Indian Journal of Orthopaedics Surgery

211-214

Authors: Mukesh Tiwari, Vikram Khanna, Gaurav Maddhesia, Ishan Ghuse

Introduction: Painful shoulder syndrome is also called periarthritis humeroscapularis or PHS syndrome. The shoulder is the most mobile joint, pain and reduced function may be seen because of different inflammatory and degenerative changes in soft tissues of the shoulder. It is most common musculoskeletal disorder after low back pain and cervical pain. Many approaches have been used in the treatment of periarthritis shoulder pain, including local heat, cryotherapy, transcutaneous eletrical nerve stimulation (TENS), short wave therapy (SWD), manipulation under anaethesia, acupuncture and exercise. The purpose of this study is to compare the effectiveness of TENS and SWD in decrease pain and improvement in function in Periarthritis shoulder. Methodology: A total of 40 patients coming in the year 2014 to the outpatient department with a confirmed diagnosis of periarthritis shoulder were included in this study. Two groups of 20 patients each were made. Group A: received SWD and Exercise therapy, whereas Group B received TENS and exercise therapy. Both the group of patients were assessed using the VAS scoring for pain and the Likert’s scale for the functional outcome. Result: Pain improved significantly in both the groups with more pain relief seen in group B as compared to group A. The functionality which was calculated using the Likert’s scale showed significant improvement in both the groups with slightly more increase in the functionality in group A as compared to group B. Discussion: The long term benefits are better achieved with the SWD as compared to the TENS whereas immediate pain relief is achieved with TENS much better than the SWD. Though this cannot be confirmed as firstly the sample size is very small and also a longer follow up may be required to assess long term functional outcome of both the treatment modalities. Conclusion: This study concludes by accepting the alternate hypothesis that is application of TENS treatment along with exercise therapy will improve function and pain relief as compared to SWD therapy. Whereas long term functional result is better with SWD.

221-225

Authors: Vinay N, Rahul Kumar.

Introduction: There is no consensual agreement on the strict clinical or radiographic criteria for defining a flatfoot. Traditionally, a flatfoot has been defined subjectively as a weight-bearing foot with an abnormally low or absent longitudinal arch. This definition is based solely upon the static anatomic comparison of the height of the arch within a population. It fails to take into consideration the etiology of the flatfoot, the functional relationships between the bones, and the presence or evidence-based expectation of future pain or disability. Methodology: All patients in the study were evaluated thoroughly using detailed history and complete physical examination with special emphasis on weight, family history, findings like tight tendoachilles, ligamentous laxity, intermalleolar distance and gait analysis. The examination included biomechanical examination of hip, knee, foot and ankle. Associated conditions were also given importance to rule out any syndromic flat foot. Results: The younger the age group the better they respond to orthotic treatment. More severe the deformity the better they respond to orthotic treatment. Symptomatic fff have better results than asymptomatic fff. Early the orthotic treatment received better is the result. Arch support helps in relieving clinical features like pain and out toeing. Conclusion: Arch index may help in improvement of radiographical angles like cp, tca and tma. There is no short term and long term complications related to using of arch support.

231-235

Authors: Sriram Thanigai T, Deviprasad S, Sathik Babu M B, Pradeep E

Introduction: Ligamentous injuries of the ankle are very commonly encountered in orthopaedic practice and 40% of these injuries constitute the Anterior Talo-Fibuar ligament (ATFL) injuries. It is the weakest of the lateral ligaments. Unless there is significant joint instability, surgery is rarely indicated in the treatment of isolated ATFL injuries. Our study focused on the assessment of the long term outcome of isolated ATFL injuries treated by conservatively. Material and Methods: We included 20 patients who presented to us with isolated ATFL injury from January 2015 to march 2015 for this prospective study. The diagnosis was confirmed with an MRI. 12(60%) patients were grade II and 8 (40%) patients were grade III. All the patients were conservatively treated with the POLICE protocol and weight-bearing was advised as tolerated but strictly with a proper ankle support. Patients were followed up at the end of 1st week, 2nd week, 1 month,3rd month and at 6 months. Patients were evaluated with a Visual Analog Scale (VAS) and the Foot and Ankle Outcome score (FAOS). Results: There was statistically significant improvement in the VAS and FAOS scores. From the pre-treatment scores of 9.1 and 53, they improved to 1.4 and 91 respectively at the final follow-up. Conclusion: From our prospective study, we conclude that conservative management of isolated ATFL injuries is a safe and effective method of treatment.

