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1.  Minimum (optimum) standard of orthopedic care for all: An achievable target 
Indian Journal of Orthopaedics  2014;48(6):541-544.
doi:10.4103/0019-5413.144201
PMCID: PMC4232820  PMID: 25404763
2.  Pedicle screw piercer with warning device - A technique to increase accuracy of pedicle screw placement 
Indian Journal of Orthopaedics  2014;48(6):545-549.
Background:
Pedicle screw fixation has achieved significant popularity amongst spinal surgeons for both single and multilevel spinal fusion. Suboptimal placements of pedicle screws may lead to neurological and vascular complications. There have been many advances in techniques available for navigating through the pedicle; however, these techniques are not without drawbacks. The purpose of this study was to investigate the efficacy and feasibility of the pedicle piercer with warning device.
Materials and Methods:
Eight normal adult thoracolumbar specimens from cadavers consisting of 80 vertebras (T8–L5) were selected and randomly allocated into four groups. Each group contained 20 vertebra. Group 1 was tested for maximum pressure of the piercer within the vertebrae (F1). Group 2 was tested for maximum pressure of the warning piercer penetrating front cortex of the vertebral body (F2). Group 3 was tested for the maximum pressure of piercer penetrating vertebral body endplate (F3) and pedicle notch (F41, F42). Group 4 was tested for maximum pressure of the piercer penetrating the vertebral lateral cortex (F6), the medial and lateral cortex of pedicle (F51, F52). In the second experiment of this study, 4 normal adult specimens consisting of 40 vertebra and 80 pedicles were used for testing the alarm effects of pedicle piercer. The following indicators were adopted for the tests including true positive/negative, false positive/negative, sensitivity, specificity, availability, Youden index, and diagnostic efficiency. SPSS 16.0 was used for statistical analysis.
Results:
There were statistically significant differences between F1, and F2, F3, F41, F42, F51, F52 respectively (P < 0.05). F1 = 8.970 ± 0.2698, F3 = 13.055 ± 0.6718. We found that the threshold value of piercer warning was from 9.6 to 12.3 Kgf. Sensitivity was 92.31%, specificity was 95.12%, usability was 87.45%, Youden index was 87.43% and diagnostic efficiency was 92.5% respectively.
Conclusion:
Warning piercer is a safe, simple, sensitive device for detecting pedicle breach during regular pedicle screw placement surgery.
doi:10.4103/0019-5413.144205
PMCID: PMC4232821  PMID: 25404764
Pedicle screw piercer; thoracolumbar specimens; warning device; cadaveric study; Spine; thoracic injuries; lumbar region; bone screws; cadaver
3.  Biomechanical comparison of pedicle screws versus spinous process screws in C2 vertebra 
Indian Journal of Orthopaedics  2014;48(6):550-554.
Background:
Biomechanical studies have shown C2 pedicle screw to be the most robust in insertional torque and pullout strength. However, C2 pedicle screw placement is still technically challenging. Smaller C2 pedicles or medial localization of the vertebral artery may preclude safe C2 pedicle screw placement in some patients. The purpose of this study was to compare the pullout strength of spinous process screws with pedicle screws in the C2.
Materials and Methods:
Eight fresh human cadaveric cervical spine specimens (C2) were harvested and subsequently frozen to −20°C. After being thawed to room temperature, each specimen was debrided of remaining soft tissue and labeled. A customs jig as used to clamp each specimen for screw insertion firmly. Screws were inserted into the vertebral body pairs on each side using one of two methods. The pedicle screws were inserted in usual manner as in previous biomechanical studies. The starting point for spinous process screw insertion was located at the junction of the lamina and the spinous process and the direction of the screw was about 0° caudally in the sagittal plane and about 0° medially in the axial plane. Each vertebrae was held in a customs jig, which was attached to material testing machine (Material Testing System Inc., Changchun, China). A coupling device that fit around the head of the screw was used to pull out each screw at a loading rate of 2 mm/min. The uniaxial load to failure was recorded in Newton'st dependent test (for paired samples) was used to test for significance.
Results:
The mean load to failure was 387 N for the special protection scheme and 465 N for the protection scheme without significant difference (t = −0.862, P = 0.403). In all but three instances (38%), the spinous process pullout values exceeded the values for the pedicle screws. The working distances for the spinous process screws was little shorter than pedicle screws in each C2 specimen.
Conclusion:
Spinous process screws provide comparable pullout strength to pedicle screws of the C2. Spinous process screws may provide an alternative to pedicle screws fixation, especially with unusual anatomy or stripped screws.
doi:10.4103/0019-5413.144212
PMCID: PMC4232822  PMID: 25404765
C2 vertebrae; screw fixation; spinous process screws; pedicle screws; Spine; cervical vertebrae; cadaver; bone screws
4.  Navigated pedicle screw placement using computed tomographic data in dorsolumbar fractures 
Indian Journal of Orthopaedics  2014;48(6):555-561.
