Journal of Orthopaedic Surgery and Research - Most accessed articles

Displaced proximal humeral fractures: an Indian experience with locking plates

Sameer Aggarwal — 2010-08-23T00:00:00Z

Background: The treatment of displaced proximal humerus fractures, especially in elderly, remains controversial. The objective of this study was to evaluate functional outcome of locking plate used for fixation of these fractures after open reduction. We also attempted to evaluate the complications and predictors of loss of fixation for such an implant. Methods: Over two and a half years, 56 patients with an acute proximal humerus fracture were managed with locking plate osteosynthesis. 47 of these patients who completed a minimum follow up of 1 year were evaluated using Constant score calculation. Statistical analysis was done using SPSS 16 and a p value of less than 0.05 was taken as statistically significant. Results: The average follow up period was around 21.5 months. Outcomes were excellent in 17%, good in 38.5%, moderate in 34% while poor in 10.5%. The Constant score was poorer for AO-OTA type 3 fractures as compared to other types. The scores were also inferior for older patients (> 65 years old). Complications included screw perforation of head, AVN, subacromial impingement, loss of fixation, axillary nerve palsy and infection. A varus malalignment was found to be a strong predictor of loss of fixation. Conclusion: Locking plate osteosynthesis leads to satisfactory functional outcomes in all the patients. Results are better than non locking plates in osteoporotic fractures of the elderly. However the surgery has steep learning curve and various complications could be associated with its use. Nevertheless we believe that a strict adherence to the principles of locking plate use can ensure good result in such challenging fractures.

Extracorporeal shockwave therapy in musculoskeletal disorders

Ching-Jen Wang — 2012-03-20T00:00:00Z

The sources of shockwave generation include electrohydraulic, electromagnetic and piezoelectric principles. Electrohydraulic shockwaves are high-energy acoustic waves generated under water explosion with high voltage electrode. Shockwave in urology (lithotripsy) is primarily used to disintegrate urolithiasis, whereas shockwave in orthopedics (orthotripsy) is not used to disintegrate tissues, rather to induce tissue repair and regeneration. The application of extracorporeal shockwave therapy (ESWT) in musculoskeletal disorders has been around for more than a decade and is primarily used in the treatment of sports related over-use tendinopathies such as proximal plantar fasciitis of the heel, lateral epicondylitis of the elbow, calcific or non-calcific tendonitis of the shoulder and patellar tendinopathy etc. The success rate ranged from 65% to 91%, and the complications were low and negligible. ESWT is also utilized in the treatment of non-union of long bone fracture, avascular necrosis of femoral head, chronic diabetic and non-diabetic ulcers and ischemic heart disease. The vast majority of the published papers showed positive and beneficial effects. FDA (USA) first approved ESWT for the treatment of proximal plantar fasciitis in 2000 and lateral epicondylitis in 2002. ESWT is a novel non-invasive therapeutic modality without surgery or surgical risks, and the clinical application of ESWT steadily increases over the years. This article reviews the current status of ESWT in musculoskeletal disorders.

The direct anterior approach: initial experience of a minimally invasive technique for total hip arthroplasty

Ola Hallert — 2012-04-25T00:00:00Z

Background: Less invasive approaches for hip arthroplasty have been developed in order to decreasetraumatisation of soft tissue and shorten hospital stay. However, the benefits with a newtechnique can be at the expense of a new panorama of problems. This manuscript describes,with emphasis on postoperative complications, our experience from the first 200 cases ofunilateral hip replacement using the direct anterior minimally invasive (MIS) approach. Methods: A straight incision in front of the greater trochanter was used and the tensor muscle wasapproached subfascially and retracted laterally. The joint was opened and the femoral headwas removed. Usually excellent acetabular exposure was obtained. In order to get access tothe proximal femur, the hip capsule was released posterolaterally so that the femur could belifted using a special retractor behind the tip of the trochanter. After insertion of theprostheses, the wound was closed using running sutures in the fascia overlying the tensor,sub- and intracutaneously. Results: There was a small influence of BMI on the duration of surgery, and obese patients tended tohave the cup positioned at a higher degree of deviation. There were in total 17 complicationsof which 5 necessitated revision surgery; 3 peroperative femoral fractures and 2 dislocations.Another 4 dislocations were treated with closed reduction and did not recur. 3 cases of nerveinjury were noted, all resolved within 12 months. Three cases of DVT were diagnosed as wellas 2 cases of postoperative infection; none of these led to chronic disability. Conclusions: The technique is perhaps more technically demanding than the lateral approaches used todaydue to the somewhat limited surgical exposure. Morbidly obese or very muscular patients aswell as patients with a short femoral neck or acetabular protrusion can represent particularproblems. Our results indicate that there are certain risks when adopting this procedure butthe complications noted are avoidable.

