Functional and Radiological Outcomes of Surgically Treated Coxa-vara in Children.

BACKGROUND: Coxa vara is a condition in which the neck-shaft angle of the femur decreases below its normal value (<110 degrees) based on age. The deformity can be primarily caused by a congenital defect of the femoral neck cartilage or by secondary causes related to skeletal dysplasia, trauma, infection, and pathological bone disorders. The surgical treatment aims to restore the normal anatomy, thereby improving the mechanics and function of the hip joint. Generally, the HE angles should be corrected to <35 to 40 degrees, converting the shear forces into compressive forces. Our study aims to report the surgical outcome of coxa vara with various pathologies using radiographic measurement and functional scoring. METHODS: Thirty-eight hips in 28 patients who underwent surgery for treatment of coxa-vara from 2013 to 2022 were included. Radiographic parameters like Hilgenreiner-epiphyseal angle and neck-shaft angle were assessed preoperatively and at the latest follow-up. Harris hip score was used for functional outcome. RESULTS: The mean age was 11.13 (5 to 18). The average follow-up was 48 (ranging from 24 to 96) months. The mean preoperative neck-shaft angle was 82 degrees, and the Hilgenreiner-epiphyseal angle was 71 degrees. At the latest follow-up, the mean neck-shaft angle was 127 degrees, and the Hilgenreiner-epiphyseal angle was 33 (P<0.001). The Harris hip score improved from 63 preoperatively to 92 at the latest follow-up (P<0.001). There was no recurrence of deformities at the mean follow-up of 37.87 months. Four complications occurred with k-wire fixation in whom revalgus osteotomy was done. CONCLUSIONS: Surgical correction of coxa vara in various pathologies can be done successfully with the Hilgenreiner-epiphyseal angle corrected to ≤ 35 degrees or the neck shaft angle corrected to >110 degrees to prevent deformity recurrence. The majority of the patients reported improvement in hip function. However, a longer-term follow-up is required to determine further outcomes regarding the recurrence of the deformity.

High Dependency Unit Admissions among Patients with Lower Extremity Long Bone Fracture Visiting the Department of Orthopaedics in a Tertiary Care Centre.

Introduction: Lower extremity long bone, femoral and tibial shaft, fractures often have associated injuries. Patients with lower extremity long bone fractures in the Department of Orthopaedics can land up in high dependency unit admissions, mostly due to underlying complications. The study aimed to find out the prevalence of high dependency unit admissions among patients with lower extremity long bone fractures visiting the Department of Orthopaedics in a tertiary care centre. Methods: A descriptive cross-sectional study was conducted among patients with lower extremity long bone fractures in a tertiary care centre. The data from 1 March 2017 to 31 January 2020 was collected from the medical records from 1 August 2020 to 30 September 2020. All patients with femoral or tibial shaft fractures in isolation or a part of a multi-system injury were included. Patients with inadequate data were excluded. A convenience sampling method was used. The point estimate was calculated at a 95% Confidence Interval. Results: Among 507 patients with lower extremity long bone fractures, 137 (27.55%) (23.66-31.44, 95% Confidence Interval) required high dependency unit admission. Among them, 119 (86.86%) were males. A total of 71 (51.82%) cases involved 2-wheelers. Conclusions: The prevalence of high dependency unit admission among patients with lower extremity long bone fractures was high and majority of them required multidisciplinary approach. Keywords: femoral fractures; prevalence; tibial fractures; traffic accidents.

Hip-Spine Discordance in Bone Mineral Densities in Patients Undergoing Dual Energy X-Ray Absorptiometry Scan in a Tertiary Care Centre: A Descriptive Cross-sectional Study.

Introduction: The discordance in the diagnosis of osteoporosis is characterized by the variation in bone mineral density measurements at different skeletal sites. The presence of discordance significantly alters the treatment plan as different treatment is required for different skeletal sites. The aim of this study was to find out the prevalence of hip-spine discordance in bone mineral densities in patients undergoing dual-energy x-ray absorptiometry scans for suspected osteoporosis. Methods: A descriptive cross-sectional study was conducted among patients undergoing dual-energy x-ray absorptiometry scans from 1 December 2020 to 30 October 2022. Ethical approval was taken from the Institutional Review Committee (Reference number: IRC-2020-11-18-08). Patients undergoing dual-energy x-ray absorptiometry scans for suspected osteoporosis were included. Patients aged less than 50 years, already diagnosed and under treatment for osteoporosis, and incomplete information about T-scores of hips and spine were excluded. Convenience sampling method was used. Point estimate and 95% Confidence Interval were calculated. Results: Among 1028 patients, 602 (58.56%) (55.55-61.57, 95% Confidence Interval) had discordance in hip and spine bone mineral densities. The majority of them, 570 (94.68%) were female and 32 (5.71%) were male. Major discordance was observed in 101 (16.77%) patients and minor discordance was observed in 501 (83.22%) patients. Conclusions: The prevalence of discordance in hip and spine bone mineral densities in patients undergoing dual-energy x-ray absorptiometry scans was higher than that reported in other similar studies done in similar settings. Keywords: bone density; osteoporosis; prevalence.

