Joint awareness among total hip arthroplasty patients operated through anterior approach versus posterior approach: a systematic review and meta-analysis.

PURPOSE: The aim of this systematic review and meta-analysis was to compare joint awareness in patients who underwent total hip arthroplasty (THA) via the anterior approach (AA) versus the posterior approach (PA). The hypothesis was that patients who underwent THA via AA would have better forgetfulness of the artificial joint. METHODS: A comprehensive search of major literature databases and bibliographic details was conducted to identify studies evaluating the forgotten joint score (FJS-12) in total hip arthroplasty (THA) patients operated through the anterior approach (AA) and posterior approach (PA). Out of 234 studies identified, seven studies met the inclusion criteria for review. The Newcastle-Ottawa Scale was used to evaluate the quality of evidence and the risk of bias in the included studies. The FJS-12 was evaluated at three months, one year, and beyond 2 years. RESULTS: The mean FJS-12 at > 2 years was 82.03 in the AA group and 80.32 in the PA group. The forest plot analysis (n = 819 patients) revealed no significant difference in FJS-12 score between these two approaches (MD 2.13, 95% CI [- 1.17, 5.42], p = 0.21; I2 = 60%). However, the joint awareness was significantly lesser in the AA group at 3 months (MD 12.56, 95% CI [9.58, 15.54], p < 0.00001, I2 = 0%) and 1 year (MD 9.55, 95% CI [7.85, 11.24], p < 0.0001, I2 = 0%). CONCLUSIONS: After analyzing the available literature, it was found that THA patients operated through the AA approach have significantly lower joint awareness than those operated through the PA approach in the first year of surgery. However, there is no significant difference in joint awareness between these two approaches after 2 years. LEVEL OF EVIDENCE: III.

DEXA and Imaging in Osteoporosis.

Background: Reduced bone density and increased fragility are hallmarks of osteoporosis, making the disease a major public health concern. The disease necessitates early diagnosis and appropriate therapy depend on an accurate evaluation of bone health. Essential tools for assessing osteoporosis include dual-energy X-ray absorptiometry (DEXA) and other imaging modalities. Methods: This chapter focuses on dual-energy X-ray absorptiometry (DEXA) and other imaging methods as essential tools for assessment of osteoporosis. The chapter also explores complementary imaging modalities that help overcome limitation of DEXA by providing insights into the microarchitecture and bone quality. Results: T-scores, used to categorise bone health, are determined by DEXA by comparing bone mineral density to age-matched standards. Bone mineral density (BMD) is the most common indicator of bone health; nevertheless, DEXA may misclassify bone health owing to reasons other than BMD. These constraints may be overcome with the use of complementary imaging methods, which provide information on the microarchitecture and quality of bone. The evaluation of bone structure is aided by high-resolution peripheral quantitative computed tomography (HR-pQCT), which produces precise 3D images of the trabecular and cortical bone compartments. Independent of traditional methods of gauging fracture risk, quantitative ultrasonography (QUS) uses an analysis of the characteristics of sound waves to determine bone health. Diagnostic precision is improved by magnetic resonance imaging (MRI) due to its ability to view bone marrow and trabecular structure without the use of ionising radiation. Discussion: New methods, such as the trabecular bone score (TBS), examine bone texture and provide more data on the likelihood of fracture than conventional DEXA. By modelling bone strength using imaging data, finite element analysis (FEA) provides a biomechanical viewpoint on breakage probability. These combined methods boost diagnostic accuracy and pave the way for individualised treatment plans. Imaging helps with therapy monitoring as well as diagnosis. By monitoring bone density and structure over time, therapy effectiveness or course corrections may be quickly identified. The availability of sophisticated imaging techniques and the standardisation of procedures provide obstacles not withstanding their advantages. Ongoing work is being done to solve these issues and standardise and disseminate these methods in a variety of contexts. Conclusion: The evaluation of osteoporosis is significantly aided by DEXA and other imaging methods. While DEXA is still the gold standard for diagnosing osteoporosis, other imaging techniques may shed light on bone health in greater detail. These methods improve fracture risk prediction and treatment assessment by providing information on bone architecture, quality, and strength. Integration of several imaging modalities shows potential for bettering osteoporosis therapy and patient outcomes as the field develops.

Ethics in Clinical Orthopedic Surgery.

