Journal of Orthopedic Education

This short communication article outlined the CPRs on neck pain for use in physical therapy (PT) practice and found two studies on mechanical traction, one study on cervical spine thrust manipulation, two studies on thoracic spine thrust manipulation. Most of the identified CPRs were basically on development, with few or none found on validation or impact analysis of CPR, which threatened the external validity of such CPRs for use in evaluation and treatment of people with neck pain.

Keywords: Neck Pain; Clinical Decision Making; Ortheopaedic Examination; Orthopaedic Rehabilitation.

A 35 years old male, farmer by occupation, patient had a trivial fall from a motorcycle and sustained injury to both the wrist joints, diagnosed to have a Bilateral closed distal end intra­articular radius fracture (volar Barton), our patient had osteopenia on DEXA study, patient was treated with ORIF with volar lock plating and Umex external fixators with K­wire fixation on the left side. Patient regained full range of movements in both the wrist joints. Discussed the results of ORIF locked plating and closed reduction U­MEX external fixator with K­Wire fixation. Case Report: A 35year old male farmer by occupation came to the casualty with the history of fall from a motorcycle (trivial injury) and sustained injury to both the wrists, on examination had swelling over wrist and hand but no open wounds and no neurovasular deficits, preoperative radiographs diagnosed to have bilateral volar barton fractures . On DEXA examination patient had a T­Score of ­2.0 , categorising him as an osteopenic. Treated with Open reduction & internal fixation with titanium locked plating on right side, Closed reduction UMEX external fixator followed by percutaneous K­wire fixation on left side. Patient was put on Calcium supplements daily 500mg for 6 months and vitamin D3 60k IU once a week. Right wrist was mobilised after a week of operative intervention and left wrist mobilised after 6 weeks, patient regained normal range of movements .

Keywords: Fracture of Lower End of Radius; Volar Barton; Dorsal Barton; U­MEX External Fixator; Percutaneous K­Wire Fixation.

Most common site of giant cell tumor is distal femur and proximal tibia. Patella is not a very common site of occurrence of GCT. This case report is of a 27 year old female having GCT of patella. She presented with 18 month history of anterior knee pain and 6 month history of mild swelling on anterior aspect. Radioclinicodiagnosis was made by doing X­ray & histopathology. Treatment consists of extended curettage with help of phenol, cottary & cavity is filled with bilateral autologous iliac crest bone graft and beta­tricalcium phosphate granules. Following 24 months of surgery patient is asymptomatic and there is no local recurrence was found clinicoradiologically.

Keywords: Giant cell tumor; Patella; Bone grafting; Anterior knee pain.

This study reviewed the literature on the treatment of symptomatic lumbar degenerative disc disease with artificial disc replacement which has the advantage of motion preservation. This technique is evolving with continuous modifications in the prosthesis design and needs a long term follow­ up of clinical outcomes. The indications and contraindications of the procedure are being defined and the initial results are comparable to the lumbar fusion with preservation of motion.

Keywords: Artificial Disc; Disc Degeneration; Lumbar

Clinical prediction rules (CPR) or clinical decision rules (CDR) use a cluster of symptoms and signs to identify and subgroup patients who were likely to present with a particular diagnosis (diagnostic CPR), or to respond to a treatment (therapeutic CPR) or to have a change in outcome (prognostic CPR). The objective of this review article was to update the utility of CPRs for clinical decision making in evaluation and treatment of people with low back pain (LBP) from an evidence­informed perspective. The CPRs on LBP provide a clinical direction but not a defnitive decision rule for predicting diagnosis, therapy and prognosis. There were two reviews, four studies on spinal manipulation, one study on stabilization exercise, one study on mechanical diagnosis and therapy, one study on pilates­based exercise and one study on mechanical lumbar traction. In addition, there was one study each on prescription, rate of recovery and return to work. The reviewed studies were mostly on development and few were on validation, with no study found on impact analysis of CPR in LBP. There is thus scope for future research in this area.

Keywords: Clinical Examination; Clinical Decision Making; Orthopedic Decision Making; Orthopedic Rehabilitation.

Aim: To describe the novel technique and study the results of Transosseous disc preserving cervical discectomy in patients with posterolateral disc herniation. Background: Traditional anterior cervical discectomy followed by fusion may be non­physiological with significant fusion­related complications and adjacent segment degeneration. The functional discectomy technique, which includes removal of only the disc fragments compressing the neural structures while preserving the rest of the disc, may restore the mobility of the involved motion segment. Materials and Methods: The study included 24 consecutive patients who presented with upper limb radiculopathy with or without neurological deficits due to single level posterolateral soft disc herniation between August 2006 and June 2009. The patients were aged between 22­54 years. Approach to the herniated disc was through a 4­5 mm circular hole made in the inferior vertebral body with cephalad inclination. The lateral wall of the body was kept intact in all cases. All patients were assessed for clinical and radiological outcomes at regular intervals. Results: The mean follow­up duration was 19 months (6­34 months). Radiculopathy symptoms improved in all the patients with mean VAS score reducing from 4.5 to 2.1 following surgery. None had worsening of axial neck pain. There was loss of disc height from mean of 5.8 mm to 5.4 mm and segmental sagittal lordosis from mean of 2.3 to 2.1.The segmental mobility decreased from mean of 4.1 pre­operatively to 3.7 at last follow up. Two patients had intra­operative complications. No late complications reported so far. Conclusion: Transosseous discectomy gives satisfactory pain relief with adequate neural decompression in the studied group of patients with preservation of mobility. Long term follow up is needed to assess the mobility and its role in preserving the adjacent segment degeneration.

Keywords: Cervical Disc Prolapse; Transosseous Discectomy; Radicuopathy.

 Background: Wound healing is a complex process which includes removal of dead tissues, control of bacterial load, control of inflammation, increased blood flow, formation of granulation tissue, contracture, remodeling of connective tissue matrix and finally maturation. This usually requires lengthy hospital stays and expert nursing home care which is not always possible. Vacuum assisted closure (VAC) also called as Negative pressure wound therapy (NPWT) is a new modality of managing chronic and acute wounds.VAC therapy accelerates process of wound healing, thereby, reducing hospital stays and cost of treatment. The aim of our study was to evaluate the efficacy of locally constructed Negative pressure wound therapy in orthopaedic patients with acute and chronic wounds. Materials and Methods: VAC was applied after thorough debridement in 21 patients from orthopaedic inward department, Government medical college, Latur, Maharashtra, India. Initial assessment of all the wounds was done. After the thorough debridement, vacuum assisted closure of wounds was done. Negative pressure is set to in between 120­150 mm of Hg. Results: Analysis was done with visual inspection of wounds and end point was taken as completely granulated wound, free of discharge and ready for skin grafting or spontaneous healing with secondary intention. Age distribution of the patients was between 25 to 63 years with mean age of 43 years. There was rapid progress in the wounds with respect to decrease in oedema, formation of granulation tissue, reduction in the size of wound. We were able to cover wounds earlier. This also has reduced hospital stay of the patients and reduced the cost of treatment by a great margin. Conclusion: VAC therapy proves to be a safe and effective treatment modality for soft tissue injuries.

Keywords: Vacuum Assisted Closure (VAC); Negative Pressure Wound Therapy (NPWT).

Twenty patients of Distal Tibial fractures over a period of two and half years were retrospectively reviewed for this study. All were adult patients with males fifteen female five. 4 mm LCP plates were used (distal medial tibial LCP) in all the cases. Fibula fixation was performed in the majority of comminuted fractures to prevent collapse of the fracture. There were four cases of delayed wound breakdown in fractures fixed with the plate (DMT LCP). Five patient required primary bone grafting. MIPO with LCP was observed to be reliable method of stabilization of these fractures. The pre contoured DMT LCP was observed to be a better tolerated implant in respect to complication of soft issue, bone healing and functional outcome.

Keywords : Distal Metaphyseal Tibial Fractures; Distal Medial Tibial Locking Plate (DMT LCP); MIPO (Minimally Invasive Plate Osteosynthesis).

Introduction: The hip joint functions on the bio­engineering principle of moment of force with a fulcrum, lever arm, power arm. Hip joint with the hemi­spherical femoral head articulating in the acetabular cup with abductor muscles acting at one end, the body weight on the other, and the joint itself being the fulcrum can be compared to a ‘First order lever’. To describe the force acting on the hip joint, the body weight can be depicted as a load applied to a lever arm extending from the body’s centre of gravity to the centre of the femoral head. Methodology: During our study period 56 patients met inclusion criteria, and all patients underwent total hip replacement either cemented or uncemented through modified lateral approach. Data was collected from previous operative records, regular follow­up x­ray films and follow­up records. Results: In our study, out of 56 patients, 46 patients (82.2%) had negative modified Trendelenburg test, whereas 10 patients (17.8%) had positive modified Trendelenburg test. Most of the positive modified Trendelenburg test patients were in secondary osteoarthritis group, 7 out of 10. Conclusion: The most common indication for Total Hip Arthroplasty in our study is displaced fracture neck of femur in elderly active patients.

Keywords: Total Hip Replacement; Trendelenburg Test; Total Hip Arthroplasty.

Introduction: The ACL is the most important structure in the knee. The old name of anterior cruciate ligament was crucial ligament since cruciate or crossed arrangements of the anterior and posterior cruciate ligaments within the knee. The importance of the anterior cruciate ligament in the maintenance of joint integrity has been recently appreciated. Methodology: About 30 patients with anterior cruciate ligament injury attending the department of Orthopedics were included in the study. Clearance from Institutional Ethical committee was obtained before the study was started. An informed, bilingual consent was obtained from each patient before they were included in to the study. Results: In the PTB group, 53.3% of the patients had left sided ACL tear and 46.7% had right sided tear. In the STG group, 46.7% had left sided ACL tear and 53.3% had right sided ACL tear. Conclusion: The tears of the ACL present acutely or chronically and in the acute lesion the other ligaments may be clinically normal.

Keywords: Anterior Cruciate Ligament; RTA; Sports.

Introduction: Restoration of the stability of the knee joint is the main goal of the ACL reconstruction. Other benefits include allowing the patient to return to normal activities, including sports; and to delay the onset of osteoarthritis with associated recurrent injuries to the articular cartilage and loss of meniscal functions. Surgical management of the anterior cruciate ligament deficient knee has been evolved from the primary repair to anterior cruciate ligament reconstruction using biologic tissue grafts. Methodology: A prospective and retrospective study was conducted in the Department of Orthopedics, and about 30 patients with anterior cruciate ligament injury attending the department of Orthopedics were included in the study. Results: After two years, 86.7% of the patients in PTB group and 93.3% in the STG group had extensor lag of less than 3 degrees. About 13.3% of the patients in PTB group and 6.7% in the STG group had extensor lag of 3–5 degrees. Conclusion: The clinical and functional evaluation of both the grafts was found to be same with slight preponderance towards hamstring grafts.

Keywords: ACL Reconstruction; Hamstring Grafts; Articular Cartilage.

Introduction: In the young people, It occurs following high energy trauma. Low velocity injuries like simple fall, domestic injuries will cause fractures in elderly patients older than 50 years (9). The last and least common cause of proximal humerus fracture is due to pathological fractures. Methodology: This was a prospective study of 21 cases of proximal humerus fractures in adults treated by surgical fixation with proximal humerus locking plate. Patients aged above 20yrs and who gave their consent participated in the study. Results: In this study, 70% of study subjects were aged less than 50 years and 76% were males. Among 66.7% of patients right side was involved and RTA occurred in 76.39% of patients. Conclusion: Three part type of fracture was more common.

Keywords: Humerus; RTA; Clinical Profile.

Introduction: Any synovial joint may be affected, but the most severe degeneration occurs in joints subjected to greatest compression.The disease is twice as prevalent in the obese and mainly affects the weight bearing joints, such as lower spine, knee and hip joints. Methodology: Our study was a prospective randomised double blinded comparative study between use of autologous mesenchymal stem cells with platelet rich plasma (PRP) and platelet rich plasma alone in early osteoarthritis knee. A total no. of 32 patients were studied and they were randomised into two groups group 1 mesenchymal stem cells with platelet rich plasma and group 2 platelet rich plasma alone by computer generated algrorithm table each group had 16 patients. Results: Mean cartilage thickness group1 at final followup right side 4.0619 (SD±0.38456) and left side 3.8469 (SD±0.4843) and group 2 3.772 right side (SD±0.3307) and left was 3.660 (SD±0.2761) and both groups are statistically significant with p value 0.030 for right side and 0.001 for left side. Conclusion: The probable mechanism involved was due to paracrine effects and differentiation of mesenchymal stem cell enhanced with platelet rich plasma.

Keywords: Mesenchymal Stem Cells; Platelet Rich Plasma; Osteoarthritis.

Introduction: Over the last 3 decades, various modalities of fixations have evolved for the proximal humerus fractures. Of this proximal humerus locking plate is the implant of choice now for treatment of displaced proximal humerus fractures since they provide rigid anatomical fixation and more angular stability. Hence, It permitsearly mobilization and good functional limb. Methodology: This was a prospective study of 21 cases of proximal humerus fractures in adults treated by surgical fixation with proximal humerus locking plate. Twenty one patients were randomly selected from among the admission to the accident ward in Department of Orthopaedics and recruited into the study prospectively. Results: The average time for fracture healing is 10.15 weeks (Ranging from 8 weeks to 15 weeks). Fracture type, comminution and presence of infection shad a significant role in fracture union. 5 patients, who had stiffness, underwent physiotherapy and attained functionally acceptable range of movements. Conclusion: Anatomical restoration of the tuberosity had direct relationship with the range of movements. Cases with good anatomical restoration had excellent results.

Keywords: Humerus Fracture; Locking Plate; Anatomical Restoration.

Background: To assess a correlation between forearm length and palmarislongus tendon length in the cadavers of Indian population. A preoperative knowledge on the length of the tendon to be harvested can help a surgeon for better planning of the surgery. Methods: We dissected 84 forearms with 42 pairs of fresh frozen cadavers of Indian origin. The forearm length was measured with a measuring tape. The length and width of the tendon was measured using digital calipers. Student’s ‘t’ test was applied to analyze the data and P value <0.05 was considered statistically significant. Age, sex and side of the cadavers were noted. Pearson’s correlation coefficient was applied to find out the correlation between the forearm length & the length and the width of the palmaris longus tendon. Forearms with absence of palmaris longus or with congenital anomaly or previously operated were excluded from the study. Results: Out of the 42 fresh frozen cadavers with 84 pairs of forearm, one cadaver had bilateral absence of palmarislongus. Hence, 41 cadavers with 82 forearms were studied. There were 46 male and 36 female forearms with mean age of 69.3± 6.7 years for males and 72.1± 7.3 years for females. The mean lengths of the palmaris longus tendons were 175.18±12.12 mm in males and 165.75 ±12.30 mm in females. The mean lengths of the forearms were 268.94 ± 11.74 mm in males and 261.23 ± 12.91 mm infemales. A significant correlation was found in between the lengths of the tendon and the forearm in males (r =0.62; p <0.05), females (r=0.598; p <0.05) and for combined males and females (r= 0.651; p< 0.05). Conclusion: Our study helps the surgeon to plan the incision site based on the forearm length in Indian population.

Keywords: Palmaris Longus Tendon; Forearm Length; Fresh Frozen Cadavers; Indian Population; Preoperative Plan.

 Introduction: Isolated ACL injuries account for about half of the knee injuries in a given year. ACL tears are common in young active persons 70% occurring during sports activities. In general, the incidence of ACL injury is higher in people who participate in high­risk sports, such as basketball, football, skiing, and cricket. Methodology: As soon as the patient is admitted, a detailed history was taken & meticulous examination of the patient was done. The required information was recorded in the proforma. The patient’s Knee radiographs were taken in AP & Lateral views. The diagnosis was established by clinical & Radiological examination. Initially in patients with acute knee injuries, the Knee is immobilized in a long knee brace till reduction of Haemarthrosis / Joint effusion. Results: The functional outcome was fair in 60% of patients, 20% of patients had poor results and 20% of patients had excellent functional outcome. Conclusion: Males are more prone for anterior cruciate ligament injuries.Household injuries and sports related injury are the most common modes of injury.

Keywords: ACL Injury; Autograft; Functional Outcome

Introduction: Contact sports produce injury to the anterior cruciate ligament (ACL) secondary to twisting, valgus stress, or hyperextension all directly related to contact or collision, When matched for activities, a greater prevalence for ACL injury is found in females compared with males. Methodology: The surgery was done with patient supine under spinal anaesthesia or general anaesthesia, under tourniquet control. Initial diagnostic arthroscopy was done using standard arthroscopic portols and the status of both menisci, Anterior cruciate ligament, Posterior cruciate ligament was noted. Partial meniscectomy was done in cases where it was indicated. Results: Knee score was excellent in 18 cases of titanium screw group and 20 cases of bioscrew group. One Patient in bioscrew group had fair result. Among 50 patients in the group, 49 cases had good to excellent results in fair and 1 case. Conclusion: Arthroscopic ACL reconstruction with BPTB graft and interference screw fixation affords excellent subjective results and good clinical ligament stability.

Keywords: Anterior Cruciate Ligament; Partial Meniscectomy; ACL Reconstruction.

Introduction: Arthroscopic release of the lateral retinaculum of the knee is a common procedure that is indicated for patients who have patellofemoral pain, a tight lateral retinaculum, and lateral patellar tilt and who have failed conservative treatment. Methodology: Arthroscopic lateral retinacular release was performed on 105 knees in 79 patients. Radiographic examination of the knee should include anteroposterior, axial view (sunrise view in 30 to 45 degrees of knee flexion), and a 30­degree lateral view.  The lateral view is particularly useful, as it demonstrates the shape of the trochlear groove, the patellar height, and the relationship of the patella to the trochlear groove. Results: Majority of the patients in our study were females accounting to 43 of the total 79 cases. Majority of the patients in our study had excellent to good results with good functional outcome. 2 patients had poor results with no improvement in pain with respect to grading of functional knee score. Conclusion: Patients with grade I and grade II chondromalacia have excellent results with arthroscopic lateral retinacular release.

Keywords: Arthroscopic Release; Lateral Retinaculum; Knee.

Background: Restoration of painless and satisfactory elbow function after a fracture of the distal humerus requires anatomic reconstruction of the articular surface, restitution of the overall geometry of the distal humerus, and stable fixation of the fractured fragments to allow early and full rehabilitation. Methods: We studied 25 consecutive patients with distal humerusintercondylar (AO Type C) fracture, included in study as per inclusion criteria. The following methods of statistical analysis have been used in this study. The data collected was entered in Microsoft Excel and Statistical analyses were performed using the Statistical Package for Social Sciences (SPSS) 20.0 software. Results: A prospective study was conducted in sapthagiri hospital between September 2015 to May 2016. We studied 25 consecutive patients with distal humerusintercondylar (AO Type C) fracture, included in study as per inclusion criteria. Conclusion: Operative treatment with rigid anatomical internal fixation should be the line of treatment for all AO type C fractures, more so in young adults as it gives best chance to achieve good elbow function. Stable fixation allows early, active and aggressive postoperative mobilization.

Keywords: Distal HumerusIntercondylar; Locking Compression Plate; Mayo

 Aim: The aim of present study was to evaluate union rates and functional outcomes for displaced mid­shaft clavicular fractures that were treated with either primary open reduction and plate fixation or nonoperative treatment. Material and Methods: This prospective study was conducted in the department of orthopedics, Gujarat Adani Institute of Medical Science, Bhuj, Kutch, Gujarat, India. In this study, 32 patients between 17 and 62 years of age who had an acute displaced mid­shaft clavicular fracture were randomized to obtain either primary open reduction and plate fixation or nonoperative treatment. Functional assessment was conducted at 3 months, 6 months, and 1­year with the use of the constant scores. Union was evaluated clinically and radiographically. Complications were recorded and compared. Results: The rate of nonunion was significantly reduced after open reduction and plate fixation as compared with nonoperative treatment. Constant scores were significantly enhanced after open reduction and plate fixation than after nonoperative treatment A chief complication was originate in 35% of patients in the conservative group while they were not present in operative group. Conclusion: Open reduction and plate fixation diminish the rate of nonunion after acute displaced mid­shaft clavicular fracture compared with nonoperative treatment and is connected with better functional outcomes. Open reduction and plate fixation using precontoured locking plate have low implant­related complications.

Keywords: Clavicular Fractures; Conservative; Kutch; Open Reduction.

Introduction: Fractures of the tibial shaft are important for the reason that they are common and controversial. The exposed anatomical location of the tibia makes it vulnerable to the direct blow and high energy trauma as a result of motor vehicle accidents thus resulting in communited fractures, which are frequently open with significant loss of skin and soft tissues. Methodology: A through clinical examination was performed including detailed history relating to age, sex, occupation, mode of injury, past and associated medical illness and the limb was immobilized in the form of above knee plaster of paris posterior slab (or) Thomas splint. Limb elevation over a pillow was given in all the patients.Routine investigations were done for all patients. All patients were evaluated clinically and radiographically to assess for any injuries. Results: The predominant tibial fracture pattern was Type A1 (27%). In our study most of the cases were associated with fibula fracture. Conclusion: The mean age of patients with these fractures was 40.7 years and the maximum patients were in the age group of 18­48 years. Males predominated in our study.

Keywords: Shaft Tibia; RTA; Profile.

Introduction: Intramedually nails, such as Lottes and Ender nails, used without reaming, have been employed successfully in the treatment of open tibial fractures and have been associated with low rates of post­operative infection. They are, however contraindicated for communited fractures, as there tends to be shortening or displacement of such fractures around these small nails. Methodology: Patients were operated under spinal / general anaesthesia. Patient is placed in supine position over a radiolucent operating table. The injured leg is positioned freely, with knee flexed 90o over the edge of operating table to relax the gastro soleus muscle and allow traction by gravity. The uninjured leg is placed in abduction, flexion and external rotation to ensure free movements of the image intensifier from A.P. to lateral plane. The table is adjusted to a comfortable operating height. Results: 21 cases (70%) had excellent results. 5 cases had good results (16.6%), 2 fair (6.7%) and two case (6.7%) poor result. Conclusion: Closed reamed interlocking intramedullary nailing with the help of image intensifier seems feasible in diaphyseal fractures of the tibia.

Keywords: Fracture Shaft Tibia; Intramedullary Interlocking Nail; Clinical Outcome.

Aim: We will evaluate the functional outcomes in elderly patients with unstable distal end radius fractures who were not willing for operative treatment and were managed conservatively with cast application. Background: Despite 200 year of medical literature proving the complexity and non­solved problems in treating distal radius fractures, in no other fracture, intra­articular mal­union and metaphyseal mal­alignment is so broadly accepted [1]. Material and Methods: 30 elderly patients with unstable distal radius fractures with mean age of 57.1 years were managed conservatively and observed for an average period of six months and functional and radiological outcomes were assessed. Results: Patient Related Wrist Evaluation system (PRWE) showed all groups had minimal functional disability. Radiological assessment by Sarmiento et al modification of Lidstorm’s scoring showed that 33.3% patients in group 1A had poor radiographic scores, 50% patients in group 1B had good radiographic scores whereas in group 2 , 53.3% patients had fair radiographic scores. Functional results were not found to be correlated with radiological outcomes. Conclusion: In elderly patients, patients having low functional demands or patients presenting to us late and not willing for any surgical treatment, mal­alignment and articular incongruence can be accepted, as radiological outcomes in this study does not correlate with the functional outcomes.

Keywords: Distal Radius; Conservative; Colles; PRWE; Elderly; Low Demand.

Introduction: The 20th century was marked by the classification of two concepts in the management of clubfoot. The first is the general acceptance of the principles of manipulation, strapping and serial correction plaster casts and the other favours numerous surgical procedures for the correction of clubfoot. Methodology: Detailed personal history was recorded including the age, sex, father’s & mother’s name, address, date of first reporting, age of reporting, detailed history of previous treatment, etc. A thorough general & local examination was carried out & the deformity was scored according to Pirani’ s classification at each visit before applying cast. The score was plotted against the time and the trend of score was noted with reference to effect of manipulations or other interventions on deformity. Manipulations were done by Ponseti’s method followed by corrective casts at weekly interval without anaesthesia. Results: The number of cast application required to achieve full clinical correction were 4.7 (average) in patients whose initial Pirani scores were 3 while in patients with initial Pirani scores 6, number of cast required to obtain full clinical correction increased to 8 (average). Conclusion: Ponseti Method is an excellent conservative method for treatment of Congenital TalipesEquinoVarus.

Keywords: Ponseti’s Method; Congenital Talipes EquinoVarus; Club Foot.