bluuebunny/crossref_metadata_2025 huggingface dataset:
UNUSUAL TALUS FRACTURE IN CHILDREN
Authors: Zulfahrizzat S , Nadzim AS , Norshaidi S , Abdul Rauf A
Published: May 2020

Talus fracture are extremely rare in children. The talus is predominantly made up of cartilage with higher elastic resistance than adult bone thus the pediatric talus bone can sustain higher forces before fractures. The prevalence for paediatric trauma in talus fracture is estimated to be five times rarer than for adult trauma . The most common mechanism of injury in talus fractures is axial loading of the talus against the anterior tibia with the foot in dorsiflexion. The talar neck is the most common fracture site, followed by the talar body.

Report:

A 9-year-old boy was brought to emergency department following a fall from bicycle after his right foot caught in back wheel. He was unable to weightbear on his right foot and his anterior ankle region was swollen, with no open wounds or abrasions. Radiographs of right ankle revealed a fracture at neck of right talus (Hawkins type II ) then proceed with CT scan to characterize the fracture pattern and extent of injury. His fracture was fixed with two headless cannulated screws size 4.0 under I/I guidance. The patient was advised non-weight bearing with below knee cast for 6 weeks. After 2 months the patient was pain free and had resumed all his activities. X-ray after 1 year showed a consolidation of the fracture without evidence of avascular necrosis. The Hawkins classification can be used to describe the different types of fractures of the talar neck and to predict the risk of avascular necrosis. These injuries can be difficult to diagnose with plain radiograph, and further assessment with CT scan or MRI may be necessary. Undisplaced fracture can be managed non-operatively with cast immobilization and displaced fracture can be treated with either closed or open reduction. Complications are still likely to be encountered in the course of talus fractures treatment considering the precarious blood supply to the bone as well as complex ankle and subtalar articulations. According to Smith et al study with 29 subjects , displaced pediatric talus fractures and those associated with high-energy trauma resulted in more complications ; avascular necrosis (7%), arthrosis (17%),delayed union (3%),neuropraxia (7%) and the need for further surgery (10%). [Figure: see text][Figure: see text]

Conclusion:

Talar fractures in the pediatric age group are very rare. A minimal or undisplaced fracture of talus is less likely to undergo avascular necrosis than a displaced fracture but even with optimal treatment, avascular necrosis may still occur. It is of prime significance that these fractures should be diagnosed well in time to avert complications. Therefore an appropriate length of follow-up is required.

References:

Vivek D , Jairam DJ , Paediatric Talus Fracture :Volume 5 Issue 8, International Journal of Science and Research August 2016 PG 1040-1041
Management of Recurrent Posterior Hip Dislocation in a Down Syndrome Patient with Dysplastic Hip Using Ganz Periacetabular Osteotomy: Follow Up After 4 Years
Authors: Dilogo Ismail H. , Fiolin Jessica
Published: May 2020

Recurrent hip dislocation in a Down Syndrome patient with dysplastic hip is a very challenging case to treat even for an expert orthopaedic hip surgeon. Least compliant patient and family, lowly educated with low socioeconomic status and the dysplastic hip forces limited option as a treatment. This is the first case world wide reporting 4 year follow up of dysplastic hip with Down Syndrome treated successfully with PAO technique.

Methods:

An eighteen years old female with history of Down Syndrome had multiple posterior hip dislocation episodes since 3 years prior. Several attempts of close reduction and hip spica applications were performed upon dislocation despite no successful retaining of reduction. Acetabular index of right hip were 550 and epiphyseal plate hasclosed. PatientwasperformedopenreductionusingSouthern-Mooreposteriorapproachand osteotomy of ischium, continued with capsulorrhaphy followed with Smith-Peterson anterior approach and osteotomy of superior ramus pubis and iliac bone. Then, derotation maneuver was performed under image intensifier to obtain adequate coveragefollowedwithbonegraftandfixationusing2cannulatedscrewandhipspica castapplication.

Results:

Within four years after surgery, the hip has never been dislocated again, patient could sit without pain and walk with full weight bearing although Harris Hip Score could not be performed due to Down Syndrome. Leg length discrepancy was negligible,fracture has fully united and acetabularin dex was300.

Conclusions:

Ganz periacetabular osteotomy, although a technically demanding surgery, is a preferable treatment in recurrent hip dislocation for Down Syndrome patient with good to excellent clinical and radiological ou tcome
TRAUMATIC DORSAL DISLOCATION OF INTERMEDIATE CUNEIFORM : A RARE MIDFOOT INJURY
Authors: Shamsudin Z , Abdull Sitar MN , Alias A , Ahmad AR
Published: May 2020

Dislocation of the intermediate cuneiform is a rare injury, and only a few cases have been reported .Cuneiforms dislocations have been treated in a variety of methods, ranging from open or closed reduction, without or with fixation such as Krischner wires or screws.

Methods:

A 24 years old female presented with right foot pain following fall from motorbike after got hit by a car from back. She related a history that her right foot was forced into torsion and plantarflexion at impact . On examination there was a bony protuberance on the dorsal surface, at cuneiform area . Radiograph showed dorsal dislocation of intermediate cuneiform. CT scan was performed and supported the radiographical findings. Manipulation under sedation was attempted, but was unsuccessful.

