Indian Journal of Orthopaedics Surgery

99-102

Authors: Sujit Jos, Rajeev Anand, Joe Paul Elenjickal

Introduction: Anterior cruciate ligament avulsion from the tibia with a bony fragment of the tibial spine is an uncommon injury of the knee joint. These are predominantly seen in children and young adults. Arthroscopic reduction and fixation of the tibial avulsion fracture is a technically demanding procedure as restoring the ACL length and tension during fixation is important to ensure stability of the knee while maintaining range of motion and minimal knee laxity. The purpose of the study was to evaluate the outcome of Arthroscopic Suture bridge fixation of tibial spine anterior cruciate ligament avulsion fractures. Materials and Methods: We followed up seven patients prospectively after Arthroscopic suture bridge fixation. The patients were assessed with clinical examination, Tegner Lysholm and IKDC (International Knee Documentation Committee) knee scores. The study group consisted of 5 males and 2 females with a mean age of 24.28 years (Range 18 years to 32 years). Mean follow-up time was 28.7 months (range 24 to 36 months). The study included 4 type II and 3 type III Meyer and McKeever fractures. Results: At follow-up the mean Tegner lysholm score was 91.28. The best results were seen in younger patients. Younger patients had significantly better score for IKDC functional and final scores. Conclusion: Displaced tibial spine avulsion fractures can be successfully treated in younger and older patients using arthroscopic suture bridge fixation with most patients returning back to preinjury levels of activity

109-114

Authors: Kanwarjit S. Sandhu, Girish Sahni, Bhupinder S. Brar, Karamdeep S. Kahal, Gunvinder Singh

Introduction: Non-union of long bones is a challenging scenario to deal with as management of such fractures is difficult. Tibia is common site of non union.1 Various modes of treatment are available such as ultrasound, electrical stimulation, bone grafting and bone transport by illizarov and rail fixator. We have compared the role of Ilizarov and Rail fixator devices in our study of 15 patients each under both groups. Only Rail fixator had some more patient tolerance as compared to Ilizarov due to problems such as heavy apparatus. Materials and Methods: 15 patients of non union long bones in each group from 21 to 60 years with mean age of 37.6 year in group A and 40.5 years in group B. 90% of the patients were male. Most of the patients had non union of tibia and further the middle one third was more commoly involved in either group. Nine out of 15 patients in both the groups had infected type of non-union. Average shortening was 2.9 cm in group A and 2.86 cm in group B. Maximum number of patients had undergone about two previous surgeries. 12 patients underwent acute docking or compression in group A compared to 13 in group B. Three and two patients underwent compression – distraction for treatment of non union in group A & B respectively. Patients were followed up at 6, 12 and 24 week intervals. Result: In our study union was seen in 13 cases in group A and 14 cases in group B. The duration for union was average 8.8 months and 8.1 months in respective groups. Normal range of motion in nearby joint was achieved in 80% cases. We had excellent to good limb function in 80% of the cases in Group A and 86% of cases as per ASAMI scoring system. Conclusion: Bone results were more or less similar in both the groups. Functional results were a bit better in rail fixator group. Rate of complication were also similar in our study. However patients tolerated rail road with ease and application of rail fixator and comfortable distraction procedure had marginal benefit over Ilizarov.

121-125

Authors: Clevio Desouza, Vinod Nair, Amit Chaudhary, Nitin Wadhwa, Subhanshu Gupta

Introduction: Knee injuries are commonly associated with anterior cruciate ligament (ACL) avulsion fractures and its management is controversial ranging from conservative treatment to arthroscopic fixation. The purpose of our study was to assess the clinical and radiological results of arthroscopic staple fixation in the management of ACL avulsion fractures. Materials and Methods: This study included twenty-two patients (17 males and 5 females) who were analyzed after undergoing arthroscopic staple fixation for displaced ACL avulsion fractures. The mean age was 32.2 years (15-55 years. The mean follow up was of 21 months (6-36 months). The patients were assessed clinically by calculating their Lysholm and International Knee Documentation Committee (IKDC) scores. Radiological union was assessed in the follow up radiographs. Results: The mean Lysholm score was 95.4 (83-100) and the mean IKDC score was 91.1 (77-100) at the final follow up. Anterior drawer’s test was negative in 20 patients at the end of final follow up while two patients had grade I laxity. Seven cases had associated knee injuries. The final outcome was not greatly influenced by the presence of associated injuries when treated simultaneously. It was found that all the patients when examined at their final follow up were able to return to their pre-injury occupation. Conclusion: The procedure of arthroscopic staple fixation in the management of displaced ACL avulsion fractures was found to be safe and reliable method for producing clinical and radiological outcome.

