Introduction: The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) coronavirus disease-2019 (COVID-19) outbreak became a pandemic across the world after the outbreak in China in December 2019. This study aimed to determine the impact on the emergency orthopedic fixation during the COVID-19 pandemic in the Institute of Orthopaedics and Traumatology, Coimbatore.
Materials and methods: This is a retrospective study done on patients of trauma admitted in the emergency orthopaedic unit, under Tamilnadu Accident and Emergency Care Initiative (TAEI), Coimbatore Medical College Hospital from April 2020 to December 2020. All the patients admitted were evaluated as per the routine protocols followed in this COVID-19 pandemic in our institution and the patients were taken up for emergency orthopedic fixation based on the COVID-19 status.
Results: The total number of emergency orthopedic surgical fixation procedures done during the pandemic period from April 2020 to December 2020 was 245. Orthopedic surgical fixation done in elective theatres during this pandemic in 2020 is 245 cases. As per the results, during the COVID-19 pandemic, emergency orthopedic surgical fixation was not stopped and treated as per the COVID-19 protocol followed in our hospital.
Conclusion: The SARS-CoV-2 (COVID-19) pandemic has a major impact on orthopedic surgical fixation. All the patients admitted should be evaluated for the COVID-19 infection and use of adequate personal protective equipment while treating the patients to deliver safe and effective surgical services during this COVID-19 pandemic.
Sudipta K Patra,
Sivakumar S Palanivelayutham,
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Perumal R, Patra SK, Palanivelayutham SS, Mahender A, Jayaramaraju D, Rajasekaran S. Technical Trick to Avoid Intra-articular Screw Placement in Posterior Wall Fractures of the Acetabulum. 2021; 3 (1):7-12.
Introduction: Screw placement at the posterior margin of the acetabulum while operating for wall fractures requires additional care to avoid articular penetration which can lead to poor functional outcomes. The main objective of this study is to describe a simple four-step surgical guide to avoid intra-articular screw penetration during fixation.
Materials and methods: We prospectively analyzed 23 patients (21 males and 2 females) with posterior wall acetabular fractures treated with the described technique in our institution from 2017 to 2019. Of these 23 patients, 8 patients had isolated posterior wall fractures, 9 patients had transverse with posterior wall fracture, and 6 patients had posterior wall and column fractures. Radiograph Judet views and computerized tomography (CT) scan were done in all the patients to check for intra-articular screws on the second postoperative day.
Results: By radiograph and CT scan in all the patients, there was no intra-articular screw penetration noticed following acetabular fracture fixation. All the 23 patients in our study had a good functional outcome with Merle D\'aubigne score of ≥18 in 12 patients and ≥10 in 11 patients.
Conclusion: Good knowledge of the osseous anatomy of the pelvis is essential to prevent intra-articular screw placement during fixation of acetabular fractures. Our four-step surgical tip to insert periacetabular screws under direct vision helps prevent intra-articular screw placement during acetabular fracture fixation by posterior approach. Besides, this technique is easily reproducible and helps to minimize intraoperative radiation time.
Background: Distal radius fractures are an extensively debated topic throughout decades. The treatment options include POP casting, plating, external fixation with or without ligamentotaxis, and K-wiring. This study was conducted to assess the functional outcome of a novel percutaneous 5-pin technique in distal radius fractures.
Materials and methods: This is a prospective observational study over 16 months from January 2019 to May 2020. Novel percutaneous 5-pin technique in a sequential configuration following a closed reduction was performed, followed by physiotherapy, and functional outcome was assessed at 6, 12, and 28 weeks following K-wire removal using Cooney\'s modification of Green and Obrien scoring and evaluated for functional status, pin loosening, tendon impalement, and nerve injury.
Results: All 20 patients were assessed. The mean age of patients was 47.15 years, 10 being females, with road traffic accidents being the major mode of injury. All patients were followed up for 6 months post-K-wire removal and 90% of patients had good to the excellent outcome and 10% of patients had fair to bad outcome with a functional range of supination and pronation movements. All fracture unions were satisfactory and four patients (20%) developed minor complications. None of them developed tendon impalement or nerve injuries.
Conclusion: The novel percutaneous 5-pin technique includes two additional ulnoradial wires which provide superior rotational stability and avoid the chance of late collapse and maintain radial height, unlike conventional K-wire techniques. Thus, avoiding the need for more invasive techniques and allows early mobilization of wrist and fingers preventing stiffness, resulting in an excellent outcome.
