Indian Journal of Orthopaedics Surgery

1-3

Authors: Druvan Shaji,Anubhav Sharma*,Thadi Mohan

Introduction: It has been proposed that a narrow intercondylar notch may increase the risk of anterior cruciate ligament (ACL) injury but the data are conflicting. We performed this cross-sectional study to investigate the significance of Notch width index for ACL tears. Materials and Methods: All adult patients with knee problems, who were referred to the Department of Orthopaedics Amrita Institute of Medical Sciences, Kochi and underwent MRI knee, from August 2016 to August 2018, were included in this study. Axial and longitudinal MRI was performed using 1.5 Tesla or 3 Tesla MRI with the patient's knee in an extended position. In all patients, the femoral notch Index was measured. Patient were divided into 2 groups depending on their NWI (<0>0.2) Because of the effect of osteoarthritis in decreasing the intercondylar notch index, cases with obvious osteoarthritis were not included in the study. To test the statistical significance of the difference in Femoral Notch Width Index with respect to gender Student’s t test was used. To test the statistical significance of difference in percentage’s with respect to ACL tear (yes or no) and Femoral Notch Width Index(<0>0.2) Chi-square test was used. Results: 300 patients were enrolled in the study. The age range was 20-50 years. We found that group 1 (<0>0.2 NWI). We also found that male’s have a higher NWI as compared to females (p value <0> Conclusion: ACL tear was found to be higher among the patients with NWI < 0>0.2 which is statistically significant.

10-14

Authors: Eeshan Bhardwaj*,F Abdul Khader

Introduction: Clavicle is the bone which links thorax to the shoulder and help in movements at shoulder joints. It is the first long bone to ossify in the body. Clavicle fractures are the most common fractures in the upper limb. The purpose of this study is to measure the functional outcome of mid third displaced clavicular fractures treated by open reduction and internal fixation with plate osteosynthesis and conservative management. |Materials and Methods: This study was done in Tertiary Institute, Ammapettai, in between May 2017 – September 2018, Ethical committee approval obtained, IHEC No: 2017/312.Patients were allocated in two groups and were given treatment as per the group. 20 cases were treated conservatively and 20 with plate osteosynthesis. Patients were followed every 3rd, 6th, 9th month. Result: The mean union rate in our study was 10 weeks and constant shoulder score was 90 for conservative group. 20 patients in plate Osteo-synthesis the average union was 6wks and constant shoulder score was about 95 with an excellent grade. Conclusion: Plate osteosynthesis in displaced midshaft clavicle fracture has resulted in excellent functional outcomes and also good union rate.

21-28

Authors: Vikramjit Singh,Anirudh Bansal,Arvind Kumar*,Sudhir Rawat,Bhagirat Sinh Kela

Introduction: Lumbar spinal stenosis is a frequent indication for spinal surgery. The clinical symptoms may not be accurately reflected on radiological studies. Treatment is aimed at not only obtaining immediate pain relief but also in preventing its long?term disabling sequelae. The walking ability needs to be correlated with functional outcome measures in assessing patients with symptomatic lumbar canal stenosis (LCS). Aims and Objectives: To study and evaluate the outcome of surgery for degenerative LCS on a clinical, radiological, and functional basis, and to establish an association between various factors that may be influencing the development of LCS. Materials and Methods: A prospective study of 24 patients was carried out at the Department of Orthopaedics, Dhiraj General Hospital, Piparia, Vadodara, in whom the LCS was confirmed and measured on magnetic resonance imaging images by thecal sac cross?sectional area (CSA). The functional assessment pre-operative and post-operatively was calculated according to the Japanese Orthopaedic association score. Results: Overall, 83.33% patients (n=20) in our study showed improvement in all variables of the JOA scoring system postoperatively. 66.66% patients (n=16) showed excellent outcome, 25% (n=6) showed good outcome, and 8.33% (n=2) showed fair outcome. No patient had poor outcome. After surgery 95.83% patients (n=23) had normal gait with walking distance more than 500 m and no claudication symptoms. Conclusions: Operative treatment in patients of degenerative lumbar canal stenosis with decompression and spinal instrumentation yields excellent results as observed on the basis of JOA scoring system

35-41

Authors: Ravindra Patil,Sowen Modi*,Sreeharsha Rajoli,Ratish Kumar,Gunjan Ghelani

