Aims

The aims of this study were to determine the diagnostic yield of image-guided biopsy in providing a final diagnosis in patients with suspected infectious spondylodiscitis, to report the diagnostic accuracy of various microbiological tests and histological examinations in these patients, and to report the epidemiology of infectious spondylodiscitis from a country where tuberculosis (TB) is endemic, including the incidence of drug-resistant TB.

Aims

To describe the clinical, radiological, and functional outcomes in patients with isolated congenital thoracolumbar kyphosis who were treated with three-column osteotomy by posterior-only approach.

A prospective, randomized, controlled trial was performed to compare the outcome of treatment of unstable fractures of the proximal part of the femur with either a sliding hip screw or a short proximal femoral nail antirotation (PFNA-XS, Synthes).

Eighty one patients (April 2007 – May 2008) presenting with unstable fracture of the proximal part of the femur were randomized, at the time of admission, to fixation with use of either a short proximal femoral nail antirotation (n=42) or a sliding hip screw (n= 39). The primary outcome measure was reoperation within the first postoperative year and mortality at the end of one year. Operative time, fluoroscopy time, blood loss, and any intra-operative complication were recorded for each patient. Follow-up was undertaken at 3, 6, and 12 postoperative months and yearly thereafter. Plain AP and lateral radiographs were obtained at all visits. All changes in the position of the implant, complications, or fixation failure were recorded. Hip range of motion, pain about the hip and the thigh, walking ability score and return to work status were used to compare the outcomes.

There was no significant difference between 1 year mortality rates for the two groups. Mean Operative time was significantly less in PFNA group (Mean 25 min, range 19 – 56 min) than DHS group (Mean 38 min, range 28 – 70 min). Patients treated with a PFNA experienced a shorter fluoroscopy time and less blood loss. 6 patients in DHS group had implant failure as compared to none in PFNA group. The functional outcome was also better in PFNA group.

When compared to DHS, PFNA-XS provides better functional outcome for unstable trochanteric fractures with less operative time, less blood loss and less complications, however one year mortality rate remains the same.

A prospective, randomized, double-blind study was done on 50 patients undergoing primary cementless total hip arthroplasty to determine the effect of tranexamic acid on intra- and postoperative blood losses and on the transfusions requirements.

50 patients were randomized to tranexamic acid (15 mg/kg) given as a bolus intravenous injection or placebo (normal saline) given intravenously, 15 minutes before the incision.

The intraoperative and postoperative blood loss (at removal of the drain 24 hours after the operation) and the number of blood transfusions required were recorded. The patients were screened for deep venous thrombosis with bilateral compression Ultrasonography using Colour Doppler imaging on the tenth postoperative day. The Hemoglobin level was measured preoperatively and on the 3rd postoperative day. The D-dimer levels were measured preoperatively and 24 hrs postoperatively.

Patients receiving tranexamic acid had a mean intraoperative blood loss of 410 ml (range, 300–510 ml) versus 615 ml (range, 515–750ml) (p value<0.05) in patients receiving placebo, a postoperative blood loss of 210 ml(range, 150–325ml) versus 490 ml(range, 370–540ml) (p value<0.05), and a total need for 8 blood transfusions versus 30. Only 6 out 25 patients in tranexamic acid group required blood transfusion whereas 18 out of 25 patients in the placebo group required transfusion.

In the group receiving placebo the mean fall in hemoglobin was 2.9g/dl (range, 2.5–3.2) and in the group treated with tranexamic acid 1.6 g/dl (1.3–2) (p<0.05). At 24 hrs postoperatively, mean plasma D-dimer concentration in the Tranexamic group was half of that in the control group. No patient in either group had any evidence of deep vein thrombosis on bilateral compression Ultrasonography using Colour Doppler imaging done on the tenth postoperative day.

Tranexamic acid 15 mg/kg given as a single preoperative bolus dose reduces peroperative and postoperative and total blood loss, and transfusion requirements in primary cementless total hip replacement surgery without any increased risk of thrombus formation.

