Functional outcome in athletes at five years of arthroscopic anterior cruciate ligament reconstruction.

Introduction. The purpose of this study was to analyze the functional outcome in competitive level athletes at 5 years after ACL reconstruction with regard to return to sports and the factors or reasons in those who either stopped sports or showed a fall in their sporting levels. Methods. 48 competitive athletes who had undergone arthroscopic assisted ACL reconstruction with a minimum follow up of at least 5 years were successfully recalled and were analyzed. Results. 22 patients had returned to the preinjury levels of sports and 18 showed a decrease in their sporting levels. Of the 18 patients, 12 referred to fear of reinjuring the same or contra-lateral knee as the prime reason for the same while 6 patients reported persisting knee pain and instability as reasons for a fall in their sporting abilities. The difference in the scores of these groups was statistically significant. 8 patients out of the 48 had left sports completely due to reasons other than sports, even though they had good knee outcome scores. Conclusion. Fear of reinjury and psychosocial issues that are relevant to the social milieu of the athlete are very important and affect the overall results of the surgery with respect to return to sports.

Mini-incision dynamic condylar screw fixation for comminuted subtrochanteric hip fractures.

PURPOSE: To review the results of indirect reduction and mini-incision dynamic condylar screw (DCS) fixation for comminuted subtrochanteric femoral fractures. METHODS: 29 men and 14 women aged 25 to 65 (mean, 44) years with comminuted subtrochanteric femoral fractures underwent indirect reduction and mini-incision DCS fixation. Fractures were classified according to the AO classification (10 type 32B and 33 type 32C) and Seinsheimer classification (6 type III, 15 type IV, and 22 type V). Functional outcomes were assessed using the Harris hip score and Merle d'Aubigne score. RESULTS: The mean time to full weight bearing was 11 (range, 8-19) weeks. The mean time to union was 16 (range, 13-22) weeks. There were no cases of non-union or implant failure after a mean follow-up period of 25 (range, 18-30) months. Seven patients had a mean limb length discrepancy of 1.5 (range, 1-2) cm. Two patients had coxa vara and persistent limp. According to the Harris hip score, functional results were excellent in 12 and good in 31 patients. The mean Harris hip score was 88 (range, 80-99) and the mean Merle d'Aubigne score was 17 (range, 14-18). There was no deep infection or avascular necrosis of the femoral head. Restriction of knee flexion beyond 90 degrees was noted in 2 patients. CONCLUSION: Results of indirect reduction and mini-incision DCS fixation for comminuted subtrochanteric femoral fractures are favourable. Proper planning and execution of the technique is required to achieve good functional outcomes and avoid complications. Preservation of vascularity of the medial fragments leads to rapid callus formation and early union and hence avoids implant failure and secondary bone grafting.

Diagnostic significance of radiologic measurements in posterior heel pain.

BACKGROUND: Posterior heel pain is a common complaint in both athlete and non-athlete. For diagnosis of etiology certain angles, lines and soft tissue parameters have been developed in the literature to describe the calcaneal prominence and its relationship to Achilles tendon and its bursae. OBJECTIVES: A prospective study was undertaken to evaluate the diagnostic values of these angles, lines and soft tissue parameters in posterior heel pain. MATERIALS AND METHODS: Seventy-one painful heels in 58 patients (30 males and 28 females, mean+/-S.D. age; 41.4+/-10.82 years) were clinically and radiologically examined. This was compared with 50 heels in 25 control subjects. A lateral weight bearing film of the foot was taken to calculate different angles, lines and soft tissue parameters mentioned in the literature. RESULTS: There were 45 Pavlov's parallel pitch line positives and using test of Denis and Huber-Levernieux in only one posterior superior crest extended beyond vertical tangential. There was only one heel with Fowler & Philip angle >75 degrees. There were 10 heels with Steffensen & Evensen angle >65, 5 heels with total angle >90 degrees and 52 heels with Chauveaux-Liet angle >12 degrees. There were 73% true positive for Chauveaux-Liet angle and 63% true positive for parallel pitch line. Among soft tissue parameters ill defined retrocalcaneal recess was present in 61 symptomatic heels, plantar spur in 42 heels, posterior calcaneal step in 33 heels, Achilles tendon calcification in 29 heels, superficial tendo-Achilles bursitis in 58 heels, posterior calcaneal spur in 31 heels and antero posterior diameter of tendo-Achilles more than 9 mm in 68 symptomatic heels. CONCLUSION: Parallel pitch lines, Chauveaux-Liet angle, ill-defined retrocalcaneal recess, superficial tendo-Achilles bursa and anteroposterior diameter of Achilles tendon more than 9 mm about 2 cm above insertion are reliable objective diagnostic indicators of bony deformity of calcaneus and soft tissue affection in patients with posterior heel pain. It is the combination of these bony and soft tissue parameters, which enhance the diagnostic certitude.

