Indian Journal of Orthopaedics Surgery

117-123

Authors: Angad Jolly, Rahul Bansal.

Shaft humerus fractures account for approximately 2 to 3 % of all fractures and are commonly encountered in clinical practice. Many can be managed conservatively and those that are operated can be treated by either plating or nailing techniques. This study was done to compare the two commonly performed surgical techniques. 60 patients who were admitted with fracture shaft of humerus and given operative treatment were studied for functional outcome, radiological outcome and complications of the procedure. 30 of these patients were treated with ORIF with Locking Compression plates and the remaining 30 were treated with CRIF with IMIL nails. The two groups were comparable at baseline when the demographic characteristics were compared. Follow up showed a statistically significant difference in the operative time, operative blood loss and hospital stay post-surgery all in favour of the IMIL nail group. Functional outcome in both the groups was comparable except for a statistically significant increase in the incidence of shoulder related complications, and increased risk of implant failure in the IMIL nail group. No significant difference was seen in the radiological outcome between the groups. We concluded that ORIF with locking compression plates is a better surgical option for managing humerus shaft fractures as compared to CRIF with IMIL nails due to a better functional outcome and lesser chance of implant failure, despite there being a larger volume of intra-op blood loss and longer duration of surgery.

128-134

Authors: Biswajit Sahu, B.N.Mohapatra, Dillip Kumar Chand.

Displaced middle third clavicle fractures have always posed a therapeutic challenge to the orthopaedic surgeons. Incidence of these fractures varies from 2.6–4% in adults. Majority (about 80%) of the clavicle fractures occurs in middle third. Despite this high numbers, proper treatment is still controversial. The aim of this study is to evaluate the rate of union in mid-third fractures of the clavicle treated by non-operative methods and by clavicular plating, to determine the complications and to Compare the functional outcomes of displaced fracture of the middle third of clavicle treated with non-operartive and surgical management by plating .This is a prospective study in which 50 cases of displaced mid-shaft fractures of clavicle were treated randomly. 25 cases were operated with internal fixation by plate osteosynthesis and 25 patients were followed with conservative management. Functional evaluation was conducted at regular interval with the use of the constant murley scores. Union was evaluated clinically and radio graphically. In the non-operative group 21 cases (84%) united, while 4 cases (16%) went on to non-union and the mean constant score was 84.48±7.8. In the Operative group, 96% union rate was found and the mean constant score was 93.72. To Conclude, Excellent functional outcomes, earlier return to daily activities, decrease incidence of nonunion can be achieved with surgical management of displaced clavicle fractures compared with non-operative treatment.

143-146

Authors: Apoorva Vijaysinh Dodia, Aparna V. Dodia, Purvi A. Dodia.

Background: Traditionally there are two ways to drill a femoral tunnel – Transtibial method where the drilling is done through the already made tibial tunnel and Transportal method where the drilling is done through anteromedial portal or accessory anteromedial portal. Both the methods have their own set of advantages and disadvantages. Aims: Aim of this study is to compare the functional and clinical outcomes of arthroscopic ACL reconsturction using transportal versus transtibial approaches for femoral tunnel drilling. Materials and Methods: All patients operated with arthroscopic ACL reconstruction were screened using the inclusion and exclusion criteria, informed consent was taken and the willing patients were included. Patients were selected for either study group (transportal and transtibial groups) both prospectively and retrospectively from data dating back to 2010. 87 patients were included in the transportal group (group I) and 75 patients in the transtibial group (group II). Protocol was approved by Institutional review board. They were then evaluated using 5 different evaluation systems i.e. IKDC, Lysholm, Lower Extremity Activity Score (LEAS), Tegner and pain VAS at 3 months, 6 months and 1 year post surgery. Results and Conclusions: In our series, Statistical analysis shows that: · There was significant difference in functional outcome on comparing the IKDC knee score of Group I and Group II at 1 year. · There was significant difference in functional outcome on comparing the Lysholm knee score of Group I and Group II at 1 year. · There was no significant difference in functional outcome on comparing the LEAS score of Group I and Group II at 1 year. · There was significant difference in functional outcome on comparing the Tegner's score of Group I and Group II at 1 year. · There was significant difference in functional outcome on comparing the Pain on VAS of Group I and Group II at 1 year. · There was significant difference in the Physical Component Survey but not in the Mental Component Survey on comparing all 10 criteria of the SF-36 score of Group I and Group II at 1 year. · There was no significant difference in functional outcome on comparing the average knee ROM of Group I and Group II at 1 year. · The Percentage of cases who had a Lachman's test positive 1 year post­operatively was higher in Group II than Group I.