Introduction: Subtrochanteric typically defined as area from lesser trochanter to 5cm distal. Treating a subtrochanteric fractures is associated with difficulties due to anatomical and biomechanical factors comprising mainly due to poor reduction, varus deformity, non union, poor bone quality, comorbidities. Encerclage wire helps in reduction but its use remains controversial due to disturbance of blood supply to the underlying bone and soft tissue damage. This study was undertaken to study the use of encerclage wire for fracture reduction and associated complications. Materials and Methods: Retrospective analysis of patients of age group 20 years and above having subtrochanteric femur fracture, admitted and treated with Long PFN between June 2016 and Sept 2018 were considered in this study. After exclusion 34 patients with an average follow up of 16.8 months were included in this study. Indications for encerclage were fracture patterns like long oblique, spiral, spiral wedge or comminuted fracture with butterfly fragment. Cerclage wire was employed in 15 patients and wire passed through cerclage wire passer. Assessment was done in terms of operation time, quality of reduction, neck shaft angle, union time, complications and final functional outcome by Harris Hip Score. Result: Average operation time and blood loss was significantly higher in cerclage group as compared to without encerclage (p =0.042), anatomical reduction was achieved by in 93% in encerclage group as compared to 79% in non encerclage group. Postoperative Neck shaft angle was 132.80 versus 132.10. Mean Union rate was 14.3 weeks versus 15.6 weeks. 3 patient in non encerclage developed non-union of which 2 patients had nail breakage superficial wound infection was seen in 1 patient in encerclage group and was resolved with regular dressing. Mean range of hip flexion was 123.6o and extension was 14.8o. Conclusion: Encerclage wire gives a better outcome for fracture reduction, decreases varus deformity, and overall there are no major complications. It is although associated with increased operation time and blood loss.

46-51

Authors: S Aathithya*,Mohan B Chowdhary

Introduction: Globally about 70% of the hip fractures are due to the neck of femur fracture. Surgical management has proved to be clinically and functionally superior to conservative immobilization. Hence the study is to assess the optimal treatment modality for the treatment of neck of femur fractures. Materials and Methods: The present study is an analytical cross-sectional study. About 70 patients diagnosed with unstable neck of femur fractures who were treated with total hip replacement as 35 cases (Group 1) and bipolar hemiarthroplasty as 35 cases (Group 2). The study duration was from April 2016 to September 2018. Results: The female population was also found to be more prone for fractures in both -THR group (65%) and bipolar hemiarthroplasty group (60%). The mean duration of stay in the hospital is lower in the THR group (6 days) when compared with the bipolar hemiarthroplasty group (8 days). The mean time till full weight bearing walking (days) was observed to be significantly reduced in the THR group (2.73 days) when compared with the bipolar hemiarthroplasty group (3 days). The mean mortality rate in the THR group (3.3%) was observed to be lower than the bipolar hemiarthroplasty group (5.5%). Conclusion: Total hip replacement, however is observed to be superior to bipolar hemiarthroplasty in terms of duration of hospital stay, immediate full-weight bearing walking and better functional outcomes with fewer complications.

57-65

Authors: Madhuchandra P,Sunil Santhosh G*,Raju K.P,Pawankumar KM,Nandeesh S

Introduction: Incidence of fractures around the hip is increasing worldwide owing to increased life span of the people and secondary to osteoporotic fragile bones. Stable intertrochanteric fractures can be easily treated by internal fixation methods. Unstable comminuted and osteoporotic idsntertrochanteric fractures are very difficult to treat. They can be treated by internal fixation with proximal femoral nail. But chances of implant failure and non union are high with highly osteoporotic and comminuted fractures. In such cases primary hemiarthroplasty is an useful alternative option. We have compared the outcomes of unstable intertrochanteric fractures treated with hemiarthroplasty and proximal femoral nail. Materials and Methods: Our study was conducted in BGS Global Institute of Medical Sciences, Bangalore from January 2014 to December 2016 on patients who had sustained intertrochanteric fractures. It was a prospective study done for a period of two years. Patients with intertrochanteric fractures who had come to our hospital were included in our study. Patients aged more than 60 years with closed intertrochanteric fractures were included in the study. Patients were divided as group I- operated with hemiarthroplasty and group II- operated with proximal femoral nail. Functional outcome of both groups was assessed using Harris Hip scale and various parameters were compared. Results: Majority of the patients were in the age group 70-79 years, 16 being females and 14 males. Commonest mode of injury was trivial fall (83.33%). Average duration of hospital stay for hemi-arthroplasty patients was 14.33 days and for PFN patients was 11.86 days.15 patients had associated conditions like diabetes or hypertension. Average intra-operative blood loss was 516.66 ml for hemi-arthroplsty and 187.33 ml for PFN. Average operating time for hemi-arthroplasy was 80 minutes whereas for PFN was 83.33 minutes. Mean harris hip score at the end of one year for hemi-arthroplasty was 76.46 and for PFN was 77.8. Conclusion: The outcomes of both the modalities are almost equal. PFN has an advantage of shorter operative time, less blood loss, lower hospital stay with no difference in functional outcome or general complications as compared to hemiarthroplasty. Major advantage of PFN is patients treated with PFN can squat and sit cross legged after fracture union. Hemiarthroplasty does provide a stable, pain-free, and mobile joint with a very low complication rate as seen in our study; however a larger prospective randomized study with longer follow up comparing the use of PFN against primary hemi-arthroplasty for proximal femur fractures needs to be done