241-250

Authors: Satyendra Phuljhele, Rajendra Kumar Ahire, Harshal Sakale

Introduction: This paper determines if Osteosynthesis or Prosthesis replacement should be the treatment of choice, in active elderly patient with unstable intracapsular neck femur fracture. Material and Methods: A prospective analysis of the results of 46 patients that were performed in Pt. J.N.M. Medical College and associated Dr. B.R.A.M. Hospital Raipur (C.G.) over a period of 2 year was undertaken. The minimum period of follow-up was 2 years. Results: Out of these 46, 31 patients were treated with internal fixation (Richard’s compressive hip screw with supplementary cancellous screw fixation) and 15 patients were treated with Hemiarthroplasty (Austin Moore Unipolar Endoprosthesis). Overall, the average age of patients was 62.5 years. The mean age for internal fixation was 59 years and that of Hemiarthroplasty was 66 years. 61% of the patients were between 55-65 years of age group. Overall 29 patient (63%) were male and 17 patient were female (37%).Union occurred in 89% of cases in internal fixation. Overall, the functional outcome in internal fixation group was satisfactory with excellent/ good result found in 78% of cases, while in Hemiarthroplasty group it was 63%. Osteosynthesis group has less complication rate like pain, infection, fracture of shaft of femur, shortening and mortality than Hemiarthroplasty group. Conclusion: Osteosynthesis is justified as a primary treatment of intracapsular hip fracture even in displaced type in active elderly patient aged 55-65 years. Prosthesis replacement should be used in cases where neck is absorbed, in failed Osteosynthesis and in Non-union.

255-260

Authors: Choudhari Pradeep, Agrawal Anuj, Gurjar Abhishek

Introduction: Unstable intertrochanteric fractures in osteoporotic bones are difficult to treat. Conservative treatment with traction and prolonged immobilization lands up with many complications and often fatality. Rate of failure in internal fixation, with dynamic hip screws or intramedullary nail has been found high, especially in osteoporotic bones. The weak and porotic bone tolerates screws poorly so cut out is the major problem in internal fixation. The aim of this study was to assess the efficacy of cemented hemiarthroplasty in the management of proximal femoral fractures in elderly patients with severe osteoporosis. Material and Methods: 25 patients (11 males and 14 females) above 65 years of age with unstable intertrochanteric fractures who underwent bipolar arthroplasty were prospectively evaluated. Transtrochanteric approach was used in all patients. Greater trochanter encirclage was done in all patients. Harris hip score was used for the clinical evaluation. The minimum follow up period was one year. Results: In our study 25 cases were taken, which had a mean age 73.44 ± 7.11years. The mean Harris hip score at one year was 80.54 ± 19.74. Excellent to good results were obtained at one year in 17(68%) cases and fair in 4 (16%) cases, poor in 2 (8%). Death of two patients occurs due to age related factors. Mean hospital stay was 14.24 ± 10.46 days. There was one case of superficial infection and one case of dislocation which where managed conservatively. Mean hospital stay was 14.24 ± 10.46. Radiological follow-up showed no case with loosening of the prosthesis, break in the cement or sinking of the prosthesis. Conclusion: Cemented bipolar hemiarthroplasty through trans-trochanteric approach give good result in a majority of elderly patient with unstable intertrochanteric fracture. It has advantage of an early ambulation and less hospital stay, as compared to the internal fixation. Also, the patient rehabilitation is easy and fast and none of the patient required any revision surgery. But the follow up period in our study is not enough to make any clinical recommendations though it can serve as a critical analysis to stimulate future research. Further long term studies are required.

265-272

Authors: SPS Gill, Dinesh Kumar, Manish Raj, Pulkesh Singh, Jasveer Singh, Rakesh Vishwakarma

