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   Table of Contents - Current issue
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July-December 2020
Volume 12 | Issue 2
Page Nos. 107-165

Online since Monday, December 28, 2020

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REVIEW ARTICLE  

A Comprehensive Review of the Anatomy of Popliteus and Its Clinico-Surgical Relevance Highly accessed article p. 107
Deepa Somanath, Sudha Ramalingam
DOI:10.4103/jotr.jotr_59_19  
An extensive anatomical knowledge of the muscle popliteus and its tendon is indispensable to understand the posterolateral structures of the knee which is prone to injury compared to the medial knee structures. This study describes all the relevant anatomical details of the muscle and its clinical significance. Anatomical and clinical terms regarding the popliteus muscle are searched using databases and search engines for the collection of literature review. Abstracts and articles describing the posterolateral corner (PLC) structures apart from the muscle studied were excluded. Seventy-six articles were adopted using the inclusion and exclusion criteria, among which 62 articles had fulfilled the need. Original articles dealing with morphology and morphometric analysis of popliteus muscle are scarce. Hence, the finer details of the anatomy of the muscle in various populations are unavailable, which is considered as a deficiency of the study. This article deals with the morphology of the popliteus and its clinical and surgical implications pertaining to the PLC of the knee.
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ORIGINAL ARTICLES Top

A Comparative Study of Management of Femoral Shaft Fracture in Children: A Prospective Study p. 115
Ramji Lal Sahu, Bharat Goswamy
DOI:10.4103/jotr.jotr_15_20  
Context: Femoral shaft fracture is the most common major pediatric orthopedic fractures and treatment of them carries a lot of controversies. Aims: The aim of this study was to compare the functional outcome after internal fixation with titanium elastic nail and stainless steel Kirschner wire in unstable femoral shaft fracture in children. Settings and Design: This prospective study was conducted at Sharda University between December 2010 and December 2017 and were followed up for 12 months. Materials and Methods: A total of hundred children between the ages of 2–14 years having closed unstable fracture of the femoral shaft were included in the present study. Fifty children were managed with titanium nails (Group 1) and the same number of children was managed with stainless steel Kirschner wires (K-wires) (Group 2). Functional outcomes were evaluated using the criteria of Flynn et al. Statistical Analysis Used: Statically analysis was limited to calculation of percentage of patients who had unions, malunions, delayed unions, or nonunions and excellent, good, and poor outcomes. Results: Based on the Flynn criteria, 92% of patients had excellent results, 8% had satisfactory results, and no one showed poor results. There was no clinically significant difference between the two groups with respect to time to union, functional outcome, and complication. Conclusion: The clinic-radiological results were not significantly different between titanium nail and Kirschner wire at 1-year follow-up as observed by our study. The cost of Kirschner wire is one-third the cost of titanium nail.
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A Comparative Study of Pain Control and Early Rehabilitation after Total Knee Replacement: Local Wound Infiltration versus Epidural Bupivacaine in the Immediate Postoperative Period p. 121
M Jonathan Reddy, Shaik Waseem Md. Ahmed, IV Reddy
DOI:10.4103/jotr.jotr_21_19  
Aim: To study the efficacy and safety of a periarticular analgesic cocktail injection for early rehabilitation after total knee replacements. Patients and Methods: One hundred patients who are included for TKR were posted for unilateral total knee arthroplasty. This prospective randomized controlled study compared pain relief and functional recovery in immediate postoperative patients (initial 72 h) of total knee replacement where one group of patients are given local analgesia and the other group are given epidural analgesia. The patients were randomized into two arms by block randomization. In one arm, the patients received epidural analgesia for 48 h postoperatively. In the other arm, the patients received periarticular injection of an anesthetic cocktail of drugs. Results: The pain relief on the day of surgery (day 1) was significantly better in patients who received pericapsular injection as compared to those who used the epidural injection for postoperative pain relief. The postoperative range of motion and the distance walked in on the day of suture removal (day 14) was marginally better in the epidural group though the difference was not significant. Side effects including nausea, vomiting, pruritus, urinary retention, and respiratory depression were significantly higher in the epidural group as compared to those who received the analgesic cocktail injection. Conclusion: Patients who received epidural infusion for postoperative pain control required more medications as supplements, as evidenced by higher incidence of bolus injections/increased infusion rates/tramadol injections. There were no surgical site infections in either group.
