Indian Journal of Orthopaedics Surgery

1-6

Authors: Regupathy Annamalai, Amar Nagesh Kumar.

Introduction: Aim of the study is to measure serum 25 – hydroxy vitamin D levels in patients with knee osteoarthritis in comparison with age matched healthy controls and also to assess the association of 25-OH vitamin with osteoarthritis. Materials and Methods: The study population consists of 240 patients divided into two groups, Group 1 and Group 2. Group 1 with 120 subjects with clinical features of knee osteoarthritis served as controls and Group 2 consists of 120 patients of patients diagnosed with knee osteoarthritis. Serum 25-OH vitamin D was measured in all the participants by the ELFA method and concentrations <10ng/ml was considered as deficient. Results: In Group 1, 57(46.5%) were males and 63 (53.5%) females, while in Group 2, 57(45.5%) were males and 63 (54.5%) females. Distribution of vitamin D status according to age, BMI and gender was also made and compared between the groups. Number of patients <60 years were 55 and 56 respectively in Group 1 and Group 2. Serum 25-OH vitamin D deficiency was observed in 67(55.8%) patients in Group 2 versus 15(12.5%) of Group B (P = 0.001). Further analysis of subgroups, revealed that the mean serum 25-OH vitamin D level in Group 2 aged <60 years was significantly lower than Group 1 (8.2 ± 1.1 vs. 9.2 ± 0.8 ng/ml, P < 0.05). Conclusion: The present study findings showed a significant association between serum 25-OH vitamin D deficiency and in patients with knee osteoarthritis aged < 60 years. Screening of serum 25 – OH vitamin D measurement in patients with symptoms suggestive of knee osteoarthritis is recommended as it showed association with knee osteoarthritis.

10-12

Authors: Ganesan Ganesan Ram, P.V. Vijayaraghavan.

Introduction: Little has been published on the biochemical changes
 that can cause or a predisposing factor for osteoporotic fracture. The aim of the study is to assess whether there is any correlation of fracture to the level of serum parathyroid hormone, serum vitamin D and urinary n telopeptide. Materials and Methods: Prospective study done at Sri Ramachandra Institute of Medical Science, Chennai between October 2015 to October 2017.The Inclusion criteria were persons above 50 years of age and the patients above 50 who comes within 24 hrs following trivial fall fractures. All patients who participated in the study underwent Dexa scan for diagnosis of osteoporosis, urinary n telopeptide and biochemical tests like serum calcium, serum phosphate, Alkaline phosphatase, 25-hydroxy vitamin D and serum parathyroid. The patients were divided into two groups. Group I had patients without fracture and Group II had patients who had osteoporotic fractures. Results: We had nearly twenty one pertrochantric fractures patients followed by sixteen distal radius patients. The mean value of urinary n telopeptide was 55.7 in group I and 186.39 in group II. The mean value of serum PTH was 69.5 in group I and 72.9 in group II. Conclusion: Urinary marker correlates well with the osteoporotic fracture and will be a better diagnostic tool than the blood biomarkers of osteoporosis.

16-20

Authors: Ashok Kumar Jha, Chintapeta Ravi.

Introduction: The Lumbosacral angle (LSA), is the angle formed between a line across the plane of the superior margin of the sacrum and a horizontal line. Various literature and studies around the world shows wide normal variation in LS angle, ranging from 320 to 440. Abnormal variation in LS angle is commonly associated with low back pain. Hence research involving study of normal variation of LSA in different ethnic population plays a significant role. In Indian scenario very few studies are available, especially from rural population, to know up to what extent, variation in LS angle is normal. Hence, the present study attempts to study the normal variation in LSA in rural population of Telangana. Materials and Methods: A descriptive study of normal LSA variability, involving 100 asymptomatic subjects between the age group of 20-60 years was carried out in orthopedic department of Medical College hospital, Telangana. Ferguson’s technique was employed for calculation of LSA. Results: In this study variation of LSA ranges from 280 to 600. Overall average LSA was 340.Females have greater average LSA as compared to males. Conclusion: Results of the present study show variability when compared to other similar studies, which further strengthen the fact that normal variation in LSA differs among different region and races; hence results of the present study will be a useful tool to health care providers for treating different spinal disorders of rural Telangana population.