Introduction: Orthopedic surgeons, owing to their specialized role, have a set of medical and moral responsibilities that span beyond the confines of the operating room. The primary objective of this exploration is to emphasize the pivotal ethical and professional standards that these surgeons should uphold. Methodology: We derived key ethical and professional aspects by reviewing standard medical practices, professional guidelines, and through consultations with senior orthopedic professionals. These aspects covered both the conduct inside the surgery room and the interpersonal relations outside. Results: Several core areas of conduct were identified.Patient-Centered Care: Prioritizing the holistic well-being of the patient.Communication: Ensuring that all communications are both transparent and respectful.Informed Consent: Properly securing consent after ensuring the patient is adequately informed.Confidentiality: Taking measures to safeguard patient information.Professional Behavior: Upholding the highest standards of professional conduct.Continuous Learning: Remaining committed to updating skills and enhancing competence.Interpersonal Relations: Building healthy and constructive relationships with industry representatives, professional peers, and hospital staff.Personal Life Balance: Recognizing the importance of a balanced personal and professional life for holistic well-being. Conclusion: For Orthopedic surgeons, strict adherence to the outlined ethical and professional principles is essential. Such commitment not only ensures the trust and safety of patients but also serves to maintain and elevate the prestigious standing of the orthopedic community in the broader medical landscape.

Ethical Practice for Postgraduate Students in Orthopedics: Nurturing Professionalism and Patient Care.

Background: In the domain of orthopedics, ethical practice significantly influences professionalism and the quality of patient care delivered by postgraduate students. This narrative review aimed to investigate the implementation and impact of an ethics-centric curriculum tailored for orthopedic postgraduate students. Methods: The proposed curriculum incorporates methodologies such as case-based learning, interactive discussions, and dedicated mentoring sessions, focusing on the unique ethical challenges encountered in orthopedics. Results: Introducing the curriculum provided postgraduate students with a robust foundation in ethical principles, enhancing effective communication, and fostering better doctor-patient relationships. Consequently, the students displayed an increased aptitude in navigating intricate ethical dilemmas in their clinical practice. Conclusion: There is a crucial need for continuous ethics education in orthopedics. Creating a supportive learning environment is essential to cultivate professionalism and promote patient-centered care. This study underscores the transformative potential of ethics training in molding orthopedic professionals who are both competent and deeply committed to maintaining the highest ethical standards.

Standard practice in the treatment of unstable pelvic ring injuries: an international survey.

PURPOSE: Unstable pelvic ring injury can result in a life-threatening situation and lead to long-term disability. Established classification systems, recently emerged resuscitative and treatment options as well as techniques, have facilitated expansion in how these injuries can be studied and managed. This study aims to access practice variation in the management of unstable pelvic injuries around the globe. METHODS: A standardized questionnaire including 15 questions was developed by experts from the SICOT trauma committee (Société Internationale de Chirurgie Orthopédique et de Traumatologie) and then distributed among members. The survey was conducted online for one month in 2022 with 358 trauma surgeons, encompassing responses from 80 countries (experience > 5 years = 79%). Topics in the questionnaire included surgical and interventional treatment strategies, classification, staging/reconstruction procedures, and preoperative imaging. Answer options for treatment strategies were ranked on a 4-point rating scale with following options: (1) always (A), (2) often (O), (3) seldom (S), and (4) never (N). Stratification was performed according to geographic regions (continents). RESULTS: The Young and Burgess (52%) and Tile/AO (47%) classification systems were commonly used. Preoperative three-dimensional (3D) computed tomography (CT) scans were utilized by 93% of respondents. Rescue screws (RS), C-clamps (CC), angioembolization (AE), and pelvic packing (PP) were observed to be rarely implemented in practice (A + O: RS = 24%, CC = 25%, AE = 21%, PP = 25%). External fixation was the most common method temporized fixation (A + O = 71%). Percutaneous screw fixation was the most common definitive fixation technique (A + O = 57%). In contrast, 3D navigation techniques were rarely utilized (A + O = 15%). Most standards in treatment of unstable pelvic ring injuries are implemented equally across the globe. The greatest differences were observed in augmented techniques to bleeding control, such as angioembolization and REBOA, more commonly used in Europe (both), North America (both), and Oceania (only angioembolization). CONCLUSION: The Young-Burgess and Tile/AO classifications are used approximately equally across the world. Initial non-invasive stabilization with binders and temporary external fixation are commonly utilized, while specific haemorrhage control techniques such as pelvic packing and angioembolization are rarely and REBOA almost never considered. The substantial regional differences' impact on outcomes needs to be further explored.

Safety and Efficacy of Tranexamic Acid in Hip Hemiarthroplasty for Fracture Neck Femur: a Systematic Review and Meta-analysis.