72-82

Authors: R Sahaya Jose*

Introduction and Objectives: The Aim of this study is to evaluate the Short Term Functional Outcome of Unipolar and Bipolar hemiarthroplasty in Intracapsular neck of femur fracture. Materials and Methods: 40 patients with Intracapsular fracture neck of femur were included in this study. 20 patients were treated with unipolar hemiarthroplasty and 20 patients with bipolar hemiarthroplasty, respectively. In both the groups, patients were evaluated for functional outcome by using Harris hip score. The Data was analysed by SPSS 20.00 using Chi-square test. Results: Our overall mean Harris hip score pre operatively for unipolar hemiarthroplasty was 36.2 and bipolar hemiarthroplasty was 39.1 which increased to 81.8 for unipolar and 85.05 for bipolar hemiarthroplasty respectively, with p-value of <0> Conclusion: The results of our study shows that uncemented bipolar hemiarthroplasty gave better results when compared with uncemented unipolar hemiartheoplasty. Our results also shows that, cemented bipolar hemiarthroplasty gave better results when compared with cemented unipolar hemiarthroplasty clinically. Thus, Bipolar hemiarthroplasty did better when compared with unipolar hemiarthroplasty in general.

88-94

Authors: Varun Khanna*,Rakesh Sharma

Introduction: For decades, knee OA had been viewed as a disease mostly affecting older population, consequently, only few population-based studies have examined the frequency and characteristics of OA knee in persons under the age of 40 years leading to dearth of literature over this subject matter. Recent evidence however, documents increased incidence of two key risk factors for knee OA – traumatic knee injury and obesity, particularly in the young. Studies have shown that mean age of onset of osteoarthritis knee has decreased over couple of decades and projected incidence of the disease in young is on the rise. Materials and Methods: Patients of either sex coming to the OPD of the Department of Orthopaedics with chief complaint of knee pain were assessed as per the preformed and pretested questionnaire and subjected to AP view of both knee in standing position until 200 such cases with age ? 40yrs were separated. The cases were assessed as per Kellgren Lawrence grading. The patients were also assessed for height, weight, BMI and other parameters. Cases were selected carefully after excluding the subjects as per the adopted exclusion criterion. Results: After survey of 200 knee pain patients below 40 years of age, over a period of one and a half years, incidence of primary osteoarthritis knee on the radiological basis was found to be 6.54%. Mean age of 200 subjects were 34.7 years with female: male ratio being 6:1(p=0.004). 82.1% cases of OA had BMI >24.9kg/m2 (p=0.004) whereas 80 females cases had BMI>24.9kg/m2 (p=0.007). 53.5% cases had predominantly sitting/ squatting /kneeling as household habits (p=0.02). 67.8% cases were of medium activity group on the basis of their occupation while 57.1% (p=0.05) of cases had history of OA knees in the first degree relatives. Conclusion: The incidence of OA knee in the young is increasing. Knowing the risk factors and disease volume in younger age groups would allow primary prevention of OA to be implemented in young adulthood to curtail the emergence of radiographically-defined OA at the mid-life and also prevent disabilities saving the healthcare system from the tremendous economic burden of the disease.

