Erratum: Author Correction: Telemedicine-Rehabilitation and Virtual Reality in Orthopaedics and Sports Medicine

[This corrects the article DOI: 10.1007/s43465-022-00766-6.].

Telemedicine-Rehabilitation and Virtual Reality in Orthopaedics and Sports Medicine

Introduction

Tele-rehabilitation is a method of delivering rehabilitation services using information, technology and communication to everyone, irrespective of their geographic location. National zeal for competitive sports and COVID pandemic has led to an increase in its demand and popularity worldwide. The athletes need immediate treatment and correct rehabilitation to keep them in their game. This review aims to bring into perspective the importance of telemedicine and telerehabilitation in orthopaedics and sports medicine with a focus on virtual reality.

Methods

Articles were searched based on suitable keywords 'telemedicine', 'telerehabilitation' 'orthopedics', 'orthopaedics', 'sports' and 'India*' which were combined using suitable boolean operators in PubMed, Scopus and Web of Science. Government guidelines and laws were also reviewed in view of telehealth and telemedicine.

Conclusion

Tele-rehabilitation and virtual physical therapy are innovative and cost-effective ways to provide the best rehabilitative services to the patients at their doorstep. Virtual reality should be incorporated into the Indian telehealth delivering system with a special focus on the remote athlete population.

Measurement of Distance Between Femoral Insertion of Fibular Collateral Ligament and Popliteus: A Cadaveric Study in Indian Population

Background

Injuries to posterolateral corner (PLC) of knee are often neglected. The three key components of PLC are lateral collateral ligament (LCL), popliteofibular ligament (PFL) and popliteus tendon (PT). For adequate reconstruction, anatomic location of these ligaments should be well understood.

Material and methods

Twenty formalin fixed cadaveric knees were dissected. PT and LCL identified. Circumference of the two structures marked with pen just after cutting them close to bone surface. Distance between the centre of LCL and PT was measured along with the measurement of distal femoral medio-lateral dimension (MLD) and Anteroposterior dimension (ALD) of lateral condyle.

Result

The mean distance between PT and LCL measured in 20 specimens was 8.3 ± 0.84 mm, with a range of 7 mm to 10 mm. MLD was 81.0 ± 3.6 mm and APD was 62.7 ± 3.2 mm.

Conclusion

The distance in Indian population is significantly smaller compared to the western. This has clinical implication in drilling the tunnels for PLC reconstruction.

Correlation between height and semitendinosus tendon length, prediction of minimum semitendinosus tendon length based on height-an easy and accurate method

PURPOSE

To find out an easy method to predict tendon length on the basis of patient height.

METHODS

A prospective study which included 256 patients. All patients underwent ligament reconstruction using semitendinosus graft. Pre-operatively age, gender, height and weight were noted. Harvested semitendinosus graft's length and diameter was measured.

RESULTS

Both the patient height as well as weight correlated with tendon diameter and tendon length (p-value < 0.05). A simple equation was also derived to pre-operatively predict tendon length.

CONCLUSION

To predict graft size, surgeon should consider anthropometric variables. If we divide height of the patient with six, we get the approximate length of the tendon and by subtracting three from the obtained value we are more than 90% sure that ST would not be shorter than this.

LEVEL OF EVIDENCE

level 4.

Impact of COVID-19 on Clinical Practices during Lockdown: A pan India Survey of Orthopaedic Surgeons

Introduction:

The social lockdown measures imposed to contain the COVID-19 pandemic, have had profound effects on the healthcare systems across the world and India has been no exception to it. The study was aimed to evaluate the impact of COVID-19 on orthopaedic practice in India during the lockdown period and assess the preparedness of orthopaedic surgeons for resuming clinical practice after the initial lockdown was lifted.

Materials and Methods:

An online survey of 35 questions was conducted to evaluate impact on (i) general orthopaedic practice (ii) hospital protocols (iii) out-patient practice (iv) surgical practice (v) personal protective equipment (PPE) use and (vi) post-lockdown preparedness.

Results:

A total number of 588 practising orthopaedic surgeons from India completed the survey. Majority (88.3%) found severe impact (>50%) on trauma surgery and non-trauma surgery with significant reduction in out -patient attendance compared to corresponding time in 2019. There were significant changes made in individual hospital protocols (91.7 %). Appropriate required PPE was available in majority of the hospitals (74.3%). No remodelling or upgrading of the existing operating theatre infrastructure was done by most surgeons (89.5%).

Conclusion:

This pan India survey of orthopaedic surgeons has indicated that COVID-19 has had a profound impact on their outpatient and surgical trauma and non-trauma practice, due to the lockdown and resulted in significant changes to hospital protocols. Preparedness to resume clinical and surgical practice was associated with anxiety in two-thirds of the respondents. Majority of the orthopaedic practitioners felt that they would continue to conduct pre-operative COVID-19 screening and use PPE even after the lockdown is over.