Introduction: Femoral neck fracture at any age always shows relatively higher rate of complications like non union, avascular Necrosis of femoral head, loss of fixation, screw cut-out and delayed secondary osteoarthritis. These fractures in physiologically old age are managed by replacement of femoral head. In Femoral neck fractures in young adult the main aim is to preserve the natural head and these cases are managed by Multiple cancellous screw, CanulatedCancellous Screw(CCS) with fibular graft either free fibular or vascularised fibular graft. Replacement surgeries in these cases are a difficult choice as young age and also high cost of implants. Also in these patients it is difficult to restrict squatting for lifelong due to social culture and lack of toilets. Now days also preferences are given to head sparing surgeries and osteosynthesis. We use primary double angle barrel plate with intertrochanteric valgus osteotomy for the management of femoral neck fracture in young adults. Material and method: Cases were selected from the patients attending in Orthopaedics OPD and emergency trauma centre of UPRIMS & R, Saifai, Etawah from May 2006 to August 2013. During this period total 44 cases of fracture neck femur were selected for primary fixation with dauble Angle Barrel Plate (DABP). Out of 44 cases 30 were female and 14 were male with age range from 18 yrs to 48 yrs and average age of 42 yrs. Average duration from injury to operative procedure was 1.3 weeks (10 Days) and range from 2 days to 15 weeks. These cases were operated by Double angle barrel plate with intertrochanteric valgus osteotomy and long term result evaluated using Modified Askin and Bryan criteria. Result: Out of 44 cases operated 42 cases followed up to the average duration of 48 months and all these 42 cases show good(18) to Excellent(20) results after 4 yrs according to Harris hip score. 4 cases shows fair result and other secondary procedure were required in these cases. Complication seen during follow up were avascular necrosis in 7 cases and out of these 7, 4 cases given poor result as these were also shown loosening of fixation and crew cut out. Out of 42 cases 38 cases were able to perform squatting after 4 yrs of follow up and also there were no radiological sign AVN of head at all. Loss of reduction and screw cut out seen in two cases and these were in poor outcome group. Discussion: Fracture neck femurs are not rare presentation in developing countries. Various modalities of treatment are fibular graft, ileac bone graft, multiple screws with fibular graft, muscle pedicle graft. We in our series done primary osteotomy combined with double angle barrel plate (DABP) achieved excellent to good results in 90% cases. Primary osteotomy with double angle barrel plate is a good alternative for the management of femoral neck fracture in young patients.

279-281

Authors: Prasad Soraganvi, Anand Kumar BS, Gadiyar HB, Satyarup Dasanna

Background and objective: Anterior cruciate ligament (ACL) rupture is the most common among young population involved in sports activates. In previous literature it is evident that delay in reconstruction results in increased incidence of meniscal injury and degenerative changes due to knee instability. The aim of this study is to find out incidence of meniscal injury and cartilage damage in ACL deficient knee and weather the incidence is more in chronic ACL deficient knee. Methods: All cases of ACL reconstruction done in our institution during 2011 to 2015 were included in study. Patients above 50 years were excluded. The case records reviewed and data collected. The time period between primary injury and surgery noted along with findings in diagnostic arthroscopy. The cases were divided as per the times when surgery was done after primary injury in to two groups as early reconstruction group (Group A) and late reconstruction group (Group B). The associated injuries of meniscus and cartilage damage were noted in both groups. Results: After considering inclusion and exclusion criteria 113 patient were included in study. 65 patients were in Group A and 48 patients in Group B. 36 patients (74%) in Group B and 23 patients (25%) in Group had meniscal injury. It was observed that Group B had high incidence of medial meniscal injury compared to Group A. four patients in Group B had chondral damage compared to one patient in Group A. Conclusion: Incidence of medial meniscus injury and both meniscus injury was found to be more in late reconstruction group. Chondral damage also is more in late reconstruction group. Delay in ACL reconstruction results in early onset of degenerative changes and meniscal injury. We recommend early reconstruction of ACL preferably within three months.

286-290

Authors: Prashant Upadhyaya, Jayant Sharma

We present a study of open arthrolysis of the elbow for Elbow stiffness due to an unusual aetiology. The range of movement of the elbow, pain scores and functional outcomes were recorded pre- and postoperatively. An improvement in the mean range of movement from 70° (0° to 95°) to 110°(55° to 135°) was obtained in our patients at one year. On the basis of this study, we believe that the results of open arthrolysis for posttraumatic stiffness of the elbow are durable over the medium term.