Background:
Computed tomographic (CT) based navigation is a technique to improve the accuracy of pedicle screw placement. It is believed to enhance accuracy of pedicle screw placement, potentially avoiding complications arising due to pedicle wall breach. This study aims to assess the results of dorsolumbar fractures operated by this technique.
Materials and Methods:
Thirty consecutive skeletally mature patients of fractures of dorsolumbar spine (T9–L5) were subjected to an optoelectronic navigation system. All patients were thoroughly examined for neurological deficit. The criterion for instability were either a tricolumnar injury or presence of neurological deficit or both. Patients with multilevel fractures and distorted spine were excluded from study. Time taken for insertion of each pedicle screw was recorded and placement assessed with a postoperative CT scan using Laine's grading system.
Results:
Only one screw out of a total of 118 screws was misplaced with a Laine's Grade 5 placement, showing a misplacement rate of 0.847%. Average time for matching was 7.8 min (range 5-12 min). Average time taken for insertion of a single screw was 4.19 min (range 2-8 min) and total time for all screws after exposure was 34.23 min (range 24-45 min) for a four screw construct. No neurovascular complications were seen in any of the patients postoperatively and in subsequent followup of 1-year duration.
Conclusion:
CT-based navigation is effective in improving accuracy of pedicle screw placement in traumatic injuries of dorsolumbar spine (T9-L5), however additional cost of procuring CT scan to the patient and cost of equipment is of significant concern in developing countries. Reduced radiation exposure and lowered ergonomic constraints around the operation table are its additional benefits.
doi:10.4103/0019-5413.144216
PMCID: PMC4232823  PMID: 25404766
Dorso lumbar spine; Laine's grading; navigation; paired point matching; Spine; spinal fractures; bone screws; neuronavigation; tomography
5.  Minimally invasive transforaminal lumbar interbody fusion 
Indian Journal of Orthopaedics  2014;48(6):562-567.
Background:
The use of minimally invasive surgical (MIS) techniques represents the most recent modification of methods used to achieve lumbar interbody fusion. The advantages of minimally invasive spinal instrumentation techniques are less soft tissue injury, reduced blood loss, less postoperative pain and shorter hospital stay while achieving clinical outcomes comparable with equivalent open procedure. The aim was to study the clinicoradiological outcome of minimally invasive transforaminal lumbar interbody fusion.
Materials and Methods:
This prospective study was conducted on 23 patients, 17 females and 6 males, who underwent MIS-transforaminal lumbar interbody fusion (TLIF) followed up for a mean 15 months. The subjects were evaluated for clinical and radiological outcome who were manifested by back pain alone (n = 4) or back pain with leg pain (n = 19) associated with a primary diagnosis of degenerative spondylolisthesis, massive disc herniation, lumbar stenosis, recurrent disc herniation or degenerative disc disease. Paraspinal approach was used in all patients. The clinical outcome was assessed using the revised Oswestry disability index and Macnab criteria.
Results:
The mean age of subjects was 55.45 years. L4-L5 level was operated in 14 subjects, L5-S1 in 7 subjects; L3-L4 and double level was fixed in 1 patient each. L4-L5 degenerative listhesis was the most common indication (n = 12). Average operative time was 3 h. Fourteen patients had excellent results, a good result in 5 subjects, 2 subjects had fair results and 2 had poor results. Three patients had persistent back pain, 4 patients had residual numbness or radiculopathy. All patients had a radiological union except for 1 patient.
Conclusion:
The study demonstrates a good clinicoradiological outcome of minimally invasive TLIF. It is also superior in terms of postoperative back pain, blood loss, hospital stay, recovery time as well as medication use.
doi:10.4103/0019-5413.144217
PMCID: PMC4232824  PMID: 25404767
Degenerative spine; lumbar fusion; minimally invasive transforaminal lumbar interbody fusion; spondylolisthesis; Spinal arthritis; spondyloarthritis; spondylolisthesis; minimally invasive; spinal fusion
6.  Thoracolumbar fracture dislocations treated by posterior reduction, interbody fusion and segmental instrumentation 
Indian Journal of Orthopaedics  2014;48(6):568-573.
Background:
Literature describing the application of modern segmental instrumentation to thoracic and lumbar fracture dislocation injuries is limited and the ideal surgical strategy for this severe trauma remains controversial. The purpose of this article was to investigate the feasibility and efficacy of single-stage posterior reduction with segmental instrumentation and interbody fusion to treat this type of injury.
Materials and Methods:
A retrospective review of 30 patients who had sustained fracture dislocation of the spine and underwent single stage posterior surgery between January 2007 and December 2011 was performed. All the patients underwent single stage posterior pedicle screw fixation, decompression and interbody fusion. Demographic data, medical records and radiographic images were reviewed thoroughly.
