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   Table of Contents - Current issue
Coverpage
September-December 2022
Volume 5 | Issue 3
Page Nos. 115-196

Online since Thursday, September 1, 2022

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EDITORIAL  

Postgraduate orthopedic training – Where are we today? p. 115
Ritesh Runu
DOI:10.4103/jodp.jodp_70_22  
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REVIEW ARTICLE Top

Prognostic factors to predict the progression of adolescent idiopathic scoliosis: A narrative review p. 117
Amrit Gantaguru, Nandan Marathe, Alhad Mulkalwar, Abhinandan Reddy Mallepally
DOI:10.4103/jodp.jodp_36_22  
Scoliosis has always presented a challenge to the clinicians both at the stage of decision-making and at the stage of correcting the same. Predicting curve progression is important as it helps in selecting the patients who may benefit from an earlier intervention. Patients can be treated either by brace application or by operative intervention depending on the magnitude of curve and potential of curve progression. In this review, we have summarized the past and present parameters used to predict scoliosis progression with a brief introduction about the future trend in this respect. We identified and reviewed a total of 46 relevant papers written in English language utilizing PubMed, Google Scholar, and Scopus search engines. Many clinicians had come up with various radiological methods such as Risser grading, Tanner–Whitehouse staging (TW2-RUS and TW3) methods, Greulich–Pyle method, Sauvegrain method using only olecranon process radiographs and various clinical methods such as age of menarche and Tanner staging for sexual maturity. Apart from these, recently, various genetic factors such as single-nucleotide polymorphism of various genes, platelet calmodulin, peripheral blood mononuclear cell, impairment in melatonin signaling, DNA-based test called “ScoliScore” and hormones such as serum ghrelin and leptin have been investigated. Changes in brainstem vestibular function and alteration in electrical activities of paraspinal muscles are also studied to predict the curve progression. The two most important dilemmas faced by clinicians while approaching patients with scoliosis are the identification of patients requiring intervention and the right time to intervene in the selected patients. The goal of scoliosis treatment is to halt the progression. Predicting the growth spurt in an individual patient will guide the appropriate timing of intervention which can prevent complications associated with adolescent idiopathic scoliosis so that they can lead a better quality of life.
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ORIGINAL ARTICLES Top

Surgical result of distal humerus fractures in adults: A consecutive series of 55 cases and review of the literature p. 123
Omar Lazrek, Mehdi Omar Krimech, Moncef Boufettal, Bassir Rida Allah, Moulay Omar Lamrani, Mohammed Kharmaz, Mohamed Salah Berrada
DOI:10.4103/jodp.jodp_1_22  
Introduction: Fractures of the humeral pallet are more and more frequent; this is linked to the increase in road accidents and their violence. Methods: We have collected in our archives 55 cases of fracture of the humeral pallet at the Traumatology–Orthopedics Department of the IBN SINA CHU in RABAT from January 2015 to December 2019. Results: They mainly affect young adults with a clear predominance of men (73%). The trauma most often occurs by direct mechanism (65%). The main cause of these fractures is represented by road accidents (56%), followed by assaults and falls. Supra and intercondylar fractures are the most described anatomical form (65%). The treatment is surgical in all cases, with predominance of the posterior approach. Discussion: Considering the comminution often encountered, only a solid and stable osteosynthesis allows the anatomical restoration of the elbow, by adapting the indications to the types of fractures and by using a more codified technique, to allow an early rehabilitation, better guarantee of recovery of elbow function. The LECESTRE premolded plate is the most used in supra and intercondylar fractures; it seems to be a real progress in osteosynthesis (31.03% good results and 51.72% average results) for this type of fracture. Conclusion: The management of humeral paddle fractures is based on perfect anatomical reduction, by a solid assembly which must allow early rehabilitation ensuring good functionality. Level of Evidence: IV-retrospective study.
