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   Table of Contents - Current issue
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January-June 2022
Volume 14 | Issue 1
Page Nos. 1-107

Online since Wednesday, June 15, 2022

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ORIGINAL ARTICLES  

Prevalence of osteoporosis in Eastern Odisha – A cross-sectional study of bone mineral density Highly accessed article p. 1
Madhuchhanda Pattnaik, Tanmoy Mohanty, Sunil Kumar Jena
DOI:10.4103/jotr.jotr_60_21  
Introduction: Osteoporosis is a common metabolic disease of the bone characterized by decreased bone mass and micro-architectural deterioration in bone tissues that results in increased susceptibility to fractures. Osteoporosis is a significant public health problem in many parts of the world, also in India. The primary purpose of the article is to find out the prevalence of osteoporosis in Eastern Odisha through the cross-sectional study of bone mineral density (BMD). Materials and Methods: Two thousand and one hundred individuals within the age range of 20–82 years were included in the study. It was conducted between February 2016 and August 2017. The instrument to measure BMD was the Achilles Express Bone Ultradensitometer. Their average BMD was calculated according to T score by using the World Health Organization guidelines for the classification into normal, osteopenic, and osteoporotic. The findings were statistically analyzed. The results were compared with the results of other authors. Statistical analysis was performed using the SPSS software version 16 (IBM Corporation, Armonk, New York USA). Results: Prevalence of osteoporosis was found to be 22.4% and osteopenia 37.9%. There was a significant difference in the prevalence of osteoporosis between premenopausal and postmenopausal women. Conclusion: In India, no centralized data are available to show the prevalence of osteoporosis. This study was an effort to find out the prevalence of osteoporosis in Eastern part of Odisha, India. Ultrasonic heel densitometry is a safe and noninvasive method for the assessment of BMD to diagnose and assess the osteoporotic individuals so that adequate steps can be taken in them to prevent fracture and other complications of osteoporosis.
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Evaluation of functional and radiological outcome of five-pin technique in management of distal end radius fractures Highly accessed article p. 5
Mahendra Solanki, Dev Krishan Sharma, Rakesh Prasad, Mitul Jain
DOI:10.4103/jotr.jotr_113_21  
Introduction: Distal end radius fractures are the most common fractures of the upper extremity. The most common mode of injury is a fall on outstretched hand. Closed reduction and percutaneous pinning with “the five-pin technique” improve the reliability of fixation. The current study aimed to assess the clinical and functional outcome of fixation of distal radius fractures using the five-pin technique. Materials and Methods: Thirty patients with fracture of distal end radius Frykman type 1 and 2 were subjected to close reduction and K-wire fixation by five-pin technique. Results: Functional outcome-using Obrien scoring system for functional outcome, there was 90%–100% score in 11 patients, 80%–89% in 18 patients, and <80 in one patient. Radiological outcome-using Sarmiento modification Lindstrom criteria for radiological outcome, 11 patients had excellent results, and 18 had good results, and one had fair results. Conclusion: “The five-pin technique” is a versatile tool which provides optimum functional and radiological outcomes.
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Functional outcome of delayed surgical fixation of capitellar fractures treated by open reduction and internal fixation with herbert screw Highly accessed article p. 9
Sanjay Keshkar, Riddhideb Barman, Mohammad Nasim Akhtar
DOI:10.4103/jotr.jotr_46_22  
Introduction: Capitellar fractures are rare injuries and difficult to manage, especially so if the patient presents late. Treatment is almost always operative. The purpose of this study is to evaluate the functional outcome of capitellar fractures in adults treated by open reduction and internal fixation (ORIF) with cannulated compression headless screws (Herbert screw) with an inadvertent delay of 2 weeks or more. Materials and Methods: Twelve patients (4 males and 8 females) of capitellum fracture who were reported after an inadvertent delay of at least 2 weeks, with near-normal elbow range of motion, operated by ORIF with Herbert screw, were studied retrospectively from April 2013 to March 2019. All cases were operated between 2 to 3 weeks of injury. All patients had a follow-up for a mean period of 34 months, and the final functional outcome was assessed using Mayo Elbow Performance Index (MEPI) and by radiology. Results: The mean MEPI score was 92.9 points, and as per this evaluation of the functional rating, all but one patient had excellent results. The mean range of elbow flexion/extension was 125 (90–140), while the range of movement in supination/pronation was 170 (130–180). Conclusion: ORIF of capitellum fractures with Herbert screw was found to be superior and gives excellent result, even with a delay of around 2 weeks. Preoperative computed tomography is helpful not only to know clear picture of fracture configuration but also to choose right surgical approach and right implant. Apart from stable internal fixation, early mobilization and rehabilitation are the keys for optimum functional outcome.