Results:
Ten females and 20 males with a mean age of 39.5 years were included in this study. Based on the AO classification, 13 cases were Type B1, 4 cases were B2, 4 were C1, 6 were C2 and 3 cases were C3. The average time of the surgical procedure was 220 min and the average blood loss was 550 mL. All of the patients were followed up for at least 2 years, with an average of 38 months. The mean preoperative kyphosis was 14.4° and reduced to -1.1° postoperatively. At the final followup, the mean kyphosis was 0.2°. The loss of correction was small (1.3°) with no significant difference compared to postoperative kyphotic angle (P = 0.069). Twenty seven patients (90%) achieved definitive bone fusion on X-ray or computed tomography imaging within 1 year followup. The other three patients were suspected possible pseudarthrosis. They remained asymptomatic without hardware failure or local pain at the last followup.
Conclusion:
Single stage posterior reduction using segmental pedicle screw instrumentation, combined with decompression and interbody fusion for the treatment of thoracic or lumbar fracture-dislocations is a safe, less traumatic and reliable technique. This procedure can achieve effective reduction, sagittal angle correction and solid fusion.
doi:10.4103/0019-5413.144219
PMCID: PMC4232825  PMID: 25404768
Fracture dislocation; posterior interbody fusion; segmental instrumentation; spine trauma; thoracolumbar spine; Spine; spinal fractures; dislocations; spinal fusion; instrumentation
7.  Short term outcome of posterior dynamic stabilization system in degenerative lumbar diseases 
Indian Journal of Orthopaedics  2014;48(6):574-581.
Background:
Decompression and fusion is considered as the ‘gold standard’ for the treatment of degenerative lumbar diseases, however, many disadvantages have been reported in several studies, recently like donor site pain, pseudoarthrosis, nonunion, screw loosening, instrumentation failure, infection, adjacent segment disease (ASDis) and degeneration. Dynamic neutralization system (Dynesys) avoids many of these disadvantages. This system is made up of pedicle screws, polyethylene terephthalate cords, and polycarbonate urethane spacers to stabilize the functional spinal unit and preserve the adjacent motion after surgeries. This was a retrospective cohort study to compare the effect of Dynesys for treating degenerative lumbar diseases with posterior lumbar interbody fusion (PLIF) based on short term followup.
Materials and Methods:
Seventy five consecutive patients of lumbar degenerative disease operated between October 2010 and November 2012 were studied with a minimum followup of 2 years. Patients were divided into two groups according to the different surgeries. 30 patients underwent decompression and implantation of Dynesys in two levels (n = 29) or three levels (n = 1) and 45 patients underwent PLIF in two levels (n = 39) or three levels (n = 6). Clinical and radiographic outcomes between two groups were reviewed.
Results:
Thirty patients (male:17, female:13) with a mean age of 55.96 ± 7.68 years were included in Dynesys group and the PLIF group included 45 patients (male:21, female:24) with a mean age of 54.69 ± 3.26 years. The average followup in Dynesys group and PLIF group was 2.22 ± 0.43 year (range 2-3.5 year) and 2.17 ± 0.76 year (range 2-3 year), respectively. Dynesys group showed a shorter operation time (141.06 ± 11.36 min vs. 176.98 ± 6.72 min, P < 0.001) and less intraoperative blood loss (386.76 ± 19.44 ml vs. 430.11 ± 24.72 ml, P < 0.001). For Dynesys group, visual analogue scale (VAS) for back and leg pain improved from 6.87 ± 0.80 to 2.92 ± 0.18 and 6.99 ± 0.81 to 3.25 ± 0.37, (both P < 0.001) and for PLIF, VAS for back and leg pain also improved significantly (6.97 ± 0.84–3.19 ± 0.19 and 7.26 ± 0.76–3.56 ± 0.38, both P < 0.001). Significant improvement was found at final followup in both groups in Oswestry disability index (ODI) score (both P < 0.001). Besides, Dynesys group showed a greater improvement in ODI and VAS back and leg pain scores compared with the PLIF group (P < 0.001, P = 0.009 and P = 0.031, respectively). For radiological, height of the operated level was found increased in both groups (both P < 0.001), but there was no difference between two groups (P = 0.93). For range of motion (ROM) of operated level, significant decrease was found in both groups (P < 0.001), but Dynesys showed a higher preservation of motion at the operative levels (P < 0.001). However, no significant difference was found in the percentage change of ROM of adjacent levels between Dynesys and PLIF (0.74 ± 8.92% vs. 0.92 ± 4.52%, P = 0.91). Some patients suffered from degeneration of adjacent intervertebral disc at final followup, but there was no significant difference in adjacent intervertebral disc degeneration between two groups (P = 0.71). Moreover, there were no differences in complications between Dynesys and PLIF (P = 0.90), although the incidence of complication in Dynesys was lower than PLIF (16.67% vs. 17.78%).