Results:

Patient was placed supine under spinal anesthesia . A dorsal incision was made centering over the protuberance proceeded distally up to the base of the second-metatarsal. The dislocated middle cuneiform was identified. There was proximal soft tissue attachment to the middle cuneiform which was carefully preserved. It temporarily reduced with Krishner wires and a 2.7 mm variable angle locking plate was fixed dorsally to butress the bone dislocation . The foot was immobilized with a boot slab for 6 weeks and subsequently physiotherapy was instituted and gradual weight-bearing started. Postoperative follow-up was uneventful.

Discussion:

Intermediate cuneiform is a part of the transverse and medial longitudinal arches of the foot and the stability is achieved by the deep transverse, dorsal, and plantar ligaments. It’s shaped like a wedge, the thin end pointing downwards, situated between medial and lateral cuneiforms, and articulates with the navicular posteriorly, the second metatarsal anteriorly and with the other cuneiforms on either side. Because it is wedge shaped and positioned dorsally, it has a tendency to dislocate dorsally, particularly when a plantar flexion force is applied to the midfoot. Immediate reduction and maintaining in reduced position is needed for good ligamentous healing.

Conclusion:

Intermediate cuneiform dislocation is a rare injury to encounter due to stable articulation of joints and ligament. Significant trauma is required for these injuries to take place. Open reduction is the gold standard treatment for these injuries.

References:

Kumaravel S et al An isolated middle cuneiform dislocation with a rare violence Journal of clinical orthopaedic and trauma 5 (2014) 161-171 Name
Salmonella Sp. as the Cause of Periprosthetic Joint Infection of the Hip: Report of a Rare Case and Literature Review
Authors: Santoso Asep , Anwar Iwan Budiwan , Sibarani Tangkas , Soetjahjo Bintang , Mariyanto Ismail
Published: May 2020

Periprosthetic joint infection of the hip due to Salmonella sp. is rare. It is sometimes difficult to treat and needed a prolonged antibiotic treatment. We reported a case of periprosthetic joint infection of the hip in a 67 years old female who received prior left total hip arthroplasty. Two-stage revision surgery with antibiotic-loaded cement spacer has been performed to the patient and successfully control the infection. Review of the literatures also has been done. Salmonella Sp. has to be considered as one of differential etiology in the case of infected arthroplasty especially in an immunosuppressed patient. It showed still there has been no consensus in the treatment of choice for this particular case.
Knee Arthroplasty in Severe Varus Advanced Knee Osteoarthritis with Proximal Tibia Malunion: a case report
Authors: Sindunata Nyoman Aditya , Suvarly Prettysia , Aditya Rio , Butarbutar John
Published: May 2020

Alignment is crucial for successful knee arthroplasty.1 Tibia malunion will make arthroplasty more challenging. In this case, we present advanced knee osteoarthritis with tibia vara due to malunion that needs corrective osteotomy during knee arthroplasty.

Case Presentation:

A 70 years old female presented to our office complaining pain in both knees markedly on the left, profoundly felt during walking. She has a history of being hit by motorcycle 15 months ago and left knee was more bent since then. Physical examination of the left knee showed severe varus, mild effusion, tenderness on medial tibial condyle, otherwise normal. Plain radiographs showed advanced bilateral knee osteoarthritis with left proximal tibia malunion. Patient underwent left knee arthroplasty with corrective tibia and fibula osteotomy.

Solutions and Outcome:

Patient underwent closed wedge tibial osteotomy together with fibula osteotomy followed by knee arthroplasty with posterior-stabilized implant and tibial stem extension in a single surgery. Tibial osteotomy was reinforced using plate and screws. Partial weight bearing was achieved in second postoperative day and discharged on the third day. Patient able to walk with painless left knee after 1 month.

Discussion:

Severe deformity that causes huge malalignment makes knee arthroplasty difficult. Some methods are available to correct malalignment.1 In this case, the surgeon chose to do closed wedge tibial osteotomy reinforced with plate and screws to correct the proximal tibia malunion. Arthroplasty was done using posterior-stabilized implant and tibial stem extension. Patient shows good result in alignment and function.

Conclusion:

Correcting the associated deformity is crucial in achieving good alignment in knee arthroplasty. Even in our case of severe genu varus due to proximal tibia malunion, correcting proximal tibia varus deformity prior to knee arthroplasty shows good alignment and function.

References:

Mullaji AB, Padmanabhan V, Jindal G. Total Knee Arthroplasty for Profound Varus Deformity. 2005;20(5):550–61.
Cemented Hip Arthroplasty: Dealing with Bone Cement Implantation Syndrome
Authors: Ifran S , Ramzi D , Handi SE , Melyana S
Published: May 2020

Bone Cement Implantation Syndrome (BCIS) is a rare but potentially fatal complication of cemented orthopedic surgery, 0.5 – 1.7% resulting in cardiovascular collapse. BCIS characterized by hypoxia and/or hypotension, pulmonary hypertension, arrhythmias, loss of consciousness, and the worst is cardiac arrest. We experienced two cases with fatal outcomes.