Clinical profile and outcomes of De novo posttransplant thrombotic microangiopathy

Thrombotic microangiopathy (TMA) after kidney transplant is rather uncommon but an important reversible cause of graft loss. This retrospective study of biopsy-proven posttransplant TMA was done to identify the important etiological factors, clinical features, and outcomes of post transplant TMA in a tertiary care referral hospital in northern India. This retrospective study was conducted among all renal transplant recipients who presented with graft dysfunction between 1989 and 2015. All the cases were looked for their etiology, clinical course, treatment modalities, and renal outcomes. The study was conducted in accord with prevailing ethical principles and reviewed by our own institutional review board. Seventeen patients out of 2000 (0.008%) transplants done during the study period had posttransplant TMA, out of which all the patients had de novo TMA, and the median time of presentation after transplantation was four months. Systemic TMA was noted in only four patients. Biopsy revealed associated rejection in five patients and associated calcineurin inhibitor (CNI) toxicity in 12 patients. Patients with TMA due to CNI toxicity were managed with CNI reduction or switching to alternate CNI or mammalian target of rapamycin inhibitors. In addition, antithymocyte globulin and plasma exchange were used in rejection-associated TMA. While four out of 12 patients (33%) in CNI-related TMA developed end-stage renal disease (ESRD), all patients in rejection-associated TMA developed ESRD. The overall one-year graft survival was 47%, whereas five- and 10-year survival was 35%. There was no significant difference in graft survival between localized and systemic TMAs (P = 0.4). Posttransplant TMA should be suspected even if there are no systemic features of hemolysis and early graft biopsy and prompt action is needed. The occurrence of TMA in the setting of rejection is associated with grave prognosis.

Comparison of semitendinosus tendon length and diameter in sports and non-sports group for ACL reconstruction

Different anthropometric parameters such as weight, height, body mass index, thigh circumference, and thigh length have been extensively studied and their correlation assessed with hamstring graft length and diameter. This study is to analyse the difference of semitendinosus graft characteristics with sports activity of the patient.

METHODS

110 patients undergoing any ligament reconstruction with semitendinosus were included, 55 in sports and 55 in non-sports group. Height, weight, BMI, sports activity were noted pre-operatively. Semitendinosus harvested and graft length and diameter measured.

RESULTS

98 patients completed the study. The mean length of the harvested semitendinosus tendons was 28.45 ± 2.54 cm in non-sports group and 28.06 ± 4.18 cm in sports group. The mean diameter of semitendinosus was 6.29 ± 0.61 mm in non-sports group and 6.35 ± 0.6 mm in sports group. Positive correlation was found between height and graft length. No statistically significant difference between tendon length (p = 0.994) and diameter (p = 0.549) of sports and non-sports group was found.

CONCLUSION

Patient height should be considered for preoperative prediction of tendon length and thickness without any difference in sports or non-sports group. A taller patient has a longer and thicker graft.

Innovative Use of Posterior Vertebral Wall Impactor in Tibial Plateau Depressed Fractures

Depressed articular fractures of tibial plateau are treated by elevation of the fracture fragments to maintain the articular congruity and filling the void with any bone substitutes, followed by screw or plate fixation. This elevation of the fragments to maintain articular congruity poses a surgical challenge even in experienced hands. Many techniques have been described for the same, as the use of the metallic-bone-tamps, elevators and more recently inflatable-balloon-tamps. But due to the lesser cross-section area, these often led to comminution of the fragile articular bone fragments. The inflatable-balloon-tamp caused extrusion of contrast-dye or unintentional posterior-wall displacement. We treated a series of 25 patients with tibial plateau depressed fractures by a novel technique using posterior-vertebral-body-wall-impactor. This helped in a uniform dissipation of force over a large cross-sectional area under the fracture fragment, leading to minimal comminution of the depressed fragment, maintaining the articular congruency. Rest of the fixation was done in the standard manner. There were no intra-operative or post-operative complications. All patients had good knee function according to Rasmussen Knee Function Grading System and achieved radiological union of fracture at follow-up (with a range of 12-18 months). Hence, this technique may be a safer and effective alternative for the elevation of depressed articular fractures of tibia.

Fracture management during COVID-19 pandemic: A systematic review

PURPOSE

The COVID-19 pandemic has affected orthopedic practices worldwide. Few studies focusing on epidemiology and management of fractures in COVID-19 patients have been published. We conducted a systematic review to evaluate the fracture types, presentation, treatment, complications, and early outcomes of fractures occurring amidst COVID-19 pandemic.

METHODS

A systematic review of the all published papers was conducted with a comprehensive search of PubMed, Google Scholar, Scopus, and Cochrane Library database using keywords 'COVID-19', 'Coronavirus', 'trauma∗'and 'fracture' from January-April 2020.

