4%) had initial abductor power grade 1, grade 2 -64.4% and rest had grade 3 muscle power. Only 2 patient (due to varus malunion) had grade 4 power at 6 months follow-up rest all patients regained power grade 5. Conclusion: Abductor weakness and trendelenberg gait are fairly common in patients treated with PFN and this complaint is often overlooked. Abductor muscle power should be properly assessed post-operatively and physiotherapy for abductor weakness is essential for complete rehabilitation of patients.

240-244

Authors: Gaurav Pawar,Nilesh Darawade*,Yogesh R. Gaikwad

Introduction: The treatment of paediatric femoral fractures has been evolving from nonoperative modalities to operative intervention, especially in older children. Different methods of fixation include flexible intramedullary nailing, modified locked intramedullary nailing, external fixation, open compression plating, and sub muscular bridge plating. Treatment of complex paediatric femur diaphyseal fractures is difficult by conventional methods. External ?xation can lead to malalignment and refractures, casting is difficult for polytrauma patients and larger children, elastic nails do not provide adequate stability to unstable fractures and metaphyseal areas, and lateral trochanteric entry rigid nails are unsuitable for very proximal and distal fragments and are ideal for older children for the want of larger medullary canal. Sub muscular bridge plating has emerged as a viable alternative procedure. We present our results of sub muscular bridge plating in 12 patients. Materials and Methods: We retrospectively reviewed 12 patients with pediatric diaphyseal femoral fractures treated with SBP from 2014 to 2016. The average age was 9 years with follow up of 1yr. Results: All the children had complete union and could return to full activity. Two patients had superficial infections. There were no cases of significant malalignment or leg length discrepancy. Implant removal was performed in 8 patients without complications. Conclusion: We find sub muscular plating of paediatric femoral fractures to be an effective and reliable procedure. SBP is a minimally invasive technique that allows early mobilization with minimal complications.

249-255

Authors: Keshav Goel*,D K. Taneja

Objectives: Comparison of operative management and functional outcome of femoral intertrochanteric fractures by dynamic hip screw v/s proximal femoral nail implants. Materials and Methods: During 2013 to 2016, 50 patients with intertrochanteric femur fracture were prospectively studied. Fractures included were AO type 31 A1 & A2. 25 patients each were taken in two groups DHS & PFN. These groups were compared for functional outcomes based on parameters: Harris hip score, operative time, radiation exposure, blood loss and postoperative rate of union. Results: The age group in both groups was comparable with mean of 72.9 years. Domestic fall was found to be the most common cause of intertrochanteric fracture femur. Among the patients, 12 had A1 type fracture while 38 of them had A2 type fracture. PFN had the mean blood loss of 111.8ml as compared to 325.6 ml in DHS group. Radiation exposure was greater in PFN than DHS surgery. PFN had the mean operating time of 116.4 min and DHS had 106.4 min. Among the DHS treated group one case had superficial infection while two cases went into non union. Of the PFN treated group Z effect was observed in one case. Although the PFN treated patients showed a better Harris Hip Score on the initial 3 month follow up, both the implants DHS & PFN had a similar functional outcome on long term follow up. Conclusion: Any patient with intertrochanteric femur fracture AO type 31A1 & A2 treated with good surgical skill and reduction of fracture was achieved has similar results with DHS or PFN.

264-269

Authors: Ejajahmed Ansari,Parag M. Tank*,Rajesh V. Chawda,Vijay J. Patel,Nimish B. Patel

Introduction: Distal radius reconstruction every time needs aggressive operative intervention is still a debate among researchers and upper extremity surgeons. There is a role of nonoperative treatment in geriatric population and unfit patients. Novel techniques and revolution of implants advocated the best clinical outcome. Materials and Methods: We conducted a prospective study of 25 patients having AO OTA type A, B & C distal radius fractures treated with volar locking plate at our institute between 2015 to 2017. We include all close injuries in skeletally mature patients between ages 20-60 years. Outcome of the study was evaluated by using the Gartland and Werley score modified by Sarmiento & Patient Rated Wrist Evaluation (PRWE) score. Results: 6 patients had AO OTA type A, 11 patients had type B and 8 patients had type C fractures. Mean palmar flexion was 77 degrees. Dorsi flexion was 82 degrees observed. Average supination and pronation were 85 & 80 degrees respectively. Radial & ulnar deviations average 11 and 25 degrees were observed. 80% of the patients had loss of radial inclination less than 9 degrees. All the patients had less than 6 mm radial shortening. Loss of palmar tilt less than 6 degrees was observed. More than 90% of the patients had excellent to good outcome based on Gartland and Werley score. Conclusions: Volar plating is a proven method of choice in majority of distal end radius fractures regardless of comminution and fragments separation.

273-281

Authors: Shashikant B. Ganjale*

Introduction: Most of the hip fractures are managed in supine position on a fracture table with foot attached to foot plates and biplanar fluoroscopy supervision under c-arm. But this procedure has its own difficulties in managing especially comminuted subtrochanteric fractures, where in different fragments and segments are being pulled by strong muscles around hip, and getting good reduction and alignment is difficult due to displaced bony fragments being held in traction on fracture table and cannot be manipulated easily. This leads to prolonged operative time, opening of fracture site, increased bleeding, increased chances of infection and over all increased anaesthesia time adding up to risk factors. The purpose of this study was to report how these difficulties can be overcome by operating on a simple radioluscent top operating table in lateral position without a fracture table. Materials and Methods: 74 cases of subtrochanteric fractures with or without comminution were operated in lateral position on simple ordinary radioluscent top table with lesser attachments and adjustments to operating table during the study duration were included in the study. We used long Proximal Femur Nail (PFN) (length more than 25cms 34, 36, 38, 40cms long) to fix these fractures. Results: In the present study, age group of patients was 25yrs to 74yrs. Male patients (83.7%) were more than female patients (16.3%) An average of less than 150 ml in closed surgery. The average operative time for all cases was 80 minutes. Union time varied from 16 weeks in simple fractures to 26 weeks in comminuted fractures. Clinical function of hip and knee was excellent with full range of movements. Conclusions: Reduction and fixation of proximal femoral fractures in the lateral position with fluoroscopy or portable radiography in the anteroposterior view for small set ups and rural hospitals that lack a fracture table or advanced fluoroscopic devices may be executable and probably safe.