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Infective Spondylodiscitis: A Comparative Analysis of Magnetic Resonance Imaging Findings with Etiology p. 129
Ibad I Sha, Ajin Edwin, Namitha Shah, SR Roshna
DOI:10.4103/jotr.jotr_27_20  
Introduction: Spondylodiscitis in the Indian population is mostly tubercular and pyogenic. Gadolinium-enhanced magnetic resonance imaging (MRI) is currently most suited for radiological evaluation of the spine in patients with suspected vertebral osteomyelitis. Histology is highly sensitive in detecting the presence or absence of spondylodiscitis but fails in addressing the causative organism. The identification of organism is mainly through microbiological methods such as culture and tuberculosis (TB) polymerase chain reaction. The use of both pathologic examination and culture of the specimen along with imaging findings is paramount in establishing the diagnosis. Methodology: We performed prospective analysis of MR images obtained from patients with suspected spondylodiscitis who have undergone spinal biopsy for confirmation of diagnosis. T2- and T1-weighted images with and without contrast enhancement were subjected to assessment in coronal, axial, and sagittal planes. The sample obtained from biopsy was sent for microbiological and pathological analyses. Based on the final results, MRI findings and histopathological findings were correlated. Results: Out of 45 studied cases, 35 were confirmed to be infective spondylodiscitis, 5 were degenerative disc disease, 1 lymphoma, and 4 metastatic disease of the spine. Out of 35 confirmed cases, 17 (48.6%) were caused by TB and 18 (51.4%) by pyogenic organisms. The sensitivity and specificity of MRI for correctly diagnosing tuberculous spondylodiscitis were 70.6% and 77.8%, respectively, whereas the sensitivity and specificity of MRI for correctly diagnosing pyogenic spondylodiscitis were 44.4% and 85.2%, respectively. The statistically significant features specific for tuberculous spondylodiscitis for MRI were thin and smooth abscess wall, involvement of >2 vertebral bodies (52.9% in tuberculous vs. 44.4% in pyogenic), skip lesions (23.5% in tuberculous vs. 0% in pyogenic), and cold abscess (17.6% in tuberculous vs. 0% in pyogenic). Conclusion: It has been found that MRI is highly sensitive in detecting infective spondylodiscitis and has been widely accepted as the imaging modality of choice for the same. Although many imaging features have been identified to differentiate pyogenic and tuberculous etiologies, due to overlapping of these features, the sensitivity of MRI to conclusively diagnose the etiology needs further studies.
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Evaluation of Clinical Outcomes of Management of Pediatric Both Bone Forearm Fractures Using the Titanium Elastic Nailing System: A Prospective Study of 50 Cases p. 134
Rajesh Kapila, Rakesh Sharma, Ankush Chugh, Mahesh Goyal
DOI:10.4103/jotr.jotr_40_15  
Context: Forearm fractures are common injuries in children. In older children, their management is difficult due to increased chances of redisplacement after closed reduction. Aims: The aim of this prospective study was to evaluate the clinical outcome of managing pediatric forearm fractures using the titanium elastic nailing system (TENS). Subjects and Methods: Fifty patients in the age group of 6–14 years with fractures both bones forearm were managed by internal fixation using the TENS, and prospective follow-up was done for 6 months. Results: On final evaluation, we had excellent outcomes in 92% patients and good in 8%. There were no significant complications except for superficial pin-tract infections at entry site of nail in only 6% of patients. Conclusions: We conclude that TENS is an effective and minimally invasive method of fixation of forearm fractures with excellent results in terms of bony union and functional outcomes with minimal complications and without jeopardizing the integrity of the physis.