Conclusion:
Dynamic stabilization system treating lumbar degenerative disease showed clinical benefits with motion preservation of the operated segments, but does not have the significant advantage on motion preservation at adjacent segments, to avoid the degeneration of adjacent intervertebral disk.
doi:10.4103/0019-5413.144222
PMCID: PMC4232826  PMID: 25404769
Degenerative lumbar disease; dynamic neutralization system; posterior lumbar fusion; Spinal arthritis; spinal fusion; instrumentation lumbar vertebrae
8.  All levels versus alternate levels plate fixation in expansive open door cervical laminoplasty 
Indian Journal of Orthopaedics  2014;48(6):582-586.
Background:
Expansive open door laminoplasty with the use of titanium miniplate is becoming popular. Usually, the plate is applied at each level to prevent re-closure of the opened lamina. However, it is also used at alternating levels (i.e., C3, C5 and C7) in clinical settings in order to reduce the cost. Whether they have any difference in clinical efficacy? There is a lack of comparative data between the two kinds of plate fixation in the literature.
Materials and Methods:
83 patients who underwent cervical laminoplasty with alternating levels plate fixation (51 patients in Group A) or all levels plate fixation (32 patients in Group B) between January 2008 and October 2012 were evaluated in our institute retrospectively. Clinical and radiologic outcomes were assessed.
Results:
No statistical difference was found in the mean operation time, blood loss, incidence of significant axial symptoms and C5 palsy, preoperative anteroposterior diameter (APD) and preoperative Japanese Orthopedic Association score between the two groups. However, Group B showed a higher rate of neurologic recovery after surgery. Postoperative increased APD and open angle in Group B were significantly larger than Group A. The mean cost for Group B (12801 ± 460.6 USD) was higher than Group A (8906 ± 566.7 USD).
Conclusions:
Despite the higher cost of all level fixation, it is more effective in maintaining the expansion of the spinal canal and can obtain better clinical improvement compared to alternating levels fixation.
doi:10.4103/0019-5413.144225
PMCID: PMC4232827  PMID: 25404770
Cervical myelopathy; laminoplasty; open door; Spinal cord compression; compressive; myelopathy; cervical vertebrae
9.  Plate versus titanium elastic nail in treatment of displaced midshaft clavicle fractures 
Indian Journal of Orthopaedics  2014;48(6):587-593.
Background:
With changing trends in treatment of displaced midshaft clavicle fractures (DMCF), plating remains the standard procedure for fixation. An attracting alternative method of fixation is the titanium elastic nailing (TEN). However, prospective randomized studies comparing the two methods of fixation are lacking. We assessed the effectiveness of minimally invasive antegrade TEN and plating technique for the treatment of DMCF.
Materials and Methods:
80 unilateral displaced midclavicular fractures operated between October 2010 and May 2013 were included in study. This prospective comparative study was approved by the local ethical committee. Followups were at 2nd and 6th weeks and subsequently at 3, 6, 12, 18 and 24 months postoperatively. Primary outcome was measured by the Constant score, union rate and difference in clavicular length after fracture union. Secondary outcome was measured by operative time, intraoperative blood loss, wound size, cosmetic results and complications.
Results:
During analysis, we had 37 patients in the plate group and 34 patients in the TEN group. There was no significant difference in Constant scores between the two groups. However, faster fracture union, lesser operative time, lesser blood loss, easier implant removal and fewer complications were noted in the TEN group.
Conclusion:
The use of minimally invasive antegrade TEN for fixation of displaced midshaft clavicle fractures is recommended in view of faster fracture union, lesser morbidity, better cosmetic results, easier implant removal and fewer complications; although for comminuted fractures plating remains the procedure of choice.
doi:10.4103/0019-5413.144227
PMCID: PMC4232828  PMID: 25404771
Clavicle fractures; internal fixation of clavicle fractures; plate; titanium elastic nailing; Fractures; clavicle; fracture fixation; internal; bone plates; intramedullary nailing
10.  Outcome of free digital artery perforator flap transfer for reconstruction of fingertip defects 
Indian Journal of Orthopaedics  2014;48(6):594-598.
Background:
Fingertip defect can be treated with many flaps such as random pattern abdominal flap, retrograde digital artery island flap, V-Y advancement flap, etc. However, swelling in the fingertip, dysfunction of sensation, flexion and extension contracture or injury in the hemi-artery of the finger usually occurs during the recovery phase. Recently, digital artery perforator flaps have been used for fingertip reconstructions. With the development of super microsurgery techniques, free flaps can be more effective for sensory recovery and durability of the fingertip.
Materials and Methods:
Six cases (six fingers) of fingertip defects were treated with free digital artery perforator flaps of appropriate size and shape from the proximal phalanx. During surgery, the superficial veins at the edge of flap were used as reflux vessels and the branches of the intrinsic nerve and dorsal digital nerve toward the flap were used as sensory nerves. The proximal segment of the digital artery (cutaneous branches) towards the flap was cut off to form the pedicled free flap. The fingertips were reconstructed with the free flap by anastomosing the cutaneous branches of digital artery in the flap with the distal branch or trunk of the digital artery, the flap nerve with the nerve stump and the veins of the flap with the digital artery accompanying veins or the superficial veins in the recipient site.