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A retrospective study to compare early outcomes of bilateral total knee replacement done in single sitting versus double sitting p. 13
Jitendra Wadhwani, Ramchander Siwach, Ravi Sihag, Pradeep Kamboj, Karan Siwach
DOI:10.4103/jotr.jotr_78_21  
Aim: We aimed to conduct a study comparing early outcomes of bilateral total knee replacement (BTKR) done in single sitting versus double sitting. Materials and Methods: The study included 58 patients who were already operated case of BTKR done in single sitting (sequential BTKR) – Group I (n = 30) and double sitting (staged BTKR) – Group II (n = 27), during time period April 2016 to May 2019. At follow-up, functional outcome in both the groups was assessed by Knee Injury and Osteoarthritis (OA) Outcome Score, Western Ontario and McMaster Universities OA Index score, and Visual Analog Scale scores. Results: The mean age in Group I was 64.5 ± 10.52 years and in Group II was 63.92 ± 5.76 years. The mean body mass index (BMI) in Group I was 28.42 ± 1.365 kg/m2, whereas the mean BMI in Group II was 29.19 ± 1.898 kg/m2. The mean length of hospital stay in Group I was 15.23 ± 2.921 days as compared to 23.69 ± 5.259 days in Group II. There was no mortality in both the groups within 90 days after operation in both the groups. There was significantly less requirement of hospital stay in Group I as compared to Group II (P = 0.001, Mann–Whitney U-test). Conclusion: We found that the single sitting BTKR is cost-effective and a relatively safe surgery. There was significantly lower length of hospital stay in single sitting BTKR along with no major complication in our study. Thus we advocate BTKR as a single sitting surgery with proper patient selection and preanesthetic workup.
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Inter- and intra-observer variation of schatzker classification of tibial plateau fractures and morphological characteristics of each fracture subtype on computed tomography scan p. 18
Siddharth Gupta, Raskesh Malhotra, Amit Srivastava, Rajesh Arora, Aditya N Aggarwal, Puneet Mishra
DOI:10.4103/jotr.jotr_71_21  
Background: There is little information regarding inter- and intra-observer variation when classifying tibial plateau fractures using Schatzker classification system. There is paucity of literature regarding morphological characteristics of each Schatzker subtype on computerized tomography. Materials and Methods: Fifty-three patients (age 18–70 years) of either sex with fresh (<3 weeks old), closed tibial plateau fracture were included after obtaining their informed consent. Patients with previous surgery around tibia or knee and the ones with pathological fractures were excluded from the study. Standard plain radiographs (anterior, posterior, and lateral views) and an additional noncontrast computed tomography (CT) scan (with three-dimensional reconstruction) of knee and leg of the affected side were done. Five different surgeons classified these fractures as per Schatzker classification on two separate occasions. The intra- and inter-observer variations were calculated using the kappa test of Cohen. Additional morphological characteristics were also evaluated on CT scan. Results: The mean kappa values for five observers (A to E) for inter-observer agreement on Schatzker classification were 0.41 (moderate). The mean kappa value for intra-observer agreement was 0.71 (substantial). Six morphological characteristics were defined on CT scan-lateral condylar impaction (79.2%), tibial tuberosity fracture (3.8%), coronal plane (3.8%), tibial spine avulsion (22.6%), medial condylar impaction (17%), and posteromedial shear fracture (7.5%). Conclusion: There is inter- and intra-observer variation in Schatzker classification of tibial plateau fracture. The intra-observer variation (kappa 0.71) was found to be greater than the inter-observer variation (kappa 0.41). The additional morphological characteristics of tibial plateau fractures are better evaluated on CT scan. The articular depression, splits, and fracture geometry are better delineated on a CT scan than on plain X-rays alone.