99-100

Authors: Ashok Goel,Mridul Maheshwari,Mohammed Saif Niyazi*,Alok Gupta

An End cap for an Intra- medullary nail is normally used to prevent bone overgrowth into the proximal end of the nail and to facilitate nail removal at a later date. End cap migration into the proximal redundant space in the medullary canal behind the nail is rare but an avoidable complication. Maintenance of a fixed position of knee flexion during reaming and nail insertion and the use of Cannulated End Cap systems with Image control and may reduce the incidence of this complication.

310-315

Authors: Keyur Shah,Abhishek Gol*,Dhimant Patel,Hriday Acharya,Ranjan Patariya

Introduction: Intertrochanteric Femur fractures comprise approximately more than half of hip fractures caused by low energy mechanism seen more commonly in geriatric people, women,osteoporosis,a history of fall and gait abnormality. There are surgical managments available for this kind of fractures but still there are some failures. Above mentioned factors are responsible for failures. For that revision surgery is required. Here we are going to search outcomes of DCS in failed PFN in IT fractures. Materials and Methods: A retrospective study of 10 patients, treated with dynamic condylar screw (DCS) for implant failure after doing PFN in Intertrochanteric fracture were stastastically reviewed from march 2017 to march 2018. Observation and Results: Out of 10 cases 4 were young (<60>60years). 4 out of 4 young patients and 3 out of 6 elder patients were united properly. Nonunion was seen in 1 patient. Delayed union was seen in 1 patient and Implant failure was seen in 1 cases (10%). Restricted weight bearing status post-operatively was associated with significantly lower incidence of implant failure.Using the DCS, the results were good in the young patients with high-energy injuries. However, the implant failure rate is high in elderly patients who suffer low-energy fractures. The DCS should not be used if weight bearing cannot be minimized in this group. Conclusion: The dynamic condylar screw is a safe and reliable implant for the management of Periimplant Subtrochanteric fractures in previously operated with PFN with predictable results when principles of open reduction and internal fixation is followed as compare to other methods of fixation in developing country.

320-324

Authors: J Tharik Ajees*,Mohan Kumar M

Introduction: Primary osteoarthritis is a very common progressive disease which usually ends up in deformities and morbidity. Osteoarthritis usually presents with joint pain, tenderness, limitation of movement, crepitus. BMAC can be useful in reducing pain and improve functional outcome with also in progressive of disease. Materials and Methods: This is an observational study conducted during the period of April 2015 to June 2017 on 30 samples. The descriptive statistical analysis was performed. The surgical procedure of Bone marrow aspirate concentration was carried out. Evaluation of Pre-Operative and Post-Operative functional outcome. Results: In this 19 (63.3%) patient presented with left knee osteoarthritis and 11 (36%) patients right knee osteoarthritis. 19 patients presented with grade 2 osteoarthritis and 11 patients presented with grade 3 osteoarthritis. VAS pain score 86.6% were in score range of 3-4 preoperatively which decreased to score range of 0-2 100% of the patients after BMAC Injection postoperatively at 6 months follow up. Conclusion: The use of Bone marrow concentrate injection (BMAC) in Osteoarthritis of knee was found to be more efficacious with good clinical and functional outcome.

332-337

Authors: Sanjeev Kumar Singhal*,V K Sahni,Manoj Garg,Anand Gupta

Introduction: The purpose of this study was to report the clinical and radiological outcome following treatment with locking plate fixation in patients of comminuted fractures of the proximal ulna including olecranon and Monteggia fractures. Materials and Methods: Between 2015 and 2017, thirty patients with comminuted fractures of the proximal ulna including 21 cases of fracture olecranon and 9 cases of Monteggia fractures were managed with locking plate fixation. The patients were followed for clinical and radiological examination for minimum 6 months post operatively. Validated patient-oriented assessment scores involving the Mayo Elbow Performance Score (MEPS) and postoperative range of motion and patient's satisfaction were evaluated. Results: The mean arc of elbow motion in 21 cases of olecranon fractures was 108° and mean MEPS was 89.3 with 57% excellent and 43% good results. While in 9 cases of Monteggia fractures mean arc of motion was 108° and mean MEPS were 93.8 with 89% excellent and 11% good results. All patients achieved fracture union by 24 weeks. Mean duration of fracture union for olecranon fractures was 16.1 weeks and for Monteggia fractures 14.3 weeks. Conclusion: Locking plate is an effective fixation method for fractures of the proximal ulna allowing reliable stability for early elbow motion. The functional results are comparable with formerly described plating systems. The good radiological outcomes highlight the usefulness of plate fixation in cases of proximal ulna fractures, provided optimal plate positioning achieved.