RESULTS

The searches yielded a total of ten studies with 112 Patients who were positive for COVID-19 associated with fractures was performed for six studies, reporting data separately for 44 patients with COVID 19 and an associated fracture. A diagnosis of COVID 19 was made on the basis of positive Computed Tomography scan in 39 patients and 30 patients had a positive Reverse Transcription-Polymerase Chain Reaction test. Overall, there were 29 proximal femoral fractures, 8 spine fractures, 7 fractures of the other bones. The fractures were treated surgically in 30 cases (68.18%) and the remaining 14 cases (31.82%) were managed conservatively. There were 16 patients (36.36%) who died, mostly due to respiratory failure with a median age of 82 years.

CONCLUSION

COVID-19 has led to a significant reduction in a load of fracture patients globally, though the incidence of fragility fractures continues to be unaffected. There is a significantly higher risk of mortality in elderly patients with fractures and hence they should only be operated in a facility with a robust intensive care. Conservative treatment should be adopted as far as possible in non-obligatory fractures and in lesser equipped centers. Surgery in patients with proximal femur fragility fractures when judiciously selected did result in improvement in respiratory status. Reorganizing medical services is vital to deliver effective fracture care and also mitigate disease transmission.

Post COVID-19: Planning strategies to resume orthopaedic surgery -challenges and considerations

The Coronavirus SARS-CoV-2 (COVID-19) pandemic has had a substantial effect on the health care systems around the world. As the disease has spread, many developed and developing countries have been stretched on their resources such as personnel as well as adequate equipment. As a result of resource disparity, in a populous country like India, the elective orthopaedic surgeries stand cancelled whilst trauma and emergency services have been reorganised following Indian Orthopaedic Association and recent urgent British Orthopaedic association guidelines. Though these guidelines provide strategies to deal with trauma and orthopaedic surgery management in the present scenario, once the COVID-19 pandemic stabilizes, restarting elective orthopaedic surgery and managing delayed trauma conditions in evolving health care systems is going to be a profound task. We look at the future challenges and considerations of re-establishing trauma and orthopaedic flow during the post-COVID-19 phase and suggest an algorithm to follow (Fig. 1).

Out Patient Department practices in orthopaedics amidst COVID-19: The evolving model

Severe Acute Respiratory Syndrome COVID-19 was declared as a pandemic on 11^th March 2020 by the World Health Organization and consequent lockdown imposed in several areas resulted in a marked reduction in orthopaedic practices. Although some guidelines for patient care in orthopaedic practice have been published, overall, publications focusing exclusively on guidelines on starting orthopaedic outpatient departments (OPD) after the COVID-19 lockdown amidst the on-going pandemic are lacking. We hereby propose the evolving knowledge in changes in OPD management practices for orthopaedic surgeons in the COVID- 19 era. The emphasis on online registration (e-registration) should be given impetus and become the new norm supplemented by telephonic and spot registration for the uneducated patients. The review highlights the safety of patient and orthopaedic surgeons in OPD by screening and maintaining hygiene at various levels. The article also mentions the duties of the help desk, OPD hall supervisor and the new norms of air conditioning, ventilation, safe use of elevators, sanitization of OPD premises and biomedical waste disposal. The optimum and safe utilization of human & material resources, DO's and DON'Ts for patients & health staff have also been proposed. The reorganization of plaster room, the precaution during plastering, fracture clinic, dressing and injection room services are discussed as per evolving guidelines. This article will also give deep insight into the OPD plan & telemedicine graphically. The authors suggest updating and downward permeation of existing e-infrastructure of government health services that is up-gradation of existing tertiary level online registration services, a paperless model of OPD consultation & dispensation. The future updating of Aarogya Setu App (https://mygov.in/aarogya-setu-app/) for convenient online OPD registration and dispensation has been discussed and proposed. This review will help in containing the spread of COVID 19 and build upon the health gains achieved after lockdown. The easy concept of CCCATTT has been introduced, and the OPD Plan has also been suggested. We have endeavoured to holistically detail an orthopaedic OPD setup and its upkeep in COVID-19 pandemic, but since the knowledge of COVID 19 is ever-evolving it needs replenishment by regular education for health staff.

3D printing and its applications in orthopaedic trauma: A technological marvel

BACKGROUND

With rapid emergence of 3D printing technology, surgeons have recently started to apply this for nearly all areas of orthopaedic trauma surgery. Computed tomography or magnetic resonance images of trauma patients can be utilized for making graspable objects from 3D reconstructed images. Patient specific anatomical models can thereby be created. They enhance surgeon's knowledge of their patients' precise patho-anatomy, regarding both traumatized bones and soft tissue as well as normal areas, and therefore help in accurate preoperative planning. 3D printed patient specific instrumentation can help to achieve precise implant placement, and better surgical results. Most importantly, customized implants, casts, orthoses and prosthetics can be manufactured to match an individual's anatomy. Three dimensional (3D) printing, also called as 'additive manufacturing' and 'rapid prototyping' is considered as the "second industrial revolution", and this appears to be especially true for orthopaedic trauma surgery.

