Journal of Orthopedic Education

 Ebstein’s anomaly is a rare congenital heart disease, which involves downward displacement of tricuspid valve and atrialisation of right ventricle associated with either atrial septal defect or patent foramen ovale through which shunting of blood occurs. In such patient, clinical presentation varies from congestive cardiac failure in childhood to incidental diagnosis in adulthood. If such patient presents with fracture neck of femur, it will be a challenging job for orthopaedic surgeon as well as anaesthesiologist. The main goals of treatment are to stabilize the hip, decrease pain and restore the level of pre-fracture function with minimal operative intervention.

Keywords: Ebstein’s anomaly; intra-capsular femur neck fractures; hemi-replacement arthroplasty; avascular necrosis; epidural anaesthesia.

 Background: Dynamic hip screw has been regarded as the average implants in the management of fractures of trochanter. Even with various studies that indicate the advantages of proximal femoral nail, they were still associated with failures at technical level. The aim of the present study was to evaluate the Effectiveness of Dynamic Hip Screw and Proximal Femoral Nail in the management of Inter-Trochanteric Femur fracture. Materials and Methods: Patients were arbitrarily classified into two groups. Group I patients were managed with dynamic hip screws and Group II subjects were managed with proximal femoral nails. A total of 50 patients were enrolled in this study.Any post-operative complications occurring during the stay at hospital was managed before discharge. All the subjects were made to follow up for four months. Student test and chi square test were used for statistical analysis. Probability value of less than 0.05 was considered as significant. Results: The mean intraoperative time in Group I was 103.6±37.64 minutes and in group II was 93.8±23.5. There was no significant difference between the two groups. The mean blood loss in Group I and Group II was 485.3±176 ml and 275±141.0 ml respectively. There were 5 cases of bed sore in Group I and no case of bed sore in Group II because of early mobilization. Conclusion: When dynamic hip screw was compared with proximal femoral nails, the study found no characteristic difference in the groups.

Keywords: Dynamic; Trochanteric; Fractures;

 Introduction: Neglected fracture neck of femur in young adults has high rate of non-union, avascular necrosis (AVN) and secondary arthrosis. Only stable fixation is under surgeon`s control as other complications are part & parcel of injury itself. We achieved hip preservation with a simplified operative technique of valgus inter-trochanteric osteotomy fixed with 120 degrees double angled barrel plate and cancellous screws. Objectives: To develop an easily reproducible surgical technique with stable fixation to convert high grade pauwel fractures to low grade leading to hip preservation in majority of young adults & delay the need for future arthroplasty. Materials and Methods: 18 cases of Neglected fracture neck of femur (>3 weeks) in young adults (<50 yr) were operated using the simplified technique and followed from June 2016 to April 2018. Average presentation was 37 days from injury & average follow-up of 10.4 months. Radiological parameters analyzed were fixation and union at osteotomy and fracture site. Functional outcomes were assessed using modified Askin & Bryan Criteria. Results: Out of 18 cases, Good (9) to Excellent (6) results were seen in 15. 3 had fair outcomes necessitating replacement arthroplasty. AVN was seen in 5 cases and non-union at fracture site in 3 cases. Osteotomy united in all cases. No implant failure was encountered. 13 were able to perform activities of daily living satisfactorily and showed no signs of AVN till last follow-up. Conclusion: The simplified technique offers good results in majority of young adults with neglected fractures neck of femur with minimal complication rates.

Keywords: Valgus Osteotomy; Fracture Neck of Femur; Hip Preservation; Operative Technique; AVN.