Results:
Six flaps survived with successful skin grafting. Patients were followed up for 6-9 months. The appearance and texture of the flaps was satisfactory. The feeling within the six fingers recovered to S4 level (BMRC scale) and the two point discrimination was 3-8 mm.
Conclusion:
Free digital artery perforator flap is suitable for repairing fingertip defect, with good texture, fine fingertip sensation and without sacrificing the branch of the digital artery or nerve.
doi:10.4103/0019-5413.144228
PMCID: PMC4232829  PMID: 25404772
Fingertip defect; perforator flaps; reconstruction; Surgery; plastic; surgical flaps; finger injuries
11.  The timing of surgery and mortality in elderly hip fractures 
Indian Journal of Orthopaedics  2014;48(6):599-604.
Background:
Early surgery is recommended for elderly hip fracture patients, but some studies show no clear advantage. The benefits of early surgery may differ according to the medical environment in different countries. The purpose of this study was to identify the potential benefits of early surgery in elderly hip fracture patients by evaluating the effect of timing of surgery on mortality.
Materials and Methods:
A retrospective study was conducted at multiple centers on hip fracture patients aged over 65 years. The primary outcome was 1 year mortality and the secondary outcomes were 30-day/6-month mortality and complications during admission. The effect of time to surgery on mortality was analyzed using a Cox proportional-hazards model.
Results:
Among the 874 patients, 162 (18.5%) received surgery within 3 days and their 1-year mortality rate was 9.9%. However, the 1-year mortality rate for the delayed surgery group was 12.5%. After adjustment for potential confounders, the 1-year mortality rates in patients who received surgery in 3-7 days (Hazard ratio = 1.0; 95% confidence interval [CI]: 0.7-1.6) and over 7 days (hazard ratio = 1.3; 95% CI: 0.9-1.8) were not significantly different. In addition, the time to surgery did not have a significant effect on 30-day mortality, 60-day mortality or complications arising during hospitalization.
Conclusions:
The time to surgery did not affect short and long term mortality or the in hospital complication rate in elderly hip fracture patients. We recommend concentrating more on optimizing the condition of patients early with sufficient medical treatment rather than being bound by absolute timing of surgery.
doi:10.4103/0019-5413.144232
PMCID: PMC4232830  PMID: 25404773
Hip fracture; morbidity; mortality; hip surgery; Hip fractures; morbidity; mortality; Orthopedic surgery
12.  Large diameter metal on metal total hip replacement for femoral neck fractures with neurological conditions 
Indian Journal of Orthopaedics  2014;48(6):605-611.
Background:
Patients with Parkinson's disease and poliomyelitis can have a femoral neck fracture; yet, the optimal methods of treatment for these hips remains controversial. Many constrained or semi-constrained prostheses, using constrained liners (CLs) with a locking mechanism to capture the femoral head, were used to treat femoral neck fractures in patients with neurological disorders. We retrospectively studied a group of patients with Parkinson's disease and poliomyelitis who sustained femoral neck fractures and were treated by total hip arthroplasty using an L-MoM prosthesis.
Materials and Methods:
We retrospectively reviewed 12 hips in 12 patients who underwent large-diameter metal-on-metal (L-MoM) total hip replacement between May 2007 and October 2009. Eight of the 12 patients (8 hips; 66.7%) had Parkinson's disease and 4 patients (4 hips; 33.3%) were affected with poliomyelitis.
Results:
The followup time was 5.2 years (range 3.6-6.0 years). At the latest followup, all the patients showed satisfactory clinical and radiographic results, with pain relief. No complications, such as dislocation or aseptic loosening occurred.
Conclusion:
We believe the use of L-MoM can diminish the rate of instability or dislocation, after operation. The L-MoM is an option for patients with Parkinson's disease and poliomyelitis with femoral neck fracture.
doi:10.4103/0019-5413.144236
PMCID: PMC4232831  PMID: 25404774
Femoral neck fracture; Parkinson's disease; poliomyelitis; total hip arthroplasty; metal on metal prosthesis; Femoral neck; Parkinson's disease; poliomyelitis; hip replacement
13.  Outcome of rail fixator system in reconstructing bone gap 
Indian Journal of Orthopaedics  2014;48(6):612-616.
Background:
Bone loss following open fracture or infected gap nonunion is a difficult situation to manage. There are many modes of treatment such as bone grafting, vascularized bone grafting and bone transport by illizarov and monolateral fixator. We evaluated the outcome of rail fixator treatment in reconstructing bone and limb function. We felt that due to problems such as heavy apparatus, persistent pain, deformity of joints and discomfort caused by an Ilizarov ring fixator, rail fixator is a good alternative to treat bone gaps.