Methods:

Two case report were reviewed from medical record and meeting discussion between orthopedic and anesthesiologist department.

Case Presentation:

Hip hemiarthroplasty was performed in two patients on February and March 2019. A 90-years-old man had history of cemented hemiarthroplasty on his left hip two years ago, low back pain, and osteoporosis, and a 77-years-old woman had no history of cemented hemiarthroplasty, controllable diabetic, corrected hypo-albumin. Both of them have same BCIS high risk comorbidity as right intertrochanter fracture, geriatric, and ASA III. Five minutes after cementation, the patients suffered a cardiac arrest and anesthesiology’s team start CPR with advanced cardiac life support protocols, surgeon finished the surgery immediately, and patients transferred to Intensive care, but the patient didn’t survive.

Discussion:

These cases urge us to pay more attention to BCIS and some recommendation must be made to improve better management and increasing the survival chances. With agreement of final theory of BCIS etiology is multimodal model, the understanding of cement behavior and cementing techniques are the keys of orthopedic role. Preparation, closely observation at peri-cementing to 24 hours post-surgery, and appropriate management are the keys of anesthesiologist role. As a concrete recommendation that our discussed, BCIS risk assessment tools made by Cheryl and Angela at AORN journal are believed to be able to increase alertness and preparation to manage severe BCIS.

Conclusion:

Propose a pre-operative BCIS risk assessment tool based on Cheryl and Angela’s tool to minimalized fatality of BCIS incidence is being our concern. Alongside that, communication and suggestion protocol between surgeon and anesthesiologist, knowing the BCIS clinical features, timing of BCIS incident, and informed concern are important to BCIS management.
Neuropathic Pain Component Insights in Patients with Knee Osteoarthritis: An Observational Study
Authors: Prapto Devindra , Tertia Clarissa , Purvance Ivander
Published: May 2020

Osteoarthritis (OA) is one of the most leading cause of chronic disability in musculoskeletal area with pain as the main manifestation. Chronic pain often leads to an abnormal excitability in pain pathway, resulting a central sensitization which corresponding to neuropathic pain (NP). To date, the existence of neuropathic component in osteoarthritis of the knee remains controversial.

Methods:

The cross-sectional study involved 74 patients of knee osteoarthritis who were diagnosed by using ACR classification criteria for osteoarthritis of the knee. The presence of NP component was assessed by DN4 and painDETECT questionnaire. All participant also completed the WOMAC score to evaluate their status of knee OA, and was divided into two groups, which were mild and severe OA. The prevalence of NP component within knee OA patients was evaluated and then compared between the mild and severe groups.

Results:

45,9% of the participants examined with DN4 score were likely to have the NP component, while the others were doubtful. On the other hand, painDETECT score revealed that 36,5% of the patients were likely to have NP component, 21,6% unclear, and 41,9% unlikely. Comparison between WOMAC score and DN4 showed that 67,6% of the severe population had NP component, significantly higher than the mild population, 24,3% (p<0,05). Alternatively, painDETECT score showed 13,5% likely to have NP component, 24,3% unclear, 62,2% doubtful in the mild population, while in the severe group 59,5% likely, 18,9% unclear, 21,6% unlikely (p<0,05).

Conclusion:

Knee osteoarthritis has a significantly high prevalence of neuropathic pain component. NP component prevalence appears higher in the severe OA population, whether it assessed by DN4 or painDETECT scoring.
Surgical Technique of Percutaneous Iliosacral Screw Fixation in S3 Level in Unstable Pelvic Fracture with Closed Degloving Injury and Morrell Lavallee Lesion: Two Case Reports
Authors: Dilogo Ismail H. , Fiolin Jessica
Published: May 2020

Unstable pelvic ring fractures raise treatment challenges in severely injured patients. Beside patient survival, demanding surgical technique also required. Classic technique of internal fixation requires extensive surgical exposure that leads to most complications of the pelvic fractures fixation. Therefore less invasive technique is a reasonable alternative especially in unstable pelvic fracture with soft tissue injury or potential infection. Unfortunately in sacral dysmorphism pelvic injury or in complete vertical sacral fracture, we need S3 level insertion to improve stability of iliosacral (IS) screw in S1 or S2. Purpose of this study was to show feasibility technically inserting IS screw in S3 level.

Methods:

We reported 2 cases of unstable pelvic injury. First case was an 11 years old boy with Torode and Zieg IV or Marvin Tile C1 pelvic fracture with right sacroiliac joint disruption and soft tissue injuries of skin avulsion on the left hip and Morel-Lavallée lesion on the right hip. He was managed with early anatomic reduction and fixation with percutaneous screws on both pubic rami and IS screw (sacroiliac lag screw type) on S1 and S3. Second case was a 30 years old male with open pelvic fracture Faringer zone III type, Marvin Tile B2 or YoungBurgess LC I and also with vertical sacral fracture Denis zone 1. This polytrauma case had associated injuries includes Morel-Lavallée lesion, intraperitoneal bladder rupture, infected laparotomy wound dehiscence, and immunocompromised. The same minimal invasive management of pelvic fracture was performed in this case by inserting percutaneous screws on pubic rami and IS (sacral screw type) on S1 and S3. Functional outcome was evaluated using Majeed and Hannover pelvic scoring system.