METHODS

A literature search was performed for extracting all papers related to 3D Printing applications in orthopaedics and allied sciences on the Pubmed, and SCOPUS; using suitable key terms and Boolean operators ("3D Printing" OR "3 dimensional printing" OR "3D printed" OR "additive manufacturing" OR "rapid prototyping") AND (''Orthopaedics" OR "Orthopaedics'') AND ("Trauma" OR "Injury")in June 2018. Search was also performed in Web of Science, Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews. No limits were set on the time period or evidence level, as 3D printing in orthopaedics is relatively recent and mainly low level evidence is available. Titles and abstracts were screened and all duplicate and unrelated papers were excluded. Papers related to orthopaedic trauma were manually selected for this review.

RESULTS

The search on Pubmed retrieved 144 Papers and similar search on SCOPUS retrieved 94 papers. Additional searches did not reveal more relevant papers. After excluding duplicates and unrelated papers, and on screening of titles and abstracts, 59 papers were considered for review. Papers related to spine fractures only were not included, as they have been covered in another paper in this journal issue.

CONCLUSION

All over the world, orthopaedic Surgeon's and allied professionals and scientists are enthusiastically using 3D printing technology for designing patient specific models, instrumentation, implants, orthosis and prosthesis, besides 3D bioprinting of bone and cartilage scaffolding, and the same has been applied for nearly all areas of orthopaedic trauma surgery, from head to foot.

Role of Preoperative Duplex Ultrasonography to Predict Functional Maturation of Wrist Radiocephalic Arteriovenous Fistula: A Study on Indian Population

Radiocephalic arteriovenous fistula (RCAVF) is the first choice for native arteriovenous fistula (AVF). Preoperative vessel assessment with ultrasonography (USG) has been reported to enhance the outcome of native AVF, but data regarding its predictive value for functional maturation of RCAVF are scanty. We aimed to determine the role of preoperative duplex USG (DUS) for prediction of functional maturity of radiocephalic fistula in the wrist. The data from 173 patients were analyzed prospectively. The estimated duplex variable included size, patency, and continuity of cephalic vein and size, peak systolic velocity, and wall calcifications in radial artery at the wrist. The subjects underwent RCAVF creation and were reviewed 6-8 weeks post procedure for adequacy of maturation. Doppler variables between successful and failed maturation groups were compared. Successful functional fistula maturation was noted in 138 (80.9%) patients. Values of radial artery diameter, cephalic vein diameter, and peak systolic velocity were >2 mm, 2.2 mm, and 32.8 cm/s, respectively, for successful maturation of RCAVF in more than 90% of cases. Vascular calcifications were detected preoperatively in 15 diabetic patients and 9 (60%) of them had fistula failure. Preoperative DUS can provide a good prediction on functional maturation of RCAVF. Vascular calcifications were associated with high risk of maturation failure in diabetics.

Late posttransplant lymphoproliferative disease: Report of a rare case and role of positron emission tomography-computed tomography

Posttransplant lymphoproliferative disease (PTLD) is an uncommon complication of immunosuppression after solid organ transplantation. Early PTLD (<1 year after transplantation) is frequently found around the allograft, whereas late PTLD (>1 year after transplantation) does not have such a preference. 18-Fluorodeoxyglucose positron emission tomography-computed tomography (¹⁸FDG PET-CT) has clinical significance in the evaluation of PTLD. ¹⁸FDG PET-CT scan allows precise anatomic localization of FDG-avid lesions, hence helpful in staging of disease and evaluation of response to therapy. It can better characterize persistent lesions and differentiate residual tumor from fibrosis or necrosis. We present a rare case report of a perigraft PTLD developing 12 years after renal transplantation sparing the graft, in an Epstein–Barr virus-negative patient.

Compound posterior cruciate ligament and popliteal artery injury due to dog bite: A case report

Injuries due to dog bites are a common occurrence and are mostly trivial. Severe dog bite injuries requiring hospitalization and complex reconstructive procedures are more common in children. We present the case of a five year old child with popliteal artery thrombosis and compound Posterior Cruciate ligament injury due to a dog bite. The child was managed by immediate thrombectomy, meticulous debridement and knee spanning external fixation followed by Skin Grafting. At one year post surgery range of motion was 10–110°, with no distal neurovascular deficit and no sign of instability.

Randomised comparison of pretensioning using cyclical loading and on tendon board for arthroscopic anterior cruciate ligament reconstruction using hamstring autograft

OBJECTIVE

Pretensioning is usually done using two methods - manual cyclical loading and using tensioner with a tendon board. Both the methods are being used with little knowledge about the superiority of either method. This study was done with the objective of trying to find out the better method.