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Functional Outcome of Open Reduction and Internal Fixation of Intra-articular Distal Radial Fractures by Buttress Plate p. 138
Ajay Goel, Saurabh Daga, Sujata Bhowal, Bhaskar Sen, Riddhideb Barman, Sanjay Keshkar
DOI:10.4103/jotr.jotr_30_19  
Introduction: Treatment of displaced, comminuted, intra-articular fracture of the distal end of the radius by a closed method, such as pins and plaster or external fixation, gives unsatisfactory outcome in most of the cases. The purpose of this study is to evaluate the efficacy of open reduction and internal fixation (ORIF) of intra-articular distal radial fractures by buttress plate. Materials and Methods: We conducted a prospective study from January 1, 2015, to June 30, 2016, on patients having intra-articular distal radius fractures aged above 18 years (20–58 years), who were treated by ORIF with buttress plate. Males outnumbered females by a ratio of 2.67:1. The most common mode of injury was found to be road traffic accident (68.2%). The fractures were classified as per the Frykman classification system. Type III was the most common (54.5%), followed by Type IV (27.3%). Majority of the cases (54.5%) were operated in 2–5 days following injury. The mean time for union was 8.04 weeks. Results: Functional evaluation was done according to the modified demerit point system of Gartland and Werley. Functionally, 14 patients (63.6%) had excellent, 6 had good (27.3%), and 2 had fair (9.1%) restoration of functions. Radiological assessment and the results were graded according to the Sarmiento's modification of Lindstrom criteria. Anatomically, 16 patients (72.7%) had excellent restoration, 4 (18.2%) had good restoration, and 2 had fair (9.1%) restoration. One case of superficial infection and one case of injury to the superficial branch of the radial nerve were noted. In later follow-up, two cases presented with joint stiffness, and in one case, loss of reduction was seen at final follow-up. Conclusion: Around 91% of the patients had excellent-to-good result, both anatomically and functionally. Hence, we conclude that ORIF with buttress plate is an excellent mode of treatment for displaced intra-articular distal radius fractures.
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CASE REPORTS Top

Pigmented Villo-Nodular Synovitis of Shoulder Joint Leading to Humeral Head Erosion p. 143
Alok Chandra Agrawal, Rudra Narayan Dash, Bikram Keshari Kar, Harshal S Sakale
DOI:10.4103/jotr.jotr_81_20  
Pigmented villo-nodular synovitis (PVNS), also known as giant cell tumor of the tendon sheath or benign synovial histiocytoma, is a benign yet locally aggressive tumor of the synovium that affects both the large joints and the tendon sheaths. The most common site for the tumor includes knees, hip, ankle, and wrist joints; shoulder joint being a very unusual site for the occurrence of this tumor. We present here an unusual case of diffuse PVNS of shoulder joint with eroded humerus head treated with surgical synovectomy and adjuvant radiosynovectomy to prevent recurrence. This case report highlights the natural history of this rare disease due to late presentation, difficulty in the diagnosis, and management of recurrence.
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An Isolated Nondisplaced Medial Cuneiform Fracture Following Indirect Trauma: A Rare and Often Missed Injury p. 147
Tashi Galen Khonglah, Ashish Raj, Bhaskar Borgohain
DOI:10.4103/jotr.jotr_52_20  
A 42-year-old female presented with the complaint of acute pain on the medial tarsal region of her left foot. Initial radiographs of the injured foot at that time revealed no significant pathology, and the injury was diagnosed as a “midfoot sprain.” A week later, she presented in the orthopedic outpatient department with persistent pain. Advanced imaging showed an isolated nondisplaced medial cuneiform fracture. Being a nondisplaced fracture, she was treated conservatively, and at 4 months of follow-up, she was pain-free and was able to return to her previous level of activity. Isolated injuries, fractures and/or dislocations of one or more of the three cuneiform bones, are rare. Fractures of the cuneiforms account for only 1.7% of all midfoot fractures. Hence, this fracture is extremely rare, and it can be easily missed at initial admission. Therefore, a high index of suspicion for such mid-foot pain is necessary so that these fractures do not go unnoticed. Plain radiographs are incomplete for diagnosing these fractures, and thus, identification may require more advanced imaging such as computed tomography or magnetic resonance imaging. Prompt diagnosis and appropriate treatment of these isolated medial cuneiform fractures usually heal with a favorable outcome.
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The Role of Psychological Interventions in the Treatment of a Psychogenic Jumpy Stump p. 150
Divya Parashar
DOI:10.4103/jotr.jotr_24_16  
The aim of the study was to describe (i) the role of a psychologist in the assessment and management of a jumpy stump with a clinical picture of severe pain, fasciculations, and psychological symptoms and (ii) the key role of the psychological intervention of acceptance and commitment therapy (ACT) in working with symptoms of severe pain concomitant with emotional and behavioral disruptions. This was a case study done at a pain clinic at a private hospital. A 14-year-old boy presented to the hospital with an above knee amputation due to a congenitally malformed leg. The psychological intervention was based on the ACT and noninvasive physical therapy modalities. The main outcome measures were Self-Report for Childhood Anxiety Related Disorders, Mood and Feelings Questionnaire, and the Pain Catastrophizing Scale. A significant reduction in pain and fasciculations in the stump along with an improvement in the psychological functioning of the patient was observed after the intervention by the pain management team. The fact that the somatic symptoms responded to psychological interventions rapidly and consistently points to the jumpy stump being psychogenic in etiology. A thorough psychological evaluation and intervention must be done in movement disorders arising out of peripheral nerve injury because psychological stressors are now increasingly being known to influence these conditions.
