Journal of Orthopedic Education

As quoted by Rene Descartes [1] “The human body is a machine whose movements are directed by soul”; and knee being a complex joint with myriad ligaments and stability and may lead to varying degree of impairments. Management of four complex knee joint injuries following trauma are discussed in this article.

Keywords: Injuries; Myriad ligaments. 

Introduction: A weak spot in the clavicle is present at the midclavicular region, which accounts for most fractures occurring in this region. Numerous muscular and ligamentous forces act on the clavicle, and knowledge of these differing forces is necessary to understand the nature of displacement of clavicle fractures and why certain fracture patterns tend to cause problems if not reduced and surgically stabilized. Methodology: Patients of the age 18-60 years having closed fracture ofthe clavicle who are admitted were taken up for study after obtaining their written informed consent. The study was done in the Department of Orthopaedics. Results: Direct injury occurred in 12 patients (60%),among which 5 patients (25%) were due to road traffic accident and 7 patients (35%) were due to fall from bike. Six patients (30%) due to simple fall on shoulder and 2 patients (10%) due to indirect injury by fall on outstretched hand. Conclusion: Type 2 middle third fracture type-2B1 occurred in majority of patients.

Keywords: Clavicle; Middle Fracture; Displaced Fracture. 

Introduction: The present consensus that great majority of clavicular fractures heal with non operative treatment is no longer valid. The amount of pain and disability during the first three weeks of conservative treatment has been underrated and the common view that nonunion does not occur is wrong. Pressure from a displaced fragment on the retroclavicular part of the brachial plexus may cause symptoms after conservative treatment. Methodology: General information like name, age, sex, occupation and address were noted. Then a detailed history was elicited regarding mode of injury like fall on the shoulder, Road traffic accident, direct injury to shoulder and fall on outstretched hand. Enquiry was made to note site of pain and swelling over the affected clavicle. Results: In this study 17 patients (85%) had excellent functional outcome, 2 patients (10%) had good functional outcome and fair in 1 patient (5%). Conclusion: In this study precontoured locking plates were used as it is contoured to the shape of the clavicle. It is necessary to put the plate superiorly and atleast three screws to be applied medially and three screws laterally.

Keywords: Functional Outcome; Displaced Fractures of Middle Third of Clavicle; Operative Treatment. 

Hand surgery is an emerging subspecialty in India, which depends on referrals from general physicians (GPs) and emergency medicine physicians (EMDs). An appropriate referral requires the referring physician to have knowledge and understanding of common hand surgical conditions and awareness of hand surgery as a subspecialty. The aim of this study is to assess and compare the knowledge and awareness of hand surgical conditions among GPs and EMDs. The sample size for our study was calculated to be 39 GPs and 23 EMDs following a pilot study. The questionnaire based cross sectional study was conducted among GPs at primary care hospitals and EMDs at tertiary care hospitals, following which the results were analysed. A total of 62 physicians responded to our study (39 GPs and 23 EMDs). Areas in which knowledge gap was noted include penetrating palm injuries, carpal tunnel syndrome, osteoarthritis and peripheral nerve repair. Interventions to bridge the gap may be required at many levels such as undergraduate education , post graduate education and continuing medical education. These interventions would not only improve the primary care provided but also facilitate a smooth referral process to hand surgeons for further management.

Keywords: Hand Surgery; Knowledge of Hand Surgery; General Practitioners; Emergency Medicine Department Physicians.

 Introduction: Intertrochanteric fractures like femoral neck fractures, are commonly encountered in the practice of orthopaedic surgery. Intertrochanteric fractures usually occur in patients over 60 years of age commonly and are three times more frequent in women than men because women tend to be less active and develop postmenopausal osteoporosis. Methodology: 40 elderly patients who were admitted and operated between July 2014 to July 2016 and had fulfilled the inclusion criteria, were enrolled for this study. Patients operated with PFN were allocated to Group A and operated with Bipolar prosthesis were allocated to Group B.20 patients each were allocated into 2 groups A and B according to randomized tables. Results: Majority of patients in study were between 60-85 years with a mean age of 70 years. Sixty percent of patients were female. Trivial fall was most common mode of injury. T3 fractures constitute 55% and T4 fractures constitute 45%. PFN required shorter incisions and less blood loss and operative time. Conclusion: Both modalities, PFN and Bipolar Hemiarthroplasty have shown good functional outcome.

Keywords: Proximal Femoral Nailing; Cemented Hemiarthroplasty; Intertrochanteric Fractures.