METHODS

A total of 50 patients were selected for the above mentioned study who were randomised into each of the two groups using chit system - In group A patients, cyclical loading was done by twenty times full flexion -extension movements but in group B patients, the graft was placed on a tensioner with 15 pounds tension for 10 minutes. All patients were operated by the same surgeon. The patients were put on a strict rehabilitation protocol. Patients were allowed to bear weight as tolerated. Patients returned for follow up at 6 weeks, 3 months, 6 months and 12 months. At each visit patients were followed with Lysholm's Score and ROLIMETER reading.

RESULTS

The ROLIMETER reading and Lysholm's score were seen to improve from preoperative to postoperative period and improved further over time with the progress of the rehabilitation protocol in both the groups. When compared to each other Group A i.e. patients pretensioned with cyclical loading had better Lysholm scores and ROLIMETER readings with the difference being statistically significant at all time periods except at 1 year when the difference between the ROLIMETER readings in the two groups were no more significant, though the difference of the Lysholms score was still found to be statistically significant.

CONCLUSION

It was concluded in this study that cyclical loading is a better method of pretensioning in ACL reconstruction than tensioner on tendon board with 15 pounds of tension for 10 minutes.

Experience of supracondylar cheveron osteotomy for genu valgum in 115 adolescent knees

PURPOSE

Medial close wedge Coventry type osteotomy is commonly performed procedure for adoloscent Genu valgum. However this osteotomy has some inherent problems, a wedge resection causes shortening of affected site. An additional plate for stabilization causes increase in soft tissue dissection and surgical time. A cheveron osteotomy is an alternative procedure, not requiring any internal fixation due to its inherent stability. We started this study with aim to analyze the results of Cheveron osteotomy, to see if the osteotomy was stable enough without implants, time required for healing of osteotomy, post-operative range of motion, limb length discrepancy and to evaluate any other complication.

METHODS

This study was conducted to evaluate the efficacy of cheveron osteotomy in cases with genu valgum in our department from 2005 to 2012. 75 children with 115 knee deformities were included in the study. Patients were followed upto minimum 3 years post surgery. Clinical and radiological assessment was done on all subsequent visits.

RESULTS

Preoperative mean valgus angle was 21° (12-30°) and mean inter malleolar distance was 12.3 cm(11-21 cm). The mean post-operative angle was 6.5° and mean intermalleolar distance was 5.6 cm. The difference was statistically significant. The mean tourniquet time was 26 min and mean surgical time including plaster cast application was 38 min. Mean blood loss was 75 ml. The mean time to union was 10.3 weeks.

CONCLUSION

Supracondylar cheveron osteotomy is simple, stable, low cost osteotomy for surgical correction of genu valgum. The osteotomy provides excellent clinical, radiological and functional results in short surgical time and has an added advantage of omitting the need of second surgery.

Transforaminal epidural Etanercept for the treatment of prolapsed lumbar intervertebral disc induced sciatica

STUDY DESIGN

Hospital based prospective study.

OBJECTIVE

To study clinical response of transforaminal epidural Etanercept for lumbar prolapsed intervertebral disc induced sciatica.

METHOD

Patients presenting to O.P.D and Emergency services of our hospital were screened for inclusion and exclusion criteria & suitable candidates were enrolled in study. Patients received 2 transforaminal epidural injections of Etanercept 2 mg, 2 weeks apart, and were assessed for efficacy at 2 week, 1 month and 3 months after the second injection. Primary outcome was based on Visual Analog Scale for leg (VASL) and back pain (VASB) and secondary outcome was based on Modified Oswestry back related disability index (ODI).

RESULTS

31 of 33 enrolled patients completed study. Patients showed clinically and statistically significant (p < 0.001) reduction in VASL, VASB and ODI. There was no incidence of adverse events.

CONCLUSION

Epidural Etanercept is promising and effective non-operative treatment for patients with sciatica. But these results need to be confirmed by a randomized controlled trial.

Spontaneous spinal epidural abscess in a normoglycemic diabetic patient - Keep it as a differential

Spinal epidural abscess (SEA) is a rare and serious condition which can lead to permanent neurological deficit. Spontaneous SEA is even rarer condition with an incidence of less than 1 per 10,000 person-year. Being spontaneous, it has high chances of being misdiagnosed, more so when the risk factors are not clearly explainable for the condition. This is a case report of such a case in a middle aged normoglycemic recently diagnosed diabetic man with atypical presentation. The diagnosis was made after magnetic resonance imaging and confirmed after surgical intervention in form of spinal decompression and patient recovered after appropriate antibiotics. This article also sums up the risk factors of spontaneous SEA.

Postrenal transplant metastatic colonic neoplasm: Posttransplant lymphoproliferative disorder or adenocarcinoma?