Degenerative lumbar spinal stenosis-results of expansive laminoplasty.

Expansive laminoplasty, a procedure used more and more often for cervical myelopathy, was carried out in patients with lumbar spinal stenosis in the Department of Orthopaedics, Paraplegia, Physical Medicine and Rehabilitation of our institute. Twenty-five such clinico-radiologically proven cases were operated upon. For radiological evaluation, computed tomography (CT) was used. Expansive laminoplasty decompresses the nerve roots by osteoplastic enlargement of the lumbar spinal canal, with the maintenance of spinal stability. These advantages were confirmed during the follow-up of 3 to 5 years. Using CT, the spinal canal was found to be enlarged to a nearly rectangular shape and the average enlargement was 124%. The visual analogue scale (VAS) was used for subjective pain assessment before and after the surgery. The ultimate outcome was assessed by the Surin et al. criteria (Spine 17:1-8, 1992).

Unusual K-wire migration.

The authors report a case of intra-abdominal migration of a Kirschner wire from the left hip to the right lobe of the liver in a 5-year-old child. The wire was used for stabilization of the left hip after open reduction for neglected unreduced congenital dislocation of the left hip. The migrated wire was removed by laparotomy. Surprisingly, no injury was noted to any intervening abdominal structure intra-operatively. This unusual migration of a Kirschner wire into a child's liver has not been reported previously.

Prolapsed intervertebral disc with sciatica: the role of common peroneal nerve block.

A total of 210 patients of Lumbar disc prolapse with sciatica were given common peroneal block by infiltrating 2% xylocaine around the common peroneal nerve 3 cm below the head of fibula on the affected side. After receiving the block the pain decreased on from grade 2.99 +/- 0.46 to 0.91 +/- 0.99, and straight leg raising increased from 32.1 +/- 12.55 to 59.66 +/- 12.11 degrees. The method, as an outpatient procedure, has been found to be simple and useful in the patients of sciatica with prolapsed lumbar intervertebral disc potentially appropriate for a low-resource setting.

Percutaneous bone marrow grafting for the treatment of tibial non-union.

This is a prospective study to evaluate the efficacy of percutanous bone marrow grafting in patients with established tibial non-union and minimal deformity, whilst on the waiting list for open surgical procedures. Twenty consecutive patients with established tibial non-union and minimal deformity were treated by percutanous bone marrow injection under local anaesthesia. Bone marrow was obtained from the iliac crest, 3-5 ml of marrow was aspirated and injected immediately into and about the non-union site. Subsequent aspirations were performed 1 cm posterior to the previous site until a maximum of 15 ml of marrow was injected. Our results revealed clinical and radiological bone union following percutanous injection in 15 out of 20 patients (75%), with an average time to union following the first injection of 14 weeks. Four patients (20%) showed no evidence of union and were considered a failure. There were no cases of infection following the injection, and no complications at the donor site. We conclude that percutanous bone marrow grafting is a safe, simple, and reliable method of treating tibial non-union with minimal deformity. It is a limited invasive technique with minimal complications. It can be performed under local anaesthesia, is cost effective and potentially can avoid major surgical reconstruction.

Compressive peroneal neuropathy during harvesting season in Indian farmers.

Thirty patients (34 limbs) with compressive peroneal neuropathy induced by prolonged squatting of more than 5 h during harvesting season were treated conservatively and followed-up to an average of 28.2 months. A marked preponderance of involvement of the left side was noticed. We attribute this to the intermittent extension of the right lower limb habitually used by Indian farmers to propel themselves forwards while squatting during harvesting. All but two lesions recovered fully within 3 to 9 weeks: one patient took 16 and another 20 weeks. We recommend non-operative treatment for this benign lesion.

