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   Table of Contents - Current issue
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January-June 2020
Volume 12 | Issue 1
Page Nos. 1-105

Online since Friday, June 26, 2020

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ORIGINAL ARTICLES  

Risk of infection following total knee arthroplasty in patients with asymptomatic bacteriuria: A meta-analysis Highly accessed article p. 1
David Sadigursky, Mariana Drummond Sousa, Lucas Rocha de Jesus, José Marques Neto, Diogo Maciel Vieira Lobão, Matheus Lemos Azi
DOI:10.4103/jotr.jotr_8_20  
Introduction: In recent years, the treatment of asymptomatic bacteriuria (AB) is a topic approached in the orthopedic literature, with conflicting results about the need for treatment in the preoperative total knee arthroplasty (TKA). Objective: Systematic review with meta-analysis relating the presence of AB, as preoperative routine finding, to the risk of surgical site infection (SSI) following TKA, as well as the need for preoperative treatment of this condition. Methods: For the systematic review performed, five original articles were selected, following the PRISMA-p 2015. The keywords such as “asymptomatic bacteriuria” and “arthroplasty” or “joint replacement” or “joint infection” were used for the literature search in the databases of Bireme, PubMed, Medline, Science Direct, Google Scholars, and SciElo, between January and July 2018. Statistical analysis using the Mantel–Haenszel method and statistical test of relative risk with random effects were performed. Risks for publication bias were examined using a funnel plot. All analyzes were conducted using Review Manager version 5.3. Results: The results were inconclusive as to the increase in infection rates in patients undergoing TKA with AB. Conclusion: The study showed that the treatment of AB with antibiotics in the TKA preoperative period remains controversial due to the lack of data that reinforce this hypothesis.
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Changes of shoulder balance, sagittal alignments, and curve correction in the treatment of Lenke 1 and 2 adolescent idiopathic scoliosis using a three-dimensional-based correction strategy in correlation to health-related quality of life using the Scoliosis Research Society-22 Questionnaire Highly accessed article p. 6
Bobby Kin-Wah Ng, Wai-Wang Chau
DOI:10.4103/jotr.jotr_46_19  
Background: Shoulder balance in Lenke 1 and 2 adolescent idiopathic scoliosis (AIS) is a complex condition without a reliable strategy to achieve full correction. Moreover, none reported health-related quality of life of surgically treated Lenke 1 and 2 suffering severe AIS patients before and after the surgery. Subjects and Methods: Preoperative standing, side bend, and postoperative Cobb angles were analyzed to determine the relationship between shoulder balance, curve flexibility, and correction rates. The sagittal alignment was analyzed in these patients by cervical lordosis (CL) (C2–C7), thoracic kyphosis (TK) (T1–T12), lumbar lordosis (LL) (L1-S1), pelvic incidence, pelvis tilt, sacral slope, and C7 sagittal vertical axis (SVA). All recruited patients completed the Scoliosis Research Society-22 questionnaire before, after surgery, and follow-up. Results: There were 26 Lenke 1 and 2 severely AIS patients recruited in this study. The shoulder balance changed from left down to the left up after the operation as reflected by the changes in T1tilt (medial shoulder) and clavicular angles (lateral shoulder). The sagittal alignment changes of this group of patients moved toward increased CL, TK, and LL and an SVA toward zero. “Function” and “Self-image” were significantly improved after surgery, particularly in female Lenke 2 patients regardless of age. Conclusions: The sagittal alignment changes of this group of patients moved toward increased CL, TK, LL and SVA toward zero. “Function” and “Self-image” were significantly improved after the surgery. Sex and age-specific analysis showed that female Lenke 2 AIS patients were the group of patients showing the improvements regardless of age at operation.
