Can We Predict Severity of Osteoarthritis of Knees and Compartmental Involvement Based on a Set of Predefined Clinical Questions in Patients of Knee Pain?

BACKGROUND: We investigated whether the severity of Osteoarthritis (OA) knees can be predicted based on a set of predefined clinical questions (PCQs) about activities of daily living (ADL). We studied the association of demographic factors and advanced radiographic OA (KL 3 and 4) and the relationship between various physical activities and radiographic involvement of knee joint compartments based on PCQs. MATERIALS AND METHODS: Demographic data, radiographic grading of knee OA and PCQs score, were obtained prospectively. Patients' responses to PCQs were marked as scores-that were predefined and graded according to the severity of knee pain. Radiographic knee OA grades were dichotomized and patients were classified as either negative (KL grade 1, 2) or positive (KL grade 3, 4). Multivariate logistic regression was performed to obtain the adjusted odds for total PCQs score in relation with positive radiographic OA considering confounders like age, gender and BMI in the model. Log odds score (LOS) were obtained and ROC analysis was performed on scores to obtain the cut-off value for the screening of knee OA in patients of knee pain. RESULTS: Age and BMI were significantly negatively correlated with PCQs score (r = - 0.473; P < 0.0001 and r = - 0.136; P = 0.046). PCQs scores were significantly lower in females (P = 0.031). Total PCQs score had corresponding OR of 0.901 (P = 0.002) towards knee OA after adjusting for age, gender and BMI. Multivariate model-based LOS resulted in a cut-off of 1.315, which had a sensitivity of 85.5%, specificity of 66.7% and PPV of 92.7%. CONCLUSION: Severity of knee OA can be predicted based on PCQs. PCQs can predict severity of knee OA and patellofemoral or medial tibiofemoral compartment without radiographs. LOS based on demographics and total PCQs score can be developed as a screening tool for advanced knee OA.

DHS osteosynthesis with internal bone grafting in unstable delayed presented intracapsular neck femur fractures.

OBJECTIVES: The aim of this study was to assess fracture union and complications following use of dynamic hip screw (DHS) with internal bone grafting in treatment of unstable delayed presented intracapsular neck femur fractures in patients younger than 65 years of age. MATERIAL AND METHODS: Thirty two patients with displaced intracapsular neck femur fractures(Garden III and IV, Pauwels III, with comminution) with delayed presentation (15-60 days) in the 45-65 year age group (mean 54.4±10.2 years) were included in this study. All patients were treated with dynamic sliding hip screw with closed cancellous bone grafting through a tunnel of a triple reamer. The average time to union was 3.8 months (3-5 months). Satisfactory union was achieved in all patients except two. One case developed avascular necrosis of the femoral head. Other complications were coxa vara in two, shortening of less than 10mm in three cases but there were no cases of infection or implant failure. Excellent results were achieved in 27, good/fair in 4 and poor in 1 patient. CONCLUSION: Osteosynthesis with DHS and primary cancellous bone grafting in indicated cases is a simple, providing biological stimulation for early union. Failure in a particular case can be treated with any appropriate second procedure.

Augmentation of proximal femoral nail in unstable trochanteric fractures.

INTRODUCTION: Biomechanically proximal femoral nail (PFN) is a better choice of implant, still it is associated with screw breakage, cut out of screw through femoral head, Z effect, reverse Z effect, and lateral migration of screws. The purpose of this study is to evaluate the results of augmented PFN in terms of prevention of postoperative complications and failure rates in unstable trochanteric fractures. MATERIAL AND METHODS: We carried out a prospective study of 82 cases with unstable trochanteric femoral fractures from April 2010 to December 2015. Forty-two females and 40 males in the age group between 58 and 81 years were included in this study. There were 45 cases of AO 31 A2 (2.2, 2.3) and 37 cases of AO 31 A3 (3.1, 3.2, 3.3). Fractures were fixed by PFN with augmentation by an additional screw from trochanter to inferior quadrant of femoral head or cerclage wire to strengthen the lateral trochanteric wall. RESULTS: The bone healing is observed in all the cases in the mean period of 14.2 weeks. Nine patients developed complications, including lateral migration of neck screws (n = 5), Z effect (n = 1), infection (n = 2), and breakage of distal interlocking bolt in one case. Removal of screws was required in five cases. Patients were followed up for a mean of 8.4 months. At the end of follow-up the Salvati and Wilson hip function was 32 (out of 40) in 88% of patients. CONCLUSION: The stabilization of lateral trochanteric wall with additional screw or cerclage wire increases the stability of construct.

Valgus intertrochanteric osteotomy and fibular strut graft in the management of neglected femoral neck fracture.

PURPOSE: A prospective study of neglected femoral neck fractures in mostly young patients was conducted to evaluate whether our technique of valgus intertrochanteric osteotomy with fibular strut grafting and osteosynthesis with dynamic hip screw and double-angle side plate can facilitate union with consistent satisfactory clinical outcomes. METHODS: Forty-one consecutive patients (27 males, 14 females) of neglected femoral neck fractures treated between April 2002 and December 2009 were studied. The average age of patients was 45.41 years (±11.67, range 20-62 years). The average interval since injury was 14 weeks (±10.21, range 4-44 weeks). The cases were evaluated radiographically and clinically. RESULTS: The average follow-up period was 32.5 months (±8, range 24-54 months). Radiographically union was seen in 39 patients at the nonunion site. The average time to radiographic union was 16.82 weeks (±3 weeks, range 12-24 weeks). Average Harris Hip Score (HHS) was 19.9 (±7.9, range 10-35) preoperatively and 90.9 (±10.35, range 62-100) at the latest follow-up. At that time clinical outcomes were excellent in 31, good in four, fair in three and poor in three patients. CONCLUSION: Our mechanobiological surgical technique is reproducible with radiographic union achieved in 95.12% cases (39 patients) at the nonunion site and consistent excellent or good functional outcome in 85% of patients over a 32-month average follow-up. We recommend this procedure for neglected femoral neck fractures.

