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   Table of Contents - Current issue
January-April 2022
Volume 5 | Issue 1
Page Nos. 1-52

Online since Tuesday, March 15, 2022

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Best practices in orthopedics p. 1
Ritesh Runu
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Functional outcome of hemiarthroplasty vs internal fixation for femoral neck fracture in elderly population: A comparative prospective study p. 3
RK S. Dhakad, Abhilekh Mishra, Tarun Naugraiya, Vivek Singh Dhakad
Introduction: Femoral neck fractures are one among the leading causes of death in elderly patients. Magnitude of fracture displacement, patient's age, comorbid disorders, and prefracture activity level are some of the critical factors in determining the clinical practice for treating femoral neck fracture. In this study, we have studied the functional outcome and survivorship in fracture neck of femur in the elderly population operated with both internal fixation (IF) and cemented hemiarthroplasty (HA). Material and Method: All 100 patients were reviewed clinically and radiologically at 15 days, 1 month, and then subsequent 1 year. Out of 100 patients, 54 have been operated with HA and 46 have been operated with screw fixation. Results: Overall reoperation rate in HA group was 5.05%, with total mortality rate being 7.4% compared to 6.5% of IF group. Out of 46 patients of screw fixation, the overall reoperation rate was 20% with 4 patients being developed avascular necrosis and 13 being developed nonunion, and rest of the patients have average Harris hip score of 60–65 with 34%, while patients having poor Harris hip score compared to those of HA with Harris hip score of 80–90 with 88.2% having excellent to fair. Conclusion: Hip arthroplasty as compared to Internal fixation for the treatment of femoral neck fractures significantly reduces the risk of reoperation at the cost of higher superficial infection and blood loss. Furthermore, postoperative function as evaluated by the Harris hip score was significantly higher in the arthroplasty compared to the IF group up to the 6-month evaluation.
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Clinical and radiological evaluation of proximal tibia fracture fixed with variable angle proximal tibial interlocking plate: A prospective observational study p. 8
Sudhanshu Shekhar, Ankit Pranjal
Background: Tibial plateau fractures are complex injuries produced by high- or low-energy trauma and principally affect young adults. In view of the ever-increasing high-velocity road traffic accidents, there is an increase in complex, multifragmentary periarticular fractures of the tibia. The goal of proximal tibial fracture treatment is to obtain the early union of fracture in the most acceptable anatomical position with the early and maximum functional return of activity. The use of more modern implants with locking screws and precontoured locking plates provides better stability and may further improve outcome. In this regard, this study was undertaken to study the functional outcome and radiological outcome of closed proximal tibial fracture Schatzker's type I, II, and III treated with variable angle-locking compression plate (VA-LCP). Methods: A hospital-based prospective study was undertaken among the 54 adult patients with closed proximal tibial fracture Schatzker's type I, II, and III requiring surgical intervention and treated by VA-LCP. A predesigned, self-administered pro forma was designed to keep the objectives of the study at the center point. The patients were categorized based on their relevant age, gender, fracture type, and complications. Qualitative data were represented in the form of frequency and percentage. The final outcome was obtained using modified Rasmussen clinical and radiological score as well as the total healing period of the subjects followed up for a period of 24 weeks. All care and caution were exercised while utilizing the patient data for the current research as outlined in the hospital guidelines pertaining to the usage of patient data for this study, and confidentiality was maintained throughout. Results: The maximum study population belonged to the age group of 50–59 years, which comprised about 44.5%. 26 (48.2%) of the tibial fractures were diagnosed to have Schatzker's type II fractures followed by 15 (27.7%) type III and 13 (24.1%) type I. Group I (30–39 years) showed faster healing with a mean healing period of 18.6 ± 1.9 weeks, followed by Group II (40–49 years) with a mean healing period of 19.6 ± 4.1. Mechanical failure (7, 12.9%) and some secondary complications (12, 22.2%) were also observed during follow-up in the outpatient department. At the end of follow-up, 35 patients (64.8%) had excellent clinical result, 19 (35.2%) had good clinical result, and no patient had a poor functional outcome. For the radiological assessment, there were 29 patients (53.8%) with excellent, 18 (33.3%) with good, 7 (12.9%) with fair, while none with poor results. Conclusion: Treatment of proximal tibial fractures is challenging because of limited soft tissue cover and less vascularity. There are various treatment options for these fractures starting from closed reduction with casting to open reduction and internal fixation with a plate. The excellent functional results and lack of soft tissue complications suggest that a VA-LCP should be considered as an option in tibial plateau fractures. A balance between anatomical reduction and soft tissue stripping is required to avoid any complications.
