Kerala Journal of Orthopaedics

RCTs and Beyond

Ashok Ramakrishnan — 2021-06-01

In God we trust, everyone else must bring data
This the often quoted statement by W. Edwards Deming - American engineer, statistician, professor, author, lecturer, and management consultant and winner of the Japanese emperors order of sacred treasure1 - is well known to us in the medical field and is often mentioned in all RCT discussions and journal clubs

Anterior Cruciate Ligament Injuries: Patterns of Association Between the Mechanism of Injury and Spectrum of Intraarticular Knee Lesions

R S Vaishnav — 2021-06-01

ACL injuries are extremely common in young active population and have significant socio-economic impact.1 Though different mechanisms leading to ACL injuries have been described in the literature,2 the association between these mechanisms and the spectrum of associated meniscal, chondral, ligamentous and bony lesions have not been highlighted. This cross sectional study attempts to give an insight to the different mechanisms of ACL injury in 353 patients (aged 15-50 years) who underwent arthroscopic ACL reconstruction, and shows its association to the spectrum of lesions seen during arthroscopy and MR imaging. We found that “Solid foot plant with rotation of the knee” (46.5%), had a significant association with ACL injuries (p<0.001). Associated Medial meniscal injuries (75%) were the most common, followed by chondral damage (54%), lateral meniscus (33%), LCL(29%) and MCL(10.5%). The mechanism of “Solid foot plant with rotation of the knee” was associated to concomitant medial meniscal injury and “Solid foot plant with valgus stress on the knee “was associated to concomitant lateral meniscal injury (χ² 17.98; p<0.003, χ² 47.51; p<0.001). LCL, MCL and bone contusions also had significant association with the mechanism of Solid foot plant with valgus stress on the knee (p<0.001). We suggest the need to highlight these injury patterns and to focus on plyometric training to reduce ACL & associated injuries.3

Delayed Reamed Interlocking Nailing after Initial External Fixation in Gustilo-Anderson Type III B Open Tibial Shaft Fractures

Cherry Cheriyan Kovoor — 2021-06-01

Background: To evaluate union and infection rates in Gustilo – Anderson type III B open tibial shaft fractures treated by delayed interlocking nailing after initial external fixation.
Materials and Methods: Twenty-five patients who had sustained type III B open fractures of the tibial shaft were treated with external fixation as a temporary stabilization with conversion to reamed interlocking nailing later were retrospectively studied. Once the wounds had healed the external fixator was removed, plaster of Paris posterior slab was applied and after the pin tracts had healed closed reamed interlocking nailing was done
Results: Union occurred in twenty-four patients [96%]. Infection occurred in three patients [12%]. Additional unplanned surgeries included nail removal and intra medullary reaming in three patients for infection, conversion to Ilizarov ring fixator in one patient and additional skin grafting surgery in one patient
Conclusions: Delayed interlocking nailing after initial external fixation gives a good union rate but increased incidence of infection in Gustilo – Anderson type III B open tibial fractures.

A Case Report - Treating Chronic Bilateral Patellofemoral Instability with Combined Trocheoplasty and MPFL Reconstruction

Mohamed Riyaz Varikapulakal — 2021-06-01

Patients with trochlear dysplasia have recurrent patella-femoral instability (PFI) due to a missing bony guidance for the patella in early flexion. An isolated medial patella-femoral ligament (MPFL) reconstruction can be insufficient, since it mainly addresses instability close to extension. Trochleoplasty has become more popular because of a better knowledge of knee anatomy and biomechanics. When patients are prudently selected and the surgical rationale is carefully followed, very encouraging results are achieved with the application of trochleoplasty with other procedures. Results are more favourable especially in patients with severe trochlear dysplasia and recurrent patellar dislocation, in whom the “benign neglect” of dysplasia and their approach with more “conventional or traditional surgery” would lead to less favourable results. The surgical steps and technical pearls of the procedure are described in this review.

Traumatic Unstable Acute on Chronic Slipped Capital Femoral Epiphysis Managed with Modified Dunn’s Procedure: A Case Report

Rohith Ravindran — 2021-06-01

Introduction: Slipped capital femoral epiphysis (SCFE) is the most common adolescent hip disorder. In case of an unstable slip, the line of management is still a controversy. Mismanagement may result in consequences of poor hip function.
Case History: A 15-year-old obese boy presented with left sided hip pain of one-year duration. Examination and radiographs revealed a stable chronic slip and he was advised in situ pinning. The patient refused surgery. After one month he presented with severe pain over the left hip following a fall. He was unable to weight bear and had severe restriction of movements of left hip. Plain radiographs and MR imaging was suggestive of unstable acute on chronic SCFE. We proceeded with a modified Dunn’s procedure. At 3 year follow up he has painless hip with full range of movements with no clinical or radiological signs of osteonecrosis.
Conclusion: Open reduction utilizing safe surgical dislocation of hip is the treatment of choice in an unstable SCFE. Closed reduction is associated with increased incidence of osteonecrosis of femoral head.

