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   Table of Contents - Current issue
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July-December 2018
Volume 10 | Issue 2
Page Nos. 87-147

Online since Thursday, November 22, 2018

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ORIGINAL ARTICLES  

Epidemiology of traumatic fractures in a tertiary health center in Nigeria p. 87
OM Babalola, Oni Nasiru Salawu, BA Ahmed, GH Ibraheem, A Olawepo, SB Agaja
DOI:10.4103/jotr.jotr_35_16  
Background: The incidence of fractures from trauma is increasing due to increase in means of transportation, poor roads and disobedience of road safety laws. Adequate knowledge about the involvement of different parts of the body in trauma will aid planning towards management of these fractures. Aim: This is to show the etiology and frequency of the affected bone of the body by trauma, which can serve as a template for future health care planning and delivery. Patients and Methods: This was a prospective study in which data from all patients that presented at the accident and emergency unit of University of Ilorin Teaching Hospital with fractures, from January 2012 to December 2012 were analyzed. Results: During the study period, a total of 401 fractures in 334 patients were seen. Isolated fractures were seen in 227 patients, while 107 patients had multiple fractures. Male to female ratio was 2.8 : 1, the mean age was 34.2 ± 5.4 years. The commonest bone fractured was the Tibia which accounted for 25% (100 cases). The commonest form of trauma causing these fractures was motor vehicle crash which accounted for 75.6% (303 cases). Conclusion: Prevention of road traffic accident by provision of good roads and enforcement of road safety laws will reduce fractures significantly.
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Chemoprophylaxis for deep vein thrombosis after hip surgery: The Indian prospective p. 90
Chandra Prakash Pal, Rajendra Kumar Shakunt, Danish Altaf, Asif Hussain, Gaurav Deshwar, Yajuvendra Kumar Sharma
DOI:10.4103/jotr.jotr_6_17  
Background: Deep vein thrombosis (DVT) or venous thromboembolism is a fatal complication of patients undergoing elective hip surgeries. Not much evidence is provided in the Indian literature regarding the incidence of DVT in the Indian population and ideal prophylaxis for the same. This issue has gained much importance in recent history due to the increase in a number of elective hip surgeries. Low-molecular-weight (LMW) heparin is commonly used for chemoprophylaxis against DVT. Our study is to identify the role of LMW heparin (enoxaparin) for prophylaxis against DVT. Materials and Methods: The present study is a prospective study for the role of enoxaparin in prophylaxis against DVT in patients of elective hip surgeries carried out over a period of 2 years. A total of 110 patients were selected based on the stringent inclusion and exclusion criteria. Randomization was done and patients were divided into two groups of 55 patients each. Group 1 (case) received postoperative enoxaparin at a dose of 40 mg subcutaneous daily for 7 days whereas Group 2 (control) did not receive any prophylaxis, following which color Doppler was performed on all patients. Results: The overall incidence of DVT in our study group was found to be 23.6%, of which 61.5% had distal thrombus and 28.5% had thrombus in the proximal vein. The incidence of DVT in case group was 12.5% compared to control group, in which the incidence of DVT was found to be 34.5%; hence, statistically significant difference (P = 0.0071) in the incidence of DVT was found in both groups. Duration of surgery and patient's age were two most significant risk factors associated with the occurrence of DVT. No statistically significant difference was noted regarding postoperative bleeding complications between two groups (P > 0.05). Conclusion: DVT/venous thromboembolism is relatively less common in Indian patients following elective hip surgeries as compared to the Western population, and LMW heparin is a safe and effective method of prophylaxis against DVT.