  Introduction: Subtrochanteric femur fractures are the commonest paediatric fractures. These fractures are quite challenging injuries to treat. Intramedullary nails though have been used to treat paediatric femur shaft fractures, their effectiveness for managing the subtrochanteric fractures are of doubt. Aim: The union rates and fracture alignment after elastic nailing of paediatric subtrochanteric femur fractures. Materials and methods: The study was conducted between June 2016 and Dec 2017, in which 22 subtrochanteric fractures were treated with elastic stable intramedullary nails and were followed up for clinical and radiographic union. For subtrochanteric fractures especially after failed spica cast treatment in children of 5 to 15 years age group, elastic nailing was used. Fracture union and alignment were measured clinically and radiographically. Results: Among the 22 cases, 09 were female cases and 13 were male cases. Out of this, 20 fractures were healed with acceptable complications which included malunion (n = 4), loosening of nails (n = 2), re-fracture (n = 1), wound dehiscence at the nail insertion site (n = 1) and limb length discrepancy (n = 1) and only 2 (6%) had poor outcomes. Hence on overall, there were 13 (61%) excellent, 7 (33%) satisfactory and 2 (6%) poor outcomes. Conclusion: Although complication rates were variable (40 %) with elastic nailing for paediatric subtrochanteric femur fractures, it represents an important option for complex subtrochanteric femur fractures.

Keywords: Functional Outcome of Paediatric Subtrochanteric Femur Fracture Treated With Titanium Elastic Nails.

 Background: Utilization of LCP system in supracondylar fractures of distal femur couples the advantage of conventional plate osteosynthesis together with internal fixator systems. LCP involves use of compression plating and locked internal fixation method into one implant. The study was carried out to clinically explore the practical consequence of LCP in fracture associated with supracondylar region of distal femur on several aspects under investigation. Materials and methods: Ninety patients with age more than 18 years, with prolonged comminuted supracondylar fracture of femur were regarded eligible for the investigation. On the contrary, patient exemption criteria for the study included existence of pathological and periprosthetic fracture, patients with existing deformity of same limb or open fracture, or condition of polytrauma. Patients were operated, and the LCP was grafted according to standard surgical procedure. Post-operative follow-up data was collected for 6 months. Results: More than 50% patients exhibited outcome score as good, of which most them were above 30 years age. Less than 10% patients exhibited complications in both the cases of open and closed fracture. In patients with open fracture, reunion took place between 20-22 weeks, whereas in closed fractures, 70% patients indicated reunion between 16-18 weeks. Time of union was 16-18 weeks for maximum patients. Conclusion: Results reflected that the LCP condylar plate is the treatment of choice in the management of comminuted distal femoral fractures. LCP helped in maintaining limb length and had fewer complications, emphasizing the need to follow basic principles of fracture fixation.

Keywords: LCP; Supracondylar; Neer’s score; femoral fracture.

 Introduction: The anterior cruciate ligament (ACL) is an important stabilizing ligament of the knee that is frequently injured in athletes and trauma victims. We aimed to evaluate the correlation between anthropometric measurements of the patients and their graft dimensions. Methodology: This observational study was conducted on 50 patients with ACL injury treated by arthroscopic quadrupled hamstring graft reconstruction at AJ Institute of Medical Sciences and Research Centre, Mangalore between May 2017 and April 2018. Patient related data like age, gender, side involved, symptoms reported, anthropometric measurements, graft length and diameter was replace was with ‘were’ noted. Correlation of graft length and diameter with age and anthropometric measurements was assessed. Results: Mean graft length of all patients was 11.39±1.31 cms, and was significantly higher in male as compared to female patients (11.82 ±0.76 vs 9.13±1.36, p value <0.001). Average graft diameter was 7.24±0.75 cms and was also significantly larger among male patients as compared to female (7.40±0.69 vs 6.38±0.35, p value <0.001). Graft length was found to have a significant inverse correlation with age of the patient (r = -0.39, p value <0.01), significant direct correlation with height (r = 0.71, p value <0.001) and weight (r = 0.29, p value <0.05) of the patients. Diameter of graft used was found to have a significant positive correlation with height of the patients (r = 0.50, p value <0.001). Conclusions: Anthropometric measurements can be used for preoperative planning and to help counsel patients on appropriate graft choices prior to surgery.