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Evidence-based practice versus experience-based practice in orthopedics Highly accessed article p. 13
Ganesan Ram Ganesan, Raghav Ravi Veeraraghavan
DOI:10.4103/jotr.jotr_58_19  
Background: Evidence based medicine helps in improving medical decision and service conveyance to patients. Experience based medicine depends on the unequivocal and verifiable learning regulated by the past clinical encounters other than the other social, lawful, and moral systems of the practice. The aim of our study is to find out the evidence-based practice amongst the orthopaedic fraternity and to compare the magnitude of evidence-based practice in different groups allotted based on the experience in the field. Materials and Method: It is a Prospective study done amongst Orthopaedic surgeon in two cities in Tamilnadu Madurai and Chennai. The study populations were Orthopaedics practicing doctors with minimum of 3-year experience. The Orthopaedic Surgeons were given a questionnaire and were asked to fill it. The questionnaire was self-explanatory and they have to tick the best response, which they think was the most appropriate. Questionnaire was prepared based on the AAOS guidelines of clinical orthopaedic practice. The AAOS strong recommendation guidelines were considered as gold standard and the response from the Orthopaedicians were collected and corrected. The main emphasis was given to the second component only. Out of the 120 doctors 14 of them had either one or more wrong answer and only 106 orthopaedicians had given correct answer and their answers only were evaluated. Results: The total percentage of evidence-based practice in our study was 43.4% and experience-based practice was 56.6%. Conclusion: Experienced based practice is comparably more amongst the practicing orthopaedic surgeons. Upcoming Orthopaedic surgeons rely more on evidence to treat their patients than their experience.
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Short-term functional evaluation of posterior lumbar interbody fusion done for degenerative spondylolisthesis at L4–L5 level p. 17
Ansari Muqtadeer Abdul Aziz, Ansari Ishtyaque Abdul Aziz
DOI:10.4103/jotr.jotr_7_19  
Context: Low back pain due to degenerative spondylolisthesis in the elderly especially the rural Indian population involved in farming and agriculture hard work is a common and incapacitating problem. Aims: Degenerative spondylolisthesis of L4/L5 is commonly observed with associated disc degeneration leading to foraminal stenosis causing radiculopathy and neuroclaudication. Materials and Methods: We have evaluated a short-term prospective follow-up of 26 patients treated with posterior lumbar interbody fusion (PLIF) with titanium pedicular screws and cage for L4–L5 degenerative lumbar spondylolysthesis (DLS) for 1, 3, and 6 months after surgery using Japanese Orthopaedic Association (JOA) criteria and MacNab's criteria. Statistical Analysis Used: Chi-square test or McNemar's Chi-square test. Results: The rate of improvement as calculated from the JOA score improved from 8.34 preoperatively to 72.19 at 6 months postoperative after PLIF for DLS and also good to excellent results in 84.61% of cases according to MacNab's criteria. Conclusions: Hence, we conclude that PLIF for DLS significantly improves quality of life postoperatively because of relief of back pain and neurological symptoms.