Medial opening wedge high tibial osteotomy for osteoarthritis of knee: long-term results in 50 knees.

To retrospectively study the long term results of high tibial valgus osteotomy in management of primary medial compartment osteoarthritis, with special reference to patient satisfaction and functional assessment, we conducted this study in radiologically established 50 knees of patients with primary osteoarthrosis of knee. In these patients with medial compartment disease (varus knee), medial open wedge osteotomy was performed using full thickness iliac crest grafts. These were called for follow-up after average 7.5 years and clinico-radiological assessment was done. Although many surgeons of the west do not favour this osteotomy, we found the procedure to be quite acceptable to our patients in whom the primary concerns of cost and squatting habits are well taken care of. The authors feel that this osteotomy is still relevant in the third world. Results do deteriorate with time but most patients consider the surgery satisfactory.

An innovative compression-clamp for open contaminated fractures of patella: a short report of five cases.

Five patients with open contaminated fractures of the patella were managed using an indigenously designed external clamp cum compressor. All had an infected lacerated wound at the fracture site, and one had open exposed knee joint (Gustilo grade IIIB open fracture). These patients reported after 3-7 days of injury. The wounds were thoroughly washed and débrided and the clamp cum compressor was applied. They were encouraged to do active knee movements immediately post-operatively. The wounds healed within 3-4 weeks, and the fractures united within 10-16 weeks. Good functional results were achieved in four of the five.

Critical evaluation of compartment pressure measurement by saline manometer in peripheral hospital setup.

A hundred limbs of patients suffering limb trauma were assessed by at least two different reviewers for symptoms of compartment syndrome, both clinically, and by a simple, locally devised apparatus for pressure measurement. We have found the apparatus to be very effective, safe, reproducible and simple. Orthopaedic surgeons working in peripheral hospitals in the developing world can make use of this apparatus which costs less than 5 dollars to assemble. This technique may assist an early decision regarding surgical decompression at a peripheral hospital or referral to specialist unit, thus saving valuable time and expense.

Evaluation of myelography and computed tomography in clinically diagnosed patients of lumbar disc herniation.

Forty patients with dinical diagnosis of lumbar disc herniation were evaluated with myelography and CT scan. Myelography diagnosed lumbar disc hemiation at 59 levels in 40 patients, while CT diagnosed disc hemiation at 64 levels. Lumbar disc hemiation was confirmed peroperatively in 30 out of 40 patients at 48 levels. Myelography correctly diagnosed 43 levels out of 48 levels and thus had a sensitivity of 89.6 per cent. CT diagnosed all the 48 levels correctly with a sensitivity of 100 per cent. Thus CT is super to conventional myelography in the diagnosis of lumbar disc herniation. However, conventional myelography supplements CT examination by limiting the number of scans to the level of interest and thus reduces radiation exposure.

Leeds procedure--a treatment modality for scoliosis.

The present study comprises of forty patients of scoliosis in growing age group (10-25 years) with Cobbs angles ranging from 52"-98". They were treated with Leeds procedure which is by anterior loosening followed by Posterior Harrington fixation + Luque derotation + Fusion and Costoplasty. Majority of the curves were thoracic (60%), and right sided (72%). Average correction of the deformity after surgery was 45%. Satisfaction level of patients and parents was good in 60% of the cases. The modality of treatment was decided on the basis of personality of each case, its demand and requirement, time of presentation and the potential for increasing severity. Anterior spinal surgery for scoliosis is an effective procedure in hands of experienced surgeons and it reduces stiffness of the curve, shorten the anterior column, decreases thoracic lordosis which leads to some improvement of pulmonary function. But there is greater risk of damage to vital structures with higher risks of cardiorespiratory failure. The potential risks have to be balanced with the expected rewards. The optimum method of correction has to be decided by careful preoperative evaluation. Combined procedure of anterior and posterior surgery causes lesser decrease in pulmonary functions than costoplasty alone, and achieving better cosmetic correction. This study reaffirms the role of anterior spinal surgery in India as the patients due to lower levels of health awareness present late and with severe deformities.

External fixator in the management of trochanteric fractures in high risk geriatric patients--a friend to the elderly.