Keywords: Anterior cruciate ligament; ACL reconstruction; Hamstrings; Anthropometry

Introduction: Rheumatoid arthritis is the most common inflammatory disease of the joints with an incidence of about 4-13 in 100,000 males and 23-36 in 100,000 females. It is recommended that the drug treatment should start within short period of 6 weeks to arrest progression of disease, joint erosion and deformation. Aggressive treatment in the initial stage of the disease with DMARDS reduces the disease progression. The responses of patients with rheumatoid arthritis to treatment with a single so-called disease-modifying drug, such as methotrexate, are often suboptimal. Despite limited data, many patients are treated with combinations of these drugs. Objective: The aim of the study was to compare the efficacy of hydroxychloroquine, methotrexate and combination of hydroxychloroquine, methotrexate and sulfasalazine in induction of remission in early rheumatoid arthritis. Methodolgy: The present study included 50 randomly selected cases of rheumatoid arthritis, who presented at PES Hospital, during July 2014 to July 2016 fulfilling the inclusion and exclusion criteria. Following collection of data in a pretested proforma, which included brief history, physical examination and ACR criteria, the patients were divided randomly into two groups. The first group, Group A, was treated with once a week oral methotrexate 7.5 mg and twice daily oral Hydroxychloroquine. The second group, Group B, was treated with once a week oral methotrexate 7.5 mg and twice daily oral Hydroxychloroquine 200 mg and salfasalazine 500 mg twice daily. Patients in both the groups received additional oral folic acid 5 mg thrice daily once a week. Patients in both the study group received oral sustained release aceclofenac and paracetamol twice daily for the first 10 days. All the patients were followed up in the out-patient department of the hospital at 4 weeks interval for 12 weeks and evaluated by the ACR criteria for remission and improvement in symptoms. Blood investigations like haemoglobin level, RA factor, ESR, and liver enzyme levels were done before initiating treatment for all patients. All patients underwent haemoglobin level, ESR, and liver enzyme levels at every followup visit. Results: At the end of three months group A which was treated with two drug regimen had remission in 32% and group B patients treated with three drug regimen had 52% remission rate according ACR criteria for remission. Remission was more in seronegative arthritis than seropositive. Conclusion: Remission was induced in higher number of patients on combination therapy with methotrexate, hydroxychloroquine and sulfasalazine when compared to patients on treatment with methotrexate and hydroxychloroquine.

Keywords: RA factor; methotrexate; Rheumatoid arthritis; Hydroxychloroquine.

 Introduction: Surgeon’s primary goal in distal humerus fracture is to obtain fixation with sufficient stability so that the elbow can be mobilized as early as possible. The present study aimed at assessing the functional outcomes in distal humeus fracture patients managed with open reduction internal fixation with triceps sparing approach. Methodology: The present study included adults presenting with distal humeral fractures and managed with open reduction and internal fixation with triceps sparing approach at the Department of Orthopedics, AJ Institute of Medical Sciences, Mangalore from August 2015 to April 2017. The Mayo Elbow Performance Score (MEPS) was used as an objective measure of overall outcome. Grades of MEPS were compared between different age groups and different fracture types. Results: There was only one case of extra-articular type fracture. In the fractured elbow, the mean range of motion increased significantly from 63.4±14.2 at 6th week to 120±6 at 24th week. In our study population, the mean MEPS was 81.7±10.7. The MEPS was found to be excellent in 40% of the patients, fair in 20%, good in 36.7% and poor in only one patients. The MEPS was found to be similar among different age groups (p value = 0.92). Similarly, MEPS did not vary with the fracture type (p value = 0.21). Conclusions: Excellent grade of MEPS was observed in majority of the patients and only one case yielded poor grade. Age and fracture type were not found to be associated with the grade of MEPS.