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Long-term study of functional outcomes of floating knee injuries Highly accessed article p. 23
Rajeev Shukla, Adhir Jain, Ravi Kant Jain
DOI:10.4103/jotr.jotr_10_20  
Background: Floating knee injuries are commonly occurring fractures in the high-velocity trauma. The mode of injury is usually due to road traffic accidents. Over the years, there have been many studies which have shown results of various conservative, external fixation, and finally, internal fixation treatment all over the world. However, still, there is very less work on long-term outcome-based analysis of functional outcomes of floating knee injuries. The aim of the study was to assess the long-term functional outcome of operated patients of floating knee injuries. Materials and Methods: A total of 30 patients with floating knee injuries who were undergone surgical fixation by any means were included in ths study. The study was done at a tertiary teaching institute and hospital from April 2013 to May 2019. The patients were followed up at 6 weeks, 6 months, 1 year, and 5 years (final) after the surgery. The assessment of pain, functional activity, walking ability, and range of motion was assessed by Karlstrom and Olerud criteria at 6 months, 1 year, and 5 years. Results: We included 30 patients diagnosed with floating knee injuries in our study with a mean age of 40.83 years (18–75 years range) and a female-to-male ratio of 5:1 with 25 males (83.3%) and 5 females (16.7%). All the patients underwent fixation under spinal/epidural anesthesia/general anesthesia. Fifteen patients were Fraser type 1, 4 patients were Fraser type 2A, 5 patients were Fraser type 2B, and 6 patients were Fraser type 2C. Average operating time was 120 ± 55 min. Right-sided involvement was more common (17 patients) than the left side (13 patients). The good/excellent outcome was found in 63.4% of the cases. Patients with age <40 years had better prognosis as compared with patients of >40 years of age (df = 12, P = 0.014). Final outcomes had no difference in males as compared to females at 5 years postoperatively (df = 4, P = 0.265). Complications such as knee stiffness, infection, malunion, delayed union, and nonunion were also encountered. Conclusion: Surgical fixation is an effective treatment for floating knee injuries worldwide. On long-term follow-up of patients treated surgically, the functional and radiological outcomes were good with few complications rates.
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Functional outcome and revision rate of proximal femoral nail antirotation versus dynamic hip screw for osteoporotic intertrochanteric femur fracture: A systematic review and meta-analysis p. 31
Sherly Desnita Savio, I Made Arya Susila, Cokorda Gde Oka Dharmayuda
DOI:10.4103/jotr.jotr_17_20  
Introduction: Intertrochanteric femur fracture in elderly presents a challenge as the source of morbidity if not well-treated. This study investigates the functional outcome and revision rate of two of the most common treatments of choice for this condition, proximal femoral nail antirotation (PFNA) and dynamic hip screw (DHS), while furthermore investigate the secondary functional outcome of the two procedures if proceeded to conversion to total hip arthroplasty (CTHA). Methods: A systematic search was conducted based on PRISMA guideline to identify relevant studies through PubMed, Google Scholar, and Cochrane database. A total of 9 studies (2.251 patients) were included, divided into three meta-analysis, processed using Review Manager 5.3. Results: For primary Harris Hip Score (HHS), 3 articles were included, with a total sample of 371 patients (184 PFNA vs. 187 DHS). For primary HHS, the mean HHS at 12-month follow-up for PFNA (n = 184) was 77.77, as for DHS (n = 187) was 78.33, indicating no significant difference (P = 0.73). For the revision rate, 4 articles were included, with a total of 1550 samples (784 PFNA vs. 766 DHS). The mean revision rates for PFNA (n = 784) was 2.68%, as for DHS (n = 766) was 2.48%, indicating no significant difference (P = 0.61). For secondary HHS after CTHA, two articles were included, with a total amount of 332 patients (142 PFNA vs. 190 DHS). In terms of secondary HHS after CTHA, the mean HHS 12-month postoperatively for PFNA (n = 142) was 83.97, as for DHS (n = 190) was 83.65, indicating no significant difference (P = 0.59). Conclusion: The current systematic review and meta-analysis suggest that PFNA and DHS both have comparable primary functional outcome, revision rate, and post-CTHA secondary functional outcome.
