Assessment of osteoporotic fracture risk in urban Indian population using quantitative ultrasonography & FRAX tool.

BACKGROUND & OBJECTIVES: There have been studies around the world on the prevalence of osteoporosis and its related risk factors, but there have been limited studies on risk factors and osteoporosis in the Indian population. In this study, the incidence of osteoporosis and the associated clinical risk factors (CRFs) were studied in the urban Indian population. METHODS: Bone mineral density of 445 individuals >38 yr of age using qualitative ultrasound (QUS) was assessed. The patients were also questioned regarding the presence of the various CRFs as per the FRAX tool. The patients were categorized into normal, osteopenia and osteoporosis groups on the basis of T-score from QUS. RESULTS: There were 223 males and 222 females in this study. Sex was significantly associated with T-score (P<0.001). Forty (8.99%) patients were osteoporotic, 265 (59.55%) were osteopenic and the remaining 140 (31.46%) were normal. A significant association of T-score was found with parent history of fracture (P<0.05), rheumatoid arthritis (P<0.05) and secondary osteoporosis (P<0.05). Previous history of fracture's association was not found to be significant. Smoking, alcohol intake and steroid intake were not found to be significantly associated with T-scores. INTERPRETATION & CONCLUSIONS: The incidence of osteoporosis was found to be high in the urban Indian population. More care and attention should be targeted towards elderly, especially the ones with the risk factors to prevent osteoporosis in future.

Outcome of distal end clavicle fractures treated with locking plates.

PURPOSE: Fractures of the lateral end of the clavicle are relatively uncommon. These fractures are unstable due to the various deforming forces which act on the fragments as well as the small distal fracture fragment. At most times the deforming forces are not taken into consideration, and the fracture is not fixed securely. In this study, we assessed a fixation technique using the precontoured locking plates to find out whether it provided a stable fixation with good functional outcome. METHODS: Totally, 32 patients with lateral end clavicle fracture (Neer's Type II) were included in the study. After the informed consent and preoperative investigations were obtained, open reduction and internal fixation was done using a 3.5 mm precontoured superior locking plate with lateral extension under general anesthesia. Postoperative X-rays were done on day 1 and every 6 weeks after operation, until radiological union was achieved. The postoperative pain was assessed using Visual Analogue Scale (VAS) on postoperative days 1, 2 and 10. Postoperatively arm pouch sling was given for 2 weeks followed by active mobilization. Patients were asked to do their daily routine work and avoid lifting heavy weights. The functional outcome was assessed at the end of 2nd and 6th months with the help of Disabilities of the Arm, Shoulder and Hand (DASH) scoring. RESULTS: There were no intraoperative complications in the procedure. The mean VAS score on postoperative day 1 was found to be 5 which decreased to 3 on day 2 and 0 on day 10. The mean DASH score was calculated as 11.63 at the end of postoperative month 2 and then 4.6 at the end of month 6. There was one case of malunion in whom the overhead abduction was restricted but was not painful and was managed conservatively. CONCLUSION: The precontoured locking plates with lateral extension may be a good method to fix the fractures of the lateral end clavicle, which provide a stable fixation with good functional outcome with very few instances of stiffness and decreased range of motion of the shoulder with the hook plates and failure of fixation in screw and K-wire fixations. It may well be the answer to the fixation questions of the lateral clavicle fractures, although larger comparative studies between the surgical treatment methods are required to confirm the same.

Open reduction and internal fixation of capitellar fracture through anterolateral approach with headless double-threaded compression screws: a series of 16 patients.