Results:

All patients survived and considered to have good reduction, with no residual displacement on the sacroiliac joint. The former case, at 21-month follow up, present with excellent outcome (80 out of 80) by Majeed score and very good outcome (4 out of 4) by Hannover score; while the latter case, at 18-month follow up, present with poor outcome (50 out of 100) by Majeed score and fair outcome (2 out of 4) by Hannover score.

Conclusion:

Percutaneous screw fixation for pelvic ring injury is a less invasive alternative that can be used for early stabilization of unstable anterior and posterior pelvic fractures and provide stable internal fixation. IS screw is feasible to be inserted in S3 level either sacroiliac joint type or sacral screw type.
Fungal Periprosthetic Joint Infection of Hip – Report of 2 Cases
Authors: Ho Sheung Tung , Chiu Ming Yu
Published: May 2020

A 72-year old woman had revision unipolar hemiarthroplasty for AMA loosening with vertical split fracture of greater trochanter. This was complicated by PJI, treated with staged arthroplasty with articulated antibiotic loaded cement spacer. Revision of antibiotic loaded cement spacer for dislocation and cable plate fixation of greater trochanter was done. Then the tissue specimen grew Candida ablicans. Fluconazole was given. Repeated debridement and exchange of antibiotic loaded cement spacer was done twice again with amphoteric B and vancomycin added to the cement. Unfortunately, the frozen section was still positive despite the CRP was returned to normal for 1 month. Oral fluconazole was continued. Finally, revision total hip replacement was done 14 months after the initial insertion of antibiotic loaded cement spacer. The patient could manage to walk with frame indoor with no hip pain at 3 year follow-up. Another 80-year old woman had removal of AMA, debridement and antibiotics loaded cement spacer was done for PJI. This was complicated by breakage of the articulated cemented spacer during reduction and later hip dislocation despite of cemented acetabular liner. A total of 3 debridement and antibiotics loaded cement spacer were done. Besides Candida albicans, tissue also grew Enterobacter cloacae and Pseudomonas aeruginosa. Exchange of cement space loaded with gentamicin and voriconazole was done as the 4th reoperation 22 weeks after the debridement and antibiotics loaded cement spacer insertion. Intraoperatively, the patient developed haemorrhagic shock and complicated with myocardial infraction and pneumonia postoperatively and eventually succumbed 12 days after the last operation.

The control rate of fungal PJI of only 36% was reported in the literature. The use of systemic and local antifungal agents, surgical treatment strategy and outcomes will be reviewed.
Ankle Eversion and First Ray Plantar Flexion Muscle Strength After Peroneus Longus Tendon Harvest for Anterior Cruciate Ligament Reconstruction
Authors: Wicaksono Fidelis H. , Rhatomy Sholahuddin , Budipharama Nicolaas C.
Published: May 2020

The peroneus longus tendon has been used for a graft in orthopedic reconstruction surgery due to its comparable biomechanical strength to the native Anterior Cruciate Ligament (ACL) and hamstring tendon. However, one of the considerations in choosing autograft is donor site morbidity. This study aimed to compare ankle eversion and first ray plantar flexion strength between donor site and its contralateral.

Hypothesis:

The study hypothesis was that the eversion and first ray plantar flexion muscle strength were different between harvest site and contralateral healthy site.

Methods:

From March 2017 to December 2018, patients who underwent ACL reconstruction using peroneus longus tendon autograft were included in this study. From the first day after surgery, the patients followed rehabilitation protocol. Ankle eversion and first ray plantar flexion strength were measured using a modifieddynamometer 6-months after surgery. Donor site morbidities were assessed 6 months after surgery using the Foot and Ankle Disability Index and American Orthopedic Foot and Ankle Society scoring system for ankle and hindfoot.

Results:

Thirty-one patients fulfilled the inclusion criteria, with 22 males and 9 females, ranging from 18-45 years of age (mean: 27.58±8.69). There was no significant difference in ankle eversion strength at donor site compared to contralateral (p=0.54) with means 65.87±7.63 N and 66.96±8.38 N, respectively. Also, there was no significant difference in ankle first ray plantar flexion strength at donor site compared to contralateral (p=0.68) with means 150.64±11.67 N and 152.10±12.16 N, respectively. The FADI score of 99.71±0.57 and AOFAS score of 98.71±3.03 were considered excellent results.

Conclusion:

Our study shows that donor site ankle eversion and first ray plantar flexion strengths were similar with the contralateral healthy site with no donor site morbidity. This suggests that peroneus longus tendon is a promising graft in ACL reconstruction.
Functional Outcomes and Hop Tests Results in ACL Reconstruction Patients with Adjustable Loop Fixation: 2 Years Follow-up
Authors: Rhatomy Sholahuddin , Primasara Shinta , Budhiparama Nicolaas C. , Wahjudi Chairul , Setyawan Riky , Edison Thomas
Published: May 2020

Background:

Arthroscopic Anterior Cruciate Ligament (ACL) reconstruction is one of the most performed knee surgery, which results in early return to sport and good clinical outcomes. The outcomes are affected by various factors, namely type of grafts, graft fixation methods, tunnel orientations and diameters. If good operative results and intensive pre- and post-operative rehabilitation lead to an optimal outcome, patients can return to the pre-injury level of sports activity in the short term.