138-145

Authors: Atin Kumar Kundu, Satyendra Phuljhele, Mantu Jain, Kamal Kishore Sahare

Background: Distal tibial fractures including tibial pilon present a challenge as to their best method of management due to subcutaneous location of larger portion of tibia, paucity of soft tissue coverage and precarious blood supply of distal leg. MIPO (Minimal invasive plating osteosynthesis) has evolved as a newer concept to treat distal tibial fractures with minimal articular comminution and minimal soft tissue damage. It works on Biological fixation principle which assists physiological process of bone healing wisely with minimal operative intervention. Method: A prospective study for the management of distal tibial fractures by MIPO technique by using pre-contoured metaphyseal LCP (locking compression plate) was done, in 20 patients, between January 2012 and October 2013. Fractures were classified as per AO system and patients were followed and scored according to TEENY and WISS clinical scoring criteria. Result: Among 20 patients operated, there were 15 males and 5 females with a mean age of 38.95yrs (range from20-67yrs). 17 patients sustained extra-articular fractures (type A), 02 partial-articular fractures (type-B) and 01 total-articular fracture (type-C). High energy trauma (road traffic accident) predominated causing 13 fractures. Average trauma surgery interval was 12 days (02-22days). Patients were followed minimum for 6 months (range 06-18 months). Superficial wound infections were seen in 02 cases, surgical wound breakdown with implant exposure in 01 case and prominent hardware in 01 case. 17 patients (85%) had excellent/good outcome and 03 cases with complications had fair (02 cases) to poor (01 case) outcome. Conclusion: MIPO is an effective and safe technique for the management of distal tibial fractures without intra-articular comminution and minimum soft tissue damage. It preserves bone biology by maintaining balance between devascularisation and mechanical perfection. Further studies with longer follow-up and large sample size are warranted.

149-152

Authors: Pradeep Choudhari, Dev Padia

Background: In orthopedic practice glove punctures are very common entity. Integrity of gloves act as a barrier in protecting the operating team from various blood related infections. Breach in this integrity of gloves make the operating team susceptible to patient’s body fluid and hence increases the infection chances. In today’s world due to presence of conditions such as HIV, Hepatitis B and C, our study is pointing out the infection rate and factors that can lead an operating team vulnerable to such infections. Material & Methods: Gloves that were collected from respective orthopaedic procedures were subjected to the standardized water leak test. These gloves were evaluated for leakages and were compared to a control group of unused gloves from the same pack after each respective surgical procedure. Result: The perforation rate of gloves was found to be 12.6 (240/1856) with operative perforation rate of 45%. The gloves of the surgeon got perforated at a rate of 21.4% (120/560). The perforation rate of index finger and thumb were the found to be 57% and 22% respectively. The perforation rate of outer glove was 81.3% and the inner glove was 20.4%. Those surgeries lasting more than 100 minutes were related to a perforation rate of 67%. Conclusion: Double gloving techniques are preferred to delineate the chances of glove perforation related infections and also encouraged for prolonged procedures which will eventually lead to the decreased chances of exposure.

159-163

Authors: Siddharth Madhav Khadilkar, Vijay Vasant Nemade, Nakul S. Shah, Yogesh R. Gaikwad

Background and Objectives: The occurrence of low back pain of short duration and without positive clinical findings is high. 15% and 30% of the population suffer from this condition. Young working adults are most commonly affected by this condition. Aim of this study is to assess the necessity of plain radiography of lumbosacral spine in diagnosing and treating young patients presenting in Orthopaedic outpatient department with low back pain of short duration without history of trauma and no positive clinical findings. Methods: We prospectively studied 500 young patients of age between 25 to 40 years presenting with low back pain of less than 3 months duration without any history of trauma and no positive clinical finding. We excluded patients with history of trauma, fever, patients with radiating pain, neurodeficit, Patients with bladder/bowel complaints and Patients with any other systemic disorder. All these patients received standard treatment in the form of short term medication, postural training and application of ergonomic principles while working. Results: 64% of the patients recovered fully within 2 weeks of treatment. 36% of the patients were not relieved hence Lumbosacral spine radiographs were performed after 2 weeks of treatment. Positive findings on radiographs were early degenerative changes and loss of lumbar lordosis due to para-spinal muscle spasm, seen in 9.7%of the patients in whom radiographs were performed. These radiographic changes were not indicative of different modality of treatment, hence we continued the same treatment and further31% of the patients were recovered fully after 4 weeks of treatment. Interpretation and Conclusions: Performing lumbo-sacral radiographs does not have any influence on treatment or outcome in young patients presenting with low back pain of less than 3 months duration without any history of trauma and no positive clinical finding.