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Comparative analysis of functional and radiological outcome of proximal femoral nail versus dynamic hip screw in treatment of intertrochanteric fractures p. 24
Rajeev Shukla, Prateek Pathak, Arpit Choyal
DOI:10.4103/jotr.jotr_73_21  
Background: Intertrochanteric fracture is one of the most common fractures of the hip, especially in the elderly with osteoporotic bones, usually due to low-energy trauma like simple falls. This study was done to compare the functional and radiological outcome of PFN with dynamic hip screw (DHS) in treatment of type 31-A2, intertrochanteric fractures. Materials and Methods: From June 2019 to June 2021, prospective randomized and comparative study was conducted on the 162 patients of type 31-A2 intertrochanteric fractures of hip who were operated using PFN or DHS. Intraoperative complications were noted. Functional outcome was assessed using Harris hip score (HHS) and radiological findings were compared at 6, 12, and 24 months postoperatively. Results: In our study, out of 162 patients, 77 patients are managed with DHS, while 85 patients are managed with PFN. The average age group of the patients was 61–70 years. In our series, we found that patients with DHS had longer duration of surgery (111 min) and required longer time for mobilization, while patients who underwent PFN had shorter duration of surgery (97 min) and allowed early mobilization. In addition, complications such as DVT, lag screw cutout, shortening, and superficial infection are more in DHS group as compared to PFN group. The patients treated with PFN started early ambulation as they had better HHS in the early postoperative period as well as late postoperative period. Conclusion: PFN is better than DHS in type 31-A2 intertrochanteric fractures in terms of decreased blood loss, reduced duration of surgery, early weight-bearing and mobilization, reduced hospital stay, decreased risk of infection, and decreased complications.
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Management of unstable fractures of the distal end radius using bicolumnar radius plating p. 32
Ashok Sharma, Nayyar Ali, Umesh Vyas, Arvind Kumar Bohra, Shiv Bhagwan Sharma
DOI:10.4103/jotr.jotr_100_21  
Background: Controversy still exists regarding the current treatment modalities for unstable distal radius fractures. A prospective study was performed to evaluate efficacy of bicolumnar plating (radial buttress and volar plating) technique, which is designed to providing sufficiently secure fixation treatment of distal radius fractures. Materials and Methods: The prospective randomized study was done under the department of orthopedics at SRG hospital Jhalawar. We operated 20 patients, with distal end radius fracture of type 23C2 and 23C3 with radial column fracture using bicolumnar plating between May 2019 to MAY 2021. All patients presented for follow-up till union. Patients belonged to age group 20-75 years with the mean age of 45 years. Twelve patients were male and eight were female. The duration of follow-up was 12-18 months. Results: Bicolumnar plating led to complete union of unstable distal radius fractures without additional procedures. The assessment of post-operative functional outcome was done using the MODIFIED MAYO WRIST SCORE. At the final follow-up, 15 patients had excellent score, 3 had good score and 2 had fair score. Conclusions: Bicolumnar plating is feasible option for the management of displaced distal radius fractures and can result in favorable surgical outcomes.
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The safety and efficacy of biceps tenodesis performed using a novel suture anchor p. 38
Andrea H Johnson, M Brook Fowler, Michaline West, Justin J Turcotte, Daniel E Redziniak
DOI:10.4103/jotr.jotr_83_21  
Introduction: Biceps tendon degeneration or tearing is a significant cause of shoulder discomfort and dysfunction. Biceps tenodesis is commonly performed to treat symptomatic biceps tendon pathology. A variety of fixation techniques can be used including screw fixation, endobutton, or suture anchor techniques. This study examines the patient outcomes when the FOOTPRINT™ Ultra suture anchor system is used for biceps tenodesis. Materials and Methods: Retrospective review of consecutive patients undergoing biceps tenodesis was conducted. All patients underwent biceps tenodesis using the FOOTPRINT™ Ultra suture anchor. The primary endpoint was any device-related complication during the intraoperative or postoperative period. Descriptive and inferential statistics were performed to assess patient characteristics and outcomes. Results: Twenty-nine patients were included in this study; 20 (69.0%) underwent arthroscopic biceps tenodesis and the remainder underwent open surgery. The mean follow-up time was 8.51 ± 5.28 months postoperatively. One patient experienced a postoperative infection within the first 30 days requiring a return to the operating room. Two patients experienced a complication within the first 6 months postoperatively. No patients experienced a device-related complication. No patients experienced a retear of their biceps tendon; two patients experienced a retear to their rotator cuff repair. The mean pain Numeric Rating Scale improved from 5.88 ± 2.58 on a scale of 0–10 preoperatively to 1.94 ± 2.32 postoperatively (P < 0.001). Conclusion: The FOOTPRINT™ Ultra suture anchor appears to be safe for the use in patients undergoing arthroscopic or open biceps tenodesis.