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Anatomical variation in the first extensor compartment during treatment of De Quervain'S tenosynovitis p. 39
Shilp Verma, Alok Chandra Agrawal
DOI:10.4103/jotr.jotr_24_20  
Background: De Quervain's disease is ste¬nosing tenosynovitis of the abductor pollicis longus and the extensor pollicis brevis within the first extensor retinaculum compartment of the wrist. The patient usually present with clinical symptoms like pain and a painful range of motions of the thumb which occur either due to increased friction force or due to increase in contain within the compartment during the gliding of the adductor pollicis longus (APL) and the extensor pollicis brevis (EPB) first extensor compartment. Following conservative trials of rest, moist heat, NSAID, and local steroid injections, surgical release of the first compartment are effective treatment modalities for De Quervain's disease, but these even leads to failure of treatment as there may be variation on the anatomy of first extensor compartment of wrist. We had done this study to find out anatomical variation in first extensor compartment during treatment of De Quervains tenosynovitis. Method: Anatomical Variations like presence or absence of septum between APL and EPB, number of tendon slip of APL and EPB in the first extensor compartment were studied in 16 patients of dequervains tenosynovitis who underwent open surgical release as the treatment. Result: 7/16 (43.75%) of patient has partial or complete Sub compartment in the fibro-osseous tunnel and 4/16 (25%) patient has extra Abductor Pollicis Longus (APL) tendon sheath in first extensor compartment. Conclusion: We found significant increase in variation of anatomy in first extensor compartment of De Quervains tenosynovitis patient which will be for the surgeon during the surgical release of first extensor compartment.
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Correlation of curve flexibility analysis with patient health outcomes after scoliosis surgery using Scoliosis Research Society-22 Questionnaire p. 42
Wai-Wang Chau, Victor Illescas, Bobby Kin-Wah Ng
DOI:10.4103/jotr.jotr_54_19  
Introduction: Outcome of corrective scoliosis surgery is dependent on radiographic improvements as well as patients' perspective and satisfaction, where the inter-relationship has not yet been reported elsewhere. The lack of discussion on this inter-relationship between the change in spinal curvatures before and after surgery and health-related quality of life explained by Scoliosis Research Society (SRS) domains remains an important topic to discuss. Patients' quality of life was also influenced by how best surgical planning on spinal bending correction. Materials and Methods: Seventy-six adolescent idiopathic scoliosis patients who underwent posterior spinal fusion from 2014 to 2017 in our specialized center were recruited. Demographic variables and radiological measurements were collected. Patients filled out the SRS-22 questionnaire from a mobile device, of which the SRS-22 was digitally adopted using mobile technology and cloud computation. Results: The mean age at surgery is 17.52 years. “Function” and “pain” scores showed a similar pattern of score changing over the four time points. The patterns of SRS-22 score changes over the three time periods were similar in the six domain scores except a slight difference in “satisfaction,” which showed an increase 12–24 months after surgery, and the scores at “>24 months” returned to the scores at “<12 months” after surgery. Conclusions: Results from SRS-22 outcome measurements showed that “function” and “pain” were increased and better than “preoperative” years after surgery. “Mental” and “self-image” were improved after surgery. “Self-image” will be better with a more flexible spinal curve. Surgery was recommended when higher curve flexibility was detected to conserve a higher self-image.
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Bosworth screw for acromioclavicular joint injuries: Indications and operative outcomes p. 49
Kirtan Vijay Tankshali, Zulfikar M Patel, Hriday Prashant Acharya
DOI:10.4103/jotr.jotr_69_17  
Introduction: Acromioclavicular joint is a biomechanically complex joint, isolated injuries of which are rare. Complex classification system (Rockwood) and no universally approved guidelines for the treatment with the ever evolving surgical techniques pose further challenge for the treatment of the condition. We have in our current study, assessed operative outcomes of Bosworth screw fixation for AC joint injuries and the role of occupation in deciding treatment regimen and predict operative outcomes. Materials and Methods: This is a prospective cohort study of 11 patients having isolated AC joint injury classified as grade II or higher according to Rockwood classification treated with Bosworth screw fixation at high patient turnover tertiary care centre. Results: AC joint injuries are more common in males and RTA accounts for the most of the injuries. There is significant difference in outcomes of operative fixation between high demanding and low demanding occupation as evaluated by constant shoulder score (P < 0.01). Operative treatment in failed conservative treatment of type II/III injuries yields better constant score. The earlier the treatment, the earlier the vocational rehabilitation especially in high demanding occupation. Conclusion: Occupation should be considered in making treatment choice of AC joint injuries and not only type of injury. Bosworth technique of fixation is old but cost effective, easily reproducible, less time consuming technique with smaller learning curve and should be considered in all type V injuries and in patients with type II/III injuries involved in high demanding occupation.