131-136

Authors: Madhu Chandra. P, Pawankumar. K.M, Raju K. P, Arun K. N

Introduction: Bisphosphonates are one of the commonly used drugs for the treatment and prevention of osteoporosis. Many of the old generation oral bisphosphonates have got lesser affinity to bone mineral matrix and low patient compliance. Newer generation intravenous zolendronic acid has got a better compliance due to once a year dose and it is more effective due to its more affinity towards bone mineral matrix. Hence this study was conducted to evaluate the results of intravenous zolendronic acid in osteoporotic individuals using Dual Energy X ray Absorptiometry. Materials and Methods: The study was conducted in a tertiary centre between January 2012 to January 2016. The sample size was 36. The patient recruitment was done in a consecutive manner. Patients were diagnosed by DEXA scan and Lumbar spine BMD taken as representative and inj. zolendronic acid was given once a year, repeated every year, total for 3 years duration therapy. Student Paired t-test was used to find the statistical significance. Gender, fracture sustained during the study, complication, hypothyroidism and status of improved were expressed as frequency and the percentage. p < 0> Results and Analysis: The mean age of our study population was 67.7 yrs. 12 patients in our study had improvent in BMD (t - score) which was 40% of the whole study group. These 12 patients had an actual percentage rise in BMD by 11.62% on average, detected by DEXA Scan. All these patients were under the age bracket of 65 years. 18 patients did not have any improvement in or worsening of BMD and were above the age bracket of 65 yrs of age. This could be attributed to their medical co - morbid conditions and nutrional status. The incidence of another fracture was 8% among people who had a previous fracture. 10% of the study population had adverse effects like fever and myalgia. There were no other serious adverse effects.

141-146

Authors: Siddalingamurthy .G, Sheshagiri .V, Shreyas. M.J

The approach of surgical management of distal intraarticular radial fractures is gaining popularity in the current scenario, and there is no concluding evidence as to which method of surgery fares better than the other, this article attempts to compare the radiological and functional outcome of trinary surgical treatment (percutaneous pinning, ligamentotaxis and plate and screw fixation) for distal end radius intraarticular fractures. Materials and Methods: It was a prospective study involving 90 patients who presented with distal end intra-articular radius fractures, each of these patients were randomly assigned to be treated by ligamentotaxis and plate and screw fixation, percutaneous pinning, (n = 30) each who were operated between January 2016 to May 2017 and their data with respect to functional and radiological outcome were collected over one year. Results: In this research paper out of the 90 patients, the excellent scores were in 13 patients accounting 14.4%, good scores 47.8% in 43 patients and fair and the poor scores 25.6% and 12.2% functionally were seen in 23 and 11 patients respectively, The Cramer s V value was not found significant, the values noted are 0.84. A significant association between groups and Volar tilt, Radial angle and Radial shortening. Cramer’s V was found to be significant (P- value 0.0001) radiologically. The outcome with respect to radiology and the function was measured using werley and gartland scoring and the lidstorm scoring system. Conclusion: In this study the open reduction and internal fixation with plate and screws gave a restored radiological outcome compared to the ligamentotaxis and percutaneous pinning group but the functional outcome remained the same in all the three treatment groups.