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Is conventional knee radiograph reliable enough to assess the anatomical knee alignment and total knee prosthesis position in Indian population? p. 42
Suryamanikanta Balabadra, Ratnakar Vecham, Maryada Venkateshwar Reddy, Adarsh Annapareddy, M. Mahendra Kumar, A. V. Gurava Reddy
DOI:10.4103/jotr.jotr_59_21  
Background: The success and survivorship of primary total knee replacement mainly depend on the postoperative alignment and implant position. Long-leg radiograph (LLR) is considered gold standard in assessing knee alignment postoperatively. Studies have reported that bowing of the femoral shaft in the coronal plane is prevalent in Asian population, which is not fully visualized on a conventional knee radiograph (CKR) and may affect the assessment of coronal alignment. However, postoperatively, CKR is easy to perform and has several advantages if it provides similar precision. Purpose: The purpose was to evaluate the validity of CKR in assessing the anatomical knee alignment and prosthesis position as compared with the LLR in Indian population. Materials and Methods: One hundred knees in 83 patients were subjected to CKR and LLR during postoperative follow-up at 6 weeks. Three parameters were evaluated to assess the coronal alignment and the component positions - femoral component angle (FCA), tibial component angle (TCA), and tibiofemoral angle (TFA). Results: There was an excellent correlation between the TCA as measured from the long and CKRs (r = 0.884, P = 0.01). There was a high positive correlation between the FCA (r = 0.703, P = 0.01) and TFA (r = 0.754, P = 0.01) as measured from the long radiographs and the conventional radiographs. Regression analysis defined these relationships to be linear. Conclusion: CKR could be an appropriate alternative for the LLR in evaluating the postoperative knee alignment and total knee prosthesis position despite the fact that there is excessive femoral bowing in Indian population.
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The dimensions of pronator quadratus and its neurovascular structures – A cadaveric study with its clinical implications in distal forearm surgeries p. 46
Sudha Ramalingam, Deepa Somanath
DOI:10.4103/jotr.jotr_67_21  
Introduction: The pronator quadratus is one of the deep muscles of the front of the forearm. The neurovascular supply of the muscle is derived from the anterior interosseous nerve and vessels. This muscle is approached in various surgical procedures involving the distal radius. Its nerve can be utilised as a graft in case of peripheral nerve lesions and the anterior interosseous artery perforator flap is used for wrist and hand surgeries. Hence, the anatomy of the muscle and its neurovascular pedicle is needed in orthopedic surgeries. Materials and Methods: In this study, 84 upper limbs from 24 male and 18 female cadavers, age ranging from 55 to 78 years, were dissected to study the pronator quadratus muscle and its neurovascular supply in the Department of Anatomy, Sri Manakula Vinayagar Medical College and Hospital, Pondicherry. Various levels of measurements regarding the length and width of the muscle were considered. The number of branches of its neurovascular structures and their levels of entry into the muscle from various landmarks was measured. The Student t-test was applied to identify the P-value regarding the difference between the subjects. Results: No significant differences were observed regarding the measurements of the muscle and its neurovascular structures between male and female cadavers. Conclusion: This study can be useful for the surgeries involving the lower part of front of forearm. Since no significant difference was found between the genders regarding the variables, the morphometry of the muscle and its supply can be generalised for both sexes.
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Management of extra articular distal femoral fractures with nail plate combination p. 50
Ashok Sharma, Deepak Varma, Umesh Vyas, Arvind Kumar Bohra, Shiv Bhagwan Sharma
DOI:10.4103/jotr.jotr_103_21  
Background: Junctional distal femur fractures are considered difficult to unite and often can led to a degree of disability. The incidence of malunion, nonunion, and infection is relatively high in many reported series. In elderly patients, low-energy distal femur fractures can cause devastating injuries, carrying high rates of morbidity and mortality. Operative fixation can be more challenging in comminuted fractures of osteoporotic bones. The management of junctional fractures of the distal femur by using the nail plate combination (NPC) technique can provide stable, well-balanced fixation, allowing for immediate weight-bearing and early mobilization and improve quality of life. Materials and Methods: A prospective randomized study including 16 patients with distal femur extraarticular and junctional fractures, was conducted in the department of orthopedic surgery Jhalawar medical college and SRG hospital Jhalawar, from May 2019 to June 2021. There were 9 male and 7 female patients, age range from 43 years to 70 years, with a mean age being 53 years. The average length of follow-up was 18.5 months (12 months to 24 months). Results: Patients followed up at 1 month, 3 months, 6 months, annually thereafter. Regular fracture healing was observed in 15 cases. Delayed union seen in 1 case who had infection postoperatively, which was treated with debridement and antibiotics as culture and sensitivity. mild rotational misalignment (~5°) seen in one case and there was no axial misalignment (Varus/valgus angulations) was found in any case. There were no implant failures. Conclusion: In our study, functional results trended toward better outcomes in nails plates combinations in terms of knee flexion, early weight-bearing, less union time, and better alignment. NPC system could take the challenges such as poor bone stock, severe comminution both metaphyseal and diaphyseal region.