286-289

Authors: Vijay C*,Ravikiran HG,Sumit Raj

Introduction: Intracapsular fracture of neck femur usually present with severe swelling, difficulty in walking reduced length of affected limb. The most common Risk factors are old age, osteoporosis, taking excessive medications, alcohol, smoking and cancer. Diagnosis can be done by using X-rays, CT scan and MRI. Materials and Methods: It is a prospective study consists of all the patients admitted to JSS hospital with intracapsular fracture neck femur treated with unipolar or bipolar endoprosthesis. Results: The selected patients were randomized and divided into two groups, Group one (I) and Group two (II). Patients were suction tube is used are categorized into Group I and in those were suction tube is not used are categorized into Group II. These two groups were studied and observed for the following, fall in haemoglobin and PCV at 48 hours post-operatively. Complications are Persistent discharge, serous discharge from the wound for more than 10 days. Discussion: When the doctors are in doubt, then they need to insert a drain was countered by Halsted (1898). Now days in orthopedic cases, closed suction drains are being commonly used to decrease the complications. Blood accumulation in and around the tissue site will raise the tissue tension and thereby reduces tissue perfusion in and around the surgical wound site. Conclusion: We consider that there is ample evidence that closed suction drains is of no benefit in primary uncomplicated hemiarthroplasty. The advantage of the drains in orthopaedic surgeries should be debated as non use of drains drastically reduces anemia and requirement of blood transfusion after surgery. In a developing and under-developing countries, the cost increases because of the blood transfusion needs and costs of drain device which will outweigh any advantages of putting a drain.

296-301

Authors: N Selvam*,Raju Babu Rapeta

Introduction: Cause of chronic low back pain in persons over the age of 50 years include degenerative diseases like osteoarthritis of spine and spinal canal stenosis. Osteoarthritis of spine is a degenerative process19-30 identified radiologically by joint space reduction, marginal osteophytes and sub-chondral sclerosis. Nathan et al3 classified significantly osteophyte positive if more than SIX osteophytes are found from L1 / L2 to L5 /S1 vertebrae in the lumbar spine X-rays. Serum beta carotene is a carotenoid, which has anti-oxidant effect35-37 by increasing Glutathione levels in cells. Normal serum beta carotene level ranges from 0.74 nmol/ml to 3.72 nmols/ml. Based on literature, higher serum beta carotene levels are shown to halt the progression of many diseases including cardiac diseases 38,39 and degenerative changes in knee joint. But so far only a single study is available to co-relate the levels of serum beta carotene and lumbar spine osteophytes. Hence this study was done. Materials and Methods: This study was conducted at JIPMER, Pondicherry, from August 2015 to March 2017. It was conducted as OP procedure. 153 patients of over 50 years of year who complained of low back pain of more than 3 months duration were selected. Their personal history regarding alcohol drinking and smoking noted. Radiographs of lumbar spine A.P. and lateral views were taken. They were divided into osteophyte positive or negative as defined by Nathan.3 These patients’ serum beta carotene levels were assessed. The level of serum beta carotene and its relationship with lumbar spine osteophyte formation was analysed. Results: Females predominated study 67% of patients were osteophyte negative and 33% were positive. 74% of osteophyte positive patients had serum beta carotene less than 0.7 nmol/ml and 26% had more than that. But, nearly all 98% of osteophyte negative had more than 0.7 nmol/ml of serum beta carotene, showing that the lumbar osteophyte formation is inversely proportional to the level of serum beta carotene levels. Our statistics also showed that there is a strong association between alcohol consumptions and smoking with lumbar osteophyte formation. Conclusion: Our study showed that low serum beta carotene levels predisposed and increased lumbar osteophyte formation. It also showed strong association between Alcohol consumption and Tobacco use with lumbar osteophyte formation.

306-309

Authors: Sainath K Andola,Saara Neeha*,Anita A Mahanta

Introduction: Desmoplastic fibroma is an extremely rare, locally aggressive, benign bone tumour with incidence of 0.1% of primary bone tumors. It is composed of spindle cells with minimal cytological atypia and abundant collagen. Diagnosis is made on radiology and histopathology. Case Summary: A 17yr female patient presented with pain and swelling in left forearm since 9yrs, slowly progressive in nature. Radiograph showed an osteolytic lesion of the proximal ulna. En-bloc excision was done. Grossly the tumor was 13x6x2.5cm, hard in consistency with grey-white mass on cut section. Microscopically it was composed of spindle shaped cells with elongated bland appearing nuclei arranged in whorled pattern and fascicles with abundant collagen present between spindle cells. No pleomorphism or mitoses were noted. Conclusion: Desmpoplastic fibroma is a very rare locally aggressive benign neoplasm of bone. The diagnosis and management are often difficult and requires a combined speciality approach.