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Khan F, Rengarajan N, Manoharan M, Rajarajan D. Functional and Radiological Outcome of Displaced Supracondylar Humerus Fracture in Children: A Prospective Observational Study. 2021; 3 (1):18-22.
Introduction: Around 60% of all the elbow injuries in the first decade, supracondylar fractures of the humerus are the most widely recognized elbow injuries in youngsters. Accompanied with problems like compartment disorder, neurovascular harm, Volksman\'s ischemic contracture, and malunion. The most widely recognized choice of pinning is either cross-pin fashion or two parallel pins. Closed reduction and percutaneous K-wire fixation are best with the least problems in contrast with different modalities. In our study, we want to assess the functional and radiological outcome of pediatric displaced supracondylar humerus fracture treated with closed reduction percutaneous K-wire fixation.
Materials and methods: Sixteen patients were selected for the study based on the inclusion and exclusion criteria based on the consecutive sampling. For all patients, the standard technique of percutaneous k wire fixation was performed, and patients were evaluated on 6 weeks, 3 months, and 6 months with functional scoring by Flynn et al. Criteria and Mayo elbow scoring and radiological scoring with Baumann\'s angle.
Results: Ten children (62.5%) were affected in their first decade of life, with a clear male predilection than females. Mayo elbow scoring was 2.5, 6.0, and 3.75 at 6 weeks, 3 months, and 6 months. Pin-tract infection (4), two cases of malunion of our study population. In all 16 cases, the union was achieved with 14 cases satisfactorily excellent and satisfactorily good in 1 case and unsatisfactorily poor in 1 case.
Conclusion: Closed reduction and percutaneous pinning are the treatment of choice for pediatric supracondylar humerus fractures with Modified Gartland\'s type II and type III. Appropriate pinning technique ensures a successful outcome with cross configuration providing excellent outcome with good rotational stability. Closed reduction and percutaneous pinning is a safe, cost-effective, less morbid procedure.
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Chau W, Illescas V, Ng BK. Comparing Health-related Quality of Life of Lenke 1–2, and Lenke 5–6 Severe AIS Adolescent Idiopathic Scoliosis Patients 2 Years after Surgery Using SRS-22 Questionnaire. 2021; 3 (1):23-30.
Introduction: Lenke classification organizes curve patterns into six major “curve types”. Health-related quality of life (HRQOL) in AIS patients is gaining attention particularly on whose undergone surgery and findings are sometimes not expected. Comparisons of HRQOL in severe patients between Lenke 1 (main thoracic) and Lenke 2 (double thoracic) and patients with Lenke 5 (thoracolumbar/lumbar) and Lenke 6 (thoracolumbar/lumbar-main thoracic) curve types have yet to be carried out.
Materials and methods: Forty-six severe AIS patients classified Lenke type 1, 2, 4, and 5 undergone surgery from 2016 to 2019 were recruited. Demographic variables and surgical details were collected. Patients filled out the SRS-22 questionnaire at (1) Before surgery (preoperative), (2) Before hospital discharge (post-op1), (3) 1 year postoperative (post-op2), and (4) 2 years post-op (post-op3). Statistical comparisons of HRQOL domain scores were carried out between Lenke 1 + 2 group and Lenke 5 + 6 group longitudinally and between groups.
Results: The mean age at surgery is 18.14 years. Longitudinal comparisons showed “Function” and “Pain” scores dropped before hospital discharge and recovered at post-op follow-ups. “Function” and “Pain” in Lenke 1 + 2 group at between-group comparisons were significantly higher than Lenke 5 + 6. Self-image, satisfaction, and mean scores were also higher in Lenke 1 + 2 without statistical significance.
Conclusion: All domains showed improvements 2 years after surgery in both Lenke type groups, of which significant improvements were statistically found in “Function”, “Pain”, and “Mental health” in Lenke 1 + 2 patients.
Key messages:• All HRQOL domains in both Lenke 1 + 2 (main thoracic + double thoracic) group and Lenke 5 + 6 (thoracolumbar/lumbar + thoracolumbar/lumbar-main thoracic) group improved after spinal surgery.• “Function”, “Pain”, and “Mental health” in patients of Lenke 1 + 2 group significantly were improved statistically than patients in Lenke 5 + 6 group.• “Self-image” and “Satisfaction” were also improved without statistical significance.
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Chau W, Ng BK. Longitudinal Changes of Spinal Appearance Questionnaire and SRS-22 Questionnaire Domain Scores on Surgical Adolescent Idiopathic Scoliosis Patients before and after 2 Years of Operation. 2021; 3 (1):31-35.