Materials and Methods:
20 patients (17 males and 3 females with mean age 30.5 years) who suffered bone loss due to open fracture and chronic osteomyelitis leading to infected gap nonunion. Ten patients suffered an open fracture (Gustilo type II and type III) and 10 patients suffered bone gap following excision of necrotic bone after infected nonunion. There were 19 cases of tibia and one case of humerus. All patients were treated with debridement and stabilization of fracture with a rail fixator. Further treatment involved reconstructing bone defect by corticotomy at an appropriate level and distraction by rail fixator.
Result:
We achieved union in all cases. The average bone gap reconstructed was 7.72 cm (range 3.5-15.5 cm) in 9 months (range 6-14 months). Normal range of motion in nearby joint was achieved in 80% cases. We had excellent to good limb function in 85% of cases as per the association for the study and application of the method of ilizarov scoring system[ASAMI] score.
Conclusion:
All patients well tolerated rail fixator with good functional results and gap reconstruction. Easy application of rail fixator and comfortable distraction procedure suggest rail fixator a good alternative for gap reconstruction of limbs.
doi:10.4103/0019-5413.144237
PMCID: PMC4232832  PMID: 25404775
Bone loss; corticotomy; infected nonunion; rail fixator; Bone; infections; fracture; ununited; orthopedic equipment; surgical procedure
14.  Hemophilic pseudotumor of the first lumbar vertebra 
Indian Journal of Orthopaedics  2014;48(6):617-620.
Hemophilic pseudotumor involving the spine is extremely uncommon and presents a challenging problem. Preoperative planning, angiography, intra and perioperative monitoring with factor VIII cover and postoperative care for hemophilic pseudotumor is vital. Recognition of the artery of Adamkiewicz in the thoracolumbar junction helps to avoid intraoperative neurological injury. We report the case of a 26-year-old male patient with hemophilia A, who presented with a massive pseudotumor involving the first lumbar vertebra and the left iliopsoas. Preoperative angiography revealed the artery of Adamkiewicz arising from the left first lumbar segmental artery. Excision of pseudotumor was successfully carried out with additional spinal stabilization. At 2 years followup, there was no recurrence and the patient was well stabilized with a satisfactory functional status. Surgical excision gives satisfactory outcome in such cases.
doi:10.4103/0019-5413.144238
PMCID: PMC4232833  PMID: 25404776
Hemophilia A; pseudotumor; lumbar spine; Hemophilia A; tumor; spine; lumbar vertebrae
15.  Retro-odontoid cystic mass treated by laminectomy and C1-C2 fixation 
Indian Journal of Orthopaedics  2014;48(6):621-624.
Retro-odontoid cysts associated with chronic atlantoaxial subluxation are extremely rare. This article describes a case of retro-odontoid cystic mass associated with chronic atlantoaxial subluxation and its management with posterior C1 and partial C2 laminectomy and C1-C2 pedicle screw fixation without resection of the retro-odontoid cyst. A 64-year-old woman experienced a sudden onset of neck pain, hand and foot paresthesia. Atlantoaxial instability associated with a retro-odontoid cystic mass was found in the imaging. The patient underwent posterior C1 and partial C2 laminectomy and C1-C2 pedicle screws fixation without resection of the retro-odontoid cyst. During the 24 months followup period, the cyst disappeared completely and the patient remained symptom free and returned to independent daily living. These findings suggest that posterior laminectomy and fixation without resection of the retro-odontoid cyst is relatively simple and safe and the results are satisfactory.
doi:10.4103/0019-5413.144239
PMCID: PMC4232834  PMID: 25404777
Atlantoaxial subluxation; atlantoaxial instability; retro-odontoid cyst; posterior fixation; Spine; cervical vertebrae; spinal diseases; orthopedic equipment; joint instability
16.  Fracture of the coracoid process with acute subscapularis tear without shoulder dislocation 
Indian Journal of Orthopaedics  2014;48(6):625-627.
Coracoid process fracture is an uncommon injury and can be easily missed. An associated acute subscapularis tear is still rare. Herein, we describe a 61 year old male who fell from a 2 meter height (stair case) and presented with isolated coracoid process fracture with acute subscapularis tear without dislocation of (R) shoulder joint. The plain x-rays, CT scan and MR arthrography comprised the diagnosis. He was operated upon with reattachment of subscapularis to lesser tuberosity and conjoint tendons to pectoralis major. At 6 mo followup he had good range of motion and his MRI revealed complete healing.
doi:10.4103/0019-5413.144240
PMCID: PMC4232835  PMID: 25404778
Coracoid process; dislocation; subscapularis tear; Scapula; dislocation; tendon injuries
17.  Vaginal mass following uncemented total hip arthroplasty 
Indian Journal of Orthopaedics  2014;48(6):628-630.