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Management of clubfoot in children above 5 years with differential distraction using joshi external stabilizing system p. 53
Alok Chandra Agrawal, Sharath Kowshik, Bikram Keshari Kar, Harshal Suhas Sakale
DOI:10.4103/jotr.jotr_22_20  
Introduction: Ponsetti's technique is the recommended procedure for treating idiopathic clubfoot in children below the age of 2 years, and the same is also followed in some severe clubfoot deformities including neglected, recurrent and resistant forms who eventually may need surgical intervention. In children >5 years of age (children belonging to 5–10 years), open surgical procedures make the foot rigid with soft-tissue surgery, and bony operations can make the foot even smaller. Simultaneous correction of all aspects of deformity by differential distraction using external fixator rescues the foot from such complications. Joshi's external stabilizing system (JESS) can be used to gradually correct the deformities by differential distraction. In comparison to Ilizarov ring fixators, these are lighter in weight, shorter, cheaper, and have an easier application. Purpose: The purpose of this study is to analyze the role of JESS fixator in correcting cases of clubfoot in children >5 years in terms of morphological, functional, and radiological outcomes which were assessed using the International Clubfoot Study Group (ICFSG) scores. Materials and Methods: Five consecutive children with eight clubfoot >5 years underwent differential fractional distraction in our hospital. Period of correction varied from 6 to 8 weeks, including the distraction phase and static phase. Follow-up was done by application of cast in plantigrade position for double the duration of corrective distraction. Patients were assessed preoperatively and postoperatively at 6 months for morphology, functionality, and radiological correction by the ICFSG score. Results: Excellent to good results were obtained in all cases, which were assessed using ICFSG score, with only minor complications in patients. Conclusion: JESS frame is simple, versatile, and best suited for correcting clubfoot deformities, which were neglected, resistant and recurrent, and also with residual deformity, even in the children above the age of 5 years with advanced osteoarticular development and higher rigidity.
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Assessment of musculoskeletal pain in rheumatoid arthritis patients and its relation to vitamin D levels p. 58
Alok Chandra Agrawal, J Rakshit, Harshal Sakale, Bikram K Kar
DOI:10.4103/jotr.jotr_23_20  
Vitamin D is associated with musculoskeletal function in our body, and its deficiency is a common health problem all over the world. The role of Vitamin D in rheumatoid arthritis (RA) is well established due to its immunomodulatory effect. The aim of this study was to assess the musculoskeletal pain in patients with RA in relation to Vitamin D levels. We found a negative correlation and found an increase in the pain intensity among RA patients with low levels of Vitamin D.
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Outcomes of ilizarov ring fixation in infected nonunion of tibia p. 62
Sushil Mankar, Faizan Mohammed, Gaurav Bhutada, Rahul Sakhare
DOI:10.4103/jotr.jotr_3_20  
Objective: The objective of this study was to determine the outcomes with the use of Ilizarov's external fixator in infected nonunion of tibia. Materials and Methods: In this single-center, retrospective study at a teaching medical institute, patients who were treated with Ilizarov's external fixator for infected nonunion of tibial fractures were assessed. Achievement of union and the Association for the Study and Application of the Method of Ilizarov (ASAMI) outcomes were assessed. Results: Between January 1995 and December 2018, a total of 20 patients identified who underwent Ilizarov's procedure. The median age was 43.5 years (range: 7–65 years). The median level of bone defect was 60 mm. In 20 cases, 18 had infected nonunion. The median consolidation time was 8 months. During the median follow-up of 2 years, 83.3% (15/18) achieved complete union. The median union time was 11 months. Pin-tract infections were observed in 33.3% (6/18) of the patients. As per ASAMI outcomes, bone results were excellent in 72.2% (13/18), good in 11.1% (2/18), and poor in 16.7% (3/18), and the function results were excellent in 50% (9/18), good in 33.3% (6/18), and poor in 16.7% (3/18). Conclusion: Ilizarov's ring fixation is a reliable and suitable method for providing excellent bone and functional results in infected nonunion of tibia.