BACKGROUND: Fracture of the capitellum is an often missed or inadequately treated serious elbow injury. Anatomic reduction and proper stabilization are essential to obtain articular congruity so that late-onset arthritis can be avoided. The main areas of interest in this intriguing fracture are the choice of implant and the surgical approach. We describe the use of anterolateral approach and headless double-threaded compression screws for the fixation of this fracture. MATERIALS AND METHODS: This prospective study included 16 capitellar fractures. A computed tomography scan was done for delineating the fracture line and planning the fixation technique. All fractures were treated with headless double-threaded compression screws using an anterolateral approach, over a period of 3 years, with a mean follow-up of 2.3 years (range, 1.5-4 years). RESULTS: The average time to bony union was 3.5 months (range, 2.5-5 months) with no malunion or nonunion. The mean range of flexion was 132° (range, 125°-135°). The average extensor lag was 10° (range, 0°-25°), but the range of motion remained functional in all patients. On the final follow-up, no evidence of osteonecrosis, post-traumatic osteoarthritis, or heterotrophic ossification was seen. The outcome was excellent in 10 patients, and 6 patients had a good result. CONCLUSIONS: The success of management of a capitellar fracture depends on an early diagnosis by keeping a high index of suspicion and timely management. Adequate exposure of the fracture is of paramount importance to achieve accurate reduction. This can be satisfactorily achieved by an anterolateral approach to the elbow. An adequate fixation of the fractured fragments can be achieved by the use of headless double-threaded compression screws.

Reversed distal femoral locking plate for failed proximal femoral nail with non-union of proximal femoral fractures.

INTRODUCTION: Failure of proximal femoral fracture managed by proximal femoral nail (PFN) leads to a very difficult situation to handle with conventional techniques, and reversed distal femoral locking compression plate (DF-LCP) is of great benefit in these selective cases. METHODS: Twelve patients with ununited proximal femoral fractures including subtrochanteric fractures with a failed PFN implant were included in the study. All patients with periprosthetic fractures and fractures treated by implants other than PFN were excluded from this study. RESULT: All fractures went into union in an average time of nine months and 15 days with no implant failures. The mean time of re-osteosynthesis after the primary index surgery of PFN was one year eight months. Mean surgical time of re-osteosynthesis was 110 minutes, and average blood loss during surgery was 550 ml. DISCUSSION: The PFM is one of the most commonly used implant for unstable proximal femur fractures. The use of PFN is technically demanding and is associated with high failure rates. Although dynamic compression screw (DCS), proximal femoral locking plate (PF-LCP) and other implants can be used in these failed situations, they are associated with a high complication rate. The reversed DF-LCP is a rescue implant for these complex situations. Apart from anatomical and biomechanical advantages, there are several other clinical benefits of using DF-LCP. CONCLUSION: We conclude that DF-LCP is a potential and safe implant of choice for the management of nonunion associated with failed PFN. It may be considered an implant of choice as rescue from such a complex situation. It offers several anatomical, biomechanical and clinical advantages over other available conventional implants.

Bilateral segmental pelvic and femoral fractures in a young female: A rare case report.

The management of multiple complicated injured patients remains a great challenge despite advance- ments in modern medical care. We present a rare case of bilateral unstable pelvic fractures associated with bilateral segmental femoral shaft fractures.We have proposed a mechanism of such complex injury pattern and discussed the plan of management. We believe that a timely and aggressive surgical intervention to fix all the major fractures soon after medically stabilizing the patient helped our patient to overcome these serious and lethal injuries. It is necessary to establish an optimal protocol for management of such complex fractures by conducting prospective and multicentric studies in the future.

Dislocation of a constrained total knee arthroplasty with patellar tendon rupture after trivial trauma.

Constrained total knee prostheses are used in knees with severe deformities and insufficiency of collaterals to provide stable and mobile knees. Dislocation after constrained knee prosthesis is an extremely rare and dreaded complication. When dislocation is associated with patellar tendon rupture, the management includes restoration of the extensor apparatus along with a stable knee. Repair of the patellar tendon is challenging due to poor soft tissue coverage in the area and a bulky repair can put tension on the wound closure. Ideal method of restoration of the extensor apparatus is a matter of debate. There are various modalities used ranging from primary end-to-end repair, augmentation by medial gastrocnemius flap, semitendinosus and synthetic implants and allograft tendoachilles. We report a rare case of a posterior dislocation of a constrained total knee arthroplasty in association with patellar tendon rupture due to a minor fall after a few weeks of surgery. The first episode was managed by reposition of the dislocation and V-Y plasty of the quadriceps and primary repair. The second episode of dislocation with re-rupture needed augmentation by semitendinosus along with the insertion of the thicker insert. The management of this complex problem along with the review of literature is discussed in this case report.