Effect of Infrapatellar Fat Pad Preservation vs Resection on Clinical Outcomes After Total Knee Arthroplasty in Patient with End-Stage Osteoarthritis.

Purpose: The management of infrapatellar fat pad (IPFP) during total knee arthroplasty (TKA) is the subject of ongoing debate. There is conflicting evidence whether IPFP should be preserved or resected during TKA to improve clinical outcomes. This study sought to establish if there is a benefit of one over another in terms of clinical function & patient satisfaction. Material & Methods: Total of 67 patients (96 knees), 11 males & 56 females with a mean age of 66.29 years, who underwent TKA between 2016 and 2020 were included in the study. The planning for IPFP preservation (IPFP-P) on right side (50 knees) & IPFP resection (IPFP-R) on left side (46 knees) was done prospectively. We prospectively evaluated clinical outcomes post-TKA, comparing the right knee to the left knee in terms of IPFP-P vs IPFP-R using the oxford knee scoring (OKS) system. The SF-12 was used to evaluate and compare patient satisfaction between the two groups. Results: The mean OKS in the IPFP-P group was 42.86 ± 2.63 & in the IPFP-R group was 44.22 ± 2.40. The OKS differed significantly between the two groups (p < 0.05). Patient with IPFP-R group had significantly better OKS. The mean Sf-12 (physical & mental component) in the IPFP-P was 51.05 ± 4.15 & 59.29 ± 2.53 & in IPFP-R was 51.23 ± 4.74 & 59.24 ± 2.78, showing no significant differences. Conclusion: Our study shows that IPFP-R gave marginally better patient-reported functional outcome scores (OKS), but there was no difference in patient satisfaction (SF-12 scores) between the two groups.

Factors Predictive of Tenotomy After Ponseti Casting for Idiopathic Clubfoot: A Tertiary Care Center Study.

INTRODUCTION: Parents of children with clubfoot are likely to inquire about the need for tenotomy and about any factors that may be predictive. The present study was done to identify factors that may help predict the need for tenotomy in children undergoing Ponseti treatment for idiopathic clubfoot. METHODS: A prospective observational study was conducted on patients under 5 years of age with idiopathic clubfoot and no previous treatment history treated at Hospital and Rehabilitation Centre for Disabled Children. The relationship between the Pirani score, Dimeglio score, age, and passive ankle dorsiflexion (DF) and the need for heel cord tenotomy was analyzed using appropriate statistical methods. RESULTS: Of 83 patients (125 feet) with a mean age of 6 months, 93 feet (74.4%) required a percutaneous tenotomy. The mean initial Pirani and Dimeglio score for 125 club feet was 4.5 (SD=1.68) and 13.5 (SD=6.1), respectively. The mean initial passive ankle DF was -40.4 (SD=22.31). The Dimeglio ( P =0.000), Pirani scores ( P =0 .000), and passive ankle DF ( P =0.000) showed significant association with the need for tenotomy. CONCLUSIONS: This study shows a strong association between initial Pirani and Demiglio scores and initial passive ankle DF as predictive of a heel cord tenotomy. However, age, sex, and laterality were not associated with the need for tenotomy.

Cerebral Palsy among Children Visiting the Outpatient Department of Pediatric Orthopaedics in a Tertiary Care Centre.

Introduction: Cerebral palsy is a group of neurological disorders that appear in infancy or early childhood and occur as a result of anomalies in the developing brain that impair the brain's capacity to regulate movement, maintain posture, and maintain balance. Healthcare professionals can better predict the need for the medical, rehabilitative, and support services needed by people with cerebral palsy by using accurate prevalence statistics. The aim of the study was to find out the prevalence of cerebral palsy among children visiting the Outpatient Department of Pediatric Orthopaedics in a tertiary care centre. Methods: A descriptive cross-sectional study was conducted among patients visiting the Outpatient Department of Pediatric Orthopaedics in a tertiary care centre. Data from 1 January 2018 to 31 December 2019 was collected between 25 April 2023 to 5 May 2023 from medical records after obtaining ethical approval from the Institutional Review Committee. Convenience sampling method was used. The point estimate was calculated at a 95% Confidence Interval. Results: Among 6984 children, the prevalence of cerebral palsy was 545 (7.80%) (7.17-8.43, 95% Confidence Interval). The most common type of cerebral palsy was found to be spastic diplegia 219 (40.18%). Conclusions: The prevalence of cerebral palsy among children visiting the Outpatient Department of Pediatric Orthopaedic was found to be higher than in other studies done in similar settings. Keywords: cerebral palsy; prevalence; spastic diplegia.

