Vertebral Endplate Changes Correlate with Presence of Cartilaginous Endplate in the Herniated Disc Tissue: Factor Predicting Failure of Conservative Treatment

Methods@#Fifty-one discs were obtained from patients undergoing surgery for herniated disc. Their ages ranged from 19-65 years, and 31/51 were male. Pre-surgical T1 and T2 weighted lumbar-spine MRIs were analyzed to observe Pfirrmann grade, VEP defects, herniation type, Modic changes, and high-intensity zones (HIZ) at the affected level. Five-micron thick sections were stained with hematoxylin and eosin, Alcian blue periodic acid–Schiff stain; examined for histological degeneration scores (HDS; 0–15), inflammation (0 [absence]–3 [severe]), and presence of cartilaginous endplate (CEP). Three-micron thick sections were stained with protein-gene-product 9.5 and expression was counted/mm2. Data was analyzed, and p<0.05 was considered to indicate statistical significance. @*Results@#VEP defects, Modic changes, and HIZ were respectively observed in 30/51, 16/51, and 6/51 of the samples. CEP was observed in 26/51 samples and in 23/51 with endplate defects. Discs with adjacent VEP defects showed increased HDS (p<0.001) and inflammation (p<0.001). Discs with adjacent Modic changes also revealed increased HDS (p=0.01). Histological sections with CEP showed increased HDS (p<0.001) and inflammation (p<0.001), and nerve density was significantly positively correlated with HDS (r=0.27, p=0.02). @*Conclusions@#VEP changes can modulate degeneration and inflammation of herniated discs. Presence of these changes is highly predictive of the occurrence of CEP in herniated discs, which leads to slow resorption and persistent clinical symptoms.

Outcomes of Direct Infrapectineal Buttress Plate for Quadrilateral Surface Fractures of Acetabulum Using an Anterior Intrapelvic Approach / 대한고관절학회지

Purpose@#Reduction and stable fixation of the quadrilateral plate are challenging primarily due to its location in the true pelvis, limited bone stock, juxta-articular nature, and its comminution. The current study aimed to investigate the quality of reduction and functional outcomes after open reduction and internal fixation (ORIF) with infrapectineal buttress plating of the quadrilateral surface via an anterior intrapelvic approach. @*Materials and Methods@#We conducted a retrospective review of twenty-one patients with acetabular fractures involving quadrilateral plate operated at Ghurki Trust Teaching Hospital between January 2017 and December 2018. Radiological assessment of the quality of reduction was conducted using criteria described by Matta. Functional outcomes were evaluated using a modified Postel Merle d’Aubigné score. @*Results@#The current study included 15 males and 6 females with a mean age of 40.67±12.17 years (range, 22-62 years). The most common fracture pattern was anterior column and posterior hemi-transverse in eight patients followed by true bicolumn and T-type fractures in seven and four patients respectively. Both transverse fractures were transtectal. The quality of reduction according to Matta criteria was anatomical in 14 patients, imperfect in five and poor in two. Functional outcomes were excellent in 47.6% cases, good in 42.9%, and fair in 9.5% cases. Both patients with fair outcomes had non-anatomical reduction, and one required total hip arthroplasty at a later time. @*Conclusion@#Quadrilateral plate reconstruction with an infrapectineal buttress plate applied though an anterior intrapelvic approach provides high rates of anatomical reduction and yields good functional outcomes.

Component Alignment in Simultaneous Bilateral versus Unilateral Total Knee Arthroplasty

PURPOSE: The purpose of this study was to investigate differences in component alignment between first and second knees in simultaneous bilateral total knee arthroplasty (SBTKA) and unilateral TKA (UTKA). MATERIALS AND METHODS: 274 SBTKAs and 198 UTKAs were included in study. Patients were divided into three groups as SBTKA on the right knee (group A), SBTKA on the left knee (group B) and UTKA (group C). Femoral and tibial component alignment was checked in both coronal plane (alpha [α] and beta [β] angles) and sagittal plane (gamma [γ] and delta [δ] angles) radiographs. RESULTS: There were no statistically significant differences among groups in the preoperative anatomical varus angle and Kellgren–Lawrence gonarthrosis classification grade (p=0.139 and p=0.329, respectively). In the coronal plane, the alignment of femoral component (α angle) and tibial component (β angle) was similar in all three groups (α angle, 95.01 vs. 95.14 vs. 94.9, p=0.945; β angle, 90.03 vs. 89.67 vs. 89.98, p=0.483). The sagittal plane alignment of femoral component (γ angle) and tibial component (δ angle) did not show significant differences (γ angle, 7.04 vs. 6.98 vs. 7.00, p=0.132; δ angle, 86.56 vs. 87.41 vs. 86.73, p=0.610). CONCLUSIONS: The angular alignment of components was similar between SBTKA and UTKA.