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The outcome comparison of limb salvage surgery versus amputation for high-grade osteosarcoma: A systematic review and meta-analysis of the last 7-year studies p. 67
Sherly Desnita Savio, Maria Florencia Deslivia, Putu Astawa, I Gede Eka Wiratnaya
DOI:10.4103/jotr.jotr_52_19  
Introduction: Until now, the decision to choose between limb salvage surgery (LSS) and amputation for high-grade osteosarcoma has been controversial. Both techniques keep on progressing, thus necessitating updated analysis of each outcome. Materials and Methods: A systematic search was conducted to identify studies through PubMed, Google Scholar, and Cochrane database to identify relevant articles. A total of four studies (173 patients) from the year 2012 were included in the analysis and for the meta-analysis of the Musculoskeletal Tumor Society (MSTS) functional score, random effect model was used to pool the result. In each study, mean difference with a 95% confidence interval (CI) was calculated for continuous outcomes using review manager. Results: Four studies containing 173 patients were included in this study. Patients' characteristics, treatment methods, and outcome were compared for each treatment option. The mean MSTS score at final follow-up for LSS group (n = 112) was 80.2, as for amputation group (n = 61) was 59.3. There was a significant difference in terms of postoperative functional outcome using MSTS score between LSS and amputation (heterogeneity, I2 = 88%; weighted mean difference, 20.64; 95% CI: 9.86–31.43; P = 0.0002). The pooled data showed that the functional outcome, as shown by the MSTS score is better in the LSS group. Conclusion: The current meta-analysis suggests that LSS procedure is superior compared to amputation in terms of the functional outcome as measured by the MSTS score. Although the metastatic and 5-year survival rate is lower in LSS, adjuvant chemotherapy should be considered in certain patients, in order to maximalize recurrence and overall outcome.
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Is the transpedicular bone grafting an effective technique for prevention of kyphosis in thoracolumbar fractures? p. 74
Daniel Rios, Mario Cahueque, Guillermo Moreno, Javier Ardebol, Enrique Azmitia
DOI:10.4103/jotr.jotr_12_20  
Study Design: This was an interventional randomized trial. Summary of Background Data: Fractures of the thoracolumbar spine represent 90% of all spine fractures, and the thoracolumbar burst fractures (Type A fractures) are the most common in the spine and important cause of posttraumatic kyphotic deformity. The cause of this problem appears to be the structural and mechanical deficiency of the anterior column following indirect fracture reduction by posterior fixation. Objective: The objective of this study was to evaluate the effects of transpedicular intracorporeal grafting associated with short-segment transpedicular fixation on kyphosis progression in patients with thoracolumbar burst fracture Type A3/A4. Materials and Methods: Fifty-nine consecutive patients with thoracolumbar burst fracture were treated with short-segment transpedicular monoaxial screw fixation. Patients were simply randomized divided into transpedicular grafting (TPG) (n = 35; A3 = 20 and A4 = 15) and non-TPG (n = 24; A3 = 19 and A4 = 5). The average follow-up was 21.1 ± 4.2 (range: 16–26) months for the entire study group: 22.1 ± 4.5 months for the TPG group and 20.2 ± 4.8 months for the non-TPG group (P = 0.49). Results: The global mean kyphosis angle before surgery was 21.93° ±3.92°, with 22.06° ±3.55° in the TPG group and 20.75° ±4.68° for non-TPG; P = 0.93. The mean kyphosis angle at the end of follow-up for the entire study was 9.21° ±8.86°, with 8.70° ±2.11° for TPG and 14.08° ±4.73° for non-TPG, (TPG vs. non-TPG, P = 0.010). No obvious clinical complications in both the groups were documented. Conclusions: Our findings demonstrate that transpedicular bone grafting associated with short-segment fixation in thoracolumbar burst fractures has caused a significant effect on the prevention of kyphosis progression after surgery.