Transplant recipients are vulnerable to a horde of infections and neoplastic conditions due to immunosuppression. Posttransplant lymphoproliferative disorder (PTLD) is a condition unique to the transplant recipient occurring due to monoclonal lymphocytic proliferation. It may affect any organ system with reportedly highest incidence in the gastrointestinal tract. The incidence of adenocarcinoma of the colon, however, has not been shown to be uniformly higher in transplant recipients. We report here an unusual case of adenocarcinoma of the ascending colon presenting with liver, lymph node and skin metastasis in a transplant recipient, which simulated PTLD both clinically and radiologically. For any gastrointestinal lesion in transplant recipient, the possibility of carcinoma must be considered. However, a high index of suspicion for PTLD facilitates early diagnosis since the treatment of the two conditions is starkly different.

Management of post-traumatic neglected cervical facet dislocation

BACKGROUND

Post-traumatic unilateral or bilateral sub-axial cervical spine dislocations with locked facets are quite common. In developing countries like India, many patients with cervical injuries report late due to many reasons like rural backgrounds, lack of infrastructures and skilled surgeons, unawareness, poor socioeconomic status, lack of transportation to the specialized center with proper facility, etc. Early management is essential to maximize better neurological outcome. Delayed or neglected presentation makes treatment more challenging. Very few literatures are currently available regarding management of neglected cervical facet dislocation but no one offers clear cut management. Purpose of our study is to evaluate treatment outcome of 15 patients with post-traumatic neglected cervical facet dislocation. Here we have reviewed 15 patients with post-traumatic neglected presentation of cervical facet dislocations and evaluated their treatment outcome.

MATERIALS AND METHODS

This is a retrospective type of study done in spine care unit of VMMC and Safdarjung Hospital, New Delhi from July 2013 to June 2016. Record of 15 patients with neglected cervical dislocation who were undergone anterior cervical discectomy and fusion along with posterior lateral mass screw fixation depending upon close reduction and integrity of disco-ligamentous complex.

RESULTS

15 patients were included in this study. 4 patients underwent only anterior cervical discectomy and fusion (ACDF) after complete close reduction with intact disco-ligamentous complex. Remaining 11 patients who failed to achieve complete reduction or had posterior disco-ligamentous injuries underwent posterior partial facetectomy and lateral mass screw fixation with anterior discectomy and fusion concomitantly. Mean follow up period was 14 months. All patients achieved pain relief and sufficient neck movements. 1 patient with only nerve root injuries recovered completely. 6 out of 11 patients with incomplete spinal cord injuries, improved by one Frankel grade and remaining 5 patients by two grades. 3 patients with complete quadriplegia showed no clinical and neurological improvement.

CONCLUSION

Proper decompression, reduction and fixation should be done in neglected cervical dislocation as it provides mechanical stability and alignment, facilitates rehabilitation, prevent kyphotic deformity as well as offers a fair chance of neurological recovery.

Inserting pedicle screws in lumbar spondylolisthesis - The easy bone conserving way

BACKGROUND

Pedicle screw fixation in high grade lumbar listhetic vertebral body has been nightmare for Orthopaedic and spine surgeons. This is because of abnormally positioned listhetic pedicles and non-visualization of pedicle in conventional image intensifier (C-Arm). This results into increased surgical time, more blood loss, radiation exposure and more chances of infection. To overcome this problem, we have devised a new Technique of putting of pedicle screw fixation in listhetic vertebrae.

METHODS

Total 20 patients of average age of 42 (25-56) were included during 2010 to 2015. Listhesis was classified according to etiology, Meyerding grading and DeWald modification of Newman criteria used for assessment of severity for spondylolisthesis on standing X-ray lumbosacral spine. Patients satisfying following criteria were considered for surgery. Age more than 20 years, with single involvement of either L4-5/L5-S1, high grade spondylolisthesis (≥ 50% Meyerding grade), unresolving radiculopathy, cauda equina syndrome or pain with and without instability not relieved by 6 months of conservative treatment. According to Meyerding radiographic grading system,10 patients were of type II and 8 of type III and 2 of type IV. Treatment given was pedicle screw fixation, reduction of listhesis vertebra and spinal fusion with our technique. PLT was done in 10 cases and transforaminal lumbar interbody fusion (TLIF) in the other 10 cases.

RESULTS

Mean follow up duration was 2 years (range 1.3-3.3 year). The average preoperative LBP VAS of low back pain were 6.7 and average LP VAS for leg pain 5.7. Postoperatively at final follow up there was reduction of LBP VAS to 2.2 and LP VAS to 0.5. There was rapid reduction in their LBP VAS in first two visits at 4 weeks and in LP VAS in first three visits at 8 weeks. The pain-free walking distance improved significantly. The average pre-operative ODI score was 51.4, improved to 18.6 postoperatively. There was no difference in above scores between PLT and TLIF.

CONCLUSION

Our surgical technique used for high grade spondylolisthesis is safe, cost-effective, bone-preserving, reliable, and reproducible for high grade Lumber spondylolisthesis.