Keywords: humerus; open reduction and internal fixation; triceps-sparing

Background: Hyperbaric Oxygen Therapy (HBO) is an established treatment modality, which is internationally practiced since a long time ago. International protocols for the practice of hyperbaric oxygen therapy have been established in the United States by the Undersea and Hyperbaric Medical Society (UHMS) and in Europe by the European Committee for Hyperbaric Medicine (ECHM). Objective: To look for outcome on Wound healing without tissue necrosis requiring surgical excision, new major surgical procedures in relation to progressive and massive revitalization after entry in trail, Time of healing and Length of hospitalization. Study Design: A prospective Randomized double blind placebo controlled trial performed to realize the aim and objectives of this study. Place of Study: The study was carried out at the Prana HBO Centre, which is owned by the Investigator and located in the Northern parts of Mumbai, in India. Methods: On receiving the patient to the HBO unit at Prana, patients were randomly assigned to receive HBO therapy or Placebo. HBO therapy was given with compressed with air at a pressure of 2.5 atmosphere absolute (ATA). At this pressure the patient breathed 100% oxygen via facial mask. The HBO therapy protocol included 90 minutes oxygen breathing at 2.5 ATA twice daily over 6 days as per study by G Bouachour et al. Placebo consisted of sessions in HBO chamber at a pressure of 1.1 ATA in order to stimulate compression and its effects on the ears, while the patient breathing normal air via facial mask. The placebo therapy included 90 minutes air breathing at 1.1 ata twice daily over 6 days. Results and Discussion: Total 60 patients completed the study period and no patient was excluded during the study analysis. The demographic profile was comparable in the two groups of HBO and Placebo group. It was observed in the study that complete wound healing without any tissue necrosis requiring any amount of surgical excision was observed in 24 patients in HBO group whereas only 13 patients were observed with complete healing in the Placebo group. There s a threefold effect of Hyper oxygenation in HBO Therapy, a typical treatment pressure of 2 ATA, the plasma and the tissue fluid oxygen tension increase 10 fold from about 100 and 30 mm hg respectively to more than 1000 mm hg in the plasma and more than 300 mm hg in the tissue fluids. Conclusion: HBO therapy is a very useful therapeutic adjunct especially in the management of severe trauma of the limbs in older patients with grade III soft tissue injuries. The side effects and complications of HBOT are so infrequent and/or minimal that contraindications for using this intervention as an adjunct in the management of crush injuries are almost nonexistent. However, in no situation should HBOT be used as a substitute for indicated surgical, orthopedic, and medical interventions.

Keywords: Crush Injuries; HBOT; Placebo; Clinical Trail.   

 Background: Multiple treatment modalities have been reported for managing such cases like bone grafting, tissue transfers, antibiotic cement and Ilizarov technique. Bone grafting itself poses limitations of size and morbidity of the donor site. The aim of the present study was to determine the accuracy of Ilizarov technique in managing non-united infected tibial fractures. Materials and Methods: The present prospective study was conducted in the Department of Orthopaedics, Mata Gujri Memorial Medical College, Kishanganj, Bihar (India) for duration of 2 years. All the subjects were followed up for a period of 10 months. Under complete aseptic conditions, all the subjects were taken up for surgery. Debridement of the area was done, and the material was sent for sensitivity tests. Bone nibbling was performed until fresh bleeding was encountered. At regular intervals, X-rays were taken to determine the radiological extent of bone healing. Assessment was done based on Fernandez Esteve grading. In case of any discharge from the tract, infected pin was removed and exchanged in the same sitting. Once healing was satisfactory, ring and fixator were removed, and cast was applied. Results: The mean age of the subjects was 38.87±3.22 years. There were 13 males (59.1%) and 9 females (40.9%) in the study. There were 3 males and 2 females with bone shortening of 1-3 cm. The union time amongst them was 6 weeks and the consolidation time was 9-10 months. Conclusion: Treatment using Ilizarov method with infected tibial fractures provides promising results. Optimal fixation was seen amongst subjects in the present study.

Keywords: Consolidation; Fractures; Ilizarov; Infected.