bluuebunny/crossref_metadata_2025 huggingface dataset:
Curve Length, Curve Form, and Location of Lower-End Vertebra as a Means of Identifying the Type of Scoliosis
Authors: Abul-Kasim Kasim , Ohlin Acke
Published: October 2016

Purpose.

To determine if the curve length, curve form, and location of the lower-end vertebra can identify the type of scoliosis.

Methods.

Standing posteroanterior and lateral radiographs of 78 women and 27 men with scoliosis aged 8 to 32 years were retrospectively analysed. Parameters measured were (1) the curve length (the number of vertebrae in the main curve), (2) the curve form (C-form, inverted C-form, or S-form), (3) the curve apex (the vertebral body at the apex of each curve), (4) the site of the scoliosis (thoracic, thoracolumbar, or lumbar), and (5) the location of the lower-end vertebra.

Results.

Only 3 (4%) of 77 patients with idiopathic scoliosis had a curve length of >8 vertebrae, compared with 19 (90%) of 21 patients with neuromuscular/neuropathic scoliosis (p<0.001, Fisher's exact test). 14 (18%) of the patients with idiopathic scoliosis had an S-form curve, compared with none in those with neuromuscular/neuropathic or congenital/osteogenic scoliosis (p=0.035, Fisher's exact test). No patient with idiopathic scoliosis had the lower-end vertebra located at L5, compared with 8 (38%) patients with neuromuscular scoliosis (p<0.001, Fisher's exact test). The criteria for neuromuscular/neuropathic scoliosis (a curve length of >8 vertebrae, a C-form or inverted C-form curve, and a lower-end vertebra located at L4 or L5) had 81% specificity, 76% sensitivity, 100% positive and 93% negative predictive values.

Conclusion.

These criteria may help identify patients with neuromuscular/neuropathic scoliosis for further investigation by magnetic resonance imaging or computed tomography before they undergo corrective surgery.
Impact of Preoperative Function on Early Postoperative Outcome after Total Hip Arthroplasty
Authors: Johansson Henning R , Bergschmidt Philipp , Skripitz Ralf , Finze Susanne , Bader Rainer , Mittelmeier Wolfram
Published: October 2016

Purpose.

To investigate the impact of preoperative functional status