One-stage Hip Reconstruction for Developmental Hip Dysplasia in Children over 8 Years of Age / 대한고관절학회지

PURPOSE: This study was performed to assess the clinical and radiological outcomes following one-stage hip reconstruction, consisting of open reduction femoral shortening and pelvic osteotomy, for neglected developmental dislocation of the hip (DDH). MATERIALS AND METHODS: This is a retrospective analysis of 77 hips in 65 patients (46 females and 19 males; 12 had bilateral dislocations), operated at a Ghurki Trust Teaching Hospital in Pakistan between 2013 and 2015. The average age at surgery was 11.02±3.43 years. According to the Tönnis classification, there were 10, 14, 22, and 31 patients in grades 1, 2, 3, and 4, respectively. The pelvic procedure utilized in this study was triple osteotomy (47 hips) followed by double and Salter osteotomy (18 and 12 hips, respectively). Postoperative evaluations were conducted using the modified MacKay's scoring system (functional outcomes) and Severin's scoring method (radiological assessment). RESULTS: Postoperatively, there were 38 (49.4%), 19 (24.7%), 14 (18.2%), and 6 (7.8%) hips in Severin grade I, II, III and IV, respectively. According to the modified McKay criteria, there were 22 hips (28.6%) in excellent condition, 44 (57.1%) in good condition, 9 (11.7%) in fair condition and 2 (2.6%) in poor condition. Both patients with poor outcomes had an unstable, painful hip with evidence of avascular necrosis of the femoral head. CONCLUSION: Based on the results presented here, we recommend the single stage procedure of open reduction, femoral shortening and pelvic osteotomy for treatment of DDH in older children with good to excellent functional and radiological outcomes.

Outcome of bipolar hemi arthoroplasty: analysis of using lateral and posteriolateral approach

Objective: To find the outcome of bipolar hemiarthroplasty using posteriolateral and lateral approaches

Study design: Descriptive case series

Place and Duration of study: Departments of Orthopaedics and Spine Centre, Ghurki Trust Teaching Hospital Lahore, from January 2015 to December 2016

Methodology: Patients of either sex and of age above 40 year, who presented in Emergency Department with femoral neck fractures, were included in the study. Data included basic demorgraphic profile, Harris hip scoring, duration of surgery, hospital stay and blood loss

Results: A total of 200 patients were included in the study. There were 77 [38.5%] males and 133 [61.5%] females. Male to female ratio was 0.58:1 with mean age of 58.2 +/- 6.02 year. Mean follow up was 14.2 +/- 2.5 months. In 134 [67.0%] patients there was history of fall, 41 [20.5%] presented with fracture after low energy vehicle accident, 20 [10.0%] presented after high energy vehicle accident. Duration of surgery and blood loss were less in posteriolateral approach. The complication rate and Harris hip scoring was similar in both the approaches

Conclusions: Outcome of surgery in terms of infection, mobility and pain as well as dislocations were similar in both the approaches. The posterior approach was superior in terms of short duration of surgery and less blood loss

Outcome of shish kabab osteotomies fixed with SIGN NAILI in osteogenesis imperfecta. our experience at Ghurki Trust Teaching Hospital, Lahore, Pakistan

Objective: To evaluate the results of shish kabab osteotomies fixed with SIGN NAIL in long bone deformities of patients suffering from osteogenesis imperfect

Methods: This study was carried out on 12 patients who presented in OPD or Emergency Department with deformities of long bones. Detailed history, examination and investigations including X-ray AP and Lateral view of involved bone were done. All these cases were treated with Shish Kabab Osteotomies and SIGN NAILunder spinal or general anaesthesia. These cases were followed up for up to average of 20 months [range 06 months -6 years ] and results of the nail were observed in terms of union, rehabilitation and complications

Results: It was found that 8 [66.7%] were male and 4 [33.3%] were females with a mean age of 14.83 +/- 5.24. 5 [41.7%] patients having age 10-15 years and 7 [58.3%] were between 16-20 years. Total 21 surgeries performed. 3[25.0%] had surgery on unilateral femur,2 [16.7%] on unilateral tibia, 3[25.0%] on both unilateral tibia and femur,3 [25.0%] had surgery on bilateral tibia and 1[13.3%] with bilateral tibia and femur. The parents of all patients had a first degree consanguineous marriage. The mean hospital stay were 4.17 +/- 1.75 days. All osteotomies sites heal within 06 months, better bone densities, 1 Having recurrence of deformity and no fracture were found. Only two patients using walkers while remaining need no support for walking