Purpose: Although numerous systematic reviews and meta-analyses have established the efficacy of tranexamic acid (TXA) in hip fracture surgeries, the included studies in those reviews have included all types of surgical interventions ranging from fixation to arthroplasty. Hip hemiarthroplasty is usually indicated in the elderly patients with femoral neck fracture and these patients have associated severe comorbidities and cognitive impairment. These subsets of patients with femoral neck fracture needs appropriate perioperative care and judicious use of antifibrinolytics. There is no meta-analysis evaluating the safety and efficacy of intravenous TXA in these patients. Methods: Searches of PubMed, Embase and Cochrane Central Register of Controlled Trials databases revealed 102 studies on TXA in hip fracture surgeries. After screening, eight studies were found to be suitable for review. The primary objective of this meta-analysis was to compare blood transfusion rate between TXA vs. control in hip hemiarthroplasty. The secondary objectives were total blood loss, postoperative haemoglobin, surgical duration, length of hospital stay and side effects (VTE, readmission and 30 days mortality). Results: There were one RCT, one prospective cohort study and six retrospective studies. All studies recruited the elderly patients. Intravenous (IV) TXA administration resulted in significant reduction in requirement of blood transfusion (12.7% vs. 31.9%; OR 0.28; 95% CI 0.17-0.46; p < 00,001; I 2 = 73%). The TXA group had significantly decreased total blood loss (MD - 100.31; 95% CI - 153.79, - 46.83; p < 0.0002). The postoperative Hb in the TXA group was significantly higher than the control group (MD 0.53; 95% CI 0.35, 0.71; p < 0.00001). There was no significant difference in the incidences of VTE (0.97% vs. 0.73%, OR 1.27; p = 0.81; I 2 = 64%) and readmission rate (9.2% vs. 9.64%; OR 0.79; p = 0.54), but 30-d mortality rate was significantly lower in the TXA group (3.41% vs. 6.04%; OR 0.66; p = 0.03). Conclusions: Intravenous TXA is efficacious in the reduction of blood loss and transfusion need in hip hemiarthroplasty surgery for hip fracture, without increased risk of VTE. The blood conservation protocol led to decreased 30 days mortality in these fragile elderly patients. Level of evidence: III.

Perioperative mortality and morbidity of hip fractures among COVID-19 infected and non-infected patients: A systematic review and meta-analysis.

PURPOSE: Hip fractures among elderly patients are surgical emergencies. During COVID-19 pandemic time, many such patients could not be operated at early time because of the limitation of the medical resources, the risk of infection and redirection of medical attention to a severe infective health problem. METHODS: A search of electronic databases (PubMed, Medline, CINAHL, EMBASE and the Cochrane Central Register of Controlled Trials) with the keywords "COVID", "COVID-19″, "SARS-COV-2", "Corona", "pandemic", "hip fracture", "trochanteric fracture" and "neck femur fracture" revealed 64 studies evaluating treatment of hip fracture in elderly patients during COVID-19 pandemic time. The 30-day mortality rate, inpatient mortality rate, critical care/special care need, readmission rate and complications rate in both groups were evaluated. Data were analyzed using Review Manager (RevMan) V.5.3. RESULTS: After screening, 7 studies were identified that described the mortality and morbidity in hip fractures in both COVID-19 infected (COVID-19 +) and non-infected (COVID-19 -) patients. There were significantly increased risks of 30-day mortality (32.23% COVID-19 + death vs. 8.85% COVID-19 - death) and inpatient mortality (29.33% vs. 2.62%) among COVID-19 + patients with odds ratio (OR) of 4.84 (95% CI: 3.13 - 7.47, p < 0.001) and 15.12 (95% CI: 6.12 - 37.37, p < 0.001), respectively. The COVID-19 + patients needed more critical care admission (OR = 5.08, 95% CI: 1.49 - 17.30, p < 0.009) and they remain admitted for a longer time in hospital (mean difference = 3.6, 95% CI: 1.74 - 5.45, p < 0.001); but there was no difference in readmission rate between these 2 groups. The risks of overall complications (OR = 17.22), development of pneumonia (OR = 22.25), and acute respiratory distress syndrome/acute respiratory failure (OR = 32.96) were significantly high among COVID-19 + patients compared to COVID-19 - patients. CONCLUSIONS: There are increased risks of the 30-day mortality, inpatient mortality and critical care admission among hip fracture patients who are COVID-19 +. The chances of developing pneumonia and acute respiratory failure are more in COVID-19 + patients than in COVID-19 ‒ patients.

Pelvic Malunion: A Systematic Review, Dichotomy of Definitions and Treatment.