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Efficacy of combined proprioceptive exercises and conventional physiotherapy in patients with knee osteoarthritis: A double-blinded two-group pretest–posttest design Highly accessed article p. 94
Veena Kirthika, S Sudhakar, K Padmanabhan, S Ramachandran, Mohan Kumar
DOI:10.4103/jotr.jotr_40_17  
Background: Osteoarthritis (OA) is a chronic degenerative condition of the joint. Current physiotherapy interventions for OA focus on pain reduction, improve knee range of motion, and muscle strength. OA of knee impairs quadriceps function which affects balance and gait reducing patient's mobility and function. Therefore, there is a need to find out the effect of combined proprioceptive exercises with conventional physiotherapy in Patient with knee osteoarthritis (PKOA). Aim: The aim of this study is to analyze the effect of combined proprioceptive exercises and conventional physiotherapy in PKOA. Methods: A total of 40 female POAK were recruited for the study and were divided into two groups as follows: Group A (conventional group) and Group B (experimental group). Group B in addition to the conventional treatment received proprioceptive exercises. Both the groups were instructed to perform exercises for 5 days in a week for 3 months. Visual analog scale (VAS) for pain and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score were noted pre- and post-intervention. Results: On comparing the mean values of Group A and Group B on VAS and WOMAC scores, both the groups showed a significant decrease (P < 0.001) in the posttest mean, but Group B (experimental group) was more effective than Group A (conventional group). Conclusion: The present study concluded that 3 months duration of combining proprioceptive exercises with conventional physiotherapy is more effective than conventional physiotherapy alone in PKOA.
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Percutaneous kirschner wire fixation of displaced colles' fracture p. 98
Pawan Kumar, Dasarath Kisan
DOI:10.4103/jotr.jotr_68_17  
Introduction: Colles' fractures are one of the most common adult fractures encountered during clinical practice of an orthopaedic surgeon. It occur as the result of a fall on the outstretched hand (FOOSH). They consist of a fracture of distal redial metaphyseal region with dorsal angulation and impaction but without the involvement of the articular surface. Material and Methods: Twenty eight patients with severely displaced Colles' fractures were treated with closed reduction and percutaneous pinning with two/three kirschner wires. All the fractures healed within 3 months.Anatomical result was excellent or good in 22(80%) cases, but 6(20%) cases developed malunion. Functional results were satisfactory in all the cases. At a mean follow up of 3 years after injury, none had wrist pain. Grip strength was 95% of the opposite normal side. There were no serious complications. No patient had a significant loss of rotation of the forearm. Conclusion: The study showed that additional fixation improves both the anatomical and functional results after a Colles' fracture.Our results showed that the procedure ia a very effective treatment option for severely displaced Colles' fractures.
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Management of pediatric both-bone forearm fractures by titanium elastic nailing system: A prospective study of 40 cases p. 103
Biswajit Sahu, Anshuman Mishra, Barsha Tudu
DOI:10.4103/jotr.jotr_70_17  
Context: Diaphyseal fractures of the radius and ulna are common in the pediatric population. The standard management for pediatric forearm fractures remains conservative management with closed reduction and immobilization with above-elbow plaster cast. Although the fracture unites readily, malunion is very common. Stiffness of joints and compartment syndrome are other complications of conservative management with plaster cast. The introduction of titanium elastic nailing system (TENS) has changed the treatment scenario of fracture of both-bone forearm. Aims: The aim of this study is to evaluate the functional and cosmetic outcome of the management of fracture both-bone forearm by closed reduction and internal fixation with titanium elastic nail system. Subjects and Methods: A total of 40 patients aged 5–15 years with fracture of both radius and ulna were managed by internal fixation with titanium elastic nail. Closed reduction under image intensifier control was achieved in most of the patients. Prospective follow-up was done for 6 months. Results: Results were analyzed in reference to union, symptoms, and range of motion of adjacent joints using Price et al. criteria for outcome evaluation. In our study, 87.5% of patients showed excellent, 10% showed good, and 2.5% showed fair outcome. Conclusion: Better functional and cosmetic outcome with minimal complications is achieved with internal fixation with titanium elastic nail system. TENS may be considered as an alternative to conservative treatment.
