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   Table of Contents - Current issue
Coverpage
July-December 2020
Volume 8 | Issue 2
Page Nos. 51-125

Online since Wednesday, December 23, 2020

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EDITORIAL  

Spinal problems – Spine surgeon or neurosurgeon: Is it an issue? p. 51
Pradeep K Singh, Sohael M Khan, Shraddha Singhania
DOI:10.4103/JOASP.JOASP_66_20  
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ORIGINAL ARTICLES Top

Debridement and stabilization with transpedicular screws in thoraco-lumbar spinal tuberculosis p. 52
Lenin Ligu, Moji Jini
DOI:10.4103/JOASP.JOASP_11_20  
BACKGROUND: The treatment for spinal tuberculosis (TB) remains a difficult and challenging decision-making process, given the lack of evidence and guidelines on the optimal treatment and management strategies. Conservative treatment options for spinal TB include methods such as immobilization using body casts or plaster beds, as well as a healthy diet. MATERIALS AND METHODS: The records of 26 patients who underwent posterior stabilization with pedicle screws and decompression with laminectomy for thoraco-lumbar TB with associated neurological deficit between January 2015 and December 2019 from hospitals were reviewed. The patients were followed up for a minimum of 24 months. In this study, we did not include patients with HIV co-infection. Results: In the present study, total 26 patients with thoraco-lumbar (T12-L1) TB. The study group consisted of 11 male and 15 female patients. The preoperative and postoperative mean kyphotic Cobb's angle were 23.1± 2.9° in males and 26.4 ± 2.4° in females and 8.9± 1.3° in males and 8.1± 1.4° females in the present study, respectively. At 1-year follow-up, the mean kyphotic angle was 11.2± 2.2° with a mean loss of kyphotic correction by 4.9± 1.1° in male. In our study, the C-reactive protein level decreased when compared preoperatively and postoperatively, 14.26 ± 1.8 in preoperatively, and 8.26 ± 1.2 postoperatively. Similarly, ESR value also decreased from 38.2 ± 2.3 mm to 21.6 ± 2.8. In addition, visual analog scale also decreased from 7.42 ± 1.1 to 2.9 ± 0.9. Conclusions: The procedure of one stage posterior debridement, decompression, and transpedicular screw fixation is effective and safe for treating thoracic and lumbar spinal TB.
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A cross-sectional study to evaluate the manual wheelchair-related factors associated with median nerve compression by ultrasonography p. 57
Aradhana Shukla, Anil Kumar Gaur, Anuradha Shenoy, Amit Mhambre
DOI:10.4103/JOASP.JOASP_33_20  
OBJECTIVES: The objective is to know the prevalence of median nerve compression and determine the relationship of median nerve compression with wheelchair (WC)-associated parameters. MATERIALS AND METHODS: A cross-sectional study was carried out from December 2016 to September 2018, where a total of 50 patients of either sex, aged 20–70 years, with spinal cord injury (D2 or below) who were independent manual WC ambulators (for >6 months) were included. The detailed demography, clinical details, and the wheel ergonomics (height of the shoulder from the axle of WC, weight of the WC) were noted. Ultrasonography of the bilateral median nerve was done at three levels to determine the median nerve thickness. The data were entered into the MS EXCEL spreadsheet, and analysis was performed using the Statistical Package for the Social Sciences (SPSS) version 21.0. A value of P < 0.05 was considered statistically significant. RESULTS: Median nerve compression was present in 12 (24%) patients who had significantly more weight of WC (kg) (19.42 ± 2.02 vs. 18.74 ± 7.38, P = 0.023); comparable mean duration of WC use (months) (31 ± 21.78 vs. 20.9 ± 20.02, P = 0.114); and comparable height between shoulder and axle of WC (inches) (28.17 ± 2.86 vs. 27.16 ± 2.32, P = 0.188). A significant positive correlation was seen between height from the shoulder to axle of WC (inches) and cross-sectional area (CS) of median nerve at carpal tunnel inlet (r = 0.517, P = 0.0001). CONCLUSION: The height of the axle with respect to the shoulder is important to limit the stress on the wrist to the minimum, thus preventing the median nerve compression.