Conclusion: Sign Nail along with shish kabab osteotomies in deformities of osteogenesis imperfecta is the treatment of choice. Patient rehabilitation is early, hospitalization is short, and osteotomies site healing response is good as well as decrease risk of fracture

Autologous percutaneous bone marrow injection in long bone fractures with delayed and nonunion

Objective: to determine the outcome of bone marrow injection in fractures with signs of delayed union and nonunion in terms of clinical and radiological evidence of union

Study design: descriptive case series

Place and Duration of study: department of Orthopedics and Spinal Surgery, Ghurki Trust Teaching Hospital Lahore, from October 2014 to May 2015

Methodology: patients admitted with nonunion or delayed union were included in the study. After evaluation and taking informed consent bone marrow was taken from the iliac crest with the help of bone marrow biopsy needle and injected at the site of fracture with the aid of lumbar puncture [LP] needle under image guidance. Repeat injection was given at three month interval, if needed. Clinical and radiological evidence of bone healing was assessed at six weekly follow ups till six months

Results: a total of 80 patients were included. There were 48 males and 32 females. There were 42 tibial, 18 femoral, 11 radius/ulna and 9 humeral fractures. Sixty-two procedures under local anesthesia and eighteen under short sedation were performed. In 67 patients union occurred following injection. The mean healing time was 16 weeks

Conclusion: percutaneous bone marrow injection is an alternative treatment of choice for delayed union and nonunion for long bone fractures

Selection of lowest instrumented vertebra in the management of lenke 5 adolescent idiopathic scoliosis using pedicle screw instrumentation

Objective: To determine the lowest instrumented vertebra [LIV] in the management of Lenke 5 adolescent idiopathic scoliosis [AIS] patients using pedicle screw instrumentation. [PSI]

Study design: A retrospective review

Place and Duration of study: Department of Orthopedics and Spine Surgery, Ghurki Trust Teaching Hospital Lahore, from January 2014 to April 2016

Methodology: Analysis of radiographic parameters of 32 patients was done. The patients were grouped according to the LIV level; Group I [fusion to L3, n=25] and Group II [fusion to L4, n=7]. The Group I was further subdivided into IA [L3 crossed the mid-sacral line with rotation of less than grade II on bending films - n=14] and IIB [L3 did not cross the mid-sacral line or rotation was grade II or more on bending films n=11]. All the patients in the Group II had the same location and rotation of L3 in bending films as that of patients in the group IB. Patients with lowest instrumented vertebral tilt [LIVT] of more than 10[degree] or coronal balance of more than 15 mm, were considered to have unsatisfactory results

Results: LIVT was reduced from 20.8 +/- 6.3 to 5.5 +/- 2.9[degree] in group IA and from 24.1 +/- 8.2[degree] to 10.8 +/- 5.1[degree] in group IB and from 26.7 +/- 4.6 to 6.9 +/- 5.2[degree] in group II. A significantly less reduction was obtained in group IB [49.7%] as compared to group IA [88.4%] and group II [81.8%]. Unsatisfactory results were obtained in 1 [7.1%] patient of group IA, in 7 [63.3%] patients of the group IB, and in 1 [12.5%] patient of group II which was found to be statistically significant

Conclusions: For the correction of thoracolumbar / lumbar AIS with pedicle screw instrumentation, L3 can be selected as the LIV instead of L4, thus saving one distal motion segment, when preoperatively L3 crosses the midsacral line with a rotation of less than Nash-Moe grade II in both the active bending radiographs, otherwise fusion has to be extended to L4

Geriatric fractures: an experience at a tertiary care hospital

Objective: To find out demographics, mechanism of injury and bones involved so as to suggest preventive measures in geriatric population

Study design Retrospective case series

Place and Duration of study: Department of Orthopaedics and Spine Centre, Ghurki Trust Teaching Hospital Lahore, from January 2015 to December 2015

Methodology: This study included all patients of age greater than 50 year of either sex admitted through emergency or OPD having any type fracture. The data were taken from hospital database and included clinical, epidemiological and radiological records. The results were analyzed using SPSS version 17.0

Results: A total of 1215 patients were included in the study. Of these 880 [72.4%] were males and 335 [27.6%] females. Male to females ratio were 1.38:1 with mean age of 56.21 +/- 12.603 year. Most of them were between 51-60 year [n=629 - 51.77%]. Femoral fractures were the most common and the main mechanism of injury were fall followed by road traffic accidents

Conclusions: Femoral neck fractures were the most common fractures and mostly females were involved. Fall was the main mechanism of injury