Percutaneous osteosynthesis of Galeazzi fracture-dislocation.

BACKGROUND: A Galeazzi fracture is defined as a fracture of the radius associated with dislocation of the distal radio-ulnar joint (DRUJ). The conventional surgical technique of nailing does not give enough stability and open reduction, internal fixation with the plate is associated with numerous complications. The stacked nailing for the management of these injuries provides adequate stability, maintains the relationship of the DRUJ and promotes uneventful union by closed technique. The purpose of this study is to evaluate the results of simple, user-friendly, low cost elastic stacked nailing for the management of Galeazzi fracture dislocation. MATERIALS AND METHODS: We treated 22 young adults with fresh Galeazzi fracture-dislocation of the forearm, from January 2004 to January 2008, by percutaneous fixation of fracture by stacked elastic nailing at our institute. There were 19 males and three females and the age group ranged from 20-56 years (average 35 years). Surgery was performed within 48 to 72 hours under the guidance of image intensifier. Medullary cavity was filled with two elastic titanium nails having unequal lengths and diameter. One nail acts as a reduction nail and the other acts as a stabilizing nail. The results were evaluated using Mikic criteria based on union, alignment, relationship of the DRUJ, and movements at the inferior radio ulnar joint, elbow and wrist. RESULTS: In six cases, following radiological union, nails in the radius were extracted between six to nine months after operation because of discomfort complained by the patient at site of insertion. After one year follow-up, 18 patients had excellent, four had fair results. CONCLUSION: Closed reduction and internal fixation of Galeazzi fracture by two elastic rods re-establishes the normal relationship of the fractured fragments and the DRUJ without repair of the ligaments. The stability is achieved by the flexibility and elasticity of the nails, crowding of the medullary canal and anchorage they gain in the radial diaphysis. Elastic nailing can produce excellent clinical results for Galeazzi fracture-dislocation. It has the advantages of technical simplicity, minimal cost, user-friendly instrumentation, and a short learning curve.

Short proximal femoral nail fixation for trochanteric fractures.

PURPOSE: To review outcomes of 100 patients who underwent short proximal femoral nailing for stable and unstable intertrochanteric fractures. METHODS: Records of 62 men and 38 women aged 56 to 83 (mean, 67) years who underwent short proximal femoral nailing for stable peritrochanteric A1 (n=36), unstable peritrochanteric A2 (n=40), and unstable intertrochanteric A3 (n=24) fractures were reviewed. RESULTS: 80 patients achieved anatomic reduction. At the one-year follow-up, 90% of the patients had good or excellent outcomes, and 50% had returned to their pre-injury functional level. One patient with avascular necrosis noted at 20 months and another patient with non-union/pseudarthrosis underwent a revision bipolar arthroplasty. Two patients had a Z effect and one a reverse Z effect. Six patients with osteoporosis had superior migration of the nail with varus collapse. Two patients had cutting out of the screw, but the fractures eventually healed. Ten patients had shortening of <2 cm. Seven patients had lateral thigh discomfort attributed to irritation of the protruding screws against the tensor fascia lata, and 5 of them underwent screw removal. None had fractures of the femoral shaft or trochanter or experienced nail breakage. CONCLUSION: The short proximal femoral nail is a superior implant for stable and unstable intertrochanteric fractures in terms of operating time, surgical exposure, blood loss, and complications, especially for patients with relatively small femora.

Dynamic osteosynthesis by modified Kuntscher nail for the treatment of tibial diaphyseal fractures.

BACKGROUND: We evaluated a series of diaphyseal fractures of the tibia using low-cost, Indian-made modified Kuntscher nail (Daga nail) with the provision of distal locking screw for the management of the tibial diaphyseal fractures. MATERIALS AND METHODS: One hundred and fifty one consecutive patients with diaphyseal fractures of tibia with 151 fractures who were treated by Daga nail were enrolled. One of the patients who had died because of cancer, and the two patients who were lost to follow-up at 3 months were excluded from the study.Therefore data of 148 patients with one hundred and fortyeight fractures is described. One hundred twenty closed fractures, 20 open Grade I fractures, and eight open Grade II fractures as per Gustilo and Anderson classification were included in this study. One hundred fourteen men and 34 women, with a mean age of 38.4 years, were studied. The result were analysed for Surgical time, duration of hospitalisation, union time, union rate, complication rate, functional recovery and crutch walking time. The fractures were followed at least until the time of solid union. RESULTS: The follow-up period averaged 15 months (range, 6-26 months). Union occurred in 140 cases (94.6%). The mean time to union was 13 weeks for closed fractures,17.8 weeks for Grade I open fractures, and 21.6 weeks for Grade II open fractures. Compartment syndrome occurred in two patients. Superficial infection occurred in five cases of Grade I and II compound fractures. Three closed fractures and one case of Grade I compound fracture required bone grafting for delayed union. Two cases of Grade II compound fracture with nonunion required revision surgery and bone grafting. Twelve cases resulted in acceptable malalignment due to operative technical error. In four cases, the distal screw breakage was seen, but none of these complications interfered with fracture healing. Recovery of joint motion was essentially normal in those patients without knee or ankle injury. CONCLUSION: Unreamed distally locked dynamic tibial nailing (modified Kuntscher nail/Daga nail) can produce excellent clinical results for diaphyseal tibial fractures. It has the advantages of technical simplicity, minimal cost, user-friendly instrumentation, and a short learning curve.