Role of Anteromedial Cortical Support for Unstable Intertrochanteric Fractures Being Treated With Cephalomedullary Nails.

INTRODUCTION: Reduction quality is of paramount importance for an optimal outcome in unstable pertrochanteric fractures. The non-anatomical functional anteromedial buttress is proposed to prevent impending mechanical complications. We aimed to evaluate the role of anteromedial cortical support in preventing mechanical complications following fixation with the cephalomedullary nail. MATERIALS AND METHODS: A prospective, single-arm interventional study was conducted in the Orthopaedics Department of a Combined Military Hospital (CMH) in Rawalpindi. The duration of the study was 24 months. Patients were recruited by the purposive sampling technique as per inclusion/exclusion criteria. Preoperatively, the reduction was categorized as per Baumgartner's and Chang's criteria. Post-operatively, weight bearing as tolerated was advised. Radiographs prior to discharge for loss of reduction were evaluated. Follow-up radiographic measurements of neck length, neck shaft angle, and their loss as per protocol were done at three and six months. RESULTS: A total of 202 patients were operated on from October 21 until August 23. Mortality at six months in 39 patients (19.3%) and loss to follow-up in 31 patients (15.3%) resulted in 132 patients with complete follow-up and having developed complications in 12 patients (9.09%). The mean age was 76.3 ± 7.98 years; males were 105 (79.5%), and females were 27 (20.5%). Closed reduction was 58 (43.9%), and additional manoeuvres were required in 74 (56.1%). The mean tip apex distance (TAD) was 24.56 ± 2.76, and the Calcar gap was 5.16 ± 1.27. Cleveland zone centre-centre in 54 (40.9%), inferior-centre in 65 (49.2%), and inferior-posterior (9.9%) were statistically significant for mechanical complications (p≤0.001). There was a significant association between the grading of Chang's and Baumgartner's poor groups for the development of mechanical complications (p≤0.001). The mean time to full weight bearing without support was 21 ± 1.22 weeks. The mean Hip Harris score at six months was 69.27 ± 7.68. CONCLUSION: Results suggest that anteromedial cortical support can lead to fewer potential mechanical complications at six months. A higher Chang's grade drives surgeons to engage in additional manoeuvres. Anteromedial cortical support is worth consideration for unstable pertrochanteric fractures.

Unilateral versus simultaneous bilateral total knee arthroplasty: A comparative study.

OBJECTIVE: To compare pre-operative characteristics and peri-operative findings in patients undergoing unilateral total knee arthroplasty (UTKA) and simultaneous bilateral total knee arthroplasty (BTKA). To work out safety criterion for selection of patients for simultaneous BTKA. METHODS: Patients undergoing UTKA (39) and BTKA (36) in Department of Orthopaedic Surgery, Combined Military Hospital, Rawalpindi from March 2014 to August 2014 were compared in terms of patient characteristics, underlying pathology, peri-operative blood loss, transfusion requirements and in hospital complications. RESULTS: The mean age of patients undergoing UTKA was 61±11 years and those undergoing BTKA was 64±8 years, with similar male to female ratio (1:1.8) in both groups. Males undergoing BTKA were significantly older than other patients (71±6 years). Primary osteoarthritis was the most common initial diagnosis (59% in UTKA and 89% in BTKA, p<0.05) followed by rheumatoid arthritis. Average blood loss per knee was higher in BTKA procedures but difference did not reach statistical significance. Blood transfusion requirements in BTKA patients not receiving antifibrinolytic agent were significantly higher than in similar UTKA patients (75% vs 17%, p<0.05) but were significantly reduced with peri-operative administration of antifibrolytic therapy (30% BTKA, p<0.05). Complication rates, low in both, were more frequent in BTKA patients with co-morbidities. CONCLUSIONS: In patients requiring bilateral knee replacements, staged total knee replacement [i.e. the two knees are replaced with a gap of at least 3 months] is a safe approach. Unilateral knee replacement is associated with lesser complications and blood transfusion requirements as compared to simultaneous bilateral total knee replacements.

Complex tibial plateau fractures: Clinical and radiological outcome following plate osteosynthesis.