342-347

Authors: Sandeep Krishna Avulapati*

Introduction: Periarthritis shoulder is unique condition, in sense that same pathology does not affect any other joints in particular other than shoulder.2 Spontaneous occurrence of pain in shoulder unrelated to injury, but at times associated with injury in 20-30% of cases.2 Main aim of treatment is symptomatic pain relief followed by restoration of normal joint movements. Manipulation under General Anesthesia (MUA) appears to be mainstay of treatment for people who do not benefit by physiotherapy and universal shoulder mobilization exercises.3 Aim of Study: To study effect of manipulation under general anesthesia on Periarthritis shoulder. Objective: To study improvement in Range of Movements, Pain and Short DASH score. Materials and Methods: Study was carried out in Pushpagiri Institute of Medical Sciences and Research Centre during September 2010 to September 2012. 40 patients were selected for the study, underwent MUA with intra-articular steroid injection (40mg/ml methyl prednisolone), 2% Lignocaine (5ml) and Hydrodilation (40ml cold normal saline). They were started physiotherapy immediately and continued. Result: Among the 40 patients 6 patients never returned for follow-up. Data analysis of remaining 34 patients shows improvement in shoulder range of movement. Quick DASH score decreased from 83.72(S.D + 7.1) to 27.66 (S.D + 7.0). VAS score improved from 7.29 (S.D + 1.03) to 1.71 (S.D + 0.84). Conclusion: Periarthritis shoulder, treated with MUA with intra-articular steroid (steroid+Lignocaine) and hydrodilation (with normal saline) result in good immediate pain relief postoperatively and easy breakage of adhesions during the procedure. This followed by immediate physiotherapy decreases pain, adds good functional recovery and early return to daily activities of living. Physiotherapy and universal shoulder mobilization exercises should be continued thereafter to prevent recurrence of symptoms.

354-361

Authors: Ashish Devgan,Chanchal Barman*,Monish Malhotra,Rajesh Rohilla,Pradeep Yadav

Introduction: Anterior Cruciate Ligament (ACL) is the most frequently injured knee ligament. Combination of valgus force with internal rotation is the most common mechanism involved in ACL injury. Both modifiable and non-modifiable risk factors are responsible for the ACL injury. Purpose: To determine the risk factors causing ACL injury by comparing lower limb anatomical features, ACL size and body mass index (BMI) between ACL deficient and ACL intact knees. Materials and Methods: Mechanical axis deviation from vertical axis, tibiofemoral angle, hip neck-shaft angle, posterior tibial slope, notch width index were compared using radiography. BMI and ultrasonographic (USG) diameter of ACL were also measured for comparison. Results: Among the anatomical lower limb parameters mechanical axis deviation from vertical axis, hip neck shaft angle and tibiofemoral angle showed non-significant (p value>0.05) differences while there were significant differences of femoral notch width index (p= 0.014) and posterior tibial slope angle (p < 0.001) between the two groups. ACL diameter (size) and BMI also showed significant differences (p < 0.05). ACL deficient knees have higher BMI (mean 25.82 vs 23.33: p < 0.001) and lesser diameter (mean 7.31 mm vs 7.99 mm; p < 0.001) compared to the ACL intact knees. Conclusion: Higher posterior tibial slope and smaller notch width index are associated with higher risk of ACL injury. Individuals with lesser diameter of ACL or higher BMI have more chances of injury to the ligament.

368-374

Authors: Dharmendra Kumar,Narendra Singh Kushwaha*,Yashwardhan Jaiswal,Amit Singh,Vineet Sharma

Introduction: Non-union of acetabulum fracture is a common occurrence in developing countries. Pelvic discontinuity due to ununited fracture acetabulum poses a serious challenge in the management of the patient. Results of ORIF of these fractures are not promising due to various reasons. We aim to present results on single-stage acetabulum reconstruction and total hip arthroplasty, the literature on which is lacking. Materials and Methods: We prospectively studied the outcome of single-stage acetabulum reconstruction and total hip arthroplasty in patients with pelvic discontinuity caused by ununited fracture acetabulum of more than 3 months duration. From March 2015 to December 2018, 11patients (7 males, 4 females, average age 42 years) were treated in our hospital. All cases underwent open reduction internal fixation with posterior column plate, impaction bone grafting, uncemented porous coated hemispherical acetabulum cup hip arthroplasty. Results: Union of the columns was achieved in all the cases with 7 patients (63.6%) showed union at 12 months and rest 4 patients (36.4%) took 18 months to unite. At final follow up, mean Harris hip score improved from 54.2 points (range 24-63) to 91.4 points (range 79-95). One superficial surgical site infection and one heterotopic ossification was noted in our study which had no sequel on clinical outcome at their last follow up. Conclusion: Single stage acetabulum reconstruction by posterior column plating with impaction bone grafting and uncemented porous coated hemispherical acetabulum cup hip arthroplasty is a genuine option in management of pelvic discontinuity caused by ununited fracture of acetabulum.