The best treatment option for trochanteric fracture in a geriatric high risk patient with all associated medical and surgical problems remains debatable. Conservative methods of treatment are associated with dangerous complications of prolonged recumbency while open reduction and internal fixation under anaesthesia significantly increases the mortality and morbidity rates. We treated 110 elderly patients who were unfit or high risk cases for anaesthesia and major surgery for internal fixation due to associated medical and surgical conditions, by external fixation under local anaesthesia. The average age was 65 years and mean follow up was 18 months. 83.3% were ambulatory with support and 97.2% were able to manage activities of daily living at the time of discharge. At 18 months post surgery, 74% were ambulatory with a stick or better. The fracture united in an average of 16.4 weeks. Overall satisfaction rate was 80% at end follow up. The mortality rates were comparable to series of open reduction and internal fixation. Pin tract infection and knee stiffness were the major complications. External fixation done under local anaesthesia offers advantages in the form of a quick, simple relatively inexpensive procedure with negligible blood loss, preserves fracture haematoma, can be easily removed as an out patient procedure, besides it provides earliest possible ambulation and day care to the elderly high risk patient.

Cubitus varus--correction by distraction osteogenesis.

Cubitus varus deformity in thirty children was corrected by gradual medial opening wedge osteotomy. The osteotomy was stabilized and distracted by simple external fixator-cum-distractor. The patients of both sexes and age from 6 to 14 years, had varus deformity from 17 degrees to 43 degrees. We achieved good to excellent results in 28 cases as regards to correction of deformity and range of motion at elbow joint. None of the cases had neurological deficit or permanent stiffness. One case had fair result due to under-correction and another case had a poor result as osteotomy united before correction. The main complication faced was superficial pin-site infection particularly in summer season and a in fatty children but was managed by good pinsite dressing and care. The technique has been found to be quite effective, technically simple, cosmetically acceptable and with little, if any, lazy S deformity.

Functional restoration by excision arthroplasty in temporomandibular joint ankylosis--a report of 35 cases.

OBJECTIVE: To evaluate the long term functional results of excision arthroplasty in treatment of temporomandibular joint (TMJ) ankylosis. MATERIAL AND METHODS: This retrospective study includes 35 patients of TMJ ankylosis who were treated by excision arthroplasty and followed for a maximum period of eight years after surgery. Past trauma was documented as a major etiological factor in 63% cases. Fibrous ankylosis & unilateral involvement was found to be more common. Peroperatively a gap of 1 1/2 to 2 cm was created. The results were assessed according to a criteria based on inter-incial month opening, deviation of jaw and complications. They were satisfactory in 29 cases and there were 3 recurrences. CONCLUSION: Childhood trauma is a major cause of TMJ ankylosis in India. Long term results of excision arthroplasty are satisfactory & comparable to other surgical modalities that are in vogue, provided the patients are operated when young, the ankylosis is in early stage, gap created is adequate and post operative exercise regimen is followed diligently.

Synovial hemangioma--a case report.

True synovial based hemangiomas are rare lesions and should be differentiated from mass lesions especially pigmented villonodular synovitis. A case of 4 years old male child, presenting with recurrent painful swelling, is described in the present article. The differential diagnosis is also discussed.

Role of percutaneous bone marrow grafting in delayed unions, non-unions and poor regenerates.

The present study comprises of 72 patients of post traumatic delayed unions, established non-unions, poor regenerate in segmental bone transportation and limb lengthening procedure treated by percutaneous injections of autogenous bone marrow at the site of failed healing. The average follow up was 4 years. Bone union was achieved in 68 patients. Overall, 72.2% of the patients had an excellent result, 11.1% a good result, 11.1% a fair result and 5.5% a poor result or failure. These results with only 4 failures (5.5%) are encouraging and suggest that percutaneous autogenous bone marrow grafting is a simple, safe and useful technique in the treatment of delayed unions and non-unions. We believe that this technique of percutaneous autogenous bone marrow grafting can be a procedure of choice in those patients where Phemister or Forbes methods of bone grafting alone is required, especially in limbs with scarred and poor soft tissue coverage. This procedure can also be useful in iatrogenic delayed or non-unions which is the commonest cause of non-union in present era of enthusiastic fracture fixation.