A 53-year-old woman developed a vaginal mass following an uncemented total hip arthroplasty. The mass was in direct communication with the hip through an acetabular medial wall defect after loosening of the acetabular component. The mass formation was caused simultaneously by changes secondary to polyethylene wear, a tiny delamination of the porous titanium mesh coating and a broken antirotational tab on the acetabular cup, all of which may have served as sources of metal particles. A careful evaluation of the patient's history, symptoms, X-ray findings and computed tomography scans should always be performed to ensure accurate diagnosis.
doi:10.4103/0019-5413.144242
PMCID: PMC4232836  PMID: 25404779
Metal debris; polyethylene wear; pseudotumor; total hip arthroplasty; Metallurgy; complications; hip replacement; hip prosthesis
18.  Cultivate…. research an attitude and learning a passion 
Indian Journal of Orthopaedics  2014;48(6):631-632.
doi:10.4103/0019-5413.144243
PMCID: PMC4232837  PMID: 25404780
19.  Author's reply 
Indian Journal of Orthopaedics  2014;48(6):632-633.
PMCID: PMC4232838  PMID: 25404781
20.  Medical subject headings (MeSH) terms 
Indian Journal of Orthopaedics  2014;48(5):443-444.
doi:10.4103/0019-5413.139827
PMCID: PMC4175855  PMID: 25298548
21.  Understanding risks and complications in the management of ankle fractures 
Indian Journal of Orthopaedics  2014;48(5):445-452.
Ankle fracture (AF) is a common injury with potentially significant morbidity associated with it. The most common age groups affected are young active patients, sustaining high energy trauma and elderly patients with comorbidities. Both these groups pose unique challenges for appropriate management of these injuries. Young patients are at risk of developing posttraumatic osteoarthritis, with a significant impact on quality of life due to pain and impaired function. Elderly patients, especially with poorly controlled diabetes and osteoporosis are at increased risk of wound complications, infection and failure of fixation. In the most severe cases, this can lead to amputation and mortality. Therefore, individualized approach to the management of AF is vital. This article highlights commonly encountered complications and discusses the measures needed to minimize them when dealing with these injuries.
doi:10.4103/0019-5413.139829
PMCID: PMC4175856  PMID: 25298549
Ankle fractures; complications; diabetes; elderly; posttraumatic ankle osteoarthirits; Ankle injuries; osteoarthritis; elderly; fractures; diabetes
22.  Misconceptions about the three point bony relationship of the elbow 
Indian Journal of Orthopaedics  2014;48(5):453-457.
Introduction:
The 3 bony point relationship of the elbow is an important surface evaluation done in all cases of elbow pathology; its importance is highlighted by the fact that significant emphasis is also laid on this during the specialty board examinations. Confusion about the exact inter relationship exists even in the standard orthopaedic books, with various authors labeling it as isosceles, equilateral or a different triangle, without any citation to back this statement.
Materials and Methods:
The knowledge of the three bony points relationship in elbow was verified after a survey of orthopaedic surgeons undertaken by the senior author, produced disparate answers. Most (63%) classified this as an isosceles triangle. To clarify this further, 200 elbows were prospectively evaluated to measure the distances between these points and the angles were calculated.
Conclusion:
Our observations indicate that this triangle is neither isosceles, nor equilateral, but a scalene triangle of unequal sides. There may even be a minimal difference in the 2 sides of the same individual, which has the potential to complicate routine comparison of the two elbows during examination.
Results:
The analysis of data revealed that all surgeons were aware of the three bony points relationship; however 21 of the 179 (mostly senior surgeons) did not give too much importance to this evaluation in daily clinical practice. Nine surgeons were not sure what type of triangle was formed, 17 thought it was an equilateral triangle, 40 thought it was some other type of triangle while 113 (63%) thought these points formed an isosceles triangle. This is a reflection of the disparity in the perception about this triangle in the orthopaedic community in general.
doi:10.4103/0019-5413.139835
PMCID: PMC4175857  PMID: 25298550
Elbow surface markings; elbow triangle; three bony point relationship; Elbow joint; dislocation; observation
23.  Outcome of surgical management of developmental dysplasia of hip in children between 18 and 24 months 
Indian Journal of Orthopaedics  2014;48(5):458-462.
Background:
Developmental dysplasia of hip (DDH) is a common condition presenting to a pediatric orthopedic surgeon. There is a consensus on the surgical treatment of children with ages ranged from 18 to 24 months where majority agree on open reduction and hip spica. Open reduction was done with an additional pelvic procedure wherever required to get better results and prevent residual acetabular dysplasia (RAD) and early osteoarthritis.
Materials and Methods:
35 children with unilateral DDH were operated between 2002 and 2007 at our institute. Open reduction was performed in all using the standard anterior approach and peroperative test for hip stability was done. Nine children got an additional pelvic procedure in the form of Dega acetabuloplasty. All were followed up for a minimal period of 2 years (range 2-7 years).