Obesity and long term functional outcomes following elective total hip replacement

Heather Vincent — 2012-04-25T00:00:00Z

IntroductionObesity rates continue to rise and more total hip arthroplasty procedures are being performedin progressively younger, obese patients. Hence, maintenance of long term physical functionwill become very important for quality of life, functional independence and hip prosthesissurvival. Presently, there are no reviews of the long term efficacy of total hip arthroplasty onphysical function. This review: 1) synopsized available data regarding obesity effects on longterm functional outcomes after total hip arthroplasty, and 2) suggested future directions forresearch. Methods: A literature search was conducted from 1965 to January of 2011 for studies that evaluatedlong term functional outcomes at one year or longer after THA in obese (body mass indexvalues [greater than or equal to]30 kg/m2) and non-obese patients (body mass index <30 kg/m2). Results: Five retrospective studies and 18 prospective studies were identified as those that assessedphysical function before surgery out to [greater than or equal to] one year after total hip arthroplasty. Study samplesizes ranged from 108-18,968 and followed patients from one to twenty years. Total hiparthroplasty confers significant pain reduction and improvement in quality of life irrespectiveof body mass index. Functional improvement occurred after total hip arthroplasty among allstudies, but obese patients generally did not attain the same level of physical function by thefollow-up time point.DiscussionUncontrolled obesity after total hip arthroplasty is related to worsening of comorbidities andexcessive health care costs over the long term. Aggressive and sustainable rehabilitationstrategies that include physical exercise, psychosocial components and behavior modificationmay be highly useful in maximizing and maintaining weight loss after total hip arthroplasty.

Use of Tranexamic acid is a cost effective method in preventing blood loss during and after total knee replacement.

Yasir Sepah — 2011-05-21T00:00:00Z

Background & PurposeAllogenic blood transfusion in elective orthopaedic surgery is best avoided owing to its associated risks. Total knee replacement often requires blood transfusion, more so when bilateral surgery is performed. Many strategies are currently being employed to reduce the amount of peri-operative allogenic transfusions. Anti-fibrinolytic compounds such as aminocaproic acid and tranexamic acid have been used systemically in perioperative settings with promising results. This study aimed to evaluate the effectiveness of tranexamic acid in reducing allogenic blood transfusion in total knee replacement surgery.MethodologyThis was a retrospective cohort study conducted on patients undergoing total knee replacement during the time period November 2005 to November 2008. Study population was 99 patients, of which 70 underwent unilateral and 29 bilateral knee replacement. Forty-seven patients with 62 (49.5%) knees (group-I) had received tranexamic acid (by surgeon preference) while the remaining fifty-two patients with 66 (51.5%) knees (group-II) had did not received any tranexamic acid either pre- or post-operatively. Results: The mean drop in the post-operative haemoglobin concentration in Group-II for unilateral and bilateral cases was 1.79 gm/dl and 2.21 gm/dl, with a mean post-operative drainage of 1828 ml (unilateral) and 2695 ml (bilateral). In comparison, the mean drop in the post-op haemoglobin in Group-I was 1.49 gm/dl (unilateral) and 1.94 gm/dl (bilateral), with a mean drainage of 826 ml (unilateral) and 1288 ml (bilateral) (p-value < 0.001).InterpretationTranexamic acid is effective in reducing post-operative drainage and requirement of blood transfusion after knee replacement.

The benefits and barriers to physical activity and lifestyle interventions for osteoarthritis affecting the adult knee

Jonathan Stevenson — 2012-03-31T00:00:00Z

Osteoarthritis prevalence is increasing, placing greater demands on healthcare and future socioeconomic costing models. Exercise and non-pharmacological methods should be employed to manage this common and disabling disease. Expectations at all stages of disease are increasing with a desire to remain active and independent. Three key areas have been reviewed; the evidence for physical activity, lifestyle changes and motivational techniques concerning knee osteoarthritis and the barriers to instituting such changes. Promotion of activity in primary care is discussed and evidence for compliance has been reviewed. This article reviews a subject that is integral to all professionals involved with osteoarthritis care.

Common extensor origin release in recalcitrant lateral epicondylitis - role justified ?