Tibial Tuberosity Avulsion - Bilateral A Case Report

Tony Kavalakkatt — 2021-06-01

Bilateral avulsion fractures of tibial tuberosity are very rare injuries. It is seen in adolescent males and corresponds to maturation of extensor mechanism and growth plate closure.
13 years old male presented with hyperflexion injury while playing football. Imaging showed bilateral tibial tubercle avulsions with patellar tendon and medial patellofemoral ligament tear. He was treated with open reduction and internal fixation with 3.5mm screw and K-wire and augmentation with suture anchor was done on both sides.
Avulsion fractures of the tibial tuberosity can be associated with collateral ligament injuries, anterior cruciate ligament tears and meniscal tears. The objectives of treatment are to restore the extensor mechanism and congruency of the tibial articular surface and to address any associated soft tissue injuries.
Conclusion
Bilateral simultaneous avulsion fractures of the tibial tubercle usually occur in a muscular adolescent athletic male. Xray is diagnostic, but MRI should be done to rule out any associated injuries and to guide the treatment plan. These fractures usually require open reduction and internal fixation, and the complication rates are very low.

Osteodystrophia Deformans – Case Report

V Shyam Gopal — 2021-06-01

Polyostotic Paget’s disease has been reported in the literature, however, monostotic Paget’s disease of the tibia (confirmed with histology) is rarely reported. We report a case of localized Paget’s disease of tibia

Solid Aneurismal Bone Cyst of Proximal Tibia with Resemblance Telangiectatic Osteosarcoma - A Case Report

Johncy Itty Panicker — 2021-06-01

Case: We report the case of an 11 year-old boy presented 1 year ago with a swelling over the right proximal tibia with radiographic features of osteolytic lesion. MRI reported as aneursymal bone cyst with the less likely possibility of telangiectatic osteosarcoma to be considered. He underwent extended curettage, & bone grafting. Histopathological examination suggested a Solid-ABC with extensive new bone formation & features of malignant tumours.
Conclusion: Solid-ABC which is often deceptive to the treating clinician. Comprehensive correlation of findings between the clinician, radiologist & pathologist is mandatory to make the accurate diagnosis and to provide the optimum treatment.

Recurrent Shoulder Dislocation – What to do & When! – A Systematic Review

Sujit Jos — 2021-06-01

The understanding of recurrent instability of the shoulder joint has been evolving in the past few years with surgeons treating the problem arthroscopically, even in the presence of significant bone loss in glenoid and humeral head. The aim of this article is to evaluate the various treatment methods and to elucidate the current best options for various types of shoulder dislocation. The success of treatment depends on meticulous preoperative evaluation including radiological assessment of soft tissues and, measurements of bone loss in the glenoid (Bankart lesion) and the humeral head (Hill-Sachs lesion). When the bone loss is less than clinically significant arthroscopic reattachment of the torn capsulo-labral complex (arthroscopic Bankart surgery) provides adequate stability to the joint. But when there is ‘significant bone loss’ in either bone, bony procedures like the Latarjet where coracoid bone is transferred to anterior glenoid, or iliac crest bone grafting, or other stabilizing procedures of the humeral head like the Remplissage are required. The concept of on-track off-track bipolar bone loss gives reproducible guidelines for bone loss assessment and planning the best treatment for stabilizing the shoulder joint. Although the traditionally accepted amount significant glenoid bone loss for bony procedures is >25%, recent studies by various authors quantify much lesser amounts of bone loss, up to 15% or even less, which make the shoulder unstable even after arthroscopic Bankart surgery in an athletic young individual, where bony procedures may have to be added to give good functional results.

Evidence Versus Eminence - A Grey Area

K Viswanathan — 2021-06-01

We had a senior member in our local orthopedic club, a long retired professor, who religiously attended all meetings. The clinical discussions sometimes became heated and he always rose to such occasions. In my experience of 150 such cases in the past 50 years, he would say of some rare manifestation, this is what I used to do. End of discussion, the oracle has spoken. Nowadays he would be ignored or, in less polite society, laughed out of the room. Reference please or data, would be the question.

Posterolateral Corner Injuries of Knee

John T John — 2021-06-01

Posterolateral corner injuries have seen an increasing trend in view of the increased high velocity injuries. Though isolated injuries are rare, it is usually associated with other ligament injuries. A meticulous clinical examination with a high index of suspicion and radiological assessment is needed for the diagnosis, failure of which may lead to chronic pain, chronic knee instability, cartilage damage, and failed cruciate ligament reconstruction. Surgical or nonsurgical intervention are based on the extend of the injuries.

Prof Achyutha Menon

N J Mani — 2021-06-01

The long day of the Seminar on Cranio-Cerebral Trauma was nearing its end. Audience in the large auditorium of Trivandrum Medical College was restless and getting ready to go. The last speaker of the day was in front of the mike. “As we come to the tail end of this session, we come to the tail end of the spinal cord”, he thundered. The effect was electric. Everyone sat up and took note. That was Prof. Achyutha Menon, my teacher and mentor.

Mucoid Degeneration of Cruciates and Total Knee Replacement

Sujit Jos — 2021-06-01

It is indeed a valuable study in the south Indian population regarding mucoid degeneration of the cruciate ligaments, published in the June 2020 edition of Kerala Journal of Orthopaedics. The significance is more when we are trying to preserve the posterior cruciate ligament during Total knee replacement, which is the least constrained model for replacing an osteoarthritic knee joint.