Scapulothoracic and scapholunate dissociation in the ipsilateral upper limb of a trauma victim

Scapulothoracic dissociation is a rare and complex injury pattern with varied presentation. Here we describe a case of a 32-year-old male who presented with scapulothoracic dissociation associated with brachial plexus injury, along with scapholunate dissociation. We also propose an injury mechanism that might link the two injury patterns, suggesting that the association might be more than by chance. The patient was managed according to established trauma care and resuscitation protocols followed by open reduction and internal fixation of the clavicle fracture, and fixation of scapholunate dissociation and had a successful outcome at follow-up.

Subungual osteochondroma: Nail sparing excision

Subungual osteochondroma is a relatively uncommon benign bone tumor affecting mostly children and young adults, and is a major source of pain and nail deformity. Treatment consists of marginal excision and meticulous wound closure. In this report, we present three cases of subungual osteochondroma arising from the dorsal aspect of distal phalanx of the great toe, which were managed by marginal excision with preservation of nail apparatus under digital block anesthesia with the use of a ring tourniquet. We emphasize on the use of ring tourniquet made by glove's finger and the technique of preserving the nail apparatus to prevent nail deformity. At final follow-up, there is no evidence of recurrence or nail deformity with good functional and cosmetic result.

Total knee replacement in triple deformity with posterior subluxation of the knee joint

Dislocation or subluxation following total knee arthroplasty has been extensively reported, but vice versa that is total knee replacement for subluxed or dislocated knee has not been published. Triple deformity of knee that is flexion, external rotation, valgus at knee associated with posterior subluxation of tibia occurs in rheumatoid arthritis, advanced tubercular arthritis and neglected posttraumatic residual dislocated knee. A 50 year old female with seropositive rheumatoid arthritis had the above disabling deformity in left lower limb and varus with medial tibial thrust in the other. Bilateral total knee arthroplasty was planned. Conservative method of reduction of left knee posterior subluxation preoperatively by 90-90 skeletal traction failed; hence patient was subjected to a staged bilateral total knee replacement using an innovative technique. The most difficult and determining initial surgical step of knee replacement in such dislocated/subluxed knee is reduction of posterior subluxation and gaining flexion at knee, as only after gaining flexion and reducing dislocated tibia, will we be able to do knee arthroplasty in triple deformity of knee. These knees are grossly unstable as most of the capsule-ligamentous structures are attritioned/non-existent. So, a fine balance of bone cuts and soft-tissue release needs to be done in a sequential manner to fine tune valgus and posterior subluxation correction without jeoparadising neurovascular structures. After 3 years of knee arthroplasty the patient has painless, stable knee with good range of motion and is able to do all her activities, of living in a hilly terrain.

A Method of Open Reduction of an Irreducible Hawkins Type III Fracture of the Talar Neck

Hawkins type III fracture talar neck may sometimes be a nightmare for surgeons to reduce, even intraoperatively. It is difficult to reduce as the talar body is locked into its dislocated posteromedial position out of both the ankle and subtalar joint. Maneuvers of reduction have been described both in dorsiflexion and plantarflexion of ankle, but these are complicated and not tissue friendly. Further, various methods of grasping and pushing the dislocated talar body by use of joysticks and distractors have been advocated. To accomplish this intraoperatively, we present a convenient and utilitarian method using only 2 smooth 1.5-mm Kirschner wires and a JESS distractor clamp. Two key concepts to keep in mind while reducing such fracture dislocations are also highlighted. This was done in a 22-year-old male with 7-day-old Hawkins type III fracture of the left talar neck and a right Pilon fracture with good results at 2 year follow-up.

Anconeus pedicle olecranon flip osteotomy: an approach for the fixation of complex intra-articular distal humeral fractures

In order to achieve satisfactory reduction of complex distal humeral fractures, adequate exposure of the fracture fragments and the joint surface is required. Several surgical exposures have been described for distal humeral fractures. We report our experience using the anconeus pedicle olecranon flip osteotomy approach. This involves detachment of the triceps along with a sliver of olecranon, which retains the anconeus pedicle. We report the use of this approach in ten patients (six male, four female) with a mean age of 38.4 years (28 to 51). The mean follow-up was 15 months (12 to 18) with no loss to follow-up. Elbow function was graded using the Mayo Score. The results were excellent in four patients, good in five and fair in one patient. The mean time to both fracture and osteotomy union was 10.6 weeks (8 to 12) and 7.1 weeks (6 to 8), respectively. We found this approach gave reliably good exposure for these difficult fractures enabling anatomical reduction and bicondylar plating without complications.

Management of fractures of the distal third tibia by minimally invasive plate osteosynthesis - A prospective series of 50 patients

BACKGROUND

Minimally invasive plate osteosynthesis (MIPO) is an established technique for fixation of fractures of the distal third tibia. Our study aimed to manage intra articular and extraarticular fractures of the distal third tibia by the minimally invasive plate osteosynthesis technique and follow them prospectively. Clinical and radiological outcomes were studied and clinical indications & efficacy of the procedure reviewed. Though many studies on the subject have been done previously, these have been retrospective reviews or small series.