Objective:

Muscle strength and stability of anterior cruciate ligament in reconstructed knees have been bilaterally compared with The Peroneus Longus Tendon grafts at preoperative, 6 month and 2 years following surgery.

Methods:

Forty-seven patients, 40 men, and 7 women, participated in the study. The outcome measures using IKDC, Cincinnati and Tegner-Lysholm score. Hop tests were evaluated on 6th month after the surgery.

Results:

Results of preoperative and 2-years postoperative functional outcomes are shown the IKDC score, Tegner-Lysholm score, and Cincinnati score yielded statistically significant differences (p<0.001) between their pre- and postoperative score from 56,3% until 98,0%. The median of the hop tests were 92, 94, 94, and 95, for the single, triple, cross over, and timed tests, respectively

Conclusion:

In this retrospective study of 47 patients undergoing ACL reconstruction with adjustable loop fixation (GraftMax™ Button, CONMED) on the femoral site and peroneus longus tendon autograft, we found that in 2 years of follow up, the functional outcomes and hop tests were favorable. Good surgery technique and intensive pre- and post-surgery rehabilitation are very important. Six months after surgery patients are allowed to go back to sports activity.
PELVIC RING INJURY ASSOCIATED WITH FLOATING KNEE AND IPSILATERAL POSTERIOR CRUCIATE LIGAMENT (PCL) AVULSION FRACTURE: AN EXPERIENCE
Authors: Yeoh KH , Inderjeet S , Shukur A , Sharifudin S
Published: May 2020

Pelvic ring injury associated with floating knee is relatively rare1. For our best acquaintance, few literatures have documented such injuries in an individual patient. The aim of this study is to validate the feasibility of damage control orthopedics (DCO).

Method:

A 15-years-old girl, involved in high-energy road traffic accident presented with hemodynamic instability. The pelvis was unstable with deformity in the right upper and lower extremities. Significant lacerations over forehead, right forearm and thigh present. Her radiographs proved the unstable pelvis fracture[A], multiple fractures of right lower limb with floating knee injury associated with PCL avulsion fracture[B-E], compound right ulna fracture[F], cerebral concussion, intra-abdominal injury and multiple lacerations establishing the distinctive of polytrauma.

Results:

The algorithm of DCO was resolute as treatment. Initial procedures of pelvic external fixation, right calcaneal traction, exploratory laparotomy, wound debridement and right long arm back-slab were done. CT pelvis and right knee performed after achieving initial fracture and hemodynamic stability. Internal fixations were applied after a period of time. The patient recovered after the DCO guided management with restoration of limb functional, and the quality of life greatly improved.

Discussions:

The DCO emphasizes the need to avoid further damage by the “second hit” which may originate from surgical procedures and focus on advanced life-saving supports.1 Our surgical team followed the principles of debridement and removal of the infection factors first, carried out definite surgery during the stable period. In addition to supply of the blood volume and protein, the nutritional support was emphasized.

Conclusion:

The DCO plays a pivotal role in the management strategies of complex pelvic ring injuries and floating knee with functional good outcome.
Trigen Intertan Nail in Unstable Peritrochanteric femur fractures in the Elderly -functional and radiological outcomes in 50 cases
Authors: Patnaik Sanjeev , Panda Akash
Published: May 2020

INTRODUCTION:

Peritrochanteric femur fractures have increased significantly in recent decades and the trend continues, due to rising age of the population. Surgical treatment, in the form of rigid internal fixation and early mobilization is now the gold standard. One of the recent implant developments is the Trigen Intertan Nail (Smith & Nephew) for the treatment of peri-trochanteric femur fractures that uses 2 cephalocervical screws in an integrated mechanism allowing linear intra-operative compression and rotational 3-point stability of the head/neck fragment.

AIMS & OBJECTIVE:

To analyse the functional & radiological outcomes using TRIGEN INTERTAN nail for the treatment of peri-trochanteric femur fractures in the elderly population.

DESIGN:

Prospective study.

METHODS:

Between March 1, 2016, and March 31, 2019, 50 patients with an intertrochanteric femur fracture were treated with Trigen InterTan Nail (Smith-Nephew). All fractures were classified by OTA/AO Classification. All surviving patients were followed up for a minimum of 6 months post-operatively. Functional and radiographic evaluation were performed at 3 months & 6 months follow up using the modified Harris hip score.

RESULTS:

The age of the patients was 60-85 years. 2 patients died due to other co-morbidites, 3 did not come for follow up, leaving 45 patients available for final evaluation. The surgical time was 60-90 minutes. All fractures showed radiological union within 12-16 weeks . Radiographic analysis at healing revealed no loss of reduction, no uncontrolled collapse , no non-union, no femoral shaft fractures, and no implant failures. 2 cases had trochanteric split intra-operatively, requiring cerclage wiring, 1 case was poorly reduced and had varus malalignment. Modified Harris hip score was excellent in 20 patients, good in 10 cases, fair in 9 cases and poor in 1 case.