30-34

Authors: Venugopal S M, G. Jagadesh, Prasanna Maddiwar, Karthik Gudaru.

Introduction: One of the most common fractures an orthopaedic surgeon encounters is Malleolar fractures. As with all intra articular fractures accurate reduction and stable internal fixation of malleolar fractures is desirable. The present study aimed at analyzing the factors influencing the outcome of operative management of malleolar fractures. Materials and Methods: In this prospective study 25 patients with Malleolar fractures who were surgically treated between 2014 to 2016 were included. All patients were treated in accordance with A.O. principles. Patients aged above 18 years, with unstable fractures were included in this study. Post op protocol was below knee POP cast with a dorsal window for ankle mobilization and non-weight bearing walking with walker for 4 weeks post operatively. Baird and Jackson ankle scoring system was used to analyze the results. The follow up period for all patients was 60 weeks. Results: In this series of fixation of malleolar fractures with various techniques had Fair results in 84% and poor results in 16% as per Baird and Jackson Score. The average time to union was 12 weeks. The complications leading poor result were instability, Pain at rest, arthritic changes. Conclusion: Open reduction and internal fixation guaranty high standard of reduction besides eliminating the chances of loss of reduction. In our study, the Extent of anatomical reduction achieved in the surgery and Post-operative ankle mobilization and patients’ compliance influenced the outcome. Restoration of fibular length and rotation is critical in re-establishing a stable ankle mortise and perfect talar alignment. We conclude tension band wiring is the preferred method for small fracture fragments and osteoporotic bones of both medial and lateral malleolus.

41-43

Authors: Ramachandra N Badami, Swetha Purohit.

Introduction: Fracture shaft of tibia is one of the most common injuries presenting to a trauma center. Closed intramedullary interlocking nail is the gold standard surgical procedure. But even with advanced techniques there are several reports of delayed and nonunion of these fractures. We evaluated the results of dynamically locked tibia IMIL nail for fracture shaft of tibia. Materials and Methods: 90 patients with fracture shaft of tibia were included in the study between 2013 to 2015. AO type A1 and A2 were included in the study. Comminuted fractures, open injuries were excluded from the study. Outcomes were evaluated based on time to fracture union, limb alignment, walking ability and range of motion. Results: There was fracture union in 100% of the cases an average duration of 16 weeks. There were no cases of nonunion/delayed union, significant mal-alignment of the fracture. The mean range of motion score was 3.6 and the mean walking ability score was 3.8. Discussion: Non comminuted fracture shaft of tibia treated with dynamically locked IMIL nail gave good to excellent results in 87 of the 90 cases with respect to fracture union, limb alignment, range of motion and walking ability. There were no cases with implant failure or limb length discrepancy. It produces good fracture compression and early weight bearing adds to its advantage. Conclusion: Dynamically locked IMIL nail for non comminuted fracture shaft of tibia gives excellent clinical and radiological outcome. It also avoids any chances of delayed/nonunion of the fractures of tibial shaft.

48-52

Authors: Kaushal Anand, Hriday Acharya, Satvik Patel, Shalin Shah.