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Elastic nailing in diaphyseal fractures of femur in children p. 107
Pawan Kumar, Dasarath Kisan
DOI:10.4103/jotr.jotr_3_18  
Background: Fracture shaft femur in children is conventionally managed by traction followed by hip spica. Prolonged hospitalization, difficulty in maintaining child with traction for 3 weeks, then hip spica makes toileting and personal hygiene difficult. This may cause malunion/limb length discrepancies, rotational deformities, and sometimes psychological problems. Materials and Methods: A total of 32 children in the age group of 4-16years,25 boys and 7 girls having diaphyseal femoral fractures were stabilized with two stainless steel/titanium elastic nail retrograde way under fracture table. The average duration of surgery was 45 min (30–75 min). Patients were assessed clinically and radiologically before and after surgery for 2 years. Early mobilization and weight-bearing allowed. The results were evaluated using the criteria of Flynn et al. Technical problems and complications were also analyzed. Results: Duration of hospitalization was 4 days (3–7 days). The average duration of appearance of bridging callus was 6 weeks. Radiological union in all cases was achieved in a mean time of 8.7 weeks. All children showed sound union at an average 8 weeks without significant complications. Return to school was early with an average 10–12 weeks. Result assessed for range of motion (ROM), irritation at the distal end of the nail, pain, deformity, limb length discrepancies, union, and malunion. Overall results observed were excellent in 24, satisfactory in 5 and poor in 3 patients. The soft-tissue discomfort near the knee produced by the nail ends was the most common problem encountered. Three patients had decreased terminal ROM at the knee. Later, all the 32 patients had full ROM at hip and knee after 3 months. Conclusion: Elastic nailing in pediatrics femoral shaft fracture-simple and effective, small incisions, biological, dynamic fixation, early mobilization, rapid wound healing, rapid functional recovery.
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Study of locking compression plate in the fixation of comminuted diaphyseal humerus fracture p. 112
Ravi Kumar, Virender Kumar Sahni, Manoj Garg, Neeraj Kumar
DOI:10.4103/jotr.jotr_7_18  
Background: Humerus shaft fracture accounts for 20% of all humeral fractures. Comminuted fracture of humerus requires great surgical skill to obtain stable fixation. The aim was to study the effect of locking compression plate (LCP) in the fixation of comminuted diaphyseal humerus fracture. Materials and Methods: This is a prospective study done over 12 months in which 30 consecutive skeletally mature, closed diaphyseal comminuted humerus fractures underwent fixation with LCP and outcome evaluated in terms of radiological evidence of healing, functional outcome, and complications if any. Results: Union of all thirty fractures was achieved primarily. There was no implant-related complication. The mean Mayo Elbow Performance Score at 6-month follow-up was 90.5, while the mean University of California and Los Angeles score (UCLA) at 6-month follow-up was 29.66 with minimum 24 to maximum of 34. Conclusions: Internal fixation of comminuted diaphyseal humeral fractures with locking plates described in this study allows an intensive program of rehabilitation immediately after surgery and is associated with a high union rate.
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Comparative study of accelerated ponseti method versus standard ponseti method for the treatment of idiopathic clubfoot p. 116
Mahendra Solanki, Anand Ajmera, Sanjay Rawat
DOI:10.4103/jotr.jotr_11_18  
Introduction: Clubfoot is a common congenital deformity with incidence of one in thousand live births. Ponseti method is currently the gold standard for treatment of clubfoot which conventionally involves weekly plaster changes. A prospective comparative study was carried out at our institute where we compared one group with weekly plaster change to other group with triweekly plaster change using the classical Ponseti protocol of manipulation. Methods: A total of 40 feet, divided into two groups, were randomly allocated to either Group A – 20 feet (standard Ponseti) or Group B – 20 feet (accelerated Ponseti). Group A underwent serial manipulations and casting once a week and Group B received manipulations and castings thrice a week. Pirani score was documented at presentation, at each cast, and at the time of removal of final cast to assess the success of treatment in terms of Pirani score ≤1. Results: The average number of casts needed for correction in accelerated group was 7 (16 patients, 20 feet) and in standard group was 6.35 (15 patients, 20 feet). The mean follow-up in accelerated group was 7.84 months whereas in standard group was 6.66 months. Tendoachilles tenotomy was required in 65% feet in accelerated group and 55% in standard group. Conclusion: Both methods standard and accelerated Ponseti have proven to be equally efficacious for the management of clubfoot in our study. However, the accelerated method has a overall shorter treatment duration making it more cost effective and convenient for the parents. As patient is under direct observation of surgeons, any complications are detected early and easily. Overall, the accelerated technique is more practical, beneficial, and labor-saving for poor patients from rural part of India where recurrent visit to tertiary government care center is inconvenient and troublesome.