Correlation between Radiological Outcome and Health Related Quality of Life after Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis.

BACKGROUND: Posterior spinal surgery for adolescent idiopathic scoliosis is aimed at correcting deformity and stopping deformity progression to improve the health related quality of life. The correlation between radiological outcome and health related quality of life is yet unclear. This study aimed to assess the correlation between radiological outcome and health related quality of life. METHODS: A descriptive cross-sectional study of 31 cases of adolescent idiopathic scoliosis who underwent posterior spinal surgery at our center from July 2013 to August 2019, was done. Radiological outcomes were measured by the Cobb's angle before and after surgery in standing whole spine X-ray and compared by paired t-test. Health related quality of life was measured by Scoliosis Research Society-30 questionnaire. Correlation between radiological outcomes and Scoliosis Research Society-30 and its domains were assessed by Pearson's correlation coefficient, and Spearman's rank correlation coefficient. RESULTS: There were 18 females (58.06%) and 13 males (41.93%) with a mean age of 14.81 years (range 12-18 years). Average post-operative follow-up was 37 months (range 6-82 months).The mean amount of deformity correction post-operatively was 460 (range 300-740). The mean of total SRS-30 score was 137.64±7.84. The post-operative Cobb angle correlated significantly with the mean total Scoliosis Research Society-30 score (p=0.046). Self-image/appearance and satisfaction with management correlated significantly with residual deformity and amount of deformity correction. Self-image/appearance and pain correlated significantly with satisfaction with management. Self-image/appearance had a significant positive correlation with mental health (p=0.004). CONCLUSIONS: Posterior spinal surgery for adolescent idiopathic scoliosis provided better radiological outcomes, and a positive correlation with health related quality of life. There was significant improvement of self-image/appearance and satisfaction after surgery, which in turn, improved mental health.

A Definition of Significant Instability and a Scoring System for Predicting Meniscal Tears in ACL-Deficient Knees.

BACKGROUND: Patients with anterior cruciate ligament (ACL)-deficient knees risk recurrent instability of the affected knee, which may predispose to meniscal injuries. Various studies have correlated the incidence of meniscal tear with elapsed time from ACL tear and number of instability events. However, it is not clear how significant an instability event needs to be to contribute to a meniscal tear. PURPOSE/HYPOTHESIS: The purpose of this study was to (1) define a significant instability episode and (2) develop a checklist and scoring system for predicting meniscal tears based on significant instability episode. We hypothesized that patients with ACL-deficient knees who met the scoring threshold for a significant instability episode would have a higher incidence of meniscal tears compared with those who did not meet the threshold. STUDY DESIGN: Cohort study (prognosis); Level of evidence, 2. METHODS: This retrospective study included patients with magnetic resonance imaging (MRI)-confirmed isolated ACL tear for longer than 3 months. We determined parameters for assessing instability episodes and defined any instability events between the MRI and ACL reconstruction as significant or insignificant. Patients were then grouped into a significant instability group (≥1 significant episode) and an insignificant instability group, and the incidence and types of meniscal tears found during surgery were compared between groups. RESULTS: There were 108 study patients: 62 in the significant instability group and 46 in the insignificant instability group. During surgery, 58 meniscal tears (46 medial, 12 lateral) were recorded, for an overall meniscal injury rate of 53.70%. In the significant instability group, 47 patients (75.81%) had a meniscal tear and 15 (24.19%) had intact menisci (P < .001). In the insignificant instability group, 11 patients (23.91%) had a meniscal tear and 35 (76.08%) had intact menisci (P < .001). Regarding the 58 patients with a meniscal tear, 47 (81.03%) had ≥1 significant episode of instability before surgery, as compared with 11 (18.97%) who had insignificant or no instability. The odds of having a medial meniscal tear at ACL reconstruction was 10 times higher in the significant instability group versus the insignificant instability group. CONCLUSION: The incidence of a medial meniscal tear was 10 times greater in patients with a significant episode of instability versus those with insignificant instability, as defined using a predictive scoring system. The incidence of lateral meniscal tear did not change with instability episodes.

Effectiveness of extra-corporeal shock wave therapy (ESWT) vs methylprednisolone injections in plantar fasciitis.