Faizal Rayan — 2010-05-10T00:00:00Z

The aim of our study was to analyse the efficacy of operative management in recalcitrant lateral epicondylitis of elbow. Forty patients included in this study were referred by general practitioners with a diagnosis of tennis elbow to the orthopaedic department at a district general hospital over a five year period. All had two or more steroid injections at the tender spot, without permanent relief of pain. All subsequently underwent simple fasciotomy of the extensor origin. Of forty patients thirty five had improvement in pain and function, two had persistent symptoms and three did not perceive any improvement. Twenty five had excellent, ten had well, two had fair and three had poor outcomes (recurrent problem; pain at rest and night). Two patients underwent revision surgery. Majority of the patients had improvement in pain and function following operative treatment. In this study, an extensor fasciotomy was demonstrated to be an effective treatment for refractory chronic lateral epicondylitis; however, further studies are warranted.

Isolated thumb carpometacarpal joint dislocation: a case report and review of the literature

Elias Fotiadis — 2010-03-10T00:00:00Z

Background: Isolated thumb carpometacarpal dislocation is a rare injury pattern and the optimal treatment option is still controversial.Case DescriptionWe present a 27-year-old basketball player who underwent an isolated dorsal dislocation of the thumb carpometacarpal joint after a fall. The dislocation was successfully reduced by closed means but the joint was found to be grossly unstable. Due to inherent instability, repair of the ruptured dorsoradial ligament and joint capsule was performed.The ligament was detached from its proximal insertion into trapezium and subsequently stabilized via suture anchors. The torn capsule was repaired in an end-to-end fashion and immobilization of the joint was applied for 6 weeks. Results: At 3-year follow up evaluation the patient was pain free and returned to his previous level of activity. No restriction of carpometacrpal movements or residual instability was noticed. Radiographic examination showed normal joint alignment and no signs of subluxation or early osteoarthritis. Conclusion: Surgical stabilization of the dorsal capsuloligamentous complex may be considered the selected treatment option in isolated carpometacarpal joint dislocations, that remain unstable after closed reduction in young and high demand patients.Level of Clinical Evidence: Level IV

Chondrogenic differentiation of human subchondral progenitor cells is affected by synovial fluid from donors with osteoarthritis or rheumatoid arthritis

Jan Philipp Kruger — 2012-03-13T00:00:00Z

Background: Microfracture is a first-line treatment option for cartilage repair. In microfracture, subchondral mesenchymal cortico-spongious progenitor cells (CSP) enter the defect and form cartilage repair tissue. The aim of our study was to investigate the effects of joint disease conditions on the in vitro chondrogenesis of human CSP. Methods: CSP were harvested from the subchondral bone marrow. CSP characterization was performed by analysis of cell surface antigen pattern and by assessing the chondrogenic, osteogenic and adipogenic differentiation potential, histologically. To assess the effect of synovial fluid (SF) on chondrogenesis of CSP, micro-masses were stimulated with SF from healthy (ND), osteoarthritis (OA) and rheumatoid arthritis donors (RA) without transforming growth factor beta 3. Results: CSP showed the typical cell surface antigen pattern known from mesenchymal stem cells and were capable of osteogenic, adipogenic and chondrogenic differentiation. In micro-masses stimulated with SF, histological staining as well as gene expression analysis of typical chondrogenic marker genes showed that SF from ND and OA induced the chondrogenic marker genes aggrecan, types II and IX collagen, cartilage oligomeric matrix protein (COMP) and link protein, compared to controls not treated with SF. In contrast, the supplementation with SF from RA donors decreased the expression of aggrecan, type II collagen, COMP and link protein, compared to CSP treated with SF from ND or OA. Conclusion: These results suggest that in RA, SF may impair cartilage repair by subchondral mesenchymal progenitor cells in microfracture, while in OA, SF may has no negative, but a delaying effect on the cartilage matrix formation.

Charcot foot reconstruction with combined internal and external fixation: case report

Claire Capobianco — 2010-02-11T00:00:00Z

Charcot neuroarthropathy is a destructive and often-limb threatening process that can affect patients with peripheral neuropathy of any etiology. Early recognition and appropriate management is crucial to prevention of catastrophic outcomes. Delayed diagnosis and subsequent pedal collapse often preclude successful conservative management of these deformities and necessitate surgical intervention for limb salvage. We review the current literature on surgical reconstruction of Charcot neuroarthropathy and present a case report of foot reconstruction with combined internal and external fixation methods.