168-170

Authors: Sathik Babu M .B, Sriram Thanigai T

Introduction: Spondylolisthesis is defined as the anterior slippage of one vertebra on another. The commonest level involved is L5 – S1 (89%). The displacement is a result of loose posterior locking mechanism which in turn leads to instability with symptomatic thecal sac and nerve root compression. Surgical stabilization helps in preventing further neurological insult and to enhance the recovery. Materials and Methods: This is a prospective study comprising of 20 patients with spondylolisthesis who were treated with pedicle screw-rod fixation and postero-lateral fusion with iliac bone graft during the period of Jan 2013 to Mar 2014. These patients were reviewed periodically both clinically and radiologically for a period of 6 months following operative fixation. For determining the outcome, the Japanese orthopaedic association (JOA) Scoring system was used. Results: Patient’s perception of their quality of life improved markedly after surgery. Overall clinical result was categorized into excellent, good, fair and poor by determining final correction of slip, maintenance of correction, and the functional outcome. 10 patients (50%) had an excellent outcome. 6 patients (30%) had good result and 4 patients (20%) had fair results. Conclusion: From our study, we conclude that pedicle screw fixation and postero-lateral fusion is an effective treatment modality in patients with spondylolisthesis and the results obtained in our study are in par with the other studies that have been conducted elsewhere.

176-182

Authors: Manish Dwivedi, Vikas Sawla, Atul Varshney, Apoorv Acharya

Background: Lumbar canal stenosis (LCS) remains one of the most frequently encountered, clinically important degenerative spinal disorders in the ageing population. Diagnosing it clinicallyis made more difficult due tocoexisting degeneration of the spine, hip or knee joint or diseased vessels and nerves of lower limbs or due to de-conditioning of spinal musculature and ligaments. Purpose of the study: The purpose of our study was to assess the results of spinous process osteotomy & laminotomy in cases of lumbar canal stenosis. Material and Methods: It was prospective study with 25 confirmed cases of lumbar canal stenosis adhering to inclusion criteria and stable spine. Patients were assessed pre-operative and post- operative using LINS Functional Ability Criteria, VAS scale for back pain and leg pain, JOAS score and Satisfactory Recovery Rate- Hirabayashi Method( Based on Pre-op and Post-op JOAS scores) with an average follow-up of 1 year. Results: There were 25 patients, 12 (48%) males and 13 (52%) females. Mean age of group was 44.48 ± 7.52.There were14 (56%) patients with two level involvement followed by 6 (24%) patients with three level involvement and 5 (20%) patients with single level involvement. In single level involvement maximum number was of L4-L5.All 25 (100%) patients presented with Claudication and radiculopathy; 9 (36%) had unilateral radiculopathy while 16 (64%) had bilateral radiculopathy.10(40%) patients had motor weakness and sensory involvement.1(4%) patient presented with cauda equina syndrome with associated sphincter involvement.All patients were treated with Spinous process osteotomy and fenestration and foraminotomy. In addition to that, discectomy was done in 14 (56%) patients while laminotomy was required in 3 (12%) patients Functional assessment as per LINS criteriashowed that satisfactory results (Percentage of patients in Excellent and Good Class) were achieved in 90% of the patients.There were significant improvement in back pain (60%) and excellent improvement in leg pain (76%) in terms of VAS. Improvement in JOAS score was also excellent (72%).according to Hirabayashi method, 12 (48%) patients had ‘Excellent’ results (JOAS recovery rate >70%); and 10 (40%) patients had ‘Good’ results (JOAS recovery rate between 45% and 70%). Conclusion: The Spinous Process Osteotomy (SPO) technique is one of the surgeries associated with minimal muscle injury, effective andfaster long lasting decompression, and satisfactory neurological and functional outcomes with acceptable low risk of complication highly safe for all concerned and maintenance of spinal stability by utilizing standard outcome measures with logical expectation to maintain excellent to good results at long term follow up.