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Focal Pigmented Villonodular Synovitis in the Hip Joint – A Rare Case Report p. 153
QA Qureshi, Sharmila Dudani
DOI:10.4103/jotr.jotr_44_19  
Pigmented villonodular synovitis is characterized by villous/nodular proliferation of the synovial membrane affecting commonly the knee joint. Involvement of the hip ankle, shoulder, and elbow joint is distinctly uncommon. Young adults are mainly affected and present with localized pain with/without joint stiffness and swelling. Etiology thought to be due to synovial hyperplasia following chronic inflammation. The role of trauma is controversial. Radiography and computed tomography scan are not diagnostic in the early stages. MRI is useful in the diagnosis and follow-up. Histology reveals nodular proliferation lined by hyperplastic synovium beneath which are sheets of histiocytes, hemosiderin laden macrophages and osteoclast-like giant cells. Colony-stimulating factor 1 gene overexpression is seen in histiocytic cells. Syniovectomy is the mode of treatment. Total hip arthroplasty may be required for extensive disease. A high index of clinical suspicion is required to diagnose this rare disease to prevent the limitation of joint mobility and destruction.
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Irreducible Vertical Dislocation of Patella Incarcerated into a Lateral Condyle Femur Fracture p. 156
Sumit Kumar Jain, Rejo Varghese Jacob, Sanjay Kumar, Vivek Kumar Parasurampuriya
DOI:10.4103/jotr.jotr_1_20  
Rotational dislocations of patella around the horizontal and vertical axis are rare injuries. Unlike lateral patellar dislocations, which are easily reducible, closed reduction in vertical fractures is usually not possible due to increased tension within the quadriceps tendon. We present a case report of an 18-year-old male who presented with swelling and pain over the right knee following a road traffic accident. The clinical and radiological assessment showed a fracture of the lateral femoral condyle with dislocation of the patella, which was irreducible by closed methods. Computed tomography showed a lateral condyle femur fracture with concomitant dislocation of the patella rotated on its vertical axis and incarcerated into the fracture site. Closed reduction in these kinds of injuries is difficult, and open reduction of the patella and internal fixation of the fracture is recommended.
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Pubic Ramus Tuberculosis Masquerading as Pseudomonas Infection! p. 159
Dheeraj Attarde, Atul Patil, Parag Sancheti, Ashok Shyam
DOI:10.4103/jotr.jotr_55_20  
Diagnosing tuberculosis in the new era remains a challenge. Atypical presentation of tuberculosis is not very uncommon. The musculoskeletal system remains one of the common sites for extrapulmonary tuberculosis, but pubic ramus involvement is very rare. No case is reported in literature where tuberculosis was masked by Pseudomonas infection. A high index of suspicion is necessary to correctly and timely diagnose tuberculosis. Here, we present the case of a health-care worker who was misdiagnosed as Pseudomonas. The patient had an excellent outcome following a complete course of antituberculous chemotherapy for tuberculosis.
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Primary Coverage of Donor Site Using Expanded Meshed Skin Graft in a Polytrauma Patient with Degloving Injury of Foot p. 162
Alok C Agrawal, Sharath Kowshik, Mukund Madhav Ojha, J Rakshit, Ranjeet Choudhary, Sandeep Kumar Yadav
DOI:10.4103/jotr.jotr_84_20  
It is a known fact that following split thickness skin grafting in post traumatic wounds the donor site heals with re-epithliazation. The skin thus formed initially is fragile and takes a long time to become strong mobile and elastic. However, in some patients, donor site poses risk of nonhealing, delayed healing, hypertrophic scar formation and cosmetic disfigurement, etc., In such patients, it is ideal to identify such risk factors and manage them carefully. We are reporting a case of degloving of the foot in a poly-traumatized patient treated by split thickness skin grafting where to avoid the above problems, the donor site was also skin grafted primarily after meshing the skin and making it large.
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LETTER TO EDITOR Top

Effects of Smoking on Healing of Distal Femur Intra-articular Fractures, Treated with Distal Femur Locking Compression Plate p. 165
Bhanu Sharma
DOI:10.4103/jotr.jotr_32_18  
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