Results:
No hip got redislocated. At the end of 18 months, there were seven cases of RAD with acetabular index (AI) of 35° and above. These were all from the group where open reduction alone was done.
Conclusion:
We feel that a preoperative AI of >40° and a per-operative safe-zone <20° increases the need for supplementary pelvic osteotomy in age group of 18 to 24 months because in such cases, the remodeling capacity of the acetabulum is unable to overcome the dysplasia and to form a relatively normal acetabulum.
doi:10.4103/0019-5413.139841
PMCID: PMC4175858  PMID: 25298551
Dega osteotomy; developmental dysplasia of hip; pelvic procedure; children; Osteotomy; congenital; pediatrics; hip dysplasia
24.  Tuberculosis of the hip in children: A retrospective analysis of 27 patients 
Indian Journal of Orthopaedics  2014;48(5):463-469.
Background:
We retrospectively evaluated the pretreatment radiological presentation and the clinicoradiological outcome at the completion of 1 year chemotherapy in osteoarticular tuberculosis of hip in children to prognosticate correlation between them.
Materials and Methods:
We retrospectively analyzed the clinical and plain radiographic findings in 27 patients with an age of 12 years or younger in whom hip tuberculosis was diagnosed and treated between 2006 and 2010. The diagnosis was based on histopathology in 14 and clinicoradiological basis in 13 patients. The pre and post treatment plain radiographs were evaluated according to Shanmugasundaram radiological classification and our observations regarding unclassified cases which were not fit in this classification were suggested. The functional outcome at the completion of chemotherapy was assessed using modified Moon's criteria.
Results:
The male female ratio was 11:16. The left hip was involved more frequently than the right (17:10). The average age was 7.37 years (range, 2-12 years). In the pretreatment radiographs, 9 hips were normal, 6 traveling, 4 dislocating, 1 protrusio acetabuli, 3 atrophic and 4 unclassified types (3 triradiate; 1 pseudarthrosis coxae). There were no Perthes and mortar pestle at the initial presentation. Posttreatment, the types changed to 9 normal, 3 Perthes, 1 protrusio acetabuli, 1 atrophic, 4 mortar pestle and 9 unclassified types (3 triradiate, 3 pseudarthrosis coxae and 3 ankylosed). There were 37% excellent, 18.5% good, 26% fair and 18.5% poor results. The prognosis was best with initial “triradiate” and normal types and worst with posttreatment atrophic and “ankylosed” types.
Conclusions:
The Shanmugasundaram radiological types accurately predict prognosis only in normal types and “triradiate” pattern. The functional outcome is independent of radiological morphology of the hip in smaller children.
doi:10.4103/0019-5413.139852
PMCID: PMC4175859  PMID: 25298552
Hip; osteoarticular tuberculosis; pediatric; Hip; tuberculosis; pediatric; osteoarticular
25.  Results of triple muscle (sartorius, tensor fascia latae and part of gluteus medius) pedicle bone grafting in neglected femoral neck fracture in physiologically active patients 
Indian Journal of Orthopaedics  2014;48(5):470-475.
Background:
Femoral neck fractures are notorious for complications like avascular necrosis and nonunion. In developing countries, various factors such as illiteracy, low socioeconomic status, ignorance are responsible for the delay in surgery. Neglected fracture neck femur always poses a formidable challenge. The purpose of this study was to evaluate the results of triple muscle pedicle bone grafting using sartorius, tensor fasciae latae and part of gluteus medius in neglected femoral neck fracture.
Materials and Methods:
This is a retrospective study with medical record of 50 patients, who were operated by open reduction, internal fixation along with muscle pedicle bone grafting by the anterior approach. After open reduction, two to three cancellous screws (6.5 mm) were used for internal fixation in all cases. A bony chunk of the whole anterior superior iliac spine of 1 cm thickness, 1 cm width and 4.5 cm length, taken from the iliac crest comprised of muscle pedicle of sartorius, tensor fascia latae and part of gluteus medius. Then the graft with all three muscles mobilized and put in the trough made over the anterior or anterosuperior aspect of the femoral head. The graft was fixed with one or two 4.5 mm self-tapping cortical screw in anterior to posterior direction.
Results:
14 patients were lost to followup. The results were based on 36 patients. We observed that in our series, there was union in 34, out of 36 (94.4%) patients. All patients were within the age group of 15-51 years (average 38 years) with displaced neglected femoral neck fracture of ≥30 days. Mean time taken for full clinicoradiological union was 14 weeks (range-10-24 weeks).
Conclusion:
Triple muscle pedicle bone grafting gives satisfactory results for neglected femoral neck fracture in physiologically active patients.
doi:10.4103/0019-5413.139856
PMCID: PMC4175860  PMID: 25298553
Avascular necrosis; neglected femoral neck fracture; nonunion; triple muscle pedicle bone graft; Avascular necrosis of bone; femoral neck fractures; grafting; bone screws

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