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Nonunion of clavicle treated with precontoured locking compression plate fixation and bone grafting: A long-term outcome p. 128
Nissar Ahmad Shah, Nisar Ahmad Dar, Badoo Abdul Rashid
DOI:10.4103/jodp.jodp_2_22  
Background: Plate fixation with bone grafting is the treatment of choice for nonunion of the clavicle and the use of precontoured locking compression plate (LCP) has been proposed to have an advantage of minimal hardware prominence and low rate of implant removal surgery. Materials and Methods: The retrospective analysis was performed to assess the long-term efficacy of precontoured LCP and bone grafting in nonunion of the clavicle. Fifteen patients who had undergone the surgery were assessed retrospectively in terms of clinical and radiological outcome for 4.1 years (range 2–7 years). The outcome was assessed using clinical and functional assessment by QuickDASH scoring and visual analog scale (VAS) system, radiological assessment in terms of union, time of return to previous activities, and any adverse results during the surgery or in the postoperative follow-up. Results: The radiological consolidation was achieved in all patients in a mean period of 18 weeks (range14–20 weeks). All patients returned to their previous activity level in a mean period of 5.9 months (range 2.5–9 months). There was a statistically significant improvement in QuickDASH and VAS scores (P < 0.05); however, one patient had symptomatic hardware prominence. Conclusion: The use of precontoured LCP in nonunion clavicle is a well-tolerated surgery giving promising results with most patients returning to previous activity level with the advantage of minimal hardware prominence and low rate of implant removal surgery.
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Functional outcome of distal end radius fractures managed with variable-angle locking plates: A prospective study p. 132
Manikandan Kumarasamy, K Naveen Kumar, AA Akashdeep, KP Uma Anand
DOI:10.4103/jodp.jodp_7_22  
Introduction: Management of distal end radius intraarticular fractures is difficult to manage and these fractures account for 10% of all fractures. Multiple treatment options ranging from conservative to internal fixation, of which volar plate fixation has emerged as an effective method of internal fixation in comparison with other fixed-angle locking plates as they ensure proper restoration of the articular surfaces and anatomical alignment. Materials and Methods: A hospital-based prospective study was conducted on 14 patients with distal end radius fractures admitted in our hospital from January 2019 to December 2019. Patients with distal end radius fractures treated with variable-angle locking plate were included and were followed-up minimum of 6 months. The results were analyzed based on radiological parameters and Mayo Wrist Score (MWS). Results: Of 14 patients, 11 were male patients and three were female patients. Seven patients had right-sided fracture whereas remaining seven patients had left-sided fractures. All 14 patients were treated with variable-angle locking plate. Among 14 patients, 12 patients achieved union by 12 weeks, only two patients achieved union by 24 weeks. Ten patients had excellent results while four patients had a good outcome based on MWS. All patients in our study had painless union without any complications. Conclusion: The use of variable-angle locking plates in distal end radius fractures helps to maintain perfect anatomical reduction, early mobilization, and better postoperative outcome.
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Ten years' follow-up for cemented hip arthroplasty in patients <60 years of age with standardization of cementing technique: A multicentric study p. 138
Imran Sajid, Javed Jameel, Sukhvinder Singh, Surya Pratap Singh, Ankit Varshney, Sabeel Ahmad
DOI:10.4103/jodp.jodp_12_22  
Introduction: Total hip arthroplasty (THA) is the preferred treatment for persistent disability due to hip pathologies and restoration of normal functions. Although there is a general consensus of using un-cemented implants for adults and elderly with good bone quality and cemented for senior citizen population, implant choice for middle aged group of 40 years to 60 years is still a subject of debate, especially in financial constrained situations. In our study, we have determined the implant survivorship and functional outcomes of cemented THA in patients between 40 and 60 years of age, at the minimum follow-up of 10 years with emphasis on standardization of cementing technique. Materials and Methods: This is a retrospective study including 25 patients who had undergone cemented hip arthroplasty. Data were collected from five different surgical centres, whose orthopedic surgeons had common surgical training and were following a common cementing technique. Results: Mean Harris Hip Score of 25 hips at final follow-up was 90 and Visual Analog Scale 1.88. The functional outcome was good to excellent at final follow-up in 89% hips. There was a significant improvement in pain and activity level after surgery (P < 0.001) and maintained at the final follow-up. Conclusion: Our series provides evidence for utility of cemented hip implants in low functional demand patients along with emphasizing the importance of a good cementing technique for the long-term survival of cemented hip arthroplasty in the age group of 40–60 years.