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Functional outcome for the acromioclavicular joint disruption with or without lateral end clavicle fractures treated with hook plate p. 65
Sakthikesavan Sivanandan, Hariprasad Seenappa, Cecil Fernando, Harsha Madanamanchi
DOI:10.4103/JOASP.JOASP_37_20  
BACKGROUND: Acromioclavicular (AC) joint dislocation is most frequently encountered in contact sports and is far more common in males. Grade-III AC dislocation involves complete loss of contact between the clavicle and acromion secondary to the total disruption of both the AC and coracoclavicular ligaments, with loss of vertical and horizontal stability, respectively. The use of hook plate on open reduction and internal fixation of the AC joint dislocation had a little adverse effect on shoulder function and is an effective method for the treatment of AC joint dislocation. Hence, this retrospective study was carried out to assess the clinical and functional outcome of AC joint injuries treated with hook plate. AIM: The aim of this study is to assess and document the clinical and functional outcome of AC joint dislocation with or without lateral end clavicle fracture treated with hook plate. MATERIALS AND METHODS: This retrospective study of patients with Rockwood Type III AC joint disruption (dislocation) who were treated in our hospital. During the period from July 2013 to July 2018, a total of 33 patients with Type III AC joint disruption with or without associated lateral end clavicle fractures were included in this study, with 26 males and 7 females. The functional outcome was assessed using the CONSTANT scoring system during follow-up after hook plate fixation at 4 weeks, 3 months, 6 months, and 12 months. RESULTS: Thirty three patients with AC joint disruption were participated in the study after meeting the inclusion and exclusion criteria. There were 26 males (78.8%) and 7 females (21.2%) with a mean age of 44.7 years, eight patients had an associated lateral end clavicle fracture. All the patients were fixed with hook plate were followed up for a period of 1 year postoperatively. The mean Constant score improved progressively from a preoperative score of 44.5 to postoperative score of 68.3 at 4 weeks, 77.9 at 3 months, 89.4 at 6 months, and 93.3 at 12 months. CONCLUSIONS: In the current study, we conclude that the surgical and functional outcomes after AC joint stabilization with or without lateral end clavicle fractures using hook plate fixation yield satisfactory results. The hook plate also provides good horizontal, rotational, and vertical stability. Furthermore, the maintenance of reduction by the hook plate was significantly superior compared to the other modes of treatment. The hook plate also facilitates early mobilization and prevents stiffness of the shoulder joint.
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A study on the effectiveness of visco-supplementation in osteoarthritis knee p. 70
Sakthikesavan Sivanandan, HS Arun, Hariprasad Seenappa, JS Nagakumar
DOI:10.4103/JOASP.JOASP_13_20  
BACKGROUND: Osteoarthritis (OA) is a degenerative disease of synovial joints; recently, it is also termed osteoarthrosis. High-molecular-weight hyaluronic acid (HA) has a better increase in fluid retention within the joint and stronger anti-inflammatory effect. OBJECTIVES: The objective was to assess the efficacy of intra-articular (IA) HA in primary OA of knee joint based on clinical outcome with visual analog score (VAS) and the Western Ontario and McMaster Universities OA Index (WOMAC) score and to determine the safety of IA HA in primary OA of knee joint. SUBJECTS AND METHODS: A single-group, prospective interventional study was conducted from November 2017 to May 2019 in a tertiary care hospital. A total of 36 patients with Grades I and II of Kellegren–Lawrence radiological grading were included in the study. IA injection of HA was given to these patients and were assessed using VAS and WOMAC scores. RESULTS: The mean VAS scores improved from preinjection score of 9.03 ± 0.94 to 2.61 ± 2.15 at 6-month follow-up. In addition, the mean WOMAC scores improved from 81.14 ± 6.43 to 35.81 ± 13.44 at 6-month post-IA HA injection. CONCLUSIONS: This study observed that IA injection of HA is a reliable, productive, efficient, and safe mode of treatment of Grade I and II OA knee, which also delays the disease and reduces the need for surgical intervention.