CONCLUSIONS:

The Trigen Intertan nail appears to be a reliable implant for the treatment of peri-trochanteric femoral fractures. Its design provides for stability against rotation and minimizes neck mal-unions (shortening) through linear intraoperative compression of the head/neck segment to the shaft. As a result of the minimal complication rate and improved clinical and radiological outcomes, this implant is now used as the standard implant for most unstable peri-trochanteric femur fractures at our institution.
Better Fixation In Severely Displaced Fracture
Authors: Safie Shaqirin , Shamsudin Zulfahrizzat , Ahmad Abdul Rauf
Published: May 2020

Introduction:

Fractures of the radial neck are relatively uncommon injuries; the incidence in children is reported to be about 1% of all pediatric fractures and 5% of elbow fractures in children. The radial head may be displaced in any direction, but the most common direction is lateral. Associated injuries may signify a more severe trauma to the elbow.

Report:

16 years old boy presented with alleged fall during playing football. Patient slipped during game due to slippery grass. Patient fall with elbow hit the ground. Post trauma complain left elbow swelling, pain and limited range of movement (ROM). X-ray and CT Scan elbow done noted radial neck fracture, completed displacement. Judet classification type IVa. Operation closed manipulative reduction (CMR) and titanium elastic nail system (TENS) performed for this patient. Intraoperatively in view of delayed operation soft callus formed already and make the CMR difficult. Initially we planned to do Metaizeau technique to reduce the fracture but in view of soft callus formation we have to performed Kapanji technique also to release the soft callus formation. Anatomical reduction achieved. Then patient upper limb protected with above elbow backslab for 1 month. [Figure: see text][Figure: see text]

Discussions:

Treatment of radial neck fracture in adolescenthave to be planned properly. A lot of factor will contribute to final outcome of the injury including age of patient, grade of injury and etc. DE Mattos et al 2016 reported that older patient is more likely to have more severe displacement radial neck fracture requiring open reduction operation. Kaise M et al 2016 reported that the outcome of radial neck fracture appear to be related to severity of displacement rather than surgical manipulation. Metaizeau technique is widely used and recommended. Al-Aubaidi Z et al 2012 say that Metaizeau technique is excellent treatment and patient undergone open reduction had inferior outcome.

Conclusion:

Radial neck fracture is uncommon injury in children and severity of injury is important indicator for prognosis. Even though older patient and more severe injury can lead to poor outcome. Closed reduction still more favorable than open reduction in managing the fracture
Comparison of Pain Control Outcomes between Direct, Continuous Adductor Canal Block and Ultrasonography Guided, Continuous Femoral Nerve Block after Total Knee Arthroplasty
Authors: Na Seung-Min , Choi Ik-sun , Seon Jong-Keun , Song Eun-Kyoo
Published: May 2020

Background:

Purpose of this study was to compare the effects of direct, continuous adductor canal block (ACB) and ultrasonography guided, continuous femoral nerve block (FNB) on postoperative pain control, strength of the knee extensor, walking ability, and related complications after primary total knee arthroplasty.

Methods:

Between November 2018 and February 2019, 107 patients underwent primary total knee arthroplasty under spinal anesthesia. Forty eight patients received ACB and the other 59 received FNB for postoperative pain control. After the surgery, the patients received adductor canal or femoral nerve block via a catheter. 10 mL of 0.75% ropivacaine was administered initially, followed by continuous injection of 4 mL per hour. ACB was done before capsule repair by orthopedic surgeon and FNB was performed after the surgery. Data were prospectively collected out from these 107 patients. To evaluate postoperative pain control, the numerical rating scale scores at rest and during range of motion were recorded. To evaluate quadriceps strength, motor grade by manual muscle testing was measured. Walking ability was assessed by first weight bearing day and walking distance (steps). We also evaluated analgesic consumption using morphine equivalent and recorded related complications of peripheral nerve block.

Results:

No significant intergroup difference was observed in the numerical rating scale scores at rest and during range of motion on postoperative days 1, 2, 3, 4, and 5. ACB group had significantly greater quadriceps strength than did the FNB group, as evaluated by manual muscle testing on postoperative days 1. However, there was no significant difference onpostoperative days 2, 3, 4, and 5. These two groups showed no differences in walking ability in terms of first weight bearing day and walking distance. No significant intergroup difference was observed in analgesic consumption.

Conclusions:

The groups showed no difference in postoperative pain control. ACB showed better motor grade on postoperative day one compared with femoral nerve block, but which was similar in days after postoperative day one.
Side-Effect Profiles And Efficacy Of Low Dose Intrathecal Morphine Combine With Periarticular Injection In Elective Primary Unilateral Total Knee Arthroplasty
Authors: Pathonsamit Chompunoot , Chaiyakit Pruk , Onklin Ittiwat
Published: May 2020

Background:

Total knee arthroplasty (TKA) is concerned as a severe postoperative pain procedure. Intrathecal morphine provides good analgesia but has many side effects such as nausea, vomiting, pruritus and respiratory depression. Appropriate postoperative pain control strategy with lower side effect is still challenging. We combined periarticular injection(PI) as a multimodal analgesia with intrathecal morphine in order to decrease intrathecal morphine dosage and lower side effects.