186-193

Authors: SPS Gill, Manish Raj, Dinesh Kumar, Jasveer Singh

Introduction: Foreign body injuries with wood, metal, plastic or a piece of glass are common in children. If neglected or poorly managed, some of these injuries results in cellulitis or osteomyelitis of the affected structures. This is the rare report of both bone forearm osteomyelitis following neglected rubber band wrapped around the distal forearm in a child. Case Report: A 6 year old male patient presented with pain and swelling with discharging sinus in left distal forearm. The diagnosis of both bone forearm osteomyelitis is confirmed with plain radio-graphs. During curettage surgery, incidentally rubber band was found in the subcutaneous tissue wrapped around distal forearm. Patient was treated with complete removal of foreign body (Rubber band), surgical debridement and combination of IV and oral antibiotic for period of 6 weeks. At 12 months follow up, patient presents with no recurrence of sign and symptoms of osteomyelitis and lesion healing satisfactorily. Conclusion: The neglected foreign body can result in osteomyelitis of both bones of distal forearm in a child. Early diagnosis with adequate management of established osteomyelitis by complete removal of foreign body, curettage and antibiotics can give good results.

4-10

Authors: Younis kamal

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 Orthopaedics and 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 an orthopaedic journal. Articles on the state-of-the art of orthopaedic surgery in 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 research are always encouraged.

22-26

Authors: Ramesh Krishna. K, Manju Adithya Nayak B. S, G. Amrit

A prospective study of 30 patients with closed distal femur fractures (AO classification A, C) of both sexes & above 18 years of age managed surgically by Distal Femoral Locking Compression Plate with the aim of finding its efficacy in terms of union rate (time to union), time of mobilization, functional results, radiological results & complications over a period of 1 year. Minimum of 6 months & maximum of 16 months follow up was done. Patients were evaluated both clinically as well as radio logically at 6 weeks, 12 weeks, 6 months, 9 months & 12 months. Result of the study showed that the average time to union was 3.83 months. The average range of flexion obtained postoperatively was 111.30. Two contractures & decreased knee movements, four mal-alignment / mal-union, one implant failure & one infection were the residual complications in our study. Mean Neer’s score was 80.20. Excellent results were seen in 15 cases, satisfactory in 11, unsatisfactory in 3 & 1 case of failure was seen. So the results showed that Locking Compression Plate (LCP) system, is a safe & reliable implant for distal femur fractures AO types A & C.

32-36

Authors: Mukesh Tiwari, Vikram Khanna

Forearm fracture are one of the common fractures ,although complete data are not present regarding epidemiology of forearm fractures but at some international centers forearm diaphysis fractures account for 5% of all fractures out of which most of the fractures are distal forearm fractures. In literature little stress is given over the management of distal ulna fracture. In our research we have divided distal ulna fracture in different categories like combined fracture with radius, acute ulnar styloid fracture, ulnar styloid with nonunion, ulnar neck fracture, fracture with commination. A systematic approach towards these fracture by using this classification can be helpful in management of these fracture.

43-49

Authors: Aradhana T. R., Ramesh Krishna. K, Preetham N.

Background/Purpose: Distal radius fractures are one of the most common injuries to the musculoskeletal system. Functional outcome in these fractures depend on many factors. Our main aim was to study if good radiological outcome has any effect on functional outcome. Methods: We retrospectively studied 80 patients, of which 53 were males & 27 females. 40 cases were treated with conservative management & 40 cases with surgical management. Results: Most of the patients were between 20-30 years (Mean 40.35 years). Most commonly the mode of injury, wrist involvement & fracture type were RTA (51.7%), Right side (53.3%) & Frykmans III (41.7%) respectively. Mean pain score & Function score (PRWE) and loss of movements were less among patients where radiological parameters were restored. Conclusion: From this study, we conclude that restoration of radiological parameters will help in good functional outcome in treatment of intra-articular fractures of distal end of radius.

57-59

Authors: Ramesh Krishna. K, Aradhana. T. R, Preetham. N

Background: Intra-articular distal humerus fractures comprise 1% of all fractures in adults1. Recent studies have emphasised the importance of surgical approach, rigid fixation and early rehabilitation for good outcome. Objectives: To assess the anatomical reduction of distal humeral articular surface by radiological examination and stability of the elbow by the functional assessment over a period of 1 year. Methodology: Thirty consecutive patients with distal humerus fractures were treated from October 2012 to October 2014 .The fractures were fixed using AO double column (orthogonal) plating techniques. Physiotherapy started from 3rd day post-op. Patients were followed at 6weeks, 3 months, 6 months, 1 year interval. Clinical outcome assessed using MEPI (Mayo Elbow Performance Index) score and radiologically assessed for reduction, alignment, fracture union, and complications. Results: All patients had completed postoperative physical therapy at the time of the study and had achieved maximum function of elbow. The mean duration of follow-up was 12 months. The mean arc of flexion was 106°. Mean pronation was 76° and supination was 77°. The mean MEPI score was 95.1 points (range 0 to 100 points), indicating mild impairment. Radiographic evidence of fracture union was noted in all patients. Conclusion: We conclude that internal fixation of intra-articular fractures of the distal humerus is an effective procedure with an excellent functional outcome in most patients. Patients have a high level of satisfaction and the majority return to their previous level of activity.