OBJECTIVE: To assess the clinical and radiological outcome of complex tibial plateau fractures treated with single or dual plate osteosynthesis and augmentation of metaphyseal defects with bone graft substitute. METHODS: A retrospective review was conducted on patients presenting with tibial plateau fractures (TPF) between January 2018 and June 2019. Of the 62 patients who presented in this period, 33 met the inclusion criteria of complex type TPF. Simple split fracture types and open fractures were excluded. All patients were operated in the supine position and anatomical locking plate or low profile buttress plates for additional fragments were used. Synthetic bone graft substitute was used in filling of the metaphyseal defects. Patients were evaluated clinically using the Knee Society Score and with radiographic examination using the Heiney-Redfern Scale. RESULTS: All the patients were followed for an average of 13.39±4.63 months (range 6 - 24 months). All the included patients were males with the mean age of 41.3±12.84 years (range18-70 years). Objective knee society score graded excellent in 24 (72.8%) patients, good in 8 (24.2%) and fair in 1 (3%). Functional score, on the other hand, was excellent in 21 (63.6%), good in 9 (27.3%) and fair in 3 (9.1%) patients. Radiological outcome evaluated on x-rays and according to the H-R scale was good in 23 (69.8%) and fair in 10 (30.2%). Fracture union was achieved in all patients with no secondary loss of reduction. CONCLUSIONS: The treatment of complex tibial plateau fractures with plate osteosynthesis and graft augmentation of metaphyseal defects has shown optimal results both clinically and radiologically. Excellent joint motion and knee society score is achieved by early rehabilitation following stable fixation. However, long-term risk of post-traumatic arthritis and its severity following complex TPF needs to be determined in different methods of fixation.

Comparison of blood loss between intra-articular and intra-venous administration of tranexamic acid in primary total knee arthroplasty.

OBJECTIVE: To compare the blood loss between intra-articular and intra-venous administration of tranexamic acid (TXA) in patients undergoing primary total knee arthroplasty. DESIGN OF STUDY: It was a randomized controlled trial. Study duration and settings: This study was carried out at the Orthopedic Departments of Combined Military Hospital Lahore and Rawalpindi from Jan 2016 to March 2018. METHODOLOGY: Patients of both the genders were involved this study who had age in the rage of 40-80 years undergoing primary unilateral total knee arthroplasty for degenerative conditions like osteoarthritis and rheumatoid arthritis. These patients were randomly divided into two treatment groups. Patients in IA group received intra-articular tranexamic acid while those in IV group received intravenous tranexamic acid. From all the patients, a written signed consent was taken. FINDINGS: Females were predominant with male-to-female ratio of 1:3.7. The mean age of the patients was 67.3 ± 8.2 years while the mean BMI was 30.9 ± 2.9 Kg/m2. Majority (n = 191, 95.5%) of the patients had osteoarthritis while remaining 9 (4.5%) patients had rheumatoid arthritis. There was no statistically significant difference between intra-articular and intra-venous administration of tranexamic acid in terms of mean post-operative hemoglobin (9.93 ± 1.14 vs. 9.87 ± 1.26 g/dL; p-value = 0.724), mean post-operative hematocrit (34.8 ± 1.66 vs. 34.73 ± 1.27%; p-value = 0.594), and mean fall in hemoglobin (2.27 ± 0.34 vs. 2.25 ± 0.30 g/dL; p-value = 0.587) and hematocrit (2.34 ± 0.94 vs. 2.46 ± 0.28%; p-value = 0.216). CONCLUSION: Intra-articular administration of tranexamic acid was found to be as effective and safe as intra-venous administration in reducing blood loss in primary total knee arthroplasty. Due to convenience, the use of intra-articular administration of tranexamic acid after primary TKA may be considered in future practice.

Percutaneous Ilio-sacral Screw Fixation for Unstable Pelvic Ring Injuries.