155-159

Authors: K.M. Gopinath, Bharath .S, Roshan Kumar B.N

Introduction and Objectives: Among all the known tendinopathies plantar fasciitis and tennis elbow account for most cases.Corticosteroid injections considered the treatment of choice for tendinopathies. Emerging therapeutic modalities is the use of platelet rich plasma for tendinopathies having the advantage of being autologous and concentrated that are rich in growth factor proteins. The study was done to find the efficacy of these two modalities. Materials and Methods: The study was done at Rajarajeshwari Medical College and Hospital, satisfying the inclusion criteria and exclusion criteria. In this study, 3 ml of the extracted PRP or 40 mg of prednisolone was injected into the affected area. Post-intervention pain and functional assessment at 2 weeks, 6 weeks, 3 months and 6 months with visual analogue score and ankle hind foot scale and foot and ankle disability index score. Results: The age in our study was 18 to 55 years, the mean in the steroid group was 37. 3 and in the PRP group was 37.43, right side was most commonly involved 52%. In both the groups there was significant difference in the VAS scores p<0> In both the groups there was significant difference p<0> Interpretation and Conclusion: PRP has better effect pain in patients with longer duration as compared to local steroids but the difference is not statistically significant. The making of PRP is cumbersome but the patients did prefer to steroids due to the adverse effects.

165-169

Authors: Chitta Ranjan Sahu, Deepak K, Pavan Kumar Yadav Kondepu, Gudaru Jagadesh

Introduction: The menisci are crucial structures of the knee in maintaining function. Meniscal repair has gained importance as meniscectomy causes early arthritis. Arthroscopic repair of meniscus has become the mainstay of management replacing open surgery, because of decreased duration of surgical procedure and better accessibility to the tear location. Methods: This study prospectively evaluated functional outcome in 34 patients who underwent arthroscopic meniscal repair. Tears involving outer (red-red), middle and inner (white-white) zone were included for repair. Complex and degenerative tears were excluded from repair. Follow-up consisted of clinical assessment by using Barrett’s criteria and comparison of pre-operative and post-operative Lysholm knee score. In the absence of joint-line tenderness or effusion, and if the McMurray test was negative, it was considered that the repaired meniscus has healed. Results: After a minimum of 1.5 year follow-up, 32/34 of the cases that underwent meniscal repair were asymptomatic for meniscal tears. The mean Lysholm score increased to 95.2 as compared with the preoperative mean value of 61. Arthroscopic meniscal repair was not associated with any neurovascular or other major complications. Conclusion: Stabilizing the meniscal tear by arthroscopy in all three zones appears to be an effective procedure.

173-177

Authors: K. Deepak, Hameed Reza, G. Jagadesh, Akash, Pavan Kumar

Materials and Methods: A total of 263 knees, (150 patients), males 65, females 85 with early OA were divided randomly into two groups. Group A 75 patients (134 knees) received a single injection of PRP, group B 75 patients (129 knees) received 2 injections of PRP 3 weeks apart. PRP with a platelet count 5 times that of baseline was administered in all. Clinical outcome was evaluated using the Western Ontario and McMaster Universities Arthritis Index (WOMAC) questionnaire before treatment and at 1 month, 3 month, and 6 months post injection. A reduction in WOMAC score is suggestive of improvement in patient condition. Results: significant improvement in all WOMAC parameters was noted in groups A and B within 3 to 4 weeks and lasting until the final follow-up at 6 months. The mean WOMAC scores (pain, stiffness, physical function, and total score) for group A at baseline were 15.8, 6.22, 43.09, and 65.11, respectively, and at final follow-up were 4.83, 1.00, 14.12, and 19.95, respectively, showing significant improvement. Similar improvement was noted in group B (mean WOMAC scores at baseline: 16.51, 6.91, 41.98, and 65.38, respectively; mean WOMAC scores at final follow up: 5.50, 1.12, 13.69, and 20.37, respectively. The 2 groups were compared with each other, and no improvement was noted in group B as compared with groups A (P, value 0.77). Conclusion: Autologous PRP infiltration in early Osteoarthritis of Ahlback’s radiological grading does give relief from pain, stiffness and improves functionality without any major side effects. Double dose doesn’t offer any additional advantage.