380-385

Authors: Hrushikesh Saraf,Shreepal Munot*

Introduction: Treatment of intertrochanteric fracture in elderly is not only to mobilise early but also to avoid complications and morbidity. With available treatments it is difficult to address all the issue with same surgical option. A recent advance for treatment of senile unstable intertrochanteric fracture is PFN antirotation which may help in early mobilisation with less complications. The purpose of this study is to compare the outcome of PFNA and hemiarthoplasty and to study advantages, disadvantages, complications of both the groups. Materials and Methods: 20 patients each were included in PFNA group and hemiarthroplasty group from January 2016 to January 2017 who satisfied the inclusion and exclusion criteria. Patient followed up upto 1 year. Patients were evaluated with multiple variables, complications and harris hip score. Results: PFNA groups had significantly less blood loss, less surgery time, less hospital stay as compared to hemiarthroplasty group. Both groups had similar medical and orthopaedic complications. PFNA patients can be mobilised early as with hemiarthroplasty group. Hemiarthoplasty groups have better harris hip score in initial 3 months but similar score at the end of 1 year. Conclusion: PFNA provide less morbidity to patients with early mobilisations and good functional outcome. It can definitely be a better option than replacement in elderly intertrochanteric fracture.

390-393

Authors: Vijay Chandru*,Nagakiran K V,Anupama Chandrappa,Ishani Patel

The knee joint being very commonly injured secondary to road traffic accidents, contact sports activities and repetitive activities, in such cases especially in acute conditions its difficult to rely to arrive at a accurate clinical diagnosis depending only on the clinical tests to diagnose meniscal injuries because of the painful knee so the patient is subjected to many noninvasive imaging modalities like x-ray sonography and magnetic resonance imaging and later invasive procedures like diagnostic arthroscopy to detect the proper diagnosis. So we conducted a prospective in JSS hospital study to compare all the three modalities like clinical examination, MR imaging and diagnostic arthroscopy to know the meniscal injuries of the knee joint. There were 30 patients with 26 male and 4 female patients age ranging from 18 to 55 years. History of fall with twisting injury was most common. The sensitivity and specificity of clinical examination and MR imaging with respect to arthroscopy was 83.3% and 77.78% and 91.67% and 55.56% respectively. So diagnosing meniscal injuries is of great significance to decrease the morbidity of the patient.

402-404

Authors: Ramprasath R Dhurvas*,Karthikeyan K

Introduction: Post traumatic stiffness of knee joint developing after injury with or without surgical intervention is a difficult condition to manage. Surgical management of knee stiffness includes Thompson’s quadricepsplasty and Judet’s quadricepsplasty. Materials and Methods: We have performed modified Judet’s quadricepsplasty in two cases of post traumatic knee stiffness. One patient with 0-100 movements achieved post operative range of gain of flexion of 800. Another case with 0-200 movements achieved post operative range of gain of flexion of 700. Judet’s criteria was used to analyse the movements. We achieved “good” results in both the cases. Conclusion: Thompson’s quadricepsplasty has problems like extension lag and wound dehiscence. Modified Judet’s quadricepsplasty with step wise release seems to be the preferred procedure with lesser complication rates and better outcome. Functional outcome depends on post operative pain relief, physiotherapy and patient’s cooperation.

411-413

Authors: N Abhilash*,Ronald Menezes,Jubin Abraham

Introduction: Abductor deficiency can be a debilitating problem following hip arthroplasty surgery and causes severe pain, limp and instability. Description of Technique: The authors had experienced abductor deficiency secondary to hemiarthroplasy following which a revision hemiarthroplasty was done and abductor reconstruction was performed using the anterior fibres of gluteus maximus. This flap served as a substitute for gluteus medius and minimus. Ultimately, both limp and pain showed prominent reduction.

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.

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.

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.