Background: Both Scoliosis Research Society-22 questionnaire (SRS-22) and Spinal Appearance Questionnaire (SAQ) are well-established disease-specific patient-reported outcome questionnaires on adolescent idiopathic scoliosis (AIS). Our severe AIS patients were administered both questionnaires before and after surgery. The use of SRS-22 on surgical cases was well documented, however, SAQ which focused on patients’ perceptions of spinal appearance, was merely reported. This study summarized the longitudinal changes of SAQ and SRS-22 domain scores in surgical AIS patients from preoperative to 2 years after surgery.
Materials and methods: All surgical AIS patients operated on in the year 2014 to 2016 were recruited. They completed both questionnaires at (1) before surgery (“Pre-op”), (2) immediately before hospital discharge (“Post-op”), (3) 1 year after surgery (“Post-op 1 year”), and (4) 2 years after surgery (“Post-op 2 years”).
Results: There were 135 severe AIS patients recruited in this study, of which 74.1% were females, and the mean age at operation was 15.97. All SAQ domains were increasing (improving) until 2 years after surgery. Curve and prominence scored the highest among the nine domains across four time points. Significant increases were observed in “Trunk shift”, “Shoulders”, “Prominence”, “Curve”, and “General”.
Conclusion: Improvements in appearance after surgery responded differently from function, pain, and other factors immediately after surgery. Patients’ appearance perception was continuously improving after surgery despite function, pain, and mental were dropped then recovered in the next 2 years. Using SAQ in conjunction with SRS-22 in health-related quality of life (HRQOL)-related studies on AIS patients greatly improves and complements the interpretations on patients’ appearance which endeavors further research on cognitive behavior in AIS patients after years of surgery in long-term follow-up studies.
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Gadde S, Ganesan S, Jeyabalan V, Kannan KK, Kumar V. Prevalence of Facet Tropism in Lumbar Spine among South Indian Population: An MRI-based Radiological Study in 400 Patients. 2021; 3 (1):36-40.
Background: Facet tropism (FT) is the presence of asymmetry in the sagittal angulations of the bilateral facet joints, which is proposed to be a contributing factor for certain spinal disorders. Few studies are present in literature discussing the prevalence of FT in the lumbar spine among the South Indian population and our study shall focus on this by identifying it on MR imaging.
Materials and methods: It is a cross-sectional study, where 400 lumbar MRI scans of patients with low back pain without trauma, deformities, and surgical history were studied between 2016 and 2019. Facet angles are measured and the presence of FT and its severity is assessed on axial sections in all the patients. Data is subjected to statistical analysis.
Results: One hundred and eighty-two (45.5%) females and 218 (54.5%) males are included in this study. The age range is 26–86 years and the mean ages of the female and male samples are 52.89 ± 14.06 and 52.31 ± 13.62 years. Facet tropism is seen in 178 (44.6%) individuals and is noticed at all levels from L1 to S1. The presence of FT is 2% at L1-L2, 12.9% at L2-L3, 13.9% at L3-L4, 28.7% at L4-L5, and 21.8% at L5-S1. The degree of tropism was severe at the L4-L5 intervertebral level in 5.9% of the study population. Age and gender do not have a significant correlation with the presence of tropism. All the above results have attained statistical significance.
Conclusion: The presence of FT is not uncommon, although its incidence varies at each level of the lumbar spine. The prevalence of FT in our study population is 44.6%. The highest prevalence of FT and a severe degree of FT were noticed in the L4-L5 level.
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Somashekar V, Sowlee A, Singhi PK, Raju S, Kumar VP. A Randomized Clinical Trial Assessing the Efficacy of Periarticular Injection (LIA) during Total Knee Joint Replacement in the Asian Population. 2021; 3 (1):41-50.
Introduction: Osteoarthritis patients usually come very late in the natural course often having bilateral involvement of degenerative changes. Patients are counseled and advised for staged procedures, however, after the first knee surgery, due to postoperative pain, the majority of them are reluctant to undergo total knee arthroplasty (TKA) in the other knee. We did a prospective randomized double-blind control study comparing the amount of analgesic required in the immediate postoperative period in those patients who received a periarticular cocktail injection and those who did not, following TKA.
Materials and methods: This was a single-center prospective randomized controlled, double-blind, clinical analysis comparing 126 patients receiving intraoperative analgesia cocktail and control group during TKA. Group I (n 72) received local infiltration of analgesic (LIA), group II (n 54) did not receive any injection. Patients were assessed for pain in terms of visual analog scale (VAS) score, postoperative analgesia requirement, and knee range of motion.