This prospective interventional study was planned to determine the clinical and radiological outcome of percutaneous iliosacral screw fixation for unstable pelvic ring injuries. It was conducted from March 2008 to June 2014 at the Department of Orthopaedic Surgery Combined Military Hospital (CMH) at Lahore, Multan, Rawalpindi and Muzaffarabad. It comprised 50 patients with unstable pelvic ring injuries. Visual analogue scale (VAS), Majeed pelvic score and Lindahl criteria were used for functional and radiological outcomes assessment. The mean age of the patients was 47.82±8.94 years. Moreover, 33(66%) participants were males and 17(34%) were females. The mean pre-operative Majeed and VAS scores were 38.98±6.28 and 9.04±0.67, respectively. Operating time and blood loss were reduced significantly. VAS score for post-operative pain was 3.82±1.26 at 1 month and decreased further to 2.68±1.30 at 12 months post-operatively (p<0.001). Radiological outcome and the post-operative Majeed scores were good to excellent in 43(86%) cases. Thus Percutaneous iliosacral screw fixation of unstable pelvic ring injuries resulted in excellent radiological and functional outcome with significantly decreased post-operative VAS score for SI joint pain.

Less invasive versus standard total knee replacement: Comparison of early outcome.

OBJECTIVE: To compare less invasive quads conserving (limited parapatellar) approach with standard medial parapatellar approach with respect to early functional outcome in cases of total knee arthroplasty. METHODS: The retrospective case-control cohort study comprised cases operated upon between June 2009 and March 2012 in Combined Military Hospitals in Pakistan by a single surgeon. Data related to osteoarthritis patients who underwent unilateral primary total knee replacement were included. They were divided into two equal groups of control who had standard total knee arthroplasty, and the test group where less invasive surgery method was employed. Patients were followed up for 3 months postoperatively. The outcomes recorded included mean hospital stay, time to assisted ambulation, time to independent ambulation, mean range of motion and Knee Society Scores [KSS] 1 and 3 months postoperatively. RESULTS: There were 120 subjects with 60(50%) in each of the two groups. Mean hospital stay was 3.2±0.6 days for the test group compared to 5.8±1.6 days for the control group. Most test group patients were walking with assistance on 2nd postoperative day (mean: 1.7±0.6 days), whereas control group on the 4th day (mean: 4.1±1.1 days). Independent ambulation was seen at 2.1±0.3 weeks and 4.0±0.7weeks respectively in the two groups. Postoperative range of motion at 1 month was 118±13 for patients in the test group, and 99±13 for control group, with Knee Society Scores of 87±6 and 72±9 respectively. The difference in all results was statistically significant (p<0.05). CONCLUSIONS: Less invasive surgery for total knee arthroplasty was associated with faster recovery, earlier assisted and independent ambulation, shorter lengths of hospitalisation and better Knee Society Scores at 1and 3months postoperatively.

Operative treatment of displaced intra-articular fractures of Calcaneum: Is it worthwhile?

OBJECTIVE: To compare the results of operative treatment for displaced intra-articular fractures of calcaneum with conservative treatment. METHODS: The retrospective non-randomised comparative study using. purposive non-probability convenient sampling was conducted at the Combined Military Hospital, Rawalpindi, and comprised treatment records from March 2010 to October 2013 of patients who had been treated either by Plaster of Paris casting (Group A) or managed by open reduction internal fixation (Group B). Functional outcome was assessed using Foot and Ankle Disability Index. RESULTS: Of the 42 records in the study, 20(47.6%) related to Group A and 22(52.4%) to Group B. The mean age was 41±7.82 years (range: 28-55 years) in Group A, and 31±6.35 years (range: 21-43) in Group B. Male-to-female ratio was 10:1 in Group A; 9:1 in Group B. Union was achieved in all (100%) cases. Bone substitute was used in 16(72.7%) in Group B to fill void during reconstruction of collapsed calcaneum. Wound complications were noted in 2(9.1%) Group B patients. There was loss of reduction in 1(4.5%). Mean Foot and Ankle Disability Index score in Group A was 45±10.68.4 compared to 67.9±10.04 in Group B (p=1.99). CONCLUSIONS: For displaced intra-articular fractures, operative treatment is associated with better functional outcome in terms of absolute functional scores and should be the treatment of choice although factors such as age, soft tissue injury and surgical expertise may influence the decision.