Background and Objectives: Pelvic nonunion and malunion have been documented as rare complications in pelvic fractures and literature describing these topics is severely limited. Articles dedicated solely to pelvic malunion are nearly nonexistent. We conducted a literature search with the goal of providing a summary of the definition, causes, treatment strategies, and outcomes of pelvic malunion correction. Materials and Methods: An initial review of the literature was performed using the PubMed, ScienceDirect, and Cochrane Database of Systematic Reviews databases. Search terms used were "malunion" AND "pelvic" OR "pelvis". Duplicate articles, non-English language articles without translations available and non-human subject studies were excluded. Results: Eleven original publications were found describing experiences with pelvic malunion. Seven of the articles were exclusively dedicated to the topic of pelvic fracture malunion, and only two reported on a series of patients treated for malunion with variably staged procedures. Most reports define pelvic pain as the main indication for surgical correction, along with gait disturbance, standing or sitting imbalance, and urinary or sexual dysfunction. Radiographically, vertical displacement of one to two centimeters and rotation of the hemipelvis of fifteen degrees or more have been described in defining malunion. No treatment algorithms exist, and each patient is treated with a unique work-up and operative plan due to the complexity of the problem. Only one series reported a patient satisfaction rate of 75% following malunion treatment. Conclusions: Pelvic malunion is a rare complication of pelvic ring injury and is seldom discussed in the literature. We found two small case series reporting exclusively on malunion treatment and complications. While some of the combination studies made the distinction in the diagnosis of malunion and nonunion, they rarely differentiated the treatment outcomes between the two categories. This paper describes pelvic malunion and highlights the need for more research into surgical outcomes of treatment specifically regarding functionality, patient satisfaction, and recurrence of preoperative symptoms.

Dual-Plating in Distal Femur Fracture: A Systematic Review and Limited Meta-analysis.

INTRODUCTION: Although lateral locking plate has shown promising results in distal femur fracture, there are high rates of varus collapse and implant failure in comminuted metaphyseal and articular fractures. This systematic review evaluates the functional outcomes and complications of dual plating in the distal femur fracture. MATERIALS AND METHODS: Manual and electronic search of databases (PubMed, Medline Embase and Cochrane Central Register of Controlled Trials) was performed to retrieve studies on dual plate fixation in the distal femur fracture. Of the retrieved 925 articles, 12 were included after screening. RESULTS: There were one randomized-controlled, four prospective and seven retrospective studies. A total of 287 patients with 292 knees were evaluated (dual plating 213, single plating 76, lost to follow-up 3). The nonunion and delayed union rates following dual plate fixations were up to 12.5% and 33.3%, respectively. The mean healing time ranged from 11 weeks to 18 months. Good to excellent outcome was observed in 55-75% patients. There was no difference between the single plate and dual plate fixation with regards to the functional outcomes (VAS score, Neer Score and Kolmert's standard) and complications. Pooled analysis of the studies revealed a longer surgical duration (MD - 16.84, 95% CI - 25.34, - 8.35, p = 0.0001) and faster healing (MD 5.43, 95% CI 2.60, 8.26, p = 0.0002) in the double plate fixation group, but there was no difference in nonunion rate (9.2% vs. 0%, OR 4.95, p = 0.13) and blood loss (MD - 9.86, 95% CI - 44.97, 25.26, p = 0.58). CONCLUSION: Dual plating leads to a satisfactory union in the comminuted metaphyseal and articular fractures of the distal femur. There is no difference between the single plate and dual plate with regards to nonunion rate, blood loss, functional outcomes and complications. However, dual fixation leads to faster fracture healing at the cost of a longer surgical duration.

External fixation versus open reduction and internal fixation in the treatment of Complex Tibial Plateau Fractures: A systematic review and meta-analysis.