Objective:

To determine side-effect profiles and efficacy of 0.1 mg and 0.2 mg intrathecal morphine combine with PI in primary unilateral TKA.

Material and method:

In this prospective, double-blinded, randomized controlled trial. Patients undergoing TKA were recruited from April 2018 to April 2019. All patients were randomized into 3 groups. M 0 (n=32), M 1 (n=36)and M 2 (n=34) represent no intrathecal morphine, 0.1 mg and 0.2 mg intrathecal morphine respectively. All Group received same regimen of PI as a multimodal analgesia and same postoperative pain control protocol.

Results:

Patients in group M 2 had more nausea or vomiting side effects compared to group M 1 in early postoperative 4 hours(77.1% and 51.4%) with statistical significant(p<0.05) and also required 2 antiemetic drug to relieve symptoms (4.7% and 2.3%) with statistical significant ( p<0.05). No difference in postoperative pain score, rescue analgesic drug consumption ,pruritic score, sedation score, respiratory depression and orthopedic outcomes such as straight leg rising time and maximum active knee flexion between M 1 and M 2 groups.

Conclusion:

Lower intrathecal morphine dosage (0.1 mg) combine with periarticular injection in primary unilateral total knee arthroplasty provide similar postoperative pain control as standard intrathecal morphine dosage(0.2 mg) combine with periarticular injection with lower rates and severities of nausea and vomiting in first postoperative 4 hours.
Optimising Patients For A Successful TKR And Choosing The Winners
Authors: Patnaik Sanjeev , Sahoo Ranjan Kumar
Published: May 2020

Total knee replacement (TKR) is one of the most successful operations in the history of orthopaedic surgery and its effectiveness in relieving pain and improving functionin patients with end-stage advanced arthritis of knee is undisputed . Despite its scientific reputation as mainly successful, only 81% to 89% of patients are actually satisfied with the final result as per clinical literature. Awareness of the existence as well as identification of predictors of Patient - Surgeon disagreement, should help improve the dialogue that goes on between patients and surgeons, thus improving the clinical decision-making processes and making expectations more realistic in an attempt to enhance patient outcomes. Focussing on 5 major factors can help to ensure that patient safety is maintained, and satisfaction following a major surgery like TKR is enhanced :- 1.Correct patient selection, after a meticulous history taking and clinical examination, 2. Setting appropriate expectations 3. Avoiding preventable complications, 4. Adhering to the finer points of the surgical operation and following a meticulous surgical technique and 5. Using pre - and post- operative pathways. All these factors will help to ensure maximum patient satisfaction and aid in successful clinical outcome following Total Knee Replacement.
Early Primary Total Knee Arthroplasty in Fractures Around The Knee – Malaysia District Hospital Experience
Authors: Wui Ng Bing , Wahid Abdul Muttalib bin Abdul , Chao Ong Kean , Weng Loi Kai
Published: May 2020

Introduction:

Treatment of comminuted intra-articular fractures around the knee in the elderly population could be challenging. Factors such as pre-existing comorbidities, osteoporosis, cartilage damage and deformity could make fracture reduction difficult. Patients outcome is guarded due to risk of delayed or non-union, delayed weight bearing and prolonged rehabilitation phase.

Methods:

We present a retrospective study on 12 patients who underwent early primary total knee replacement after sustaining intra-articular fracture around the knee from 2017 to 2019. Legacy Constrained Condylar Knee (LCCK) were used and patients were follow-up at 3, 6 and 12 months.

Results:

Mean follow-up period is 14 months. All except one patient received Posterior Stabilized insert while other patients had LCCK. Two patients were complicated with prosthetic joint infection requiring debridement and revision surgery. The remaining patients achieved full knee extension and average flexion of 100 degrees.

Conclusion:

Early knee arthroplasty is able to achieve excellent short-term outcome in treatment of comminuted intra-articular fractures around the knee in elderly patients
The Role of PRP and Its Platelet Concentration in Improving WOMAC Score on Early-Stage Knee Osteoarthritis (OA) Patients
Authors: Supartono Basuki , Rahmadati Salma , Agustini Diana
Published: May 2020

Platelet concentration is one of the important factors in OA treatment with platelet-rich plasma (PRP). The purpose of this study was to determine the effect of PRP quality, which was determined by its platelet concentration, on Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores in early-stage knee OA patients. This study involved 50 patients diagnosed with early-stage knee OA (stage I to III). Twenty-five patients received PRP with moderate platelet concentration (1× to 4×), another twenty-five patients received PRP with high platelet concentration (>4× to 6×). Patients were evaluated using WOMAC questionnaire before and three months after injection with PRP. Bivariate analysis showed that there was a significant improvement of three WOMAC score subscales (pain, stiffness, and function) in both group (p<0.05) and a significant difference in the differences between WOMAC pain scores between the two groups (p<0.05), meanwhile, significant differences in the differences between WOMAC stiffness and function scores between the two groups weren’t found (p>0.05). The conclusions of this study was, PRP with moderate and high platelet concentration had been shown to improve the three WOMAC score subscales of early-stage knee OA patients, but the effect of PRP’s platelet concentration was only significant in the improvement of WOMAC pain score.
Stiff Knee After Ligament Reconstruction
Authors: Hien Pham The
Published: May 2020