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Early outcomes of ultra-congruent insert in cruciate-retaining total knee arthroplasty: A prospective study p. 145
Sandeep Singh Jaura, Punit Tiwari, Harmeet Kaur, Nitish Bansal
DOI:10.4103/jodp.jodp_13_22  
Introduction: The exponents of cruciate-retaining (CR) total knee arthroplasty (TKA) assert that the retention of posterior cruciate ligament (PCL) preserves more normal knee kinematics, femoral rollback on the tibia during flexion, greater stabilization of the prosthesis, and improved position sense as compared to PCL resection TKA. However, one has to shift to the posterior stabilized (PS) femoral component with box and accompanying cam postpolyethylene, especially in cases where PCL is too attenuated to be functional or too tight predisposing to accelerated polyethylene wear. To minimize both the cam mechanism polyethylene wear and the bone sacrifice due to the intercondylar box cut, the ultra-congruent (UC) inserts have been developed that are characterized by a high anterior wall and a deep-dished plate, promising good stability without cam mechanism. Materials and Methods: We did a prospective study to clinically evaluate the short-term results of the patients who underwent TKA using cemented posterior CR implants and UC inserts. PCL was required to be released either partially or completely in all the study patients. Thirty patients were evaluated preoperatively and postoperatively after 12 months with the new Knee Society Knee Scoring System (2011) and the findings were statistically analyzed. Results: There was a statistically significant postoperative improvement in flexion (from mean of 87.69° to 111.53°, P = 0.000), objective knee indicators (33.53 ± 8.51–70.84 ± 4.91, P = 0.000), patient satisfaction scores (7.48 ± 2.12–21.53 ± 4.26, P = 0.000), and the functional activities score (32.53 ± 5.12–69.02 ± 6.36, P = 0.000). We did not note any disadvantage of CR TKA with UC insert and no patient underwent an early revision for instability. Conclusion: Using UC insert in CR TKA is a reliable procedure that has decreased the dependence on the PS designs.
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Total contact casting: A forgotten art in the management of neuropathic foot ulcers p. 151
Manikumar Jogarao Chemboli, R Balaji Rao, Sivananda Pathri, Chandana Pathri, Varun Kumar Paka
DOI:10.4103/jodp.jodp_14_22  
Background: Neuropathic ulcers affect a patient's ambulation and are the leading cause of nontraumatic amputations. Offloading (reduction of pressure) is the key to success in managing these ulcers. Total contact casting (TCC) is considered as the gold standard of treatment for managing neuropathic foot ulcers (NFU). However, this method is less frequently used in the present-day ulcer management due to the lack of skill and laborious nature of work involved. Aim: This study aims to explore the merits and demerits of this technique and understand its relevance in modern times in managing NFUs. Patients and Methods: A total of 24 patients with NFU of different etiologies presented to outpatient unit between August 2018 and August 2020 were included in this prospective case series. All the patients were treated with TCCs applied at weekly intervals, until the ulcer healed completely. Results: Primary outcomes measured were number of casts required which reflected the time of healing in weeks. The mean number of castings required for each centimeter of ulcer healing was 2.310 cast time duration with a 91.66% percentage of success rate. Ulcers in all the patients healed on or before 16 weeks with a mean duration of healing of 58 days after commencement of treatment. Conclusion: It offers attractive healing rates in the management of NFUs and is associated with fewer manageable low-risk complications. Surgeons should incorporate this casting method as part of standard care of NFU to produce early healing and avoid major complications secondary to poor wound healing.