64-74

Authors: Sanyam Chaurasia, Georgios Karnatzikos, Alberto Gobbi, Vivek Gupta

Purpose: The purpose of this study was to review and summarize the literature and suggest the probable most effective protocol in the management of post anterior cruciate ligament reconstruction (ACLR) infection. Methods: We reviewed 16 studies (Level 1- Level 4) published between January 2000 and December 2013, by a thorough search in PUBMED, MEDLINE and EMBASE databases. Results: There were 246 cases of infection amongst 35,795 ACLR making the proportion of infection 0.68% (range- 0.14-2.6%). The mean time of onset of infection from index surgery was between 7.5 days to 32 days. The most common organism was Coagulase-negative Staphylococci (CNS) followed by Staphylococcus Aureus. Optimal outcome was reported in most studies using serial arthroscopic lavage and intravenous antibiotics with graft retention as a prime protocol. Conclusion: Septic arthritis after ACLR is a rare and disastrous complication which can be successfully managed by early diagnosis and arthroscopic debridement with a proper protocol.

79-81

Authors: Ramesh Krishna K, Aradhana T R, Sreekantha K S, Preetham N

35 year old, housewife presented with non-union right forearm following crush injury right forearm thirteen months back. Extensor tendons were lost, fixed deformities were present at wrist and x-ray showed non-union with gap of radius more than ulna and wrist arthritis. Radialization of ulna was done creating one bone forearm with bone graft. Three months follow-up showed fracture union in progress, with good cosmetic appearance and some function of the right upper limb. One bone forearm procedure can be considered to treat post traumatic bone loss in forearm when other treatment fails.

84-86

Authors: Younis kamal

Minimally invasive surgery techniques such as indirect arthroscopic assisted reduction of Periarticular fractures have gained popularity over the recent years and produced good results. The ultimate goal of the intra-articular fracture treatment should be the precise restoration of the joint surface and rigid fixation to allow immediate postoperative non–weight-bearing exercises. The treatment of tibial plateau fractures with arthroscopic assisted osteosynthesis is a novel method that is associated with lower morbidity, less extensive surgical dissection. Arthroscopic assisted reduction and fixation is reliable, safe, attractive and excellent option in the treatment of properly selected tibial plateau fractures.

93-97

Authors: Jaganmohan Sontyana, G Pradeep Gandharva, Satyaprasad Jonnalagedda, Sudhir Mahadeoprasad Shandilya,

Objective: To assess the success rate of Flexion Adduction External Rotation (FADER) technique in reducing anterior shoulder dislocation and to report our experience. Methods: A prospective study included 30 patient, with 21 male and 9 female associated with acute anterior dislocation of shoulder treated by FADER in a medical college attached hospital. Results: The FADER technique was used to reduce 30 cases of anterior dislocation shoulder during the study period. 27 cases were first time dislocations and 3 cases second time recurrent dislocations. Fracture of greater tuberosity was present in 2 cases. Reduction is achieved in first attempt in 28 cases, in second attempt in 1 case, and 1 case was reduced under general anaesthesia. No complications were noted. Overall success rate was 96.6% Conclusion: we report the successful use of FADER technique for reduction of traumatic anterior shoulder dislocations, mainly without traction, exhaustion, second assistant, anaesthesia, sedation and uncomfortable position. We believe that FADER may also be applied by inexperienced physicians, as it is simple, easily understood and reproducible with success

103-106

Authors: Hayat Ahmad Khan, Mohammad Ashraf Khan, Mohammad Shahid Bhat, Naseemul Gani, Prof Munir Farooq