Stiff knee is a difficult complication after surgery and ligament injury. There are many reasons which cause stiff knees and we should undestand them for the best treatment and prevention. Here we present cases of stiff knees after multiligament injury. They were indicated operations by ligament reconstruction or avulsion reattachment. After that, the stiff knees recurred although the patients also had 5 - 6 months of rehabilitation. Via arthroscopy, we found a scar tissue in the suprapatellar compartment, a fiber around the patella, an adhension femur - tibia at the notch, a scar tissue at the notch, and a cyclops lesion. We used the shaver and cautery to cut the fibrous tissue and release the patella and ligaments at the notch. Then, manipulation under anesthesia (MUA) was indicated. After all, the patients had the combined spinal and epidural anaesthesia (CSE) for 5 days. It is a better way to reduce pain and let the patients exercise earlier.
Natural course of Baker’s cysts in a total knee arthroplasty population
Authors: Hommel Hagen , Kopf Sebastian
Published: May 2020

Aims and Objectives:

Baker’s cysts are known to be a source of discomfort and pain due to pressure on adjacent structures. They are not uncommon in patients eligible for total knee arthroplasty (TKA). Since there is a paucity of medium-term studies that assess the natural course of Baker’s cyst following TKA, in this study we report the one- and five-year outcomes of patients to elucidate the state of their Baker’s cyst following TKA.

Materials and Methods:

In this prospective case series, 102 TKA patients were included. All patients who received surgery had a diagnosis of primary osteoarthritis and had preoperatively presented with a Baker’s cyst. Sonography was performed to evaluate the existence and the gross size of the cyst before TKA, and sonography was repeated at one and five years after TKA. Symptoms potentially attributable to the Baker’s cyst were recorded at each assessment. In addition, the five-year assessment included a sonographic assessment of the anterior aspect of the knee to identify joint effusion.

Results:

Ninety-one patients were available for the five-year assessment (with an 89% follow-up rate). After one and five years, Baker’s cyst was still present in 87 (85%) and 30 (33%) patients, respectively. Of those patients who retained a Baker’s cyst at one-year follow up, 31 patients (36%) had sustained popliteal symptoms. Of those patients who continued to have a Baker’s cyst at five years, 17 patients (56.7%) were still symptomatic. The probability of entering remission was dependent on the size of the Baker’s cyst at baseline (odds ratio, 1.41; p = 0.025). The mean preoperative cyst size was 14.5 cm2. At one and five years postoperatively, the mean cyst size was 10.6 cm2 and 9.9 cm2, respectively. At five years, no association between cyst size and popliteal symptoms was found.

Conclusion:

Five years after TKA, the majority of the Baker’s cysts that were present at baseline had gone into remission. The probability of going into remission was dependent on the size of the Baker’s cyst at baseline.
ACL rupture and posterior tibial slope - how do we handle this?
Authors: Dickschas Jörg
Published: May 2020

Aims and Objectives:

In recent publications on acl-ruptures and especially on failure of acl reconstruction there comes a strong focus on posterior tibial slope (PTS). ACL reconstructions with a PTS of >12° have an 8 times higher risk of recurrent instability and reconstruction failure. But many questions stay unclear so far-When do we have to correct the tibial slope? How do we correct it? What about simultaneous frontal axis deviations? In this publication a new algorhythm is presented.

Materials and Methods:

The following aspects have to be evaluated Is the PTS the only dimension of the deformity or do we have to correct the frontal axis simultaneuosly? Performing a anterior closed wedge extension osteotomy: when do we go distal the tuberosity and when do we perform a tuberosity osteotomy and use it as “bio plating”? Osteosynthesis only screws or always plate? Are there indications for a contineous correction, f.e. with a hexapod? Whats the role of preoperative range of motion of the knee (especially extension)? Always tunnel filling in the same surgery? What about PCL insufficiency and low PTS?

Results:

An algorhythm is presented giving a treatment path for the different questions mentioned. The procedures are shown step by step in clinical examples and surgery documentation for every pathway.

Conclusion:

Posterior tibial slope plays an critical role in ACl recontruction. In primary ACl tear a slope correction is probably not indicated. In ACL reconstruction failure a analysis of the PTS needs to be done and correction needs to be discussed. Simultaneuous varus deormities need to be corrected by openwedge valgisation - extension high tibial osteotomy (HTO), while as isolated PTS elevation is subject to an anterior closed wedge extension HTO. Preoperative range of motion needs to be respected not to create hyperextension. Osteosynthesis can be perormed with only screws using the tibial tubercle as “bio-plating”. In cases of former bone-tendeon-bone (BTB) ACL reconstruction a tibial tubercle osteotomy should be avoided and a infratuberositeal osteotomy should be performed and stabilized with plate osteosynthesis. In severe postraumatic cases contineous correction of the slope with fixateur externe, f.e. hexapodes, needs to be performed.