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Functional assessment of surgically managed ankle fractures p. 157
KK Kiran Kumar, C Lalithmohan, K Sai Pradeep, P Chandrashekhar
DOI:10.4103/jodp.jodp_16_22  
Background: Civilization has made man more prone to injuries. Ankle fractures are one of the most common injuries treated by orthopedic surgeons. Aims and Objectives: The aim of the study is to assess the functional outcome in surgically managed ankle fractures. Materials and Methods: Sixty patients were included in this study with ankle fractures that were surgically treated at NIMS Hospital, Hyderabad. Observations: The study had a male preponderance of 66.6%, with road traffic accidents being the major cause of injury. Supination-external rotation was the most common mechanism of injury and Weber's type B fractures were the most common type of fracture. The associated fractures and injuries noted and the comorbidities seen in these patients have been enumerated. Open reduction and internal fixation under image intensifier control was done in all patients. Postoperatively, patients were immobilized with a plaster splint for a period of 3–6 weeks and were followed up with full weight-bearing walking and active range of movement of ankle exercises. The final outcome as per the Weber's radiological criteria was 66.6% good, 26.6% fair, and 6.8% poor result which showed a good correlation between the immediate postoperative radiological score and the final radiological outcome. The factors that affected the final poor outcome were late presentation, patients with fracture subluxation, post massaging, the presence of long-standing and uncontrolled diabetes, and old age. Conclusion: The present study suggests that anatomical reduction of the ankle fracture and restoration of the joint congruity at the earliest will give a good functional outcome. The postoperative immobilization in a plaster slab up to 3–6 weeks (depending on associated injuries, fracture severity, bone quality, quality of fixation, and patient compliance) does not affect the final outcome with respect to achieving the ankle and subtalar range of movements as most of the patients had achieved full range of motion at the end of 12 weeks.
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A series of transforaminal epidural steroid injections in acute lumbar disc herniation with unilateral radiculopathy p. 162
Jay V Turakhiya, Himanshu N Parmar, Kushal C Zala, Nikunj D Maru, Anant C Prajapati
DOI:10.4103/jodp.jodp_18_22  
Objective: To evaluate functional outcomes of patients suffering from unilateral lower limb radiculopathy due to lumbar disc herniation conservatively treated with transforaminal epidural steroid injection (TFESI). Materials and Methods: It is a prospective study of 100 patients. We correlated clinical findings with magnetic resonance imaging. The patients are treated with dexamethasone injection through transforaminal epidural space under C-ARM guidance using Kambin's triangle approach with follow-up at 3 weeks, 6 weeks, 9 weeks, 12 weeks, and 24 weeks. Assessment of functional outcomes is done by visual analog scale (VAS) and modified Oswestry disability index (ODI). Results: Eighty-eight percent of patients significantly improved their radicular pain, according to the VAS scoring system and modified ODI. The mean modified ODI score of preinjection was found to be 64.18; it was reduced to 33.9 at 3 weeks, 30.82 at 6 weeks, 24.04 at 9 weeks, 22.04 at 12 weeks, and 19.38 at 6 months. The t = 18.49 and the P < 0.00001. Preinjection mean VAS was 8, 3.98 at 3 weeks, 3.28 at 6 weeks, 3.04 at 9 weeks, 2.72 at 12 weeks, and reduced to 2.14 at 24 weeks. The t = 19.83 and the P < 0.00001. There were no complications seen during our study. Conclusion: Our study justifies that unilateral lower limb radiculopathy due to lumbar disc herniation can be well managed by TFESI without any complication. It is very less invasive technique, safe, and effective for pain relief.