OBJECTIVE: The aim of this meta-analysis was to compare the functional outcomes and complications of external fixation (EF) versus open reduction and internal fixation (ORIF) in the treatment of complex tibial plateau fractures. METHODS: Based on a comprehensive search of major databases through PubMed, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL), 19 studies comparing EF versus ORIF in treatment of complex tibial plateau fractures (Schatzker V-VI/ OTA C1, C2, and C3) were included in the studies. There was one randomized controlled trial, two prospective comparative studies, 14 retrospective comparative studies, and two conference papers. From these studies, the data regarding functional and surgical outcomes as well as complications were obtained and pooled to conduct a comparison between the two methods of treatment. RESULTS: 1191 tibial plateau fractures were determined by the systematic review. Of those fractures, 543 were treated using EF, and 648 were treated using ORIF with plate and screws. All the studies included the young patients with traumatic tibial plateau fractures with mean ages from 40 to 60 years. The analysis of pooled data revealed significantly better functional outcome in patients operated with EF (standard mean difference [SMD] = 0.29, 95% confidence interval [CI] = 0.04-0.55, P = 0.02, I2= 0%). However, according to categorical functional outcomes, no significant differences were found (OR 0.80, 95%CI: 0.47, 1.34, P=0.39, I2= 31%). The range of movement at the knee joint was significantly better in patients treated by EF (mean difference [MD] = 7.86, 95%CI = 3.56 -12.17, P = 0.0003). The surgical time in the EF group was significantly shorter compared to the ORIF group (MD = -52.11, 95%CI = -99.62-(-4.60), P = 0.03). Similarly, the intraoperative blood loss was significantly lesser in the EF group (MD = -341.53, 95%CI = -528.18- (-154.88), P = 0.0003). Although the superficial infection was more frequent in the EF group (odds ratio [OR] = 3.22, P = 0.0002), there were no differences in the deep infection and overall infection rates. Also, there were no differences in reoperation rate, knee stiffness, compartment syndrome, and venous thromboembolism. The radiographic osteoarthritis was more common in the EF group (OR = 1.56, P = 0.04); however, there was no difference in the need for total knee arthroplasty between the two treatment modalities. CONCLUSION: EF provides better functional outcomes and range of motion compared to ORIF in the treatment of complex tibial plateau fractures. With shorter surgical time and lesser intraoperative blood loss, EF can be considered as a definite treatment method in open injuries, polytrauma patients, and chronically morbid patients who cannot withstand prolonged surgery. LEVEL OF EVIDENCE: Level III, Therapeutic Study.

Complications and Functional Outcome of Femoral Head Fracture-Dislocation In Delayed and Neglected Cases.

INTRODUCTION: Delayed reduction of the hip in femoral head fracture dislocation increases the risk of osteonecrosis and adversely affects the functional outcome. MATERIALS AND METHODS: This retrospective study was designed to evaluate the outcome and complications of 138 patients with femoral head fracture dislocation treated by a single surgeon over a period of 22 years. Only seven patients presented within 24 h of injury and remaining all presented late. The hip joints could be reduced by closed manoeuvre in 105 patients, and 33 patients needed open reduction. The patients were managed conservatively or surgically. The mean follow-up period was 3.57 years (1-18 years). RESULTS: There were 119 males and 19 females. The mean age was 35.71 years (range, 18-70 years). Forty-two patients were managed conservatively, and 96 patients needed surgical treatment. The Kocher-Langenbeck approach was used in 40 patients, the trochanteric flip osteotomy in 14 patients, the Smith-Peterson approach in 31 patients, and the Watson-Jones approach in one patient. The femoral head fragment was fixed in 47.82% patients and excised in 11.59% patients. Primary total hip replacement (THR) was performed in 7.24% of patients through the posterior approach. 24.63% of patients developed complications with 14.49% of hip osteonecrosis, 2.89% posttraumatic osteoarthritis and 2.17% femoral head resorption. 55% of patients who developed osteonecrosis were operated through the posterior approach. Secondary procedures were needed in 14.48% of patients. The clinical outcome, as evaluated using the modified Harris Hip Score, was good to excellent in 52.89% of patients and poor to fair in 47.11% of patients. CONCLUSION: The incidences of osteonecrosis and secondary procedures are increased in delayed and neglected femoral head fracture dislocation. Osteonecrosis is commonly seen in Brumback 2A injuries and posterior-based approaches. All Brumback 3B fractures in such delayed cases should be treated with THR. Osteosynthesis or conservative treatment should be reserved for other types of injuries. A careful selection of treatment plan in such delayed cases can result in a comparable functional outcome as reported in the literature.

Management of pelvic injuries in hemodynamically unstable polytrauma patients - Challenges and current updates.

Pelvic injuries are notorious for causing rapid exsanguination, and also due to concomitant injuries and complications, they have a relatively higher mortality rate. Management of pelvic fractures in hemodynamically unstable patients is a challenging task and has been variably approached. Over the years, various concepts have evolved, and different guidelines and protocols were established in regional trauma care centers based mainly on their previous experience, outcomes, and availability of resources. More recently, damage control resuscitation, pelvic angioembolization, and acute definitive internal fixation are being employed in the management of these unstable injuries, without clear consensus or guidelines. In this background, we have performed a computerized search using the Cochrane Database of Systematic Reviews, Scopus, Embase, Web of Science, and PubMed databases on studies published over the past 30 years. This comprehensive review aims to consolidate available literature on the current epidemiology, diagnostics, resuscitation, and management options of pelvic fractures in polytraumatized patients with hemodynamic instability with particular focus on damage control resuscitation, pelvic angioembolization, and acute definitive internal fixation.