Introduction: Distal end of the radius fractures are common injuries and are the commonest bony injury around the wrist. The logical treatment need to be planned based on specific fracture configuration, the extent of displacement, degree of articular disruption, stability and many other factors. The present study is intended to assess results of closed reduction, K wiring and external fixator in Fractures of Lower end Radius/ulna in 40 patients classified according to Frykman’s classification. Materials and Methods: This is a retrospective study of 40 cases of distal end radius fractures selected randomly over a period one year from March 2016 to March 2017. Observation and Results: Out of 40 patients in the study most of them were male with the mean age of patients being 44.72.Injury was commonly due to fall on out stretched hand with no associated injuries signifying it is caused by low energy trauma. Most of the patients were of Frykman type III and IV. The average period for intermittent mobilization is between 6 to 7 weeks. 90% patients have 10‐22 degrees of range of radial inclination. Most patients developed a good range of movement post-op. Few complications were reported with pin tract infection being present in 5% cases. Conclusion: We have studied 40 patients of distal end radial fracture treated with external fixator and K wires. It is simple and inexpensive implant. Technique is less demanding for surgery. It causes minimal soft tissue interference. Elbow and fingers can be mobilized immediate post operatively. It maintains reduction and provides stability to fracture fixation. Period of immobilization was short. Complication rates are comparatively low in our study. Most patients had excellent to good results. Its ease of use and successful results make external fixator and K wire versatile tool for treatment of these fractures.

60-64

Authors: G. Jagadesh, T. Naveen Babu, S.M.Venugopal, G. Karthik, K. Pavan Kumar Yadav.

Introduction: Foot deformities caused by altered or abnormal muscle forces are common in patients with cerebral palsy. The incidence of foot deformities in cerebral palsy is approximately 70% to 90%. The most common deformity is ankle equinus, with equinovarus and equinovalgus deformities being equally common. A foot deformity can have significant effects on the patient's overall ambulatory level. The purpose of this study was to assess the functional outcome of batchelor’s extra-articular subtalar arthrodesis in spastic planovalgus foot in cerebral palsy children. Materials and Methods: This is a prospective study of 40 patients (68 feet) with spastic planovalgus foot deformity presenting to BIRRD (T) Hospital from October 2015 to October 2017. Children with spastic planovalgus foot between 6 yrs-14 yrs were included in study. There were 24 male and 16 female children. The mean age at the time of surgery was 10 yrs. Both feet were involved in 28 children, 8 had right foot involvement and 4 had left foot involvement. In our study we had 12 hemiplegics and 28 diplegics. Children with mental retardation, extra pyramidal type of cerebral palsy, rigid plano-valgus foot, spastic quadriplegia were excluded from the study. All patients underwent batchelor’s arthrodesis with fibular graft and were immobilized in below knee POP cast for 8 weeks. 24 patients underwent gastrosoleus lengthening along with batchelor’s arthrodesis. Clinical and functional outcome was assessed based on AOFAS (American orthopaedic foot and ankle score) clinical rating system. Radiological assessment was done by measuring Lateral talocalcaneal angle and Talar declination angle. The results of batchelor’s arthrodesis are stated as satisfactory and unsatisfactory. Satisfactory: Clinical and roentgenographic stabilization of the hind foot and no recurrence of planovalgus deformity. Unsatisfactory: Clinical and roentogenographic evidence of failure of stabilization. Results and Discussion: All children had spastic type of cerebral palsy. Post-operatively children were followed-up for an average period of 14 months, with range from 4 to 24 months. Among 40 patients (68 feet), 8 feet (12 percent) had residual valgus, 12 feet (18 percent) had graft absorption, 4 feet (6 percent) had fracture of the graft and none had varus deformity after an average follow-up of 14 months. Out of 68 feet, 44 feet had “satisfactory” result (65 percent) and 24 feet had “unsatisfactory” result (35 percent). Conclusion: Our experience concludes that batchelor’s extra-articular arthrodesis of sub-talar joint is a good procedure for correction of plano-valgus foot deformity in cerebral palsy patients. Advantages of the procedure are simplicity of the technique, immediate firm fixation and early weight bearing.

69-72

Authors: Sathish Kumar S, Madan Ballal, T.H. Prakashappa, Vamsinath P.