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The effect of preoperative rehabilitation on the outcome of anterior cruciate ligament reconstruction p. 167
S Srinivasalu, Anoop Pilar, Sandesh G Manohar, Jobin Joseph, M Madan Mohan, Rajkumar S Amaravathi
DOI:10.4103/jodp.jodp_25_22  
Background and Objectives: Internal knee injuries account for nearly 45% of sports-related injuries, with anterior cruciate ligament (ACL) injury being the most prevalent. ACL injury is associated with pain, instability of the joint, muscle weakness, functional limitation, poor quality of life, and an increased risk of knee-related osteoarthritis. Preoperative exercise rehabilitation physiotherapy program is often performed to prepare the knee for reconstruction surgery and to maximize the outcomes of rehabilitation. The objective of our study was to evaluate the effects of preoperative rehabilitation on the outcome of ACL reconstruction (ACLR) using the International Knee Documentation Committee (IKDC) score, Tegner Lysholm score, Knee Injury and Osteoarthritis Outcome Score (KOOS), patients' symptoms, including tenderness, effusion, and range of motion limitations. Materials and Methods: Thirty patients with ACL injury were included in this study after obtaining informed consent and followed up till 12 months. A detailed history and evaluation were done. All patients who met the inclusion criteria were randomly allocated into two groups, one receiving a course of preoperative rehabilitation of 12 weeks, and one who were taken up for surgery without preoperative rehabilitation. Pre- and postsurgery, each of these groups was assessed at 3-, 6-, and 12-month intervals using the IKDC, KOOS, and Tegner Lysholm scores. Results: On analysis, it was found that the mean IKDC, KOOS, and Tegner Lysholm scores increased significantly for all patients from preoperative to postoperative 12 months. There was a statistically significant difference between the prehab and non-prehab groups, in each of these scores, with the prehab group having better functional scores. Conclusion: It was found that in individuals with ACL tear, arthroscopic ACLR improved the functional outcome, and among these patients, it was found that individuals who received preoperative rehabilitation fared better in terms of functional score assessment.
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Vitamin D deficiency in proximal femur fractures: An observational, cross-sectional study p. 173
Utkarsh Singh, Punit Tiwari, Navneet Singh, Guncha Kalia, Bhupinder Singh Brar
DOI:10.4103/jodp.jodp_29_22  
Introduction: A proximal femur fracture is the most serious complication of osteoporosis, due to the high mortality and morbidity associated with it. Its risk in the elderly is a function of multiple factors, including bone mineral density, muscle strength, and balance, all of which have been related to Vitamin D status and function. Materials and Methods: This was a prospective hospital-based study conducted over 2 years in the hilly state of Himachal Pradesh, India, to evaluate any correlation between Vitamin D levels and proximal femur fractures (PFFs). We also studied the influence of age and sex on Vitamin D levels in PFFs. Results: In our study, the female patients had lower Vitamin D levels (19.85 ± 5.28) as compared to males (20.436 ± 9.36), but this decrease was not found to be statistically significant (P = 0.2374). There was an average decrease of Vitamin D levels in patients of higher age group (20.770 ± 6.57 vs. 19.692 ± 8.40), but this was not statistically significant (P = 0.613). Thirty-four patients, i.e., 68%, had hypocalcemia, while 16 patients, i.e., 32%, had normal levels of serum calcium. Similarly, 30 patients, i.e., 70%, had hypomagnesemia, while 20 patients, i.e., 40%, had normal serum magnesium levels. The mean level of alkaline phosphatase in PFF was found to be 116.36 IU/L, i.e., within normal limits. The average Vitamin D level in our patients who were adequately exposed to sunlight was 22.5 ± 8.80 ng/ml, while the average Vitamin D level in patients who were inadequately exposed was 16.925 ± 5.98 ng/ml. The mean Vitamin D levels in vegetarian and nonvegetarian patients were 19.17 ± 6.05 ng/ml and 19.83 ± 9.56 ng/ml, respectively. We found that vitamin levels were relatively low (19.46 ng/dL) in patients from high altitudes as compared to patients from low altitudes (22.62 ng/dL), but the difference was insignificant (P = 0.3925). Conclusion: In our study, almost all patients (96%) were suffering from hypovitaminosis D (Vitamin D levels <30 ng/ml), and 38% of our patients had Vitamin D deficiency (Vitamin D levels <20 ng/ml). However, we were unable to find any significant difference in Vitamin D levels when patients of various ages, sex, and altitude were compared with each other.