153-159

Authors: Kosalaraman Padmanaban, Major Kamalanathan, Balamurugan Palaniswamy, Vivekanandan Ramasamy, Ajay Pau.

Background: The management of distal Tibia fractures has been a great challenge to orthopaedic surgeons due to soft tissue damage, extensive comminution, intra-articular extension and lack of vascularity. Materials and Methods: Twenty five adult patients treated by anterolateral 3.5mm distal Tibial LCP by MIPPO technique between December 2014 and July 2016 were included in the study. The radiological outcome was assessed by Tenny and Wiss score and the functional outcome by AOFAS scale. Results: Of the 25 patients in the study, 18 were males and 7 were females. The mean age was 49.32 years (range: 21-75 years). The majority of cases were AO type 43A3 (36%). Complete fracture union was achieved by 21 weeks (14-30 weeks). At final follow up 18 fractures united with no angulation at fracture site while 1 united in valgus (<100) and 1 varus (<50) and 3 in sagittal angulation (<10º angulation in both) which were consistent with acceptable limits. The mean AOFAS score was 79.16 after 8 months, with 4 cases having excellent outcome, 14 good, 3 acceptable and 4 cases with bad outcome. The complications in this study were angular deformity 5(20%), Infection 4 (16%), non-union 2 (8%), implant breakage 1 (4%). Conclusion: Anterolateral distal Tibial plating by MIPPO technique gives good functional and radiological outcome with advantage of minimal soft tissue dissection without stripping the periosteum and preventing subsequent devascularisation of fracture fragments but it requires a long learning curve. Thus we conclude that anterolateral distal Tibial locking plate is a good option for managing the distal Tibial fractures.

165-170

Authors: Rajendra Butala, Vinit Karn, Kuldeep Jain, Sohrab Ahmed, Udit Kapoor.

Background: A prospective study was done in the Department of Orthopedics in D.Y Hospital, Navi Mumbai from October 2015 to February 2017 to evaluate role of subchondral ulno-radial k wire to avert collapse in non-comminuted extra and intra-articular fracture of distal end radius. Methods: All the patients attending OPD and emergency with non-comminuted distal end radius fracture without ulna fracture were admitted and operated in our hospital over a period of 1 year and 6 months. A total of 30 patients were included in our study and fixed with percutaneous k-wires (Bicortical cross) along with a transverse trans ulno-radial k wire directed from distal ulnar metaphysis to distal radius subchondrally, so as to fix DRUJ & maintain ulnar variance and radial height by preventing its immediate as well as late collapse. AO classification for fractures was used and only type A (extra-articular A1& A2), type C (Complete articular C1) were included. Type B (partial articular) was excluded from study. Results: All the 30 subjects (n=30) of fracture distal end radius, were managed by closed reduction and percutaneously fixed bicortical k-wires along with subchondrally placed distal trans ulno-radial k wire. Anatomical evaluation was done according to the Sarmiento’s modification of Lindstrom Criteria. Clinical and functional outcomes were evaluated according to the demerit point system of Gartland and Werley with Sarmiento modification. Conclusion: To accomplish anatomical reduction with DRUJ congruence and neutral to negative ulnar variance along with maintenance of radial height in extra articuar and intra articlar distal radius fracture only k wire fixation is not competent enough and needs augmentation with trans ulnoradial k wire. Trans ulno-radial k wire provides addon to rigid fixation and helps in prevention of early and late collapse thus ensuring better anatomical, functional and radiological outcome.

176-180

Authors: Zulfikar M. Patel, Kaushal R. Patel, Sulay A. Sachdev, Ranjan B. Patariya, Bhavya B. Shah.