Results: The mean postoperative Oxford knee score at 2 months of group I was 30.47 (SD 4.45) compared with group II was 30.30 (SD 5.44). There was a significantly lower mean VAS score (3.16) in group I than group II (7.45) and was statistically significant with a p value of 0.0005. At the end of 2 months, both the groups had similar degrees of range of motion.
Conclusion: Local infiltration of analgesia during TKA with our combination of drugs effectively reduces postoperative pain and decreased analgesic consumption, without adding much to the cost of the surgery and also significantly improves patient compliance and rehabilitation.
This article displays the current ideology in the therapy of antibiotics. It also explains the various guidelines for safe usage with a precise choice of antibiotics in orthopedic and trauma surgery including prophylaxis in the prevention of surgical site infection.
Sivakumar S Palanivelayutham,
Sudipta K Patra,
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Palanivelayutham SS, Perumal R, Patra SK, Jayamaraju D, Rajasekaran S. Transport of Bone in Femur over an Intramedullary Nail: A Novel Corticotomy Technique. 2021; 3 (1):54-57.
Introduction: Despite successful union after intramedullary nailing of open femur fractures with bone loss or significant comminution, the discrepancy in leg length can lead to a significant impairment for the patient. Lengthening over a femoral nail is a described technique in such clinical scenarios. Corticotomy around an existing intramedullary nail (IMN) was introduced to address lengthening of the limbs without changing or removing any previously implanted IMN. Osteotomy around an existing IMN is a challenging technique that requires careful handling to avoid inadvertent damage to the IMN.
Case description: Two patients with open type IIIA shaft of femur fractures who presented with bone loss following trauma underwent debridement and IMN fixation. After nailing, the patient was placed on a fluoroscopic table to enable an anteroposterior and lateral radiograph of the femur. Under image guidance, a rail frame was applied and we used a novel technique of osteotomy for lengthening of the femur using a Gigli saw. In both cases, the bony union was achieved by the end of 1 year.
Conclusion: Lengthening over the IMN using a lengthening device helps in correcting limb length discrepancy as well as aids in achieving optimal bony union at the same time. The use of our novel corticotomy technique helps to minimize the damage to the intramedullary device. The existence of the nail minimizes the time required for the external frame since during the consolidation phase the nail supports the regenerate bone.
RP Raghavendra Raju,
Raju C Nagaraju,
Intraosseous lipomas are rare lesions often missed and confused with other tumors. They constitute 0.1% of benign tumors of bone.1 Intraosseous lipomas can occur in the calcaneum, proximal femur, tibia, and other long bones. The most common location in calcaneum is the neutral triangle. We report a case presented to our hospital with complaints of heel pain for one and a half years. The patient was evaluated and was diagnosed with intracalcaneal lipoma for which curettage and grafting were done with hydroxyapatite and iliac bone. The patient was followed up for 1 year, no recurrence was found. We discuss the case of intracalcaneal lipoma, its presentation, diagnosis, and treatment.
Background: Intraspinal facet cyst or juxta-facet cyst is a term that includes synovial and ganglion cysts in the spine. Facetal synovial cysts are fluid-containing synovial outpouchings arising from degenerated facet joints resulting from chronic hypermobility of the joints. These cysts can cause low back pain, radicular leg pain, and in rare cases cauda equina syndrome.
Case description: In this report, we would like to present the occurrence of incomplete cauda equine syndrome resulting from a facet synovial cyst in a 65-year-old woman who presented with weakness in both lower limbs, difficulty in walking, and saddle anesthesia. The symptoms resolved following a posterior decompression, cyst excision, and instrumented fusion surgery.
Conclusion: This report highlights the occurrence of acute cauda equina syndrome in a 65-year-old woman resulting from an L4–L5 facet synovial cyst. Prompt diagnosis and immediate surgical intervention in the form of decompression and fusion surgery lead to a favorable outcome.
Clinical message: Acute cauda equina syndrome in a patient with a lumbar facet cyst is a relatively uncommon presentation. It requires early diagnosis and immediate surgical intervention in the form of decompression to prevent neurological deterioration and to have a favorable outcome.
LETTER TO THE EDITOR
Shailendra C Gupta,
Ishoo R Taneja
The present correspondence presents the author\'s experience with adherence to the wide awake local anesthesia no tourniquet (WALANT) technique for hand surgery as has been recommended in the pandemic. The authors plan to hold on to the use of daycare hand surgery under WALANT in our practice as a long-lasting modification as we emerge in the post-COVID following the vaccination drive.