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Spinal tuberculosis and neurological deficit: A 10-year study in rural tertiary care center of central India p. 55
Rohan R Patil, Girish Balasaheb Mote, Aniket Kanhaiyalal Wankhede, Kiran N Wandile, Chandrashekhar M Badole
DOI:10.4103/jotr.jotr_29_21  
Background: India is a home for 27% of the world's tuberculosis (TB) cases. When compared, extrapulmonary TB (EPTB) cases have a lower incidence than pulmonary TB (PTB), but there is no significant reduction in the incidence of EPTB than PTB. Spinal TB is most common of skeletal TB. Aims: We aimed to study and to identify the clinical-radiological features in spinal TB and the incidence of neurological involvement along with factors associated with it. Settings and Design: This was a retrospective study in a tertiary care center of Central India. Subjects and Methods: A total of 114 cases with spinal TB were included in the study. Data collected retrospectively from January 2008 to December 2018 using a picture archiving and picture archiving and communication system of the hospital. Radiographs, magnetic resonance imaging scan, computed tomography, and ultrasound findings were studied. History and clinical examination findings were thoroughly analyzed. Statistical Analysis Used: Data were analyzed using Epi Info Software. Results: There were 74 (64.9%) male cases and 40 (35.1%) female cases. Most of the cases belong to rural 85 (74.5%) than urban 29 (24.5%) area. After neurological evaluation, paraparesis/paraplegia was observed in 52 (45.6%) cases and tetraplegia in 2 (1.7%) cases. Sensory deficit was observed in 10 (10.5%) cases. Bowel/bladder involvement was present in 5 (4.4% cases). Most of the cases with neurodeficit had dorsal vertebral involvement 30 (61.1%). Conclusions: The pattern of spinal TB is varied and is difficult to get diagnosed. We observed a high proportion of cases with neurodeficit. Most of them were with late-onset TB. This highlights that early diagnosis and complete treatment are very important in the treatment of TB of the spine.
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Combining proximal fibular osteotomy with high tibial osteotomy – Is it better than high tibial osteotomy alone? Comparative evaluation of early outcome p. 59
Sunil Baliga, Pausiam Tunglut, Prashant Arya, Manabendra Nath Basu Mallick
DOI:10.4103/jotr.jotr_20_21  
Introduction: Valgisation high tibial osteotomy (HTO) is a widely performed procedure for patients with medial compartment unicompartmental osteoarthrosis knee with varus malalignment of lower limbs. Over the last two decades, medial open-wedge HTO has been more popular than lateral closed-wedge techniques due to multiple advantages. Recently, isolated proximal fibular osteotomy/fibulectomy (PFO) has been advocated as a treatment for medial tibiofemoral osteoarthrosis in young patients. The role of fibulectomy as an adjunct to medial open-wedge HTO has been scarcely reviewed in the literature. Materials and Methods: This study is a retrospective comparative evaluation of clinical outcomes between patients undergoing PFO + HTO versus HTO alone. Functional outcome of ten patients in either group was assessed by Oxford Knee Score and Western Ontario and McMaster Universities score. Results: Patients undergoing PFO + HTO had a larger degree of angular correction. There were lesser complications related to HTO (no delayed union and nonunion). Furthermore, there was no loss of limb alignment. However, peroneal nerve (transient) palsy was reported in this group. Overall, patients had better pain relief and improved scores in the PFO + HTO group. Conclusion: PFO seems to be beneficial (albeit statistically insignificant in our cohort) in medial open-wedge osteotomy by allowing compression and promoting union at osteotomy site, maintaining limb alignment for longer period, and providing bone graft for osteotomy site. We recommend a larger prospective study to study the benefits of PFO + HTO for correction greater than 10°, osteoporosis, iatrogenic fracture of lateral cortex of tibia, and slope correction osteotomies. Care should be exercised while handling the common peroneal nerve during PFO.