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Outcome of nonoperative management of thoracolumbar burst fractures without neurological deficits – An analysis p. 79
Madan Mohan Sahoo, Satyajeet Ray, Prasanta Mahato, Udit Sourav Sahoo, Tapas Kumar Panigrahi
DOI:10.4103/jotr.jotr_2_20  
Study Design: This was a prospective cohort study. Background: Despite being common injury, management of thoracolumbar burst fractures without neurological deficit remains an enigma. Proponents of surgery showed the debatable advantages of canal clearance, better kyphosis correction, and prevention of neurological deterioration. This study aims to review the outcome of conservative management in these injuries. Materials and Methods: Thirty adult patients of burst fractures of the thoracolumbar spine without neurological deficits, kyphosis angle of <30°, and doubtful posterior ligamentous complex (PLC) lesions irrespective of loss of vertebral body heights were managed with bed rest and spinal bracing with an average follow-up period of 25 months. Results: Radiologically, the kyphosis angle changed from an average of 17.9° at initial presentation to 21.3° in the final follow-up. We also observed an improvement of mean kyphosis angle of 2.6° in 23% of our patients. Anterior vertebral body compression (AVC) percentage, which was 40.83% initially after injury, increased to 44.09% at the final follow-up. Five patients (16.6%) had initial AVC of more than 50% and 10 (33%) had doubtful PLC injuries. The functional outcome scores at the final follow-up using median values of the Visual Analog Scale, Oswestry Disability Index, and Roland-Morris Score were 2, 15%, and 6, respectively. There was no progression of neurological deficit in any case. Conclusion: Thoracolumbar spine burst fractures without neurological deficits can be managed conservatively with good functional outcome without any significant increase in kyphosis or neurological deterioration eliminating risks and cost associated with surgery.
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Healing of gap nonunion using autologous cultured osteoblasts impregnated over three-dimensional bio-degradable nanomaterial scaffold: A pilot experiment on rabbits p. 86
Yogesh Jain, Shivam Sinha, Amit Rastogi, Pradeep Kumar Srivastava, Yogesh Kumar, V Vivek
DOI:10.4103/jotr.jotr_42_18  
Background: Non union is a failure of fractured bones to unite.For successful treatment of non union the addition Of autograft at fracture site is recommended but it has its own disadvantages to overcome this recent studies have focused on bone tissue engineering. Bone tissue engineering involves the use of a combination of scaffolds with osteoblasts or osteogenic potential cells to form bone tissue, which can lead to new bone formation at the affected area when implanted in vivo. Aims and Objective: To present our results with the use of a novel concept of using nanomaterial bioscaffold impregnated with cultured osteoblast over experimentally created bone defects with critical size defect in rabbits. Materials and Methods: We studied the effect of nano-hydroxyapatite-tricalcium phosphate-gelatin-chitosan scaffold impregnated with autologous cultured osteoblast on gap created on 16 iliac crests of eight rabbits. The right side was implanted, and on the left side, the gap nonunion was left as control. Rabbits were followed up at 4, 8, 12, and 20 weeks for radiographic union of scaffold and gross and microscopic examination at the final sacrifice at 20 weeks for assessment of scaffold loosening, osteogenesis, immunological reaction, and persistence of graft. Result: Statistically significant difference was found between osteointegration of scaffold, however it persisted even at 20 weeks, but no immunogenicity was observed. Conclusion: Use of nanomaterials and chitosan can attributably improve the osteogenesis by autologous osteoblasts in gap nonunion.