INTRODUCTION: In Plantar Fasciitis, the main concern of the patients is the pain that disturbs their day to day activities. Different modalities of treatments are being used for its pain management. This study seeks to investigate and compare decrease in level of pain following treatment with Methylprednisolone injections (DMP) Vs Extra-Corporeal Shock Wave Therapy (ESWT) in plantar fasciitis. METHODS: This prospective comparative non randomized study was conducted in 60 patients of any age presenting with Plantar Fasciitis at B&B Hospital, Kathmandu. Patients were divided into 2 groups (30 each) based on patients preference. Methylprednisolone injection was given to one group and another group received ESWT. Follow up of both groups were carried out at 6 weeks, 3 months and 6 months and the outcome was measured with Visual Analogue Pain Scale (VAS). Statistical analysis wasdone using SPSS software, version 13. Chi-square and Independent t-test were applied to look for significant variations in outcome. RESULTS: Follow-up at 6 weeks revealed 26 (86.7%) patients attaining VAS < 5 in ESWT group in comparison to 16 (53.3%) patients of DMP group (p = 0.005). At the end of 6 months, 5 patients in DPM group still had significant pain (VAS ≥ 5) compared to 2 patients in ESWT group (p = 0.02). However 11 patients of DMP group and 23 of ESWT group received single episode of treatment only and had persistent symptomatic pain relief (VAS < 5) during all follow ups at 6 weeks, 3 months and 6 months (p = 0.004). CONCLUSIONS: Plantar fasciitis was more prevalent in overweight population and females. Significant improvement in pain was observed with both ESWT and DMP Injections. However, ESWT was found to be more effective than DMP Injections for treatment of Plantar Fasciitis.

Closed internal degloving associated with a thoracolumbar burst fracture: a case report.

Internal degloving injuries are rare in association with thoracolumbar fractures. A high index of suspicion is warranted to identify and debride such lesions to prevent infection, which can be disastrous in the presence of spinal hardware. Whether such lesions should be routinely repaired is probably dependent on the extent of avulsion.

CT evaluation of pelvic and hip fractures.

INTRODUCTION: To analyze the spectrum of pelvic and hip joint injuries by computed tomography in patients attending to emergency. METHODS: CT evaluation with multiplanar and 3-D reformations of 62 patients done with pelvic and hip fractures during 18 months. The mode of injury and treatment were recorded. RESULTS: Forty four (70.9%) of the injuries were sustained in high speed vehicle accidents (automobile, motorcycle, autopedestrian), 14 patients (22.5%) had sustained fall injury and 4 patients (6.4%) sustained injury following slip on the ground. 31 patients underwent surgery for acetabular fractures. Associated injuries included spinal fractures (5), abdominal visceral injury (3), extremity fractures (13), chest injury (5), head injury (1), urethral injury (4), clavicle fracture (1). Forty patients (64.5%) had acetabular fractures, 25 (40.3%) patients had iliac bone fractures, 47 (75.8%) had pubic bone fracture. Sacral fracture was found in 17 (27.4%) patients. Associated femoral fracture was found in 4, hip joint dislocation was seen in 5 (2- central, 3-posterior). Sacroiliac joint diastasis was found in 13(20.9%) patients, pubic diastasis in 7 (11.2%), fracture ischium in 7(11.%), protrusio acetabuli in 5 (8%). CONCLUSIONS: Spiral CT with multiplanar and 3-D reformations has clinical values for precise diagnosis and treatment plan for the pelvic and hip fractures.

Open reduction for neglected traumatic hip dislocation in children and adolescents.

Neglected traumatic dislocation of the hip is extremely rare in children, and the preferred treatment remains unclear. This retrospective case series includes 8 children treated by open reduction. The mean age was 7.5 years (range, 2-16 years), and the mean follow-up was 7 years and 7 months (range, 4 month-16 years). Presenting complaints included pain (5/8) and gait disturbance (8/8). Traction failed to achieve a reduction in all cases. At follow-up, 6 hips remained reduced, and 2 achieved a non concentric reduction. All patients had evidence of avascular necrosis. Two patients, in whom a non concentric reduction was achieved, developed progressive flattening and joint space narrowing. Two patients had mild pain at follow-up, and 6 patients were able to squat. Range of motion was restricted both before and after open reduction, most notably in abduction and rotation. Postoperative improvement was seen in abduction (4 cases). Leg lengths were within 2 cm in 7 of 8 cases, and only 1 patient had a discrepancy greater than 2 cm. The results according to Garrett et al were good in 3, fair in 3, and poor in 2. The mean Harris hip score was 89. Patients with a concentric reduction had an adequate functional outcome despite evidence of avascular necrosis. The prognosis remains guarded, and we expect that a subset of patients will develop premature degenerative joint disease. However, we continue to offer patients an operative reduction, which we feel is preferable to other methods. A failed open reduction does not preclude options for salvage.