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Evaluation of serum procalcitonin levels in patients of acute osteomyelitis and septic arthritis p. 66
Narendra Kumar, Vikas Kumar Pandey, Deepak Kumar Sharma, Mohit Kumar Patralekh, Hitesh Lal
DOI:10.4103/jotr.jotr_16_21  
Aims: The aim is to study the role of serum procalcitonin (PCT) levels in early diagnosis of acute osteomyelitis (OM) and septic arthritis (SA). Settings and Design: This is a prospective study in a tertiary hospital. Subjects and Methods: This study was done at a tertiary care hospital. Thirty-nine patients with SA or acute OM who attended the outpatient department or emergency were included in the study. 39 patients were taken as control group out of which one patient lost to follow-up, so 38 patients were left with control group. PCT level was evaluated by using immunoluminetric assay and a cutoff value of 0.5 ng/ml was taken as positive. After collection of data, sensitivity, specificity, positive predictive value, and negative predictive value are calculated for PCT. Statistical Analysis Used: Mann–Whitney U-test and Kruskal–Wallis test were used. Results: The sensitivity for PCT was 94.87 (95% confidence interval [CI] 82.68–99.37), specificity was 86.84 (95% CI 71.91–95.59), positive predictive value was 88.10%, and negative predictive value was 94.29%, when taking cutoff of 0.5 ng/ml. We have taken 0.5 ng/ml as a cutoff point for PCT; however, as per receiver operator characteristic of this study, the cutoff point was 1.1 ng/ml. Conclusions: This study clearly showed that PCT can be helpful in the early diagnosis of OM and SA, along with other indicators such as total leukocyte count, erythrocyte sedimentation rate, and C-reactive protein.
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To evaluate the role of intralesional injection of platelet-rich plasma versus corticosteroid (triamcinolone) in plantar fasciitis p. 70
Mahendra Solanki, Rajeev Kelkar, Pawan Baghel
DOI:10.4103/jotr.jotr_9_21  
Introduction: Plantar fasciitis is an aseptic inflammation of the plantar fascia and also the most common cause of plantar heel pain.Approximately more than 10% of the population is affected by it over their lifetime. Aims and Objectives: The aim of this study is to evaluate the role of platelet-rich plasma (PRP) versus corticosteroid (triamcinolone) therapy in plantar fasciitis and to study the complications associated with both the procedures and their management. Materials and Methods: The study included 36 patients of plantar fasciitis (fulfilling the inclusion criteria) who presented to the OPD/Casualty of Department of Orthopaedics and Traumatology, M.G.M. Medical College and M.Y. Hospital, Indore, between September 2018 and August 2020. The study was a prospective and interventional type. Results: The mean Roles and Maudsley Subjective Pain score (RMSPS) score at pretreatment was 3.72 ± 0.46 for PRP and 3.72 ± 0.46 for steroids; at 1 month, it was 1.61 ± 0.78 for PRP and 1.44 ± 0.70 for steroids; and at 6 months, it was 1.22 ± 0.55 for PRP and 1.94 ± 0.73 for steroids. The mean Visual Analog Scale (VAS) score at pretreatment was 7.72 ± 0.96 for PRP and 7.78 ± 1.0 for steroids; at 1 month, it was 2.89 ± 1.68 for PRP and 2.50 ± 1.47 for steroids; and at 6 months, it was 1.28 ± 1.49 for PRP and 2.61 ± 1.69 for steroids. PRP injections have shown effectiveness in providing pain relief, improving function in plantar fasciitis patients. As a result, VAS and RMSPS score was significantly reduced (P = 0.015) at 6 months as compared to preprocedure and thus proved the effectiveness of the PRP therapy. It also shows that PRP is a better method in reducing pain in plantar fasciitis compared to steroid injection. Conclusion: Our study demonstrates PRP injection to be an effective and well-tolerated alternative to corticosteroid injection in the management of chronic plantar fasciitis with an added advantage of almost no side effects due to its biological nature and better patient compliance.
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Predicting short-term outcome of Metal-on-Metal Hip Resurfacing (MOMHR): A multivariate analysis using 14 independent variables p. 75
Amrit Goyal, William Macaulay, Jeffrey A Geller, Wenbao Wang, Jonathon D Nyce
DOI:10.4103/jotr.jotr_18_21  
Introduction: The aim of this study was to research factors affecting the short-term outcome of metal-on-metal hip resurfacing (MOMHR) and develop a multivariate regression model that may predict outcome. Materials and Methods: This was a prospective study of 154 patients who underwent MOMHR and were followed for a minimum of 1 year. Fourteen independent variables (age, gender, diagnosis, co-morbidities, body mass index (BMI), pr-operative Western Ontario and McMaster Universities Osteoarthritis (WOMAC) physical component/stiffness (S)/pain (P), short form 12 (SF-12) physical (SP), SF-12 mental (SM), acetabular and femoral component sizes, operative time, and estimated blood loss) were analyzed using correlation and multivariate regression analyses. Multivariate regression model was tested by using an independent cohort for validation. Results: Correlation analyses found four variables that significantly influence short term MOMHR outcome. These include comorbidities (C, P = 0.0001), preoperative SF-12 mental (SM, P = 0.0004), BMI (P = 0.0006), and gender (G, P = 0.0454). By multivariate analysis, the subsequent regression model was obtained with an R2 value of 0.3816: Outcome = G*4.72 ‒ BMI*0.70 ‒ C*0.11 + SM*0.31 + 87.44. The average predicted outcome using this equation did not differ significantly from the observed WOMAC physical function outcome at a minimum of 1 year postoperatively. Conclusion: To the best of our knowledge, this study is the first reported multivariate analysis of factors affecting MOMHR and confirms the correlation of some of the previously proposed factors such as gender, BMI, comorbidities, and preoperative function. The multivariate regression equation can be used to predict the short-term outcome of MOMHR.