Introduction: Paediatric Supracondylar fractures are the commonest elbow injuries encountered in the emergency departments. Most commonly they are the result of a fall on an outstretched hand that causes hyperextension of the elbow. The extension-type supracondylar humeral fractures account for 95% to 98% of all supracondylar fractures. Displaced fractures are treated with closed reduction and percutaneous pinning. However the method of pinning has been a matter of debate (lateral entry vs cross pinning). The issue with the lateral entry pinning like loss of reduction and ulnar nerve injury with the cross pinning method has always kept a doubt in the surgeons mind regarding the method of pinning. The present study was aimed to see functional results of using three lateral pins in type II and III supracondylar fractures and to look for any complications occurring thereafter. Methods: Forty consecutive patients of type II and III SC fractures were taken up for the study. Three lateral pins were used for all fractures. Using the Flynn criteria, the results were graded as excellent, good, fair or poor by comparing the carrying angle and range of motion with the opposite side. Results: Among the cohort of forty patients we had 25 males and 15 females. The mean age group was 6.5 + 3.2. Sixteen patients had type II fracture while as 24 had type III Gartlands fracture. The union occurred in all cases. At the final follow up, 87.5% patients showed excellent results 10% showed good and 2.5% fair results. There was no case of poor results. There were no iatrogenic nerve palsies, and no patient required additional surgery. Conclusion: Lateral three pin fixation is a good method for displaced supracondylar fractures and has little or no chances for ulnar nerve injury. This method has an easy learning curve among orthopaedic residents. A randomised control trail comparing it with other methods involving a larger series is needed to look for the effectiveness of this technique.

111-115

Authors: Manish Dwivedi, Atul Varshney

Purpose of the study: Acromion Morphology have been implied to have a major role in shoulder pathology especially caused by affecting subacromial space. Among Acromion Morphology studied includes – Acromion Index, Acromion Types, and Acromion Slope etc. Acromion Types as classified according to Bigliani is a faster way to differentiate Acromion on a plain X-ray. Purpose of the study was to assess the effect of Acromion type on shoulder problems. Material and Methods: 100 Patients of above age 40 coming to orthopaedic OPD for shoulder problems (Impingement or rotator cuff pathology) were examined. Their Acromion type were assessed on the basis of x-ray of shoulder (supraspinatus outlet view). Acromion type was then classified according to Bigliani classification. Results: There were 100 patients in the study – 58 males and 42 females. There were 44 type I, 55 Type II and 01 Type III Acromion types accordingly to Bigliani‘s Classification. Mean age of study group was 56.67 ± 6.57.However in Impingement group patients were younger (55.4 ± 6.53) as compared to rotator cuff group patients (58.84 ± 6.06).There were more females in Type I Acromion group and subsequently number of males outnumbered females in Acromion Type II and Type III. There were 63 patients in Impingement group and 37 in rotator cuff group. Right sided shoulders were affected in 68 patients and 32 patients had their left shoulders affected. 73 affected shoulders were of dominant sides. Conclusion: As Acromion Type changes from Type I to Type III, then symptoms of impingement and rotator cuff pathology start to appear at a younger age. This warrants aggressive approach of management of these shoulder pathology in Acromion type II and type III.

121-123

Authors: Yogesh Kumar Yadav, Gaurav Kumar, Vikas Verma, Anuj Rastogi

Cystic angiomatosis is an uncommon benign multifocal disorder in which there is proliferation of endothelial lined vessels in bone. Angiomatous malformation results in progressive loss of bone. Bony cystic lesion affects the axial and proximal appendicular skeleton. Patients usually presents with pain. We report a case of 58 year old man who presented with pain and pathological fracture. X-Ray imagery showed multicystic lesions involving the whole length of multiple ribs. Rib biopsy showed the proliferating capillary network growing in to the bone marrow spaces associated with destruction of bone. Cystic angiomatosis should be kept as one of the rare differential diagnosis in a case presenting with multiple lytic lesions of bone.

127-128

Authors: Mohammad F, Singh S, Lal AK, Kumar S

Tuberculosis is still a major cause of mortality and morbidity in the world and especially in developed countries where it has been causing major disability. Relating to this we present a case report of 42yr old male patient with h/o pain and swelling of left foot and ankle from 2 years which after preliminary investigation was diagnosed as tuberculosis and was confirmed by biopsy. Under cover of anti-tubercular treatment (ATT) patient was treated with debridement and curettage of talonavicular joint with arthrodesis. Patient was continued on anti-tubercular treatment for 12 months after which patient was able to walk without pain and able to do his routine daily activities. My aim is to present a case of isolated tuberculosis of talonavicular joint which is a rare presentation of extrapulmonary tuberculosis and consideration of this diagnosis in chronic ankle and foot pain.