Management of lower limb wounds by negative pressure dressings

Objective: To determine the outcome of home-made negative pressure dressings in acute complex wounds of the lower extremity in terms of healing

Study design: Descriptive case study

Place and Duration of study: Department of Orthopaedics and Spine Surgery, Ghurki Trust Teaching Hospital Lahore, from September 2012 to February 2013

Methodology: Patients with soft tissue defects of lower extremity were included. Preoperative size of the wound with Gustilo type IIIA and IIIB was measured and negative pressure dressings were applied. Each dressing was applied for 72 hours. Outcome of the wound was assessed on 9th day after 3 dressings. The quality of granulation tissue and wound healing were noted

Results: A total of 100 patients were enrolled. There were 75 males and 25 females with a ratio of 3:1. Mean age was 32.88 +/- 6.10 year. Seventy percent patients had decrease in size of the wound. Ninety patients developed granulation tissues in the lower limb wounds

Conclusion: Home-made negative pressure dressing was a valuable therapy in the management of acute injuries of lower limb as it resulted in granulation and healing of the wound under challenging conditions

Osteoarthritis; efficacy and safety of aceclofenac in the treatment: a randomized double-blind comparative clinical trial versus diclofenac"

Objective: To assess the efficacy and safety of aceclofenac in the treatment of osteoarthritis. Study design: Randomized double blind Phase IV trial. Place and Duration of study: This study was conducted in the department of Orthopaedics and Spine Surgery, Ghurki Trust Teaching Hospital, Lahore. The duration was eight weeks

Methodology: A total of 90 subjects, fulfilling the inclusion criteria and willing to give free informed consent were enrolled in this trial. All these subjects were randomized into two treatment groups [A and B]. Subjects either received Aceclofenac 100 mg twice daily or Diclofenac 75 mg twice daily for 08 weeks. During the screening visit, information on their demographic characteristics, medical history and previous and current medications were collected. A thorough physical examination and necessary laboratory investigations were carried out before drug administration and after the completion of treatment [end of week 8]. Clinical examination was done at baseline visit, randomization and 2, 4 and 8 weeks. Gastrointestinal [GI] safety was assessed using adverse drug reaction [ADR] reports. WOMAC questionnaire was used to see improvement in activities of daily living and pain was assessed using visual analogue scale [VAS]. All data was collected in the case report form [CRF]. Statistical evaluation was performed at the end of the trial and results were analyzed using SPSS

Results: 70 subjects completed the study while 20 were lost in follow-up. There were 28 males and 34 females in the study with mean age of 56 years. There was a significant decrease in WOMAC and VAS scores in both groups. In group A [Diclofenac group] VAS decreased from 7.107 to 2.538 [p= 0.000] and WOMAC decreased from 32.75 to 7.38 [p=0.000]. In group B [Aceclofenac group], VAS decreased from 7.912 to 6.0 [p=0.001] while WOMAC decreased from 37.29 to 21.50 [p=0.000] showing the efficacy of both drugs. There was also significant decrease in the disease severity in both groups at the end of treatment. But the safety profile of [Diclofenac] group A was not significant [p=0.767] as compared to [Aceclofenac] group B [p=0.022]

Conclusions: Aceclofenac is efficacious and safe drug for the treatment of osteoarthritis in adults as compared to Diclofenac

Outcome of intramedullary interlocking SIGN nail in tibial diaphyseal fracture

To determine the outcome of intramedullary interlocking surgical implant generation network [SIGN] nail in diaphyseal tibial fractures in terms of union and failure of implant [breakage of nail or interlocking screws]. Case series. Orthopaedics and Spinal Surgery, Ghurki Trust Teaching Hospital, Lahore Medical and Dental College, Lahore, from September 2008 to August 2009. Fifty patients aged 14 - 60 years, of either gender were included, who had closed and Gustilo type I and II open fractures reported in 2 weeks, whose closed reduction was not possible or was unsatisfactory and fracture was located 7 cm below knee joint to 7 cm above ankle joint. Fractures previously treated with external fixator, infected fractures and unfit patients were excluded. All fractures were fixed with intramedullary interlocking SIGN nail and were followed clinically and radiographically for union and for any implant failure. Forty one [88%] patients had united fracture within 6 months, 5 [10%] patients had delayed union while 4 [8%] patients had non-union. Mean duration for achieving union was 163 + 30.6 days. Interlocking screws were broken in 2 patients while no nail was broken in any patient. Intramedullary interlocking nailing is an effective measure in treating closed and grade I and II open tibial fractures. It provides a high rate of union less complications and early return to function