Introduction

Scaphoid nonunions remain controversial with regard to optimal management. The objective of this article is to compare our clinical experience in the treatment of patients with scaphoid nonunion using distal radius non vascularised bone graft with that of iliac crest bone graft.

Adequate exposure is a prerequisite for treatment of distal humeral fractures. In this study, we compared the clinico-radiological and functional outcome of TRAP approach with that of olecranon osteotomy for distal humerus fractures.

27 patients with distal humerus fractures were randomized into 2 groups: Group 1 (n=14, TRAP approach), Group 2 (n=13, Olecranon osteotomy). All patients were operated with bi-columnar fixation. All patients were mobilized from day 2. Follow-up evaluation was done at 1, 3, 6 and 12 months.

All patients achieved union. The mean surgical time was higher in group 1 (120 min) as compared to group 2 (100 min). The final ROM was higher in group 1 (1160) as compared to group 2 (850). Two patients in group 2 needed posterior release. 5 patients in group 2 had hardware complications related to olecranon osteotomy and needed removal. Two patients in Group 1 had transient ulnar nerve paraesthesias. There was no difference in triceps power in both groups.

Our results demonstrate that TRAP approach is extensile and safe enough in treating these complex fractures with better final ROM and fewer complications.

Introduction

Adequate exposure is a prerequisite for treatment of distal humeral fractures. In this study, we compared the clinico-radiological and functional outcome of TRAP approach with that of olecranon osteotomy for distal humerus fractures.

Large femoral neck defects pose a great challenge for orthopedic surgeons and are frequently associated with neglected femoral neck fractures, post infective sequale and failed implants around femoral neck. We present our technique (AIIMS Box Technique) of neck reconstruction aiming to preserve the natural femoral head and restoring the function of hip in cases of large femoral neck defects.

A total number of 52 patients (age range 20 to 56 years with an average of 38 years) with large femoral neck defects were treated from January 1990 to May 1997 and were followed for a minimum of 10 years (range 10 to 17 years). Neck defect was converted into a box using osteal flaps (Base from greater trochanter, Anterior wall from head, Quadratus Femoris muscle pedicle graft posteriorly). This box was filled with cancellous bone autograft along with three cancellous screw fixation.

Union occurred in all patients in a mean time of 16 weeks (range 12–20 weeks). One patient in our series had avascular necrosis (AVN) of femoral head. Eighteen out of 52 results were classified as excellent, 28 good and 6 fair. No patient had poor result. Good functional mobility including squatting was seen in all but two patients. Complications included coxa vara in two patients, hardware problems in four patients.

Our study shows that large femoral neck defects can be managed successfully with preservation of vascularity of femoral head. This procedure can be considered an alternative to excisional or replacement arthroplasty, particularly in young adults.

Introduction

Locking plates have been especially useful in the treatment of osteoporotic fractures. This study aimed to investigate the role of locking plate in femoral fractures in patients with osteogenesis imperfecta.

Introduction

We compared standard NexGen Cruciate substituting-flex prosthesis with gender-specific NexGen Cruciate substituting flex prosthesis in patients undergoing bilateral total knee arthroplasty with regard to Coverage of the bone by femoral component, Clinical outcome, Radiographic outcome, Survival and complication rates, with special emphasis on patellofemoral complications.

Introduction

Tranexamic acid is an inhibitor of fibrinolysis that blocks the lysine-binding site of plasminogen to fibrin, and thereby decreases blood loss in patients undergoing surgery.

Introduction

Transscaphoid perilunate dislocation is a rare injury and therefore it is easily missed at the initial treatment. Once ignored, an alternative treatment such as proximal row carpectomy is indicated, but surgical outcome is not as good as that of an early reduction. Also late reduction (> 3 months) is not possible and needs extensive dissection. We present an alternative technique of staged reduction with better outcome.