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CASE REPORTS Top

Atypical stress femoral shaft fracture secondary to alendronate therapy p. 92
Javier Ardebol, Mario Cahueque, Viriato Mere, Jose Domingo Soto
DOI:10.4103/jotr.jotr_11_20  
Bisphosphonate (BP) therapy is widely used as it remains the first-line of treatment for osteoporosis. These antiresorptive drugs inhibit osteoclast function and promote apoptosis. However, atypical stress femoral fractures occurring in the diaphysis and subtrochanteric region are linked to prolonged BP use. The risk of fracture is directly proportional to the time exposed to the treatment. Ongoing BP exposure prevents bone resorption and replacement in areas with accumulated microdamage through targeted remodeling. Therefore, long-term BP use (more than 5 years) is an important risk factor. Atypical femoral fractures remain very rare, and the benefits of BP therapy for osteoporotic fracture prevention and treatment outweigh the risk. The present report consists of a rare case of a patient with an atypical diaphyseal femoral stress fracture secondary to prolonged alendronate use.
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A case of malignant scoliosis and its relationship with pulmonary lung function and long-term health-related quality of life p. 95
Bobby Kin-Wah Ng, Victor Illescas, Wai-Wang Chau
DOI:10.4103/jotr.jotr_14_20  
The relationship of spinal deformity and pulmonary impairment is so variable that it is still to be established. This study is to report the clinical pulmonary improvements of a patient with severe adolescent idiopathic scoliosis treated with corrective scoliosis surgery using posterior spinal instrumented fusion. The patient was an 11-year-old premenarche adolescent female. Preoperative Cobb angles were 102° from T4 toT12 and 58° from T12 to L4. The patient was already complaining of shortness of breath and chest pains with exertion. Pulmonary function tests (PFTs) were performed before surgery and 8 months postsurgery. Postoperative Cobb angle improved with the thoracic curve at 36° and lumbar curve at 10°. There was a marked improvement with her previous symptoms. Significant improvements were observed in her lung volume parameters on PFT. Her health-related quality of life continued to improve. This study reconfirms the influence of spinal deformities on pulmonary impairment in patients with severe scoliosis.
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Wassel's type i modification of duplicate thumb? p. 99
Rohan Dilip Newadkar, Ujwala Rohan Newadkar
DOI:10.4103/jotr.jotr_15_19  
Patients with polydactyly of the thumb demonstrate very miscellaneous manifestations, from a rudimentary floating type to a complex one. The Wassel classification system is a useful method for classifying duplicated thumbs. Bifurcation at the metacarpophalangeal joint (Type IV) is the most common type. Although Wassel classification is good, there are few shortcomings in it. Removing the nondominant part and reconstructing the dominant part are the most common procedures for thumb duplication. The aim of surgical intervention that addresses duplication thumbs is to attain a firm, mobile thumb of appropriate shape and acceptable size. Surgical concepts and techniques are still evolving. Here, we present an interesting case report of Wassel's Type I modification of duplicate thumb.
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Complications following fracture neck of femur treated with austin moore hemiarthroplasty: A rare case report p. 102
Alok Chandra Agrawal, Sameer Mittal, Harshal Sakale, Sandeep Kumar Yadav
DOI:10.4103/jotr.jotr_18_20  
A 72-year-old male patient was operated by Austin Moore hemiarthroplasty for fracture neck of femur 6 years back who developed multiple complications. In this case, the patient developed dislocation of the hip joint following which the Austin Moore prosthesis got broken. During revision with bipolar hemiarthroplasty, the patient developed fracture of proximal femur which was poorly managed by K-wires and stainless steel wires. After some time, the patient developed dislocation of the bipolar prosthesis and signs of infection. We operated this patient with a two-stage revision. In the first stage following removal of all infected metalwork and debridement, we put antibiotic cement spacer, and after 4 weeks in the second stage, we did a total hip replacement with uncemented constrained proximal femoral modular reconstruction prosthesis. The case is being reported for its rare presentation in genuine management and successful outcome.
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