Joint awareness after unicompartmental knee arthroplasty and total knee arthroplasty: a systematic review and meta-analysis of cohort studies.

PURPOSE: The purpose of this systematic review and meta-analysis is to evaluate the joint awareness after unicompartmental knee arthroplasty (UKA) and total knee arthroplasty (TKA). It was hypothesized that patients with UKA could better forget about their artificial joint in comparison to TKA. METHODS: A search of major literature databases and bibliographic details revealed 105 studies evaluating forgotten joint score in UKA and TKA. Seven studies found eligible for this review were assessed for risk of bias and quality of evidence using the Newcastle-Ottawa Scale. The forgotten joint score (FJS-12) was assessed at 6 months, 1 year, and 2 years. RESULTS: The mean FJS-12 at 2 years was 82.35 in the UKA group and 74.05 in the TKA group. Forest plot analysis of five studies (n = 930 patients) revealed a mean difference of 7.65 (95% CI: 3.72, 11.57, p = 0.0001; I2 = 89% with p < 0.0001) in FJS-12 at 2 years. Further sensitivity analysis lowered I2 heterogeneity to 31% after exclusion of the study by Blevin et al. (MD 5.88, 95%CI: 3.10, 8.66, p < 0.0001). A similar trend of differences in FJS-12 between the groups was observed at 6 months (MD 32.49, 95% CI: 17.55, 47.43, p < 0.0001) and at 1 year (MD 25.62, 95% CI: 4.26, 46.98, p = 0.02). CONCLUSIONS: UKA patients can better forget about their artificial joint compared to TKA patients. LEVEL OF EVIDENCE: III.

Cross-cultural validation of Hindi version Knee Injury and Osteoarthritis Outcome Score (KOOS) in osteoarthritis knee.

PURPOSE: To assess the reliability, validity and responsiveness of the Hindi version of the Knee Injury and Osteoarthritis Outcome Score (H-KOOS) in osteoarthritic knee. METHODS: Two hundred and fourteen patients of osteoarthritis knee (OA) between 40 and 80 years of age were evaluated with H-KOOS, Short form health survey (SF12v2) and the WHOQOL-BREF questionnaire. The H-KOOS was re-evaluated after 48 h in 125 patients to assess the test-retest reliability. For responsiveness, 40 patients were treated with the intra-articular hyaluronic acid injection, and the effect was assessed after 6 weeks. RESULTS: Most of the domains in H-KOOS did not show a ceiling effect. The floor values were observed in 3.75% of patients in sports/recreation function and 2.75% of patients in Quality of life (QoL). The test-retest reliability was excellent with the Intraclass-Correlation-Coefficient (ICC) ranging from 0.89 to 0.94. Internal consistency as assessed using Cronbach's alpha coefficient was acceptable for pain, activities of daily living (ADL) and sport/recreation function (range 0.86-0.93); however, symptoms and QoL had weak internal consistency. There were moderate to strong correlations (r = 0.35 to 0.6) between domains measuring similar constructs in H-KOOS, SF12v2 and WHOQOL-BREF indicating good convergent construct validity. The responsiveness as measured by the effect size (ES) and standardized response mean (SRM) was large for pain (ES 0.9, SRM 0.8), moderate for Sport/Rec (ES 0.66, SRM 0.2) and small for ADL, QoL and Symptoms subscales. CONCLUSION: The Hindi version KOOS is a valid, reliable and responsive measure to evaluate osteoarthritis knee with minimal ceiling and floor effects. LEVEL OF EVIDENCE: Prospective cohort study, level II.

Factors affecting quality of life after pelvic fracture.