Background: Joint replacements are being performed on ever younger patients at a time when average expectancy of life is continuing to rise. Any reduction in the strength and mass of periprosthetic bone could threaten the longevity of implant by predisposing to loosening and migration of prosthesis, periprosthetic fracture and problems in revision arthroplasty.

Aims and Objectives: This study aims to analyse and compare prospectively the femoral periprosthetic stress-shielding around 4/5th and 1/3rd porous coated cementless femoral stems in patients undergoing unilateral cementless total hip replacement done using DEXA scan by quantifying the changes in bone mineral density around femoral component.

Material and Method: Femoral periprosthetic bone mineral density was measured in the seven Gruen Zones with DEXA scan at 2 weeks, 1 years and 2 years after surgery in 60 patients who had undergone unilateral cementless total hip replacement, of which 30 patients had been implanted with 4/5th porous coated stems and other 30 patients with 1/3rd porous coated stems.

Results: At both one and two years postoperatively, bone loss due to stress-shielding was seen in both stems with maximum loss in zone VII and minimum in zone III, IV, V. The maximum mean percentage bone mineral density loss in 4/5th porous coated stems in zone VII was 16.03% at one year and 22.42% at 2 years as compared to loss of 10.07% and 16.01% in 1/3rd porous coated stems. Increased bone loss was seen in patients who had larger diameter stem (> 13.0 mm) and in patients with low bone mineral density in the unoperated hip.

Conclusion: Bone loss as a result of stress-shielding is more pronounced in 4/5th porous coated stems as compared to 1/3rd porous coated stems.

Chronic infection of bone with nonunion is traditionally treated by a 2-stage procedure involving initial debridement and antibiotic delivery and then definitive internal fixation. Alternatively, external fixators are used to provide stability. A technique with which single stage antibiotic cement-coated intramedullary nails are prepared in the operating room with the use of Kuntscher Nails and materials that generally are available is described herein. Although useful for all infected nonunions this technique is particularly useful for patients who are not ideal candidates for external fixation and for those who do not want to have an external fixator applied. We evaluated 10 cases treated with antibiotic cement-coated K nail with application of an additional unicortical plate in 7 cases. Autologous iliac crest bone grafting was done in all cases and additional bone substitutes used in 2 cases. 9 patients had stable union with complete control of infection. One patient had persistent infection at the time of last follow

Introduction: Giant cell tumor of the tendon sheath is a solitary benign soft tissue tumor of the limb. We present our prospective experience of 106 cases, over a period of 22 years to assess the effectiveness of prophylactic radiotherapy in postoperative period. We also present a classification system to help in selecting patients for postoperative radiotherapy

Material & Methods: Between 1986 and 2008, we treated 106 patients with giant cell tumor of the tendon sheath of the hand. There were 77 females and 29 males with a mean age of 31.2 years. All patients presented with gradually progressive swelling. Pain was present in 3 cases. All patients were investigated preoperatively with plain X-rays. MRI was done in 36 cases. A preoperative diagnosis of giant cell tumour of the tendon sheath was made in 98 patients preoperatively. Rest 8 patients were diagnoses on histo- pathological examination.

We developed a classification system to identify the patients for risk of recurrence and consequently selection of patients for postoperative radiotherapy. Group 1(a) and 2(a) were identifies as low risk groups and comprised of 56 patients.

Results: None of the patient in this group received postoperative radiotherapy and no patient had recurrence among them. All other patients (50 patients) were considered to be high risk and given postoperative radiotherapy. Among them 4 had recurrence. A total recurrence rate of 3.7% was found in our study, which is favourably comparable to reported incidences of between 25% to 45%.

Conclusion: In our series, we gave radiotherapy to only high risk patients and had a recurrence rate of only 3.7%. Even in high risk group alone, to whom postoperative radiotherapy was given, recurrence rate was 8%. This indicate the role of radiotherapy as well as importance of our classification system to identify the patients for high risk of recurrence

Background: The usefulness of open (fenestration/ laminotomy) discectomy for the treatment of a herniated lumbar disc has been studied extensively. In the current prospective, randomized study, the results of this procedure were compared with those of Microendoscopic discectomy.