Aim: To evaluate the functional outcome of supracondylar femur fracture treated by locking compression plate. Materials and Methods: Our study consists of 20 cases of supracondylar femur fracture operated at Sanjay Gandhi institute of trauma and orthopaedics from November 2015 to march 2017.Functional outcome was assessed through Neers scoring system. All the cases in the study were posttraumatic. Mean duration of follow up was 11 months Results: There were 7 male patients and female were 13.Average age of the patients was 40.5 years with age ranging from 18 years to77 years.14 cases involved the right femur whereas 7 left sided femur fracture occured. The study included only one case of compound type 1 femur fracture and 19 cases were closed supracondylar femur fractures. The mode of injury was RTA for 12 cases and 8 cases had history of self-fall. Only 3 cases had associated injuries. In patients with associated injuries early rehabilitation were delayed but results were comparable with other cases of the study. In our study Muller type A3 was the most common fracture presentation which consists of 7 cases followed by 5 type A1 fractures. There were 4 cases of type C1 fractures, 2 cases of type C3 fracture and one case in each type A2 and C2 group. 5 cases were operated under MIPPO technique which were extraarticular fractures. Further all fractures which had articular involvement were operated on standard open approach. Average surgical procedure timing was 101.5 minutes in our study. Most of the patients had excellent postoperative knee flexion with average knee flexion of 119 degrees. Average duration of radiological union was 19.3 weeks and average duration of weight bearing was 20.3 weeks.1 patient in the study had delayed union, 2 cases had a extensor lag of 5 degree while 1 patient had an extensor lag of 10 degrees. 10 cases in the study had fracture union without any complications. Stiffness was present in 7 cases, Knee pain was reported in 3 cases. 1 cases had shortening of 1cm .Superficial infections were reported in two cases which responded to intravenous antibiotics based on pus culture report. There was no incidence of deep surgical site infection in our study. In our study there was one case of implant failure requiring revision surgery. The patient had a episode of fall 3 months after primary surgery. Radiograph showed implant failure with varus deformity at the fracture site and no signs of callus formation.

78-81

Authors: Tushar Agarwal, Kumar Saurav, Siddharth Jadhav, Ankur Kumar, Manoj Pudari.

Distal femur fractures have been a challenge to the orthopaedic fraternity for long time. Improvement in implant material and design are expected to fetch better results in due course of time. Advent and use of locking compression plate has shown good results but requires more corroborative evidence to advocate its uses in different morphology of distal femur fracture. The present study was undertaken to evaluate clinical, radiological union and the complications associated with locking compression plate.

87-90

Authors: Pramod B Itagi, Akash Kalaskar.

Introduction: Traditionally, displaced mid clavicular fractures have been treated with conservative methods. Conservative methods like strapping gives mediocre results. The present study has been undertaken to study the role of pre-contoured locking compression plate in the fixation of mid-third clavicle fractures. Materials and Methods: 40 patients with mid-shaft clavicle fractures (Robinson 2B) with displacement >2 cms were treated with open reduction and internal fixation with a pre-contoured locking plate and functional outcome through 3 months was assessed. Results: Union was seen radiologically in all the fractures by 10-12 weeks. The average Constant-Murley score at 3 months was 93.5. None of our patients had complications like malunion, wound dehiscence, hardware irritation, early mechanical failure, incisional numbness, infections and neurovascular damage. There were 4 patients with hardware prominence, 2 cases of hypertrophic scar formation, 2 patients with delayed union at 18 weeks and 1 case of plate loosening. Conclusions: Pre-contoured locking plate fixation in displaced fractures of clavicle allows earlier return to a pain free functional shoulder.

94-98

Authors: Ashok Kumar P, Ajoy S. M..

Patient safety is of paramount importance especially in the present day scenario. It has emerged as a new discipline. One of the ways of ensuring this in the operating theatre is by following a surgical safety check list, given by the WHO and adapted by institutions. We have analyzed the compliance of this in the orthopedic major operating theatre and have found that it is adhered to very strictly. This has minimized most of the errors such as side and site of surgery to zero percent. We strongly recommend the adherence to a similar surgical safety checklist in all institutions with busy operating theatres, such that many errors could be nullified and patient’s safety is ensured.