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Evaluation of chronic anterior knee pain following interlocking nailing of diaphyseal fractures of tibia p. 120
Nirmal Chandra Mohapatra, Udit Saurav Sahoo
DOI:10.4103/jotr.jotr_18_18  
Background: Chronic Anterior Knee pain is the most common post-operative complication following Intramedullary interlocking nailing of Tibial shaft fractures. Its incidence has been reported to range between 10 % to 86% but no definite cause can be attributed. This study was conducted to analyse the prevalence & severity of anterior knee pain in post tibial nailing patients with relation to nail protrusion, approach and proximal screw size. Methods and Material: 92 consecutive patients with an isolated tibia shaft fracture; treated with reamed IMIL nailing from 2014 to 2016 were included in the study. Chronic Anterior knee pain was assessed as per VAS. Besides X-ray, Ultrasound evaluation of patellar tendon morphology and nail protrusion was done. Statistical analysis used: student t test. Chi square test. Results: In the symptomatic group (28), 25patients (89%) had nail protrusion and only 3 patients (11%) did not have nail protrusion beyond proximal tibia cortical bone. In asymptomatic group, 20(33%) patients had nail protrusion and 40(67%) patients did not have nail protrusion. This difference was statistically significant with P value 0.00. In symptomatic group, 11(39%) patients had larger screws and 17(61%) patients had normal length screws. In asymptomatic group, 41(68%) patients had normal length and 19(32%) had large screw. P value came out to be 0.48. Conclusions: Anterior knee pain may be related to protrusion of nail beyond proximal tibial cortical bone [p value 0.01], and larger proximal screw length [p value 0.08].
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Fracture union in closed interlocking nail in tibial shaft fracture p. 124
Ramji Lal Sahu
DOI:10.4103/jotr.jotr_23_18  
Introduction: The objective of this study was to find the outcome of interlocking nail in fracture tibia. Methods: This study was conducted in the Department of Orthopaedic Surgery in SMS and R, Sharda University, from December 2010 to December 2015. Two hundred and seventy-eight patients were recruited from emergency and outpatient department having closed fracture of tibial shaft. The clinical results of our study were rated on the basis of the criteria of union, nonunion, delayed union, or malunion. All patients were operated under general or spinal anesthesia. All patients were followed for 9 months. Results: Nearly 86.33% (240/278) patients had union in 90–150 days with a mean of 110.68. Union was achieved in 10.07% (28/278) patients in 95–109 days with a mean of 103.38. About 9.35% (26/278) had delayed unions and 4.31% (12/278) had nonunion which were treated with dynamization and bone graft. The results were excellent in 86.33% (240/278) and good in 9.35% (26/278) patients. All of our patients had full range of motion of their knees and ankles. Conclusion: We concluded that this technique is advantageous because of early mobilization (early weight-bearing) and less complication with good results and is economical.
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Treatment of resistant tennis elbow by a novel technique: Platelet-rich plasma injection and drilling of lateral humeral epicondyle p. 128
Medhat Tawfik Maaty
DOI:10.4103/jotr.jotr_24_18  
Introduction: Tennis elbow is a common disease in orthopedic surgery. Recently, the high-rate outcomes of local injection of platelet-rich plasma (PRP) were reported. This study was conducted to evaluate and compare the results of combining the percutaneous drilling of lateral humeral epicondyle and local injection of PRP for resistant tennis elbow to other more invasive techniques. Patients and Methods: Between January 2014 and December 2015, 25 patients underwent this study. The patients underwent percutaneous drilling of lateral humeral epicondyle and local injection of PRP. Results: The average follow-up time was 18 months (range: 12–27 months). Eighteen patients (72%) were rated as having excellent results, 4 patients (16%) were rated as having good results, and 3 patients (12%) were rated as having a poor result without any improvement. Conclusions: Combining the percutaneous drilling of lateral humeral epicondyle and local PRP injection in tennis elbow improved the results and compared favorably with other techniques.