Methods: One hundred and twelve patients who had objective evidence of a single level, central or para-central herniation of a lumbar disc caudal to the first lumbar vertebra were randomized into two groups; Group 1 (55 patients) was managed with Microendoscopic discectomy, and Group 2 (57 patients) was managed with open (fenestration/ laminotomy) discectomy. None of the patients had had a previous operation on the low back, and all had failed to respond to nonoperative measures. Analysis of the outcomes of both procedures was based on the patient’s self-evaluation before and after the operation through Oswestry scoring, the preoperative and postoperative clinical findings, and the patient’s ability to return to a functional status. The patients were followed at one week, 6 weeks, 6 months and for a minimum of one year postoperatively.

Results: On the basis of the patient’s preoperative and postoperative self-evaluation, the findings on physical examination, and the patient’s ability to return to work or to normal activity, 53 patients (96 percent) in Group 1 and 54 patients (95 percent) in Group 2 were considered to have had a satisfactory outcome. The mean surgical time, mean anaesthesia time, postoperative stay, was significantly less in Group 1. The overall satisfaction score was higher after the endoscopic microdiscectomies than after the laminotomies and discectomies especially in immediate postoperative period (one and six weeks) as assessed through Oswestry scoring.

Conclusions: The data from this randomized, prospective study suggest that Microendoscopic discectomy may be useful for the operative treatment of specific symptoms, including radiculopathy, that are caused by lumbar disc herniation, provided that patients are properly selected—that is, they must have a herniated disc at a single level as confirmed on imaging studies, have failed to respond to nonoperative management and have no evidence of spinal stenosis. All the major advantages of an endoscopic procedure like less hospital stay, lesser morbidity, and early return to work can be passed on to the patients without in anyway compromising the surgical goals viz. decompression of the canal and the compressed nerve root. However, endoscopic microdiscectomy is a demanding technique and should not be attempted without specific instruction and training.

Introduction: Factures of the acetabulum are the result of high-energy trauma. Long-term function of the hip joint is compromised in many cases as a result of imperfect reduction, chondral injuries to the acetabulum, femoral head lesion and post-traumatic avascular necrosis of the femoral head.Total hip arthroplasty is one of the treatment option for such patients who present with symptomatic post-traumatic arthritis or avascular necrosis with collapse of the femoral head following acetabular fractures

Materials and Methods: Twenty total hip arthroplasty were performed with use of a cementless cup in 17 patients and cemented cup in a cage in 3 patients for the treatment of posttraumatic osteoarthritis following acetabular fracture. The average age of the 4 women and 16 men was 49 (range, 26 to 86 years) at the time of the arthroplasty. The median interval between the time of injury and the total hip arthroplasty was 37 months (range, 8 to 144 months). The average operative time was 120 minutes and average intraoperative blood loss was 700 ml. Eight patients had previous open reduction and internal fixation of the acetabular fracture and twelve had been treated nonoperatively.Following total hip replacement,each patient was evaluated clinically and radiographically at six weeks, three months, six months and twelve months, and then yearly following total hip replacement. The average duration of clinical and radiographic follow-up was 40 months (range, 26 to 60 months).

Results: At the time of final follow-up, of twenty acetabular components, 10 had no evidence of periacetabular radiolucency, 7 components had a partial radiolucency that was < 1 mm wide,2 had a complete radiolucency < 1 mm wide and 1 component was surrounded by a complete radiolucency of > 2 mm in width without showing component migration. According to Engh’s criteria,16 (80%) femoral stems had bony ingrowth and 4 (20%) stems had stable fibrous ingrowth. The average preoperative Harris hip score improved from 35 points to 78 points at the time of final followup.

Conclusion: We conclude that total hip arthroplasty for degenerative arthritis following acetabular fractures,is a gratifying but often technically more difficult than a routine total hip arthroplasty because of extensive scarring, heterotopic bone, retained internal fixation devices, and residual deformity of the acetabulum.