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Study of functional outcome of surgical management of distal humerus fractures with bicolumnar plating p. 75
Neetin P Mahajan, Prasanna Kumar GS, Ved Ashish Ravesh, Nikhil D Palange, Shashibhushan S Varekar
DOI:10.4103/JOASP.JOASP_15_20  
INTRODUCTION: Distal humerus fractures in adults comprise 2% of all fractures and 30% of all humeral fractures. Intra-articular distal humerus fractures account for 37% and involve both medial and lateral columns. Most of the distal humeral fractures in adults must be treated surgically to get better functional outcome. The aim of this study was to assess the efficacy, technical requirements, functional outcome, radiological and clinical union, and complications of distal humerus fractures treated with bicolumnar plating. MATERIALS AND METHODS: This was a prospective study of 35 cases of distal humerus fractures conducted at a tertiary care hospital, who were treated surgically with bicolumnar plating using posterior approach with transolecranon osteotomy between 2016 and 2018. The Mayo Elbow Performance Score was used for the assessment of functional outcome. RESULTS: Thirteen (37.14%) patients got excellent outcome, 17 (48.58%) got good outcome, 4 (11.42%) got fair outcome, and 1 (2.86%) got poor outcome, and the complications observed were infections, nonunion, implant failure, and elbow stiffness. Distal end radius fracture was the common association with distal humerus fracture in our study. CONCLUSION: Open reduction and internal fixation with bicolumnar plating is the treatment of choice for distal humerus fracture mainly in type B and C fractures. Fracture types, use of locking plates, stable fixation, and meticulous repair of soft tissues along with early elbow mobilization influence the final functional outcome. Bicolumnar plating provides better stability, allows early elbow range of motion, and prevents stiffness.
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Intraoperative instrument breakage during the orthopedic elective procedures: A retrospective single-center experience p. 80
Ganesh Singh Dharmshaktu, Navneet Adhikari, Pankaj Mourya, Shailendra Singh Bhandari, Pankaj Singh
DOI:10.4103/JOASP.JOASP_18_20  
BACKGROUND: Fracture fixation accounts for majority of orthopedic surgical interventions with most procedures requiring variety of instruments as part of surgical armamentarium. Breakage of instruments during the operation is unwanted experience and may complicate or lengthen the procedure thus interfering with overall outcome. A study regarding the pattern of intraoperative instrument failures is thus important to gain fruitful insights for not only preventive strategies but for further studies in this context. MATERIALS AND METHODS: A retrospective study of all consecutive incidents of instrument breakage during a 2-year period (January 2017 to December 2019) were recorded with relevant details such as type of surgery, type of implant, type of instrument and the probable cause, management and key demographic details during 2-year period at a tertiary care center in North India. Knowledge about the risk factors was tried to be extracted from our observations. RESULTS: Out of a total 8132 elective major and minor cases during the study period, 30 (0.36%) cases of intraoperative instrument breakage were noted. The types of instrument broken in the descending order with numbers in the bracket were drill bits (5), guidewires (3), manual intramedullary reamers (3), periosteal elevator (3), screwdriver tip, and bone tap in two cases each. The power-driven flexible reamer, screwdriver tip, screwdriver handle, proximal jig for the intramedullary nail, bone nibbler, and bone lever were another instruments with singular incidents. In the general instruments, long artery forceps (4) was the most common to break followed by mosquito forceps (3) and one nose-plier in separate cases. Conclusion: The breakage of surgical and non-implant instruments during the operation is uncommon event but requires proper documentation and due acknowledgement for prohibitive and management guidelines.
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Primary intramedullary nailing in compound Type 1 and 2 femur shaft fractures and their effect on functional outcome p. 86
Neetin P Mahajan, Prasanna Kumar GS, Nikhil D Palange, Amit Kumar Yadav, Abhishek Harsoor, Harish Pawar
DOI:10.4103/JOASP.JOASP_17_20  
Background: Femur shaft fractures are the most common long bone fractures encountered in orthopedic practice. Open fractures of the femur shaft are due to high-energy trauma; these patients are usually associated with other system injuries and vascular involvement. The initial management of open fractures includes antibiotics, debridement, and stabilization. If the initial debridement is believed to be adequate, definitive fixation of the femoral shaft can be performed usually with reamed intramedullary nailing. The present study was conducted to evaluate the functional outcome in open Type 1 and 2 femur shaft fractures managed with primary intramedullary nailing and the complications related to it. Materials and Methods: Twenty-two patients, having Grade 1 and 2 compound femur shaft fractures were admitted and included in the study from January 2016 to February 2019 after obtaining valid consent. All the patients were investigated with X-rays, and fractures were classified according to Gustilo–Anderson classification. All the patients were treated primarily with intramedullary nailing, and the functional outcome was assessed by using Harris Hip Score and Oxford Knee Score. Results: Thirteen (59.09%) patients had Type 1 open femur shaft fractures and nine (40.90%) patients had Type 2 fractures. Fracture union was observed in six patients (27.27%) at 3 months and in 16 (72.72%) at 3–6 months. Complications observed were superficial wound infections in two patients, deep infections in two patients, and nonunion in one patient. Thirteen (59.09%) patients got excellent outcome, four (18.18%) patients got good outcome, three (13.63%) patients got fair outcome, and two (09.09%) patients got poor outcome. Conclusion: Primary intramedullary nailing is an effective method of managing Type 1 and 2 open femur shaft fractures if thorough early and timely debridement can be done. It is associated with less complications, helps in early mobilisation and also avoids secondary procedures.