Multifocal bilateral metatarsal tuberculosis: a rare presentation.

Tuberculosis, or phthisis (consumption) as it was popularly known in the Greek era, has been endemic in Southeast Asia and Sub-Saharan Africa; however, the human immunodeficiency virus epidemic has seen the re-emergence of this disease in the areas in which it was not very commonly reported. With this, the need for understanding and treatment of rare presentations of tuberculosis has become of paramount importance to achieve the World Health Organization millennium goal of a "reversal of incidence by 2015." Foot involvement has been reported in 0.1% to 0.3% of extrapulmonary cases. Multifocal lesions have an incidence of <10% in osteoarticular tuberculosis. Bilateral feet involvement in multifocal tuberculosis has not yet been reported in either children or adults in published studies. We report a case of tuberculosis with lesions in the bilateral metatarsals, the occurrence of which is very rare. The diagnosis was mainly histopathologic owing to the paucibacillary nature of the disease. Early identification and treatment with antitubercular drugs will normally result in a good cosmetic and functional result.

Local Infiltration Analgesia reduces pain and hospital stay after primary TKA: randomized controlled double blind trial.

Postoperative analgesia following Total Knee Arthroplasty (TKA) with the use of parenteral opioids or epidural analgesia can be associated with important side effects. Good perioperative analgesia facilitates faster rehabilitation, improves patient satisfaction, and may reduce the hospital stay. We investigated the analgesic effect of a locally injected mixture of drugs, in a double blinded RCT in 80 primary TKA. They were randomized either to receive a periarticular mixture of drugs containing bupivacaine, ketorolac, morphine, and adrenalline or to receive normal saline. Visual analog scores (VAS) for pain (at rest and during activity) and for patient satisfaction and range of motion were recorded postoperatively. The patients who had received the periarticular injection used significantly less the Patient Controlled Analgesia (PCA) after the surgery as compared to the control group. In addition, they had lower VAS for pain during rest and activity and higher visual analog scores for patient satisfaction 72 hours postoperatively. No major complication related to the drugs was observed. Intraoperative periarticular injection with multimodal drugs following TKA can significantly reduce the postoperative pain and hence the requirements for PCA and hospital stay, with no apparent risks.

A Giant Ganglion Cyst Arising from Lateral Hoffa's Fat Pad of the Knee.

INTRODUCTION: The ganglion cysts are benign fluid-filled sacs, which often arise from a tendon sheath or a joint capsule. Their origin from the fat pad of the knee is rare. Several studies have described intra-articular ganglion cysts in detail; however, extra-articular soft-tissue ganglion cysts have been reported sparingly. We report a rare case of giant ganglion cyst arising from lateral Hoffa's fat pad (HFP). CASE REPORT: A 59-year-old male patient presented with a 3-year history of swelling of the left knee, with occasional pain. There was no history of trauma or any constitutional symptoms. There was an apparent swelling (10 cm ×5 cm in size) around the anterolateral aspect of the knee joint. A magnetic resonance imaging (MRI) scan revealed a multilobular, complex cystic lesion of the lateral HFP. Surgical excision of the cyst was done, and histopathological examination confirmed the diagnosis of the ganglion cyst. CONCLUSION: Cysts and cystic-appearing lesions around the knee are not uncommon, but a ganglion cyst arising from HFP is rare. The presence of multipotent cells in the HFP may be responsible for producing a variety of cyst and cyst-like tumors around the anterior aspect of the knee joint. An MRI is the best imaging modality for the diagnosis of these cysts and cysts-like lesions around the knee. We recommend that the smaller intra-articular lesions can be resected arthroscopically, but larger lesions, with extraarticular extension, are best treated by open resection to avoid incomplete excision and recurrence.