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Bone tunnel enlargement in anterior cruciate ligament reconstruction done using hamstring tendon autografts: A prospective clinical and computed tomography-based evaluation p. 131
Anindya Debnath, Rajeev Raman, Paras Kumar Banka, Hirak Debnath
DOI:10.4103/jotr.jotr_25_18  
Context: Enlargement of osseous tunnels following anterior cruciate ligament (ACL) reconstruction is a newer discovery. This phenomenon is particularly valuable in planning for revision ACL reconstruction. Aim: The purpose of this study was to evaluate prospectively the increase in size of the tibial and femoral bone tunnel following arthroscopic ACL reconstruction with quadrupled hamstring autograft and fixation with biodegradable interference screws. Materials and Methods: A prospective study was conducted on 10 patients who underwent arthroscopic ACL reconstruction with quadrupled hamstring autograft and fixation with biodegradable interference screws. Tunnel width was measured at postoperative 2 weeks and an average of 1-year follow-up (range: 10–13 months). Clinical evaluation was done as per the International Knee Documentation Committee form. Paired Student's t-test and linear regression were used for statistical analysis. Results: There was a mean 14% enlargement in the femoral tunnel (from 9 mm at postoperative 2 weeks to 10.3 mm at postoperative 1 year) and 18% enlargement in the tibial tunnel (from 10.4 mm at postoperative 2 weeks to 12.2 mm at the postoperative 1-year follow-up). Both of these were statistically significant (P = 0.005 for femoral tunnel enlargement and P = 0.008 for the enlargement of the tibial tunnel). No statistically significant association was noted between tunnel enlargement and clinical results. Conclusion: Compared to previous similar studies, less tunnel widening was observed in the present study. We come to a conclusion that less aggressive rehabilitation program and anatomical graft fixation technique can help achieve the goal of minimum tunnel enlargement after ACL reconstruction.
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CASE REPORTS Top

Delayed presentation of brachial artery injury following fracture shaft humerus; whether amputate or salvage: A series of two cases p. 137
Bhanu Sharma, Sibashish Metia, Kavish Kapoor, Pankaj Poswal
DOI:10.4103/jotr.jotr_22_18  
Vascular injury is a complication after humerus fracture that has been associated with shoulder dislocation, fracture proximal, and supracondylar region of the humerus. Combined vascular and bony injuries are diagnosed and referred earlier than 24 h. However, delayed presentation of brachial artery injury after shaft humerus fracture beyond the golden period of 6 h has been little reported. In this series, we aimed at evaluating the likelihood of limb salvage. Case 1, was 24 years old with open fracture that presented after 18 h, managed with fasciotomy with arteriotomy with thrombectomy followed by temporary skeletal stabilization and definitive thereafter. Case 2, was 39 year old with closed fracture, presented after 76 h with digital gangrene in which definitive fracture fixation was first done followed by transbrachial thrombectomy with amputation of digits. Our results were good with minimal morbidity due to joint stiffness, restriction of range of motion, and complications of ischemia.
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Technique for the removal of a locking screw from a broken locking plate following cold welding p. 142
Alok Chandra Agrawal, Mangesh Mahadeo Chandewar, Rahul Kumar Chandan
DOI:10.4103/jotr.jotr_26_18  
The advent of locking plates has brought new problems in implant removal. Difficulties include cold welding between the screw head and locking screw hole, stripping of the recess of the screw head for the screwdriver, and cross-threading between threads in the screw head and screw hole. We are describing a technique which allowed us to remove such cold-welded, jammed single screw with simple instruments at hand and complete the prescribed operation smoothly. A 32-year-old female patient reported to us with a broken clavicle locking plate, who was operated 3 years back for fracture clavicle right side. The patient had complaints of pain and deformity in the right clavicle region for 3 months following lifting heavy weight. X-ray showed broken implant with nonunion of clavicle. The patient was planned for implant removal, freshening of edges, and fixation with anatomical clavicle plate with bone grafting. All the screws were removed with standard screw driver when it was found that the second screw of medial broken plate was jammed, round headed, and cold welded. We bent both ends of broken medial plate around screw and removed screw by just rotating bent plate anticlockwise. Fracture ends were freshened and fixation was done with anatomical clavicle locking plate and bone grafting. The patient did not develop any postoperative complication. This technique is very quick, easy to perform, and inexpensive without the use of plate cutting blade, burr, hollow mill, and other instrumentation. This technique can be used in peripheral hospitals in India where advanced gadgetries may not be available. There is no problem of thermal necrosis to the bone or the surrounding soft tissue. Osteoporotic bone is a limitation of the above method as the bone may break while bending the plate and is possible only with a single locking screw.
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Transverse terminal upper limb deficiency through the arm: The problem and management p. 145
Alok Chandra Agrawal, Harshal Sakale, Sandeep Kumar
DOI:10.4103/jotr.jotr_39_18  
Transverse terminal deficiencies of the arm differ from transhumerus amputations. Whereas transverse limb deficiency is due to congenital causes transhumerus amputation are usually acquired. The paper deals with a congenital transverse limb deficiency at the mid-arm level which presented to us with pain in the amputation stump with a projection of bone through the skin.
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