METHODS

From May 2010 to May 2013, 50 patients of closed distal tibial fractures were operated by MIPO technique with a distal tibial anatomical locking plate having 4.5/5 proximal and 3.5/4 distal screw holes. The follow up duration was for 3 years.

RESULTS

The mean fracture healing time was 21.4 weeks (range 16-32 weeks) and average AOFAS score 95.06 was out of a total possible 100 points. At last follow up, superficial infection occurred in 5 patients (10%); deep infection, implant failure and malunion in 1-patient each (2%).

CONCLUSION

MIPO technique provides good, though slightly delayed bone healing and decreases incidence of nonunion and need for bone grafting. This technique should be used in distal tibia fractures where locked nailing cannot be done like fractures with small distal metaphyseal fragments, vertical splits, markedly comminuted fractures and in fractures with intra-articular extension.

A convenient way to do valgus osteotomy for neglected fracture neck of femur

BACKGROUND

Neglected fracture of neck of femur in young adults is a major problem in developing countries. Existing treatment options varies from osteotomy to various graft techniques (muscle pedicle, vascularized and nonvascularized fibula etc.). There is paucity of literature regarding the use of double angle barrel plate and hip screw in such cases. We conducted a prospective longitudinal observational study with displaced, neglected fracture neck of femur in young adults and compared the results with literature.

OBJECTIVES

The aim of this study was to determine feasibility and effectiveness of 120° double angle barrel plate and hip screw fixation in neglected fracture neck of femur. Effectiveness of fixed 30 degree closed wedge osteotomy in neglected fracture neck of femur.

METHODS

Thirty cases of neglected (more than three weeks) femoral neck fracture (Pauwel II and III) of age 20-60 years were included in the study conducted at Postgraduate Institute Of Medical Education and Research, Dr. Ram Manohar Lohia Hospital, New Delhi, India in year 2004-06. Average age of the patient was 35.4 years (range, 22yrs-55yrs). In all cases internal fixation was done by 120° double angle barrel plate and hip Screw. At the end of follow-up, results were evaluated according to Askin Bryan Criteria and Harris-hip score.

RESULTS

Union was achieved in 28 of 30 patients. Two patients that went into nonunion were later treated with hemireplacement arthroplasty. According to Askin Bryan Criteria at the end of study, 35% patients had excellent results, 50% patients had good results. Minimum follow-up in our study was 12 months and maximum was five years.

CONCLUSION

This study validates the use of double angled screw plate configuration for successful outcome in patients with neglected fracture neck of femur. Valgus osteotomy is also technically easy operation in hands of average trauma surgeon with the use of a fixed angle plate and hip screw.

Acute pediatric septic arthritis: a systematic review of literature and current controversies

We present a review of the current literature and the author's opinion regarding Septic arthritis in the pediatric age group. The etiopathogenesis, clinical features, the laboratory parameters for diagnosis and monitoring of treatment, radiological features, are discussed along-with the debatable issues pertaining to the choice of antibiotics, their duration, and the need and mode of surgical drainage and mobilization of the joint.

Use of fourteen gauge angiocatheter needle in orthopaedics

BACKGROUNDS

Wide-bore angiocatheter is readily available in the hospital in pre-sterilized packed form. There are various uses in medical and surgical field apart from its use for transfusion. Here we are outlining its various uses in orthopaedic surgeries.

METHOD

Fourteen gauge angiocatheter which internal diameter is 1.3 mm is used in fracture of patella, olecranon to pass the stainless steel (SS) wire, in scaphoid fracture fixation and hip arthroscopy and its efficacy is noted.

RESULT

Surgical procedure assisted by 14 gauge angiocatheter reduces surgical time, and soft tissues damage and it also helped in scaphoid fixation and hip arthroscopy.

CONCLUSION

Passing SS-wire through soft tissues and bone causes lots of trouble and time consuming. With the help of angiocatheter it overcomes these problems. So, its use in orthopaedic surgeries are rewarding.

Plate mouse

Fracture shaft humerus when surgically fixed is known to go into non-union and one of the main reasons of this is implant failure. The causes of implant failure may lie in the fracture personality, faulty implant material or choice, dubious surgical technique & faulty mechanics of fixation. Implants may break and cut-through but a unique type of implant migration from one surgical compartment to the other or one anatomical part of body to the other has not been hitherto reported. A 45-year-old male, farmer by occupation, was operated for fracture shaft of humerus 15 years back. He presented to us because of pain due to subcutaneous presence of plate in forearm. X-ray of the elbow with forearm showed that the plate used for fixation of humerus had migrated from one body part to another that is from arm to forearm. The patient on deliberation regarding the pros and cons of surgical treatment options, chose not to get his humerus non-union resolved surgically. This was because he could do his activities related to farming reasonably well.