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RETROSPECTIVE COHORT STUDY Top

Posteromedial tibial plateau fractures – Functional outcome of posteromedial buttress plating with precontoured locking plate using modified lobenhoffer approach p. 180
J Unnikrishnan, Kumar Chandan, VA Bindulal
DOI:10.4103/jodp.jodp_22_22  
Posterior tibial plateau fractures have a complex intra-articular fracture pattern, representing approximately 1.2% of all fractures. The occurrence of the posteromedial shear fragment is relatively common in high-energy tibial plateau fractures. Aims and Objectives: To study the role of posteromedial plating in the management of complex tibial plateau fractures with a posteromedial fragment. Materials and Methods: Only patients with posteromedial fracture patterns alone are taken into account. Twenty cases above 20 years of age, from the patient, admitted to Government Medical College, Thrissur, with posteromedial fragment in tibial plateau fractures that were operated were undertaken for the study. The patients were followed up for 2 years. Results: Of the 20 patients with posteromedial tibial plateau fractures from X-ray and computed tomography scan of the knee joint, all patients were treated with precontoured posteromedial buttress plating using single anatomical locking plate. We analyzed patients with Rasmussen scoring postoperatively. In our analysis, among 20 patients, the functional score was excellent in 14, good in 5, fair in 1, and poor in none. There was one patient with compartment syndrome who had developed a mild surgical site infection that later resolved. No excessive collapse is seen postoperatively since locked plate is used. Four patients had transient paraesthesia of the saphenous nerve; both resolved completely.
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CASE REPORT Top

The not so familiar silent joint killer: Ochronosis – A case report with review of literature p. 185
Gowtham Bandi, Ram Kartheek Randhi, Jameer Shaik, Varun Kumar Paka, Raviteja V S. Seerapu
DOI:10.4103/jodp.jodp_32_22  
Ochronosis is rarely considered a cause for knee synovitis due to its rare occurrence. It starts affecting the joint from the third decade onward causing premature joint damage. The damaged joint and surrounding tissue present as blackish decolorated mass and can surprise the operating surgeon, unless diagnosed beforehand. Prior diagnosis helps both the anesthetist and operating surgeon to better handle the associated complications of ochronosis during surgery. Diagnosis is essentially based on prior knowledge of the disease and its markers. Here, we report a rare case of ochronosis of the knee that was treated elsewhere previously as tuberculosis of the knee. A history evaluation along with intraoperative findings helped arrive at the possible diagnosis of ochronosis. Total synovectomy was done. Postoperative improvement of visual analog scale score was significant and the patient was satisfied with the pain relief attained through treatment. Early diagnosis and timely management is critical to avoid unwanted complication related to both anesthesia and surgery pertaining to the disease. Knowledge of skin markers and urine darkening helps in identifying the disease early.
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CASE SERIES Top

Traumatic sternoclavicular joint dislocation - A case series and discussion of methods of management p. 190
VN Ravish, TS Channappa, G Bharath Raju, Manju Jayaram, CL Karan
DOI:10.4103/jodp.jodp_35_22  
Traumatic sternoclavicular (SC) joint injuries account for <3% of all traumatic joint injuries. Instability of the SC joint (SCJ) is a difficult problem to treat and can present with gross limitations in activities. Prompt diagnosis and intervention are imperative in the management of these fracture dislocations. We present three cases of posttraumatic SCJ dislocation treated conservatively and two cases treated with open reduction and internal fixation with reconstruction plate and its functional outcome and discuss the various modes of management of these dislocations.
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LETTER TO EDITOR Top

Tips and tricks of suprapatellar nailing of tibial fractures and its indications p. 195
Ashutosh Kumar, Rishabh Kumar, Anand Shankar, Rakesh Kumar, Wasim Ahmed
DOI:10.4103/jodp.jodp_19_22  
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