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A novel technique for posterior cruciate ligament tibial avulsion fixation through the burks and schaffer approach p. 81
Akshat Vijay, Dinesh Kumar Bairwa, Rajesh Goel, Amit Gupta
DOI:10.4103/jotr.jotr_6_21  
Introduction: Numerous techniques for the treatment of posterior cruciate ligament (PCL) avulsion fractures have been described in literature from closed reduction to definitive fixation, both open and arthroscopically assisted fixation. Aim: In this study, we evaluated the clinical and functional outcome after open reduction and internal fixation of tibial avulsion injuries of the PCL using number 5 polyester sutures (Ethicon-Ethibond excel) with Titanium AL (Tit) endobutton (Nebula Surgicals Private Limited, India) through burks and Schaffer posteromedial approach. Materials and Methods: It was a prospective study of 22 patients of PCL tibial avulsion fractures; fixed using number 5 polyester sutures with Tit endobutton through burks and Schaffer approach with the patient in the prone position. We included only those patients who had isolated PCL avulsion injuries and came within 12 weeks of injury. The final functional outcome was compared using the Lysholm knee scoring system. Student's t-tests were used for intergroup comparison of Lysholm knee scores before and after surgery. Results: The mean follow-up was of 11.9 months, with the loss of two patients in follow-up. Bony union was achieved in all patients within 8–15 weeks (mean-11.6 weeks). The average flexion of 122.8° with full extension achieved in all patients. Slight instability (1+) was noted in four patients. The Lysholm functional score was excellent in 16 patients and good in four patients with an average score of 94.6 ± 4.6. Conclusion: Using sutures and endobuttons for PCL tibial avulsion fixation provides secure fixation leading to satisfactory functional and clinical outcomes as well as omits placement of any hardware in joint, thus obviating risk of joint damage and burden of second surgery for removing the implant.
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CASE REPORTS Top

Hybrid external fixator for correction of genu valgum in an adult p. 86
Tanmoy Mohanty, Madhuchhanda Pattnaik, Gopal Chandra Sethy, Rabi Narayan Jee
DOI:10.4103/jotr.jotr_61_21  
Sometimes genu valgum in an adult poses a challenge to orthopedic surgeons because the deformity is very gross if it developed due to injury or infection in early childhood. If the femoral condyle is found to be hypoplastic, then the corrective osteotomy site is very close to the joint. It may be difficult to manage with a conventional fixator and a hybrid fixator may become a necessity. A limb reconstruction system (LRS) is less cumbersome than ring fixators when fixed to the thigh. A hybrid fixator fabricated using a twin-ring Ilizarov system attached to an LRS was found to be very useful during the management of corrective osteotomy of genu valgum in an adult. A special clamp was designed to fix the Ilizarov portion to the end of the rail system of LRS. Here, the use of such a hybrid fixator to correct the deformity of the right knee in a 27-year-old person has been described in detail.
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Bilateral bunionette in rheumatoid arthritis p. 90
Alok Chandra Agrawal, Ankit Kumar Garg, Deepak Kumar Garg, Rahul Ranjan
DOI:10.4103/jotr.jotr_48_22  
Introduction: Tailor's bunion or Bunionette deformities were described by Davies et al. as abnormal, painful bony prominence on the lateral aspect of the fifth metatarsal head. This prominence, though present in many individuals, seldom causes symptoms. Most deformities can be managed conservatively, and surgical interventions will be needed only for refractory cases presenting with chronic pain. Various surgical interventions (percutaneous, mini-open, open), including osteotomies at different level, has been described in the literature. Case: A thirty-three-year-old female house-maker presented with swelling over the bilateral fifth metatarsal lateral aspect and pain while walking for the last six months. The patient is a known case of Rheumatoid arthritis controlled on medication. The patient underwent Lateral exostectomy resection for bilateral swelling, At one year follow up, the patient had good functional outcome with no recurrence. Conclusion: Tailor's bunion deformity, although morphologically common, is rarely symptomatic. Its management involves identifying the cause, thorough clinical and radiographic evaluation of the deformity, and deciding the best surgical procedure to obtain optimal results.