INTRODUCTION: Functional outcome and health-related quality of life (HRQOL) after pelvis fracture is suboptimal; majority of the patients do not return to their preinjury activities. Many researchers reported that late morbidity in pelvis fracture is associated with severity of the fracture, associated trauma, pelvic fracture-related complications and methods of treatment. MATERIAL AND METHODS: One hundred and twelve patients with pelvis fracture who were treated either conservatively (n = 88) or surgically (n = 24) with a minimum of two years follow up were evaluated clinically and radiologically. The clinical outcome was evaluated using Majeed score and self-reported Short Musculoskeletal Function Assessment (SMFA). Their HRQOL was evaluated using the 36-item Short Form Survey (SF-36) and WHOQOL-BREF questionnaires. The fracture-displacement in the anterior or posterior pelvis ring was measured from the anteroposterior radiograph or inlet/outlet view. RESULTS: The average Majeed score was 76.65 ± 14.73 (range, 36 to 96). There were 81 patients with good to excellent outcomes and 31 patients with poor to fair outcomes. The average SF-36 Physical Component Summary (PCS) score was 47.71 ± 7.88 (range, 27.3 to 61.5) and SF-36 Mental Component Summary (MCS) was 49.20 ± 9.37 (range, 23.1 to 56.8). The functional level of the general population in the physical and mental domain was achieved in 48.23% and 65.3% of pelvic-fractured patients respectively. General population norms were achieved in 56.3%, 63.4%, 65.2% and 84.8% of patients in WHOQOL-BREF domain one, two, three and four respectively. The patients had significantly worse functional outcome and HRQOL if residual displacement was > 1 cm. Age, sex, associated injuries and injury mechanism were not affecting the HRQOL in patients with acceptable residual displacement of ≤ 1 cm. CONCLUSION: Pelvic fracture with the residual displacement of ≤ 1 cm in the sacroiliac joint/symphysis pubis result in better functional outcome and HRQOL. Injury mechanism and associated injury have no impact on the HRQOL if the residual displacement is within the acceptable limit.

Assessment and reliability of the World Health Organisation quality of life (WHO QOL-BREF) questionnaire in total hip replacement patients.

BACKGROUND: Several functional scoring tools are available to evaluate the outcomes of total hip replacements (THRs) for diseased or damaged hips. Majority of these scores were devised in western countries and their cross-cultural compatibilities are rarely demonstrated. The World Health Organisation quality of life (WHO QOL-BREF) questionnaire with 4 domains, is one of the best known multilingual instruments for such assessment. Its reliability has never been demonstrated for THRs and the present study was conceptualised for the same. METHODS: THRs done over 6 years were followed up retrospectively. Revision THRs and hemiarthroplasties were excluded. All the cases were done by a single senior arthroplasty surgeon. Clinical examination was done and questionnaires for WHO QOL-BREF and Harris Hip scores were given to the patients. RESULTS: The number of patients included in the study was 96 with 115 operated hips. The average age of these patients was 41.40 years ranging from 17 to 80 years. There was strong male preponderance in our series of patients with 90 THRs. The mean score of domain 1 was 70.8 (SD 21.6), domain 2: 72.4 (SD 18.8), domain 3: 74.7 (SD 16.8) and domain 4: 75.4 (SD 14.8); showed significant functional improvement post THR in domain 2 (P = 0.0001), domain 3 (P = 0.0010) and domain 4(P = 0.0001), when compared to scores of general healthy population. Similarly, the scores were significantly improved in all domains as compared to cohorts of post-operative acetabular and hip fractures. The score was found to be a reliable tool with Cronbach's alpha of 0.912 and strong correlation was present with the standard Harris hip scores (p = 0.000). CONCLUSION: WHO QOL-BREF is a potent tool to assess the quality of life in patients undergoing THRs. It can be used as a single index of measurement and it is simple, reproducible and reliable.

Can IL-6 predict the development of fat embolism in polytrauma? A rabbit model pilot experimental study.

BACKGROUND: There are few studies in the literature that correlates the level of IL-6 with fat embolism syndrome (FES). But there is no conclusive correlative evidence of its specific relation to the establishment of FES. Also it is a proven fact that polytrauma due to its associated multiple long bone fracture and/or associated shock can predispose an individual to FES. By hypothesizing that polytrauma induces Fat Embolism in the animal; it was considered worthwhile to study the association of IL-6 in polytrauma induced Fat Embolism (FE) and to compare it with induced FE by injecting fatty acids in rabbits. MATERIALS AND METHODS: An animal study was conducted in 32 New Zealand white rabbits. The animals were divided into 3 groups: control, fat embolism and polytrauma group. We injected 6 ml of normal saline and 0.2 ml of linoleic acid in the control and fat embolism group respectively. In the polytauma group we created bilateral femur and tibial shaft factures which were stabilized with intramedullary K- wires. Blood was taken before and at 6, 12 and 24 h after the procedure to measure plasma IL-6 levels. The rabbits were euthanized at 24 h and lungs were removed and stained for fat globules. RESULTS: All rabbits in the fat embolism group and around 72.22% rabbits in polytrauma group had fat embolism. The IL-6 levels were raised in all the groups reaching a peak at 6 h after procedure with a decline in the values at 12 h for polytrauma and fat embolism group. IL-6 in the control group was stationary after an initial raise at 6 h. There was no statistically significant difference seen among the groups (p value > 0.05) at 6 h. CONCLUSION: IL-6 is not a specific marker to fat embolism per se or polytrauma who later develop complications like FES. Even though the recent literature says that IL-6 is an early marker of fat embolism, still the diagnosis of fat embolism syndrome is clinical only and can be supplemented by laboratory markers. None of the laboratory markers individually is good enough to predict the development of FES in an individual.