Introduction: Fractures of lower end radius remains the most common fracture in emergency room and mostly treated with closed reduction followed by cast of paris of plaster or some surgical procedure in term of minimal invasive or invasive procedure. The minimal invasive procedure includes k wire followed by cast or external fixator. Objective: To evaluate the effectiveness of external fixation in all types of distal end radius fractures. Materials and Methods: This is the retrospective study of fractures of distal end of radius treated by external fixator in Civil Hospital, Ahmedabad from 2013 to 2015. Results: This is a retrospective study of 200 consecutive unstable distal radius fractures. - There were 66 females and 134 males. - Fractures were classified according to AO classification. - Complications included pin tract infection loss of reduction, reflex sympathetic dystrophy and tendon attrition. - The patients were reviewed at a mean of 6 months after surgery for radiological and functional assessment. - Average volar tilt on follow up was 9.6 degrees, - Average radial length on follow up was 9.7 mm - Average radial inclination on follow up was 20 degrees. - Ao type C2 and C3 and osteoporotic bone shows loss of reduction. - 150 patients had excellent or good anatomical results, according to Sarmiento criteria. - 170 patients had excellent or good functional results. According to Gartland and Werley scoring system. Conclusion: Thus close reduction followed by percutaneous pinning (k –wire) in term of external fixator is valuable technique for displaced and intra articular type of lower end radius fracture. The method is relatively simple, minimally invasive and reliable.

184-187

Authors: Ram Chander Siwach, Jagannath Desai, Pradeep Kamboj, Sumit Kumar.

Introduction: Total hip arthroplasty has been in constant change since its inception. Polymethylmethacrylate, a bone cement introduced by Haboush as a mecahanism for achieving rigid initial fixation have lost its popularity due to problems of loosening of stem and cup. Objective: Evaluation the clinical and radiological outcome of uncemented large diameter head in total hip arthroplasty. Materials and Method: Out of twenty five hips, twenty four patients were operated upon for large diameter head in total hip arthroplasty in the Department of Orthopedics, Pt. B.D.S. P.G.I.M.S. Rohtak. Results: The cases studied included patients from age of 21 years to 60 years with an average age of 40.5 years. 14 cases (58.33%) had avascular necrosis of head of femur, 5 cases (20.83%) had osteoarthritis, one patient had rheumatoid arthritis. 15 patients (60%) were operated on left side, while 8 (32%) were operated on right side and 1 (8%) case was operated on both sides. Metal-on-metal THR was done in 8 cases (32%), Metal-on-polyethylene THR was done in 17 cases (68%) and Ceramic-on-ceramic was done in none. Postoperative pain was absent in 15 patients (60%), mild pain was seen in 9 patients (36%) and moderate pain in one patient (4%). Conclusion: Total hip arthroplasty continues to be an ideal procedure for achieving painless, mobile, stable hip in cases with advanced hip disorders.

193-196

Authors: Ravikiran H G, Adarsh T, Gowrahar, Ravi Shankar, Tushar Pimpale.

Introduction: This study was undertaken to evaluate LOP (lowest occlusion pressure) is superior to the other ways of usage of Pneumatic Tourniquets in Orthopaedics surgery i.e. Fixed and Systolic BP variant. Materials and Method: 120 cases of both upper and lower limbs operated from period September 2013 to October 2015 are randomly included in the study after full filling the inclusion and exclusion criteria and managed using Fixed, Systolic BP and LOP, each of the groups included 40 cases and results were analysed according to final outcome using Ishii et al. grading, VAS Score criteria. Results: In our study 120 cases managed by LOP has a better result when compared to fixed variant and Systolic BP variant in terms of less pressure needed to keep tourniquet, good operative field, pain score (VAS) at tourniquet application region and skin injury(reddening). Bloodless field was excellent in 33 patients {[14 (35%) in LOP, 9(22.5%) in Systemic and 10 (25%) in Fixed Tourniquet variant. Among 120 patients, 11 (27.5%), 35 (87.5%) and 40 (100%) patients had experienced Skin abrasions/ Flaring were observed in the patient who underwent LOP, systemic and Fixed Tourniquet respectively. But no complications like compartment syndrome, deep vein disorder, paresis, nerve injury has occurred before and after surgery. Conclusion: LOP is superior to all other ways of Tourniquet in terms of less pressure needed for elevating tourniquet, Good operative (bloodless) field, no skin abrasions.

202-208

Authors: Subbiah Shanmugam, Gopu Govindasamy, Sujay Susikar, Jagadeesan G. Mani.