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Posterolateral migration of complete vertebral body in neglected tuberculosis of the spine p. 94
Svareen Kaur, Roop Singh, Hemant More, Mohit Khanna
DOI:10.4103/jotr.jotr_79_21  
The most common presentation of tuberculosis (TB) of the spine is paradiscal lesion secondarily involving adjacent disc and vertebral bodies. If not diagnosed early, it can lead to extensive destruction and atypical features. We report a patient who presented late with posterolateral migration of the vertebral body and multifocal spinal involvement. A 30-year-old female presented with back pain, progressive spinal deformity, and paraparesis. Plain X-rays, computed tomography scans, and magnetic resonance imaging revealed multifocal extensive TB of the spine with posterolateral migration of the first lumbar vertebra. The vertebral body showed erosions. Posterior elements involvements with pars interarticularis defects of 12th dorsal to 2nd lumbar vertebra were observed. The patient was planned for stabilization of the spine along with excision of the migrated vertebra along with antituberculous treatment, but she refused surgery. The authors discuss the pathogenesis of such a rare event and stress the early detection of this complication.
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Bilateral floating knee: A rare case report p. 98
Jay Ganesh, Sabari Selvam
DOI:10.4103/jotr.jotr_50_21  
Ipsilateral fractures of the femur and tibia have been called “floating knee” injuries and may include combinations of diaphyseal, metaphyseal, and intra-articular fractures. These are often high-energy injuries and most frequently occur in the polytrauma patient. Many of these fractures are open, with associated vascular injuries. Surgical stabilization of both fractures and early mobilization of the patient and the extremity produce the best clinical outcomes. This rare case report is of 43-year-old female from an urban setup in Chennai who underwent an Road Traffic Accident (RTA) and sustained injuries that lead to a bilateral floating knee. She was initially managed as per principles of damage control orthopedics and stabilized with knee spanning external fixators on either side. On further stabilization of the patient, bilateral definitive fixation was done in a staged manner. The patient finally regained full functional range of motions on either limb and was completely rehabilitated within 3 months.
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Dripping candle wax lesion of the hand p. 102
Leon Alexander
DOI:10.4103/jotr.jotr_30_21  
It is essential to consider melorheostosis in the differential diagnosis for patients presenting with soft-tissue swelling, joint contractures, and “dripping candle wax” like hyperostotic lesions on X-rays. Melorheostosis is a sporadic disease with an uncertain etiology. It is often diagnosed incidentally and can affect the bones of the vertebrae, trunk, and upper and lower extremities. It can present with compressive symptoms due to soft-tissue swelling and fibrosis. On the hand, symptoms of median nerve compression or trigger finger may occur. The treatment of this condition is primarily conservative, and surgery is reserved for patients with severe and disabling symptoms.
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Unilateral upper extremity ischemia in a neonate – A rare complication of prematurity p. 105
Alok Chandra Agrawal, R Dinesh Iyer, Harshal Suhas Sakale, Ankit Kumar Garg
DOI:10.4103/jotr.jotr_29_22  
Acute limb ischemia in the neonatal period is a rarely reported complication of prematurity and needs a high index of suspicion for early diagnosis and a multidisciplinary approach for its management. Here, we present a case of a preterm baby that developed unilateral upper limb ischemia in the neonatal period and discussed the problems faced in the management of such cases. A 24-day-old male baby was referred to the orthopedics department because of bluish-black discoloration of the right hand and forearm and no active movement in the wrist and hand. The baby was preterm, delivered at 29 weeks of gestation lower-segment cesarean section with a birth weight of 900 g to a healthy mother with no preexisting illness. Although the line of demarcation was just below the elbow joint and conventional wisdom would dictate us to go for a transhumeral amputation, we opted for a below elbow amputation in a bid to save the elbow joint as we could have revised the amputation at a later date if needed. Neonatal acute limb ischemia has been rarely reported and needs a high index of suspicion. Preterm and low birth weight babies are more prone to it. Treatment of such patients depends on the cause of gangrene. Amputation at such young age is psychologically disturbing for the parents. However, it is usually associated with good functional outcomes as the child has not yet learned the use of a limb or developed cortical plasticity in the brain. All attempts should be made to preserve as much joint and physis as possible to have a functional joint with better prosthetic fitting.
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