Total hip arthroplasty for arthritis following acetabular fractures-evaluation of radiological, functional and quality of life parameters.

INTRODUCTION: Total hip arthroplasty (THA) has been termed as 'operation of the century' as it provides a stable and mobile hip to patients who are debilitated by pathologies affecting the hip. Acetabular fractures pose a challenge for their initial management as well for the management of secondary osteoarthritis which is often the outcome of these fractures. The study attempts to evaluate the short term radiological, functional and quality of life outcomes of THA done in patients with prior acetabular fractures and to find a correlation between various factors. MATERIALS AND METHODS: 47 patients who provided consent for this retrospective study were clinically and radiologically evaluated at their latest follow up. Ratios of horizontal offset, vertical offset, body lever arm and cup inclination were calculated with respect to the opposite normal hip on a radiograph. Questionnaires were filled up for Harris Hip Score (HHS), Short form -12, Short Musculoskeletal functional assessment (SMFA) and WHO-quality of life (WHO-QoL). RESULTS: HHS and quality of life scores had a tendency to improve over time. A statistically significant difference (p < 0.05) was noted between scores of patients having less than 2 years follow up and more than 4 years follow-up. The HHS, radiological and quality of life parameters were not statistically significantly different when analysed based on acetabular fracture pattern, their primary management and aetiology necessitating the THA. CONCLUSION: The short term radiological, functional and quality of life parameters are dependent on the accuracy of the THA performed and are not significantly affected by the fracture type, initial management and outcomes of that management. However, longer follow up is necessary to evaluate these parameters even more accurately.

Epidemiological Profile of Femoral Head Osteonecrosis in the North Indian Population.

BACKGROUND: There are limited studies on the epidemiology of femoral head osteonecrosis in Indian population. This study was designed to look for the risk factors of osteonecrosis hip and to assess the severity as per radiological staging (Association Research Circulation Osseous [ARCO]) and clinical score (Harris hip score [HHS]). MATERIALS AND METHODS: 249 patients (382 hips) of osteonecrosis femoral head (ONFH) who were evaluated at our center between January 1, 2005, and June 30, 2013, were included in this retrospective study. The details of history, clinical examination, radiological grading, and HHS were entered into a proforma. RESULTS: The mean age was 34.71 years (range 14-70 years) and 70.28% (n=175) patients were between 20 and 40 years. Male to female ratio was 5:1. Bilateral ONFH was observed in 53.41% (n=133) patients. In atraumatic conditions, bilateral involvement was seen in 61.61% (130/211) patients. Steroid administration (37.3%, 93/249) was most commonly observed in the patients followed by idiopathic in 21.3% (53/249) patients, chronic alcohol consumption in 20.1% (50/249) patients, and trauma in 15.3% (38/249) patients. There were 48% (185/382) hips in ARCO Stage 2 followed by 33% (125/382) in Stage 3 and 16% (61/382) in Stage 4. The mean HHS was 80.97 ± 14.35 in unilateral ONFH. The mean HHS was 72.79 ± 14.43 and 80.07 ± 13.52 in more involved hip and in less involved hip, respectively, in bilateral ONFH. The ARCO staging had statistically significant correlation with HHS (Pearson's correlation coefficient r = -0.783, P < 0.01) in unilateral ONFH patients and more severely affected hip in bilateral (Pearson's correlation coefficient r = -0.654, P < 0.01) ONFH, but it did not show any association with less involved hip in bilateral cases. CONCLUSION: ONFH in the North Indian patients is a disease of young individuals with male predominance. Steroid intake is most commonly observed in these patients followed by idiopathic, chronic alcohol consumption, and trauma.

Nuclear medicine imaging in osteonecrosis of hip: Old and current concepts.

Osteonecrosis (ON) is caused by inadequate blood supply leading to bone death, which results in the collapse of the architectural bony structure. Femoral head is the most common site involved in ON. Magnetic resonance imaging (MRI) is a commonly used imaging modality to detect early ON. When MRI is inconclusive, bone scan is helpful in detecting ON during early phase of the disease. As newer nuclear medicine equipment, like single photon emission computed tomography/computed tomography (CT) and positron emission tomography/CT, are emerging in medical science, we review the role of these imaging modalities in ON of femoral head.