187-194

Authors: Shriniwas Yemul, Pravin Narote

Introduction: The anatomy of the joint makes it very unstable in cases of fractures or ligamentous injuries of the ankle, because the whole body weight is transmitted through the ankle and locomotion depends upon the stability of the ankle joint. In the post-operative period, the protocol of mobilization of the ankle has been a topic of conflict. The goals of treatment include achieving sound union of fracture and an ankle that moves and functions normally without pain. Materials and Methods: This is prospective consecutive case series of 60 patients of bimalleolar ankle fracture, undergone internal fixation in the form of plate fixation over posterior surface of fibula for lateral malleolus and cancellous screw fixation for medial malleolus. Data collection was done using history sheet, clinical examination, and radiological examination at intervals while functional outcome was assessed at follow up visits using Weber’s assessment protocol. Results: 50 (83.3%) cases radiological union is achieved by 6 weeks while 10(16.7%) cases union time was 10 weeks. Average time for union was 6.7 weeks. The final outcome as per the Weber’s assessment protocol was 50% as excellent, 40% as good and 10% as poor result which showed good correlation with level of reduction achieved graded from immediate post-operative radiographs. Conclusion: Accuracy of reduction and rigid fixation was found to be a major determinant of functional outcome irrespective of the type of fracture. Posterior plate fixation gives bicortical screw purchase leading to secure fixation, no intra- articular penetration, decreased complications, hardware prominence and wound dehiscence.

204-208

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

Introduction: Even though mini-open rotator cuff repair is still commonly performed, and results are comparable to arthroscopic repair, all-arthroscopic repair of rotator cuff tear is now fast becoming a standard care for rotator cuff repair. The purpose of the study was to evaluate the functional outcome of arthroscopic rotator cuff repair in rotator cuff tear patients. Materials and Methods: This prospecutive study included 22 cases of rotator cuff tear patients of either sex fitting the inclusion criteria at the orthopedic department of Sanjay Gandhi Institute of Trauma and Orthopedics, Bangalore from September 2016 to December 2017. Patients included were between 18 to 70yrs of age with MRI proven rotator cuff tear who underwent all arthroscopic rotator cuff repair and willing to participate in study. Exclusion criteria included associated shoulder lesions, revision rotator cuff repair, irreparable tears, acj arthritis and rotator cuff tear arthropathy. Patients admitted with MRI proven Rotator cuff tear after meeting the inclusion and exclusion criteria are selected for the study. They will undergo detailed history, clinical and radiological evaluation. Arthroscopic rotator cuff repair by single row or double row technique using suture anchors by a single trained surgeon. Postoperative rehabilitation as per standard protocol. Postoperative evaluation done at, 3rd month, 6th month and 1 year. Range of motion, UCLA and ASES scoring done at preoperative and postoperative follow-ups. Results: A Prospective study with 22 patients is undertaken to study the functional outcome of Arthroscopic rotator cuff repair. The mean age in our study is 53.5 years majority are in the age group 40 to 60yrs. Out of 22 patients, 13 were male, 9 were female. Major part of our study contained partial thickness tears (59.1%) rather than full thickness tears (40.9%). 81.8 % (18) patients in our study had traumatic tears and 18.2%(4) patients had degenerative tears. There is significant improvement of flexion from 126.8° preoperatively to 147.0° postoperatively at 1year, abduction from 125.3° to 149.5°, external rotation from 51.1° to 80.2°, internal rotation from 40.45° to 67.5°. In our study according to UCLA score, out of 22 patients, 3 patients had poor outcome, 7 patients had average outcome, 8 patients had good outcome and 4 patients had excellent outcome. Mean UCLA score increased from 9.09 preoperatively to 28.50 postoperatively at the end of 1st year. Conclusion: Arthroscopic rotator cuff repair is as good as mini open repair in outcome. Advantages of arthroscopic rotator cuff repair include, less postoperative pain, small scar and ability to diagnose other shoulder pathologies. Patients need preoperative physiotheraphy to achieve good range of motion before surgery for better final outcome.

214-216

Authors: Nareshkumar Satyanarayan Dhaniwala, Mukund Naresh Dhaniwala

Introduction: Ossifying fibroma is a rare tumor seen in children in diaphysis of tibia or fibula, maxilla, mandible or temporal bone. Its clinical and histological picture have variable and confusing features. The case report hereunder describes an atypical case of ossifying fibroma involving both radius and ulna in an adolescent girl. Benign on the basis of history, the case had features of aggressive tumor on clinical and radiological examination. Histopathology did not show any features of malignancy. The patient underwent excisional biopsy followed by below elbow amputation. The patient remains asymptomatic without any features of recurrence 24 months post-surgery.