Introduction: Inadequate knowledge still exists about Giant Cell Tumor of Bone (GCTB) incidence, treatment and prognosis and moreover, standard treatment has not been formulated till date. Hence, the objective of the present study is to assess the demographic characteristics, treatment modalities and its complications, post-operative functional outcome assessment and long-term prognosis of south Indian population with GCTB, treated from tertiary cancer center in Chennai. Materials and Method: A retrospective study of prospectively maintained data was conducted in 33 GCTB patients treated at Government Royapettah Oncology Centre (Chennai) from January 2009 to December 2016. SPSS software of version 21.0 for windows was employed for statistical analysis. Results: The mean age of the studied populations was 31.06 ± 10.83 years (range from 15 – 65 years, median-27 years). The mean duration of follow-up period was 9.6 + 6 months (range from 2 to 24 months). The male to female ratio was 1:1.5(male: 13(39.4%) and Female (20 (60.6%). GCTB patients underwent treatment ranging from cryotherapy, intralesional curettage alone and wide local excision to resection with or without reconstruction with custom mega prosthesis for different anatomical locations. Conclusion: From our analysis, we conclude that the GCTB patients of south India possess slightly different characteristics in terms of higher incidence in radial bone. In conclusion, resection with CMP reconstruction may be a suitable surgical option for advanced stage GCTB patients with reduced complication rate and provide good functional limb. Hence, devising an early identification and treatment strategy according to risk stratification becomes mandatory.

217-226

Authors: Kunal Navale, Pramod P. Neema, Vishal Gupta, Murtuza Rassiwala.

Introduction: Advanced internal fixation techniques, including pedicle screws, have been developed and used extensively in spine surgery, not only for traumatic injuries but also for degenerative conditions. Free hand pedicle screw fixation technique have the advantage of universal application, fixation strength, and stabilization of all three mechanical columns of the spine. Free hand pedicle screw placement based on external anatomy alone can be performed with acceptable safety and accuracy and avoids excessive radiation exposure. Materials and Method: This was a prospective study done in Department of Orthopaedics at our institute. 30 consecutive patients who underwent posterior thoracic instrumentation from May 2015- May 2016 were analysed. The mean age was 39 years. The etiologic diagnoses were - spinal trauma-22, spinal tuberculosis-05, spinal deformity-02, and spinal tumour-01. Titanium pedicle screws used in all these vertebrae were polyaxial in nature and of 4.5mm or 5.5mm diameter with length ranging from 25mm to 50mm. 168 screws were inserted in 84 thoracic vertebra (T1-T12) by free hand technique as described by Kim et al. Informed consent was taken. Clearance from ethical committee of the institute was taken. The patients were followed-up with X-ray, CT Scan at immediate postoperative and reviewed at 1 month and 3 months postoperative with radiograph. Results: 168 screws were inserted in 84 thoracic vertebra (T1-T12) with number of screws inserted at each level as follows T1 =0, T2=4, T3=6, T4=8, T5=14, T6=14, T7=16, T8=16, T9=18, T10=18, T11=24, T12=30. All the screw were evaluated post operatively. Of 168 screws 144 screws (85.70%) were intraosseous and accurately placed. 24 screws (14.28%) in patients were malpositioned. Of 24 perforations 3 screws (1.78%) had critical medial breach of more than 2 mm perforation, however no neurological worsening was noted post operatively in any case. Rest 21screws (12.50%) perforations were non-critical. In 3 patients (deformity 1, trauma 1 and infection 1) sudden give away was felt during gear shift probing, and a breach confirmed on palpation/probing and the screw was re directed. None of the patients had any incident of CSF leak or excessive bleeding during screw insertion. Conclusion: The free hand technique of thoracic pedicle screw placement performed in a stepwise, consistent, and compulsive manner is an accurate, reliable, efficient and safe method of insertion to treat a various spinal conditions, with almost same rate or less number of complications as performed with fluoroscopy guided pedicle screw insertion. Our results with less than 2 percent of critical breach, document that we have been able to create a safe method of thoracic pedicle screw placement without use of other intra operative imaging modalities. One must have a thorough knowledge of spine and vertebral anatomy, follow and use deligent and repetitive confirmatory steps to compulsively assure interosseous screw placement.