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Recommendations for appropriate use of tranexamic acid in total hip arthroplasty p. 91
Sunil Sheshrao Nikose, Shashank Sanjay Jain, Devashree Nikose, Kiran Saoji, Sohael Khan, Keshav Vijan
DOI:10.4103/JOASP.JOASP_22_20  
BACKGROUND: Tranexamic acid (TXA) has gained recent interest in orthopedics and trauma surgery because of its demonstrated benefit in several clinical trials. Prophylactic TXA is a safe, low-cost option to reduce bleeding in patients undergoing total hip replacement (THR), and its optimal dose and duration are unknown. Also, there is still no consensus as to the best form and dosages of the use of TXA. Hence the present study was carried out to determine the appropriate use of TXA, its dosage, timing, and recommendations for the best possible bleeding control in total hip arthroplasty. AIM AND OBJECTIVES: Present study was aimed to prove the efficacy of TXA in total hip arthroplasties when compared with a control group, to establish a criterion for the ideal use of TXA, and to identify possible complications. MATERIAL AND METHODS: A total of 238 adult patients receiving TXA undergoing replacement of hips since March 2015 were included in the study and divided randomly into four groups. Group one received a single dose of 500 mg TXA before the start of surgery (Preincision) over 10 minutes, group two received a 500 mg TXA 20 minutes prior to surgery in the operation room and just before the start of surgery (Preincision) over 10 minutes, group three received 500 mg TXA 20 minutes prior to surgery in the operation room and 500 mg just before the start of surgery (Preincision) over 10 minutes and then three hours post-surgery and group four (Control group) did not receive any TXA. Total blood loss was calculated using a formula considering hematocrit values and blood transfusions received. RESULT: Two hundred and thirty-eight adult patients were included in the study: 60 in group one, 59 in group two, 60 in group three and 59 in group four. All the groups had mean hemoglobin level above10 g/dL. Maximum benefit was observed in group three followed by group one and group two respectively with almost similar outcomes while group four did not show any benefits, thus demonstrating the beneficial effect of TXA regarding hemoglobin decrease postoperatively. CONCLUSION: The findings of the present study demonstrated that the use of TXA in THA reduced the incidence of perioperative bleeding and, consequently, a significant reduction in decrease in serum hemoglobin was observed in groups one, two, and three when compared to the group four control. Therefore, there was a reduction in the need for blood transfusion. Thus the maximum beneficial effect of TXA was observed in group three followed by group one and group two which had a similar outcome while group four did not show any benefits.
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To compare the results of anterior cruciate ligament reconstruction with preservation versus total removal of torn anterior cruciate ligament stump p. 96
TP Gupta, SK Rai, Manoj Kashid
DOI:10.4103/JOASP.JOASP_21_20  
PURPOSE: Reconstruction of anterior cruciate ligament (ACL) with torn ligament remnant preservation is done with the aim to improve the proprioceptive function and vascularization of new graft. In our study, we compared the results of ACL reconstruction with and without preservation of femoral and tibial ACL torn stumps. MATERIALS AND METHODS: This is a prospective study consisting of 100 patients distributed into two groups. Group A (n = 50) underwent reconstruction of ACL with remnant stump preservation and Group B (n = 50) underwent reconstruction of ACL with total removal of ACL remnant from the femur and tibia. RESULTS: The present study did not show any significant differences in terms of stability and ACL laxity in the study groups. However, a remarkable difference was noted in proprioception and functional results in both the groups, with Group A (>20%) showing better results. CONCLUSION: Based on our study, we can conclude that it is judicious to keep ACL stump as much as possible, and it is advisable to wait till 4 weeks to get inflammatory phase subsided. Preservation of remnant should not interfere with ACL footprint visualization. Remnant preservation improves proprioception of the knee and functional outcome.
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Comparison of conservative and operative management for unstable extra articular proximal phalanx fracture of hand: A prospective study p. 103
Jugaratna Khatua, Debi Prasad Nanda, Ramgopal Panigrahi, Ramesh Chandra Maharaj
DOI:10.4103/JOASP.JOASP_26_20  
BACKGROUND: Hand injuries are often overlooked and are not given the importance that they deserve. Decision-making in the management of phalangeal fractures is crucial rather more difficult than long bone fractures; as no treatment will lead to deformity and over treatment will cause stiffness. AIM OF THE STUDY: Compare the results of both conservative and operative managements of proximal phalangeal fractures for decision making while dealing with these innocent looking injuries. SUBJECTS AND METHODS: This was a prospective study of 60 patients of unstable extra articular proximal phalangeal fractures over 2 years. Fifty percent of the patients managed conservatively and 50% surgically. Results were analyzed by the assessment of total range of movements (TROM); functional score of Belesky et al.; grip strength; time of return to work and complications associated with each methods. RESULTS: There was no statistically significant difference between conservative and operative group (TROM P 0.063; Belesky score P = 0.135). Among all modalities best results was achieved with Close Reduction and Internal Fixation (CRIF) with percutaneous k wires which was statistically and clinically significant as compared to conservative and Open Reduction and Internal Fixation (ORIF) group (TROM P = 0.012; Belesky score P = 0.024]. Complications were mostly malunion with conservative methods and infection; implant failure; CRPS were more common in operative methods. CONCLUSION: Conservative management is preferred over surgery for unstable proximal phalangeal fractures. If surgery is needed for stability than close reduction (CRIF) with percutaneous k wire is preferred over open techniques (ORIF).
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CASE REPORTS Top

“A journey from doom to bloom” – A rare case of low-energy pediatric open supracondylar fracture of humerus with brachial artery laceration managed with “Orthoplastic Approach” p. 113
Sharat Agarwal, Swarup Sarkar, Manika Agarwal
DOI:10.4103/JOASP.JOASP_16_20  
Supracondylar fracture of the humerus (SFH) is the most common fracture of the elbow in the pediatric population (60%). The brachial artery is the most frequently injured artery in the upper extremity due to its vulnerability, and commonly, it is associated with road traffic accidents (RTAs) and occupational injuries. However, brachial artery injury in the pediatric age group is not very frequent as in adults and commonly associated with SFH. Long-term sequelae of ischemia in the forearm such as Volkmann's ischemic contracture may prove disastrous. Early aggressive management in terms of exploration of the brachial artery is recommended by Blakey et al., to prevent such serious complications. Arterial injury ranges anywhere from vascular contusion and intimal damage, to complete arterial transaction. Low-velocity injuries such as falls or sports injuries can cause isolated Type 1 open fractures (Gustilo and Anderson classification of open fractures). Open supracondylar fracture complicated by brachial artery laceration is usually seen in high-velocity injuries such as RTA and is usually a part of multiple injuries sustained in such patients. However, in search of literature, we have not found an isolated Type 3 open supracondylar fracture with brachial artery laceration following a fall from a speeding bicycle, which is considered as a low-energy trauma. This patient was managed with reduction and fixation of the fracture with crossed K-wires and repair of the brachial artery with interpositional reversed saphenous vein graft to save the limb.
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Revision spine surgery with hartshill-sublaminar wiring in operated osteoporotic fracture: A case note p. 118
Shailesh Hadgaonkar, Pradhyumn Rathi, Vivek Vincent, Ashok Shyam, Parag Sancheti
DOI:10.4103/JOASP.JOASP_5_20  
Osteoporotic vertebral compression fractures (OVCF) are one of the most common fractures seen in a day-to-day practice. We present a unique case of failure of pedicle screw instrumentation in OVCF revised by sublaminar wiring (SLW). A 70-year-old female with old operated osteoporotic fracture with the sagittal imbalance and implant loosening was revised with a single spinal rectangular loop and sublaminar wires (SLW). Pedicle screw constructs for short-segment fixation are rigid and biomechanically superior with the greatest pull-out strength, which mainly depends on the bone mineral density. However, sublaminar wires should be considered far more superior in severely osteoporotic bone.
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Superior iliac hip dislocation: A rare injury and literature review p. 123
Ganesh Singh Dharmshaktu, Navneet Adhikari, Pankaj Mourya
DOI:10.4103/JOASP.JOASP_12_20  
The anterior hip dislocations are uncommon and are further categorized into pubic or iliac type. Iliac type of dislocation is less common than pubic type. These injuries are limited to a few case reports or small series in the literature. There is no consensus on the mechanism of injury and treatment strategy for this injury. We present a case of isolated left side superior iliac type of hip dislocation in a 30-year-old male patient. The case was managed by uneventful concentric reduction under anesthesia. There was no recurrence and radiological features of osteonecrosis was not noted in the follow-up of 8 months.
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