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Spring plate for fixation of comminuted posterior wall acetabular fractures p. 14
Ashwini Gaurav, Kaushlendra Kumar, Ranjit Kumar Singh
Introduction: Comminuted posterior wall acetabular fractures always remain difficult and challenging to assemble and stabilize with surgical management without any intraoperative or postoperative complications and satisfactory functional outcomes. Hence, correct selection of implant and correct technique are always key steps in the surgical management of comminuted posterior wall fractures of the acetabulum. Methods: We performed a retrospective observational study on 16 patients that were operated between July 2016 and December 2017 at Patna Medical College and Hospital, Patna. Medical reports of all patients with comminuted posterior wall fractures operated with locally crafted spring plates placed under 3.5 mm pelvic reconstruction plates were evaluated radiographically and with the past Harris Hip Scores (HHSs). Results: The average follow-up was of 15.8 months, and there were no occurrences of implant migration, loss of reduction, or joint incongruity. One patient had developed a superficial infection that was treated with dressings and oral antibiotics. Two patients had preoperative sciatic nerve palsy, which improved gradually over the course of 3 months. No instances of hip arthrosis or osteonecrosis were found. Thirteen patients scored excellent, whereas three scored good on the past HHS records. Conclusion: Our study strongly supports the concept that locally crafted spring plates placed under 3.5 mm pelvic reconstruction plates are a good fixation strategy in the management of comminuted posterior wall acetabular fractures.
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Prospective study of posterior open pedicle screw fixation for posttraumatic thoracolumbar and lumbar burst fractures with spinal injury at a tertiary care center: A short-term clinical and radiological follow-up p. 18
Raj Kumar, Saubhik Das, Praveen Gupta, Lal Bahadur Manjhi
Background: Fractures of the thoracic and lumbar vertebrae are quite common injuries and their management remains controversial in the literature. The aim of this study was to analyze the clinical and radiological outcomes of posterior open pedicle screw fixation (OPSF) for the treatment of posttraumatic thoracolumbar and lumbar burst fractures with spinal injury. Materials and Methods: This is a prospective study of 24 patients with thoraco-lumbar and lumbar burst fracture treated with OPSF, and each patient was followed up for a minimum period of 1 year. Demographic characteristics, clinical and radiological outcomes, and adverse events were evaluated. Results: There were 70.83% male patients and 54.17% patients were in the age group of 21 to 40 years. Road traffic accident (41.67%) was the most common mechanism of injury and L1 was the most commonly fractured vertebra followed by T12. The average operative time was 125.35 min with a mean intraoperative blood loss of 480.82 mL. There was a significant improvement in Sagital Cobb's angle, vertebral body angle, anterior vertebral body height, and visual analog score at 1 year follow-up. The common postoperative complications were superficial infection, bed sore, and urinary tract infection worsening. Implant loosening was seen only in one case. Conclusions: Patients with thoraco-lumbar and lumbar burst fractures can be effectively managed with OPSF. It allows earlier mobilization and shorter recovery time and hospital stay and has contributed for better neurological outcome when combined with early aggressive and proper physiotherapy.
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Choosing the optimum method of treatment for extra-articular distal radius Colles' type fractures in adult: A retrospective cohort study p. 24
Soumendra Kumar Majhi, Ashis Kumar Gupta, Sabyasachi Das, Ramesh Chandra Maharaj, Debi Prasad Nanda, Laxman Hansdah
Context: Distal radius fractures are often encountered in orthopedic outpatient department, mostly managed with a below-elbow cast though malunion is the commonest known complication. Many researches had already been conducted comparing cast with various surgical methods; however, conclusive results yet to be ascertained. While choosing the treatment, we retrospectively analyzed the results of different methods to reach a conclusion. Subjects and Methods: A total of 92 patients with unilateral extra-articular or partially articular distal radius fracture were analyzed retrospectively over a period of 2 years, 30 of which managed conservatively and 62 with various surgical techniques (plate 27, external fixation 24, and K-wires 11). Functional results were recorded by PRWE score and radiological union was assessed. Statistical Analysis Used: Unpaired t-test was used for numerical value and Chi-square test for categorical values, and analysis of variance was used for multiple comparisons among the groups. Results: PRWE pain score, PRWE functional score, and means of individual radiological parameters measurements did not show any significant association among the study groups, P > 0.05. However, Chi-square test of association showed a significant correlation between radiology and function, P < 0.001. Conclusions: There is no difference between surgical and nonsurgical methods as a whole so as to say which one is better, thus nonsurgical methods still hold a good option today and should be the first choice while dealing with such injuries. Anatomical reduction should always be tried irrespective of methods of treatment as excellent to good function was seen with undisplaced or minimally displaced or well-reduced fractures.
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Indications of implant removal: A retrospective study in a government tertiary care hospital p. 31
G Prashanth, KL Mahendra Kumar, SS Shivaprakash, MC Dushyantha
Introduction: Metallic implant inserted for orthopedic fracture fixation may be removed for a variety of reasons. There is little consensus if such implant be removed routinely after fracture union. Hence, in our study, we would like to determine the indications for implant removal. Materials and Methods: This is a retrospective study of all cases of implant removal at the Orthopaedic Department of Mandya Institute of Medical Sciences, Mandya, Karnataka, India, from January 2019 to December 2020. Relevant information of patients were extracted and analyzed. Results: The study included 217 patients; there are 161 males and 56 females with a male-to-female ratio of 2.87. The peak age group is 16–30 years with a mean age group of 36.2 years. Distal tibia/ankle (15.66%) is the most common site for implant removal. Tibia (35.4%) is the most common bone. Plates and screws (38.7%) is the most common implant. Patients' request (31.7%) is the most common indication followed by surgeon request (25.8%), prominent hardware (21.6%), infection (17.5%), and failure (3.4%). About 37.7% of implants were removed before 12 months. Conclusion: Patients' request was the most common indication as they wanted implant to be removed and long-term effects of internal implant were not known. Surgeon request is the second most common indication, especially in the pediatric age. Prominent hardware was the third most common indication group as implants were impinging. Infection and implant failure were the other mandatory indications for implant removal.
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Can titanium elastic nails deliver a knockout punch against precontoured locking plates in handling displaced middle third clavicle fractures? p. 35
Jameer Shaik, Varun Kumar Paka, Ravi Sharma Pilaka, Srivatsava S. Dakshina Murthy Talluri
Background: Plating is the gold standard for displaced middle third clavicle fractures, which holds true at least for comminuted fractures with a fair share of complications. For displaced fractures without comminution, intramedullary titanium elastic nailing system is an emerging option which claims similar success rates with fewer complications. There is a deficit in data pertaining to prospective trials supporting such claims which has propelled us to carry out this study. This study aims to compare the functional outcome and complication rates between precontoured locking plates and titanium elastic nails for displaced clavicle fractures. Materials and Methods: A prospective cohort study carried out on 56 patients with displaced clavicle fractures without comminution treated either by nailing (with open reduction through minimal incision at fracture site) or plating, and the results pertaining to their functional outcome and complication rates were compared. Results: Nottingham clavicle score and Constant Murley score were calculated at 6, 12, and 24 months along with comparison of complication rates. Conclusion: The functional outcome scores recorded significant differences at 6- and 12-month periods between the groups, which minimized at 24 months. Complication rates were significantly different between the groups. These results of functional outcome and complication rates point toward titanium nailing as an attractive alternative to plating for a comminuted displaced middle third clavicle fractures.
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Does operative management provide better outcome in displaced mid-shaft clavicle fractures? A randomized control study p. 41
Deepak Jain, Alfven Vieira, Akshay Mahajan, Ashish Naik, Harsh Kotecha, Mohit Issrani
Background: Mid-shaft clavicle fracture management has been inclined more toward osteosynthesis in recent times for better functional outcomes. The aim of the study was to find out does operative management in displaced mid-shaft clavicle fractures provide better outcomes than conservative? Materials and Methods: The randomized trial was conducted between December 2017 and July 2019 at a tertiary trauma center on 50 consecutive patients with displaced mid-shaft clavicle fracture. The inclusion criteria included age between 16 and 60 with acute isolated closed displaced mid-shaft clavicle fracture. Patients with neurovascular deficit, compound fractures, pathological fractures, and nonunion/malunited fractures were excluded. Group A had 25 patients who were treated with operative line of management and Group B had 25 patients who were treated with a conservative line of management; division was done on basis of odd (Group A)–even (Group B) technique. Results: Out of 50 patients, the mean age group of patients was 35.5 ± 1 years of life with others ranging from 16 to 60 years. Out of 50 patients, 45 (90%) patients were male and 5 (10%) were female. Out of 50 patients, 42 had a history of road traffic accidents, while 8 had a history of falls. The right side clavicle was affected in 18 patients and left was affected in 32 patients. Out of 50 patients, the mean time of union in operative group was 11.36 ± 2.56 and 11.36 ± 2.75 weeks in nonoperative group. Constant shoulder score was 85.16 ± 15.30 and 84.64 ± 13.52 in the operative group and nonoperative group, respectively. Conclusion: In this prospective cohort study, we have concluded that long-term functional outcomes of conservative versus operative management of displaced mid-shaft clavicle fracture are similar, but primary open reduction with internal fixation of displaced mid-shaft clavicle fracture in young adult patients ensures anatomical reduction, early mobilization, and faster recovery for functional activity while avoiding complications such as malunion.
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Minimally invasive versus conventional fixation of stable intertrochanteric fracture by dynamic hip screw – A prospective study comparing the two techniques p. 46
Arnab Karmakar, Pinaki Das, Ayon Ghosh
Background: Intertrochanteric fractures of femur are one of the most common fractures encountered in the elderly population. Dynamic hip screw (DHS) with a side plate is the standard modality of treatment especially in the case of stable fractures because it creates a controlled collapse at fracture site, leading to union. A comparative study between minimally invasive surgical technique with the conventional surgical technique for the fixation of intertrochanteric fractures with the DHS device was done. Methods: Thirty patients with stable intertrochanteric fractures (31A1.1, 31A1.2, and 31A1.3) were treated with the conventional open technique and another thirty with a new minimally invasive technique. Patients in both groups were followed up for at least 9 months. Results: There was less preoperative and postoperative blood loss, less soft-tissue destruction, less pain postoperatively, shorter hospital stays, and early mobilization and faster union with the minimally invasive technique. Conclusion: The study concludes that minimally invasive technique is superior to conventional (open) DHS in stable fractures.
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