Objectives: Occupational Health should aim at the promotion and maintenance of the highest degree physical, mental and social well-being of workers in all occupations; the prevention among workers conditions; the protection of workers in their employment from risks resulting from factors adverse to health; the placing and maintenance of the workers in an occupational environment adopted to his physiological and psychological equipment, and, to summarize, the adaptation of work to man and of each man to his job. In view of the current health status of class IV workers working in hospitals was reviewed, exposure to occupational health hazards, hospital waste management and accordingly to plan and suggest preventive measures and for betterment of their working conditions was studied under this research. Methods: This study was carried out in charitable rural hospital in India for class IV workers in the year 2009. The workers were reviewed for general health parameters viz. physical examination, nutritional status, knowledge, attitude, practice of workers towards his work along with detail investigations like X-rays’, blood, urine and sputum examinations. Results: During this study 72 workers were screened. This study included 28 (38%) males and 44 (62%) female workers. The 45% of workers were between the age group of 31 – 35 years and about 25% of workers were of younger age group of 21 – 25 yrs. There are more than 35 (approx. 48% of total workers) of workers chew tobacco and are alcohol addicts. The consumption of tobacco products and alcohol in male workers is more. Overall about 25% of the total workers have mild anemia, 33% have moderate anemia, and 15.30% suffer from severe type of anemia. When female workers were focused, it was observed that more than 20% of total female workers were suffering from severe type of anemia and 34% with moderate type of anemia. Significant number of the workers is having complaints of fall of heavy object (47%), Needle Stick injuries (62.50%), and facing Abuse of assault by patients or their relatives (10%) and blood contact (37.50%). Cases of needle stick injuries are quite high accounting for more than 60% which needs attention. Conclusions: The class IV workers are addicted to tobacco chewing and alcohol. Many of them suffer from anemia, hypertension, back ache acidity, skin diseases, fall of heavy objects, needle stick injuries. Significant number of workers is using personnel protective equipments (PPE) and is immunized.

Keywords: Class IV Workers; Occupational Health; Anemia; Needle Stick Injuries; Hypertension; Tobacco; Alcohol; Skin Diseases; Bio-Medical Waste Management; Hospital Acquired Infections; Personnel Protective Equipments; Immunization.

Background and Aim: The real time capability of ultrasound in conducting dynamic studies in the shoulder is a great asset. The simplicity, rapidity, low cost, and accuracy makes ultrasound the most effective imaging method for screening of rotator cuff injuries. The purpose of our study was to compare the diagnostic efficacy of ultrasound and MRI in detection of full thickness and partial thickness rotator cuff tears in symptomatic patients, with arthroscopy used as gold standard. Materials & Methods: The authors performed a retrospective review of 150 consecutive patients who underwent arthroscopic repair of a full-thickness rotator cuff tear by a single surgeon at the study institution for a period of two years. Results: Out of 150 patients, 145 patients were found to have rotator cuff tears on arthoscopy. Out of total included 145 patients, 140 patients were positive on either ultrasound or MRI. Five patient with tendon tear diagnosed on arthroscopy was missed on both ultrasound and MRI. Out of 140 patients, 137 patients were diagnosed on ultrasound and 138 patients were diagnosed on MRI. Discussion & Conclusion: MRI also provides information about associated labral tears which are poorly evaluated by ultrasound and may need surgical management Arthroscopy is the gold standard for diagnosing rotator cuff tears. Ultrasound and MRI are comparable in both sensitivity and specificity. Since US is less expensive and more available, it could be considered as the screening method when rotator cuff integrity is the main question, and when well-trained radiologists and high resolution equipments are available.

Keywords: Diagnosis; Shoulder Pain; Ultrasound; MRI. 

Background: Both noninvasive magnetic resonance imaging (MRI) and invasive arthroscopy accomplished remarkable and impressive developments to evaluate shoulder joint [1]. These are achieved by the interaction of radiologists and arthroscopic shoulder surgeons who have shared their clinical experiences and provided feedback of mutual patients. However, the opinion of radiologists and surgeons regarding MR images of the shoulder still has undeniable inconsistencies to this date. Considering imaging modalities like MRI play a decisive role in planning the treatment protocols for patients, it is vital to know to what extent these operator-dependent imaging reports are valid, reliable and informative. Therefore, we studied the sensitivity, specificity, and positive and negative predictive values of MRI for diagnostic evaluation of shoulder disorders and compared the results with arthroscopy. Materials and methods: This is 6 months prospective study from August 2016 to January 2017. A total number of 62 subjects who underwent arthroscopic shoulder surgeries for various pathology were enrolled in the study. Pre-operative MRI was obtained with axial T1, axial T2 FAT SAT, sagittal T1, sagittal T2 FAT SAT and coronal T1 & T2 FAT SAT . Images were reported by a two expert radiologist from the radiology department of our institutions. The radiologist checked all the structures that could be evaluated in arthroscopy according to a checklist provided by the shoulder surgeon. They were biceps tendon, biceps labral complex, labrum, rotator interval, subscapularis tendon, ligaments, head and glenoid cartilages, sub-acromial bursa, supraspinatus and infraspinatus tendons. Patients underwent shoulder arthroscopy under general anesthesia within maximum four weeks. All previously mentioned structures were inspected and probed. With the same prepared checklist, pathologies were saved in detail for future comparison with the radiologist’s MRI report. Then surgical intervention of found pathologies was done as needed. Finally, MRI findings (sensitivity, specificity, and positive and negative predictive values) were compared to arthroscopy findings. Results: Sensitivity of MRI proved to be highest for Hill-Sachs lesion size and location (94.2) and lowest for infraspinatus tendon (61.5). Highest specificity was in tears of biceps tendon (100.0) whereas it was lowest for Humeral head and Glenoid cartilage (81.4). MRI reports were shown to have the most positive predictive value for supraspinatus tendon tears (94.5), while it is lowest for infraspinatus tendon tears (80.0). The highest negative predictive value was found to be 96.08 which was recorded for biceps tendon pathologies (tendinosis and tear). However, detection of anterior labrum lesions possessed the lowest negative predictive value in MRI reports (70.0) Conclusion: MRI can be considered good noninvasive instigation for the assessment of supraspinatus tendon injuries and labral injuries, further research needed with large number patients.

Keywords: Shoulder; Arthroscopy; MRI. 

Background and Aim: Measures for pain management after total knee arthroplasty (TKA) are important for early improvement in the quality of life after operation and early postoperative rehabilitation. We investigated the benefits and safety analgesic effect of locally injected drugs around the total knee prosthesis. Methods: Present study was performed at department of orthopedics, Gujarat Adani institute of medical science, Bhuj, Kutch, Gujarat. Sixty one patients undergoing TKA for osteoarthritis were divided randomly into three groups. Group A (201knees; control group), this group did not receive multimodal drug cocktail therapy; group B (21 knees), received intra-articular injection of a multimodal drug cocktail; and group C (19 knees), received localperiarticular injection of a multimodal drug cocktail. All analgesics administered in the first 24 h after surgeries were recorded. The evaluation items included assessment of pain using a 100-point visual analogue scale (VAS) after the patients awoke on the day of the operation and on postoperative day 1, the dose of diclofenac sodium suppository, the number of days for acquiring assisted ambulation with a walking cane, and side effects. Assessment of flexion angles was conducted at postoperative week 1 and at the conclusion of the study. Results: The VAS scores on the day of surgery and the amounts of diclofenac sodium used indicated good pain relief in groups B and C; the level of pain control was higher in group C than in group B. No cardiac or central nervous system toxicity was observed. Conclusion: Periarticular injection with multimodal drugs can significantly reduce the requirements for analgesia, with no apparent risks, following TKA.

Keywords: Injection; Osteoarthritis; Pain; Total Knee Arthroplasty. A 

Background: Osteoarthritis of knee is a chronic and debilitating problem of the elderly to which a satisfactory cure is yet to be found. Mesenchymal stem cells have been used in preclinical studies and were found effective in treating osteoarthritis. In this study we aim to evaluate the role of mesenchymal stem cells in treatment of primary osteoarthritis of knee in humans and analyze the results in clinical terms. Methods: 60 patients of osteoarthritis knee were randomly grouped into two categories by simple randomization. 30 patients each were allocated to group A (cases) and group B (controls). Fifteen ml of bone marrow was aspirated from patient’s sternum, concentrated stem cells solution was prepared and 1 ml of stem cell concentrate was injected into the knee joint of patients categorized as cases. Placebo injection of normal saline was given to controls. Patients were followed up at 1, 3, 6, 12, 18 and 24 months. In every follow up, patients were evaluated clinically using modified WOMAC index and compared with pre-treatment scores. The study was carried out in double blind manner. Statistical tests used were Mann Whitney test to compare the scores of cases and controls and Wilcoxon test to compare the paired data pre and post treatment within the case and control groups. Results: In group A mean [standard deviation [SD]] pre procedure pain score was 12.53 [1.187] and final score was 7.20 [1.474]. Mean [SD] pre procedure stiffness score in group A was 5.33 [0.976]. Final score was 2.47 [0.915]. Mean [SD] difficulty pre procedure score in Group A was 43.67 [5.394]. Final score was 26.00 [2.699]. Total pre procedure score in group A was 61.53 [6.300] and final score was 35.67 [4.806]. The reduction in all scores were statistically significant (p<0.001) compared to pre treatment values and compared to controls. There was no significant change pre and post-treatment in mean pain, stiffness, and difficulty and total scores in group B. Conclusion: Mesenchymal stem cells are an effective treatment modality for osteoarthritis. The one-stage stem cell isolation and injection procedure is safe, quick and cost effective in managing osteoarthritis.

Keywords: Osteoarthritis; Stem Cells; WOMAC Index 

Malleolar fractures of ankle are ususually complex injury as they are associated with significant ligament and soft tissue injury The aim of treatment is to restore normal anatomy and provide sufficient stability for early movements. Malleolar fractures require open reduction more often than any other type of ankle fracture. Our study aimed to know efficacy and outcome of operative management of it and follow then prospectively. Clinical and radiological outcome were studied and clinical indications and efficacy of procedure reviewed. Method: from April 2014 to March 2016, 30 patients of malleolar fractures admitted in Govt. Medical College and hospital, Latur were operated and followed up prospectively. 20% of patients acheived excellent, 73% good and 6% patients acheived poor resultsWe conclude that malleolar fractures encountered in clinical practice needs thorough assessment and meticulous surgical intervention as it is associated with injury to ligament complex. Abduction and external rotation types of injuries are the most common type to be seen. We can achieve stable fixation and early mobilization of the ankle joint, which limits the complications of pseudek’s osteodystrophy and ankle stiffness. Proper assesment and meticulous surgical technique to treat all above injuries is of vital importance to avoid complications and to yield good results. And by mentioned technique, we achieved good to excellent results of 90 percent.

Keywords: Tri Malleolar Fracture; Abduction; Lauge Hansen’s; Baird and Jackson Score.

Background and Aim: Fractures of the calcaneum constitute approximately 60% of all tarsal injuries, and are usually the result of a fall from a height. This randomized controlled trial compared the clinical outcomes and complications of a novel minimally invasive percutaneous osteosynthesis (MIPO) with those of conventional treatment via an extended L-shaped lateral approach for calcaneal fractures. Methods: Present study was performed at Department of orthopedics, Gujarat Adani institute of medical science, Bhuj, Kutch, Gujarat. Sixty-four patients with displaced intraarticular calcaneal fractures were enrolled. The patients were randomly allocated to receive either MIPO (29 patients) or open reduction and internal fixation via an extended Lshaped lateral approach (35 patients). The same calcaneal plate was used in both groups. Preoperative and postoperative calcaneal height, width, and length, Bohler’s angle, and Gissane’s angle were compared. Results: The operative time in the MIPO group was 52.5 ± 11.1 min, which was significantly shorter than 82.8 ± 16. 2 min in the conventional treatment group (P < 0.001). One week postoperatively, the VAS value was 3.2 ± 1.4 in the MIPO group, which was lower than that in the conventional treatment group, 3.9 ± 1.3 (P = 0.038). In the conventional treatment group, 13 of 35 fractures (37.1%) had wound healing problems, whereas this issue occurred in only 2 of 29 fractures (6.7%) in the MIPO group (P = 0.004). At the last follow-up, the SF- 36 scores and AOFAS scores in the two groups were comparable (P > 0.05). Conclusion: Compared with conventional ORIF, the advantages of MIPO are a considerably shortened operating time and hospital stay, decreased postoperative pain, and reduced risk of wound healing complications.

Keywords: Bhuj; Calcaneum; Fracture; Minimally Invasive; Randomized Controlled Trial. 

Fractures of the shaft of tibia is the most common fracture of long bones and are usually associated with severe soft tissue compromise. Conventional plating technique applied to such a multi fragmentary fracture, requires anatomic reduction, wide surgical exposure and soft tissue stripping. Minimally Invasive Percutaneous Plate Osteosynthesis (MIPPO) is a method in which a percutaneously inserted plate is fixed at a distance proximal and distal to the fracture site through minimal exposure. 30 cases of closed lower one third tibia fractures treated with internal fixation using MIPPO technique at Gujarat Adani Institute of Medical Science, Bhuj, Kutch were followed for a period of six months. AO type A 1.2 was the most common type of injury. The mean union time for fractures fixed with MIPPO technique is 20.3 ± 2.8 weeks. Incidence of complications was relatively less, with delayed union and deep infection occurring in 2 cases. The functional outcome which was measured by Mazur score was excellent or good in 60% of the cases which is comparable with rates in literature. MIPPO technique for fractures of the lower end of tibia has minimal complication rate and has good functional outcome.

Keywords: Bhuj; Fractures; Tibia; Functional Outcome. 

Introduction: Osteoporosis is a huge problem in a developing country like India, it is a challenge to the present health resources and health facility. All over the world osteoporosis affects predominately the older population and more so the postmenopausal women. world health organization (WHO) defines up to 70% of women over the age of 80 to have osteoporosis. An algorithm is developed by WHO to estimate the 10-year fracture risk, which is to be used in the absence of bone mineral density. Malnutrition, smoking and alcoholism has a negative effect on the bone mineral density. The study was performed to evaluate the prevalence of osteoporosis in the urban postmenopausal women, the associated risk factors and the correlation of the disorder to the socioeconomic status. Material and Methods: Patientspersonal data like obstetrics, medical, menstrual, drug history, diet history and daily exposure to sunlight was collected in a performer which was designed for the study. Patients measurements like height, weight, BMI were recorded. BMD was recorded by performing dual-energy X-ray absorptiometry scan of the calceneum .Women were classified according to the WHO criteria. Results: The prevalence of the condition in the postmenopausal women was 21%. The mean age of the women was 50.6+/-5.6 years. Women with more than 3 children were associated with higher risk of osteoporosis. we found no significant associated with other medical conditions like diabetes and thyroid disorder. Lack of calcium intake and regular exercise was significantly associated with low BMI. Conclusion: Osteoporosis is a rapidly evolving condition, our study brings out the need of a large community based study, and the study of risk factors, so appropriate early measurements can be taken to interrupt the progression of the disease.

Keywords: Bone Mineral Density; Dual-Energy X-ray Absorptiometry Scan; Osteoporosis; Osteopenia and Menopause 

Introduction: Intramedullary fixation with Titanium Elastic nail has become a favored stabilization technique for adolescent’s population as Shorter operative time, Decrease scarring and decreased operative dissection. Objective : Evaluate the functional clinical and radiological outcome and complications of the diaphyseal fractures of radius and ulna in adolescents treated with titanium elastic nail. Methodology: Hospital based Interventional, prospective study was conducted during March 2014 to Feb. 2015 at SMS Hospital Jaipur on patients 12-18years of age with 30 patients, with diaphyseal both forearm bone fr.actures. Indication: Open injury, unstable fracture pattern, Inability to achieve an acceptable reduction, loss of reduction. All fractures was be treated with flexible intramedullary nail fixation. Observations: In majority of cases no secondary procedure require, only 4 cases require SSG which was open injury Average blood loss was 51.66 % Out 30 patient 29 patient had radiological and clinical evidence of solid union& one ulna was completely undergo in nonunion. The minimum time taken for union was 8 to 12 weeks for radius in 83% and 10-14 weeks for ulna 68% of patients. Conclusion: The use of titanium elastic nail is the ideal implant in the management of Fractures both forearm bones in adolescents population.

Keywords: Diaphysis Fractures of Radius and Ulna; Adolescents; Titanium Elastic Nail; Outcome. 

Surgical management of intertrochanteric fractures is the preferred treatment to avoid complications of prolonged immobilization. Dynamic Hip Screw (DHS) has been the gold standard. Intramedullary devices have biomechanical advantage as they are near to the mechanical axis of hip joint. Seventy one patients with stable intertrochanteric fractures between December 2011 to January 2014 at SNMC, Bagalkot were treated with either DHS or Trochanteric Femoral Nail (TFN), 41 with DHS and 30 with TFN. Results were compared for average duration of surgery, blood loss, hospital stay and functional outcome according to Harris Hip score. There was no significant difference in functional outcome between the two modalities of treatment. However the duration of surgery, blood loss and hospital stay was significantly lower in TFN group. Our study indicates that TFN may be better choice when compared to DHS in stable intertrochanteric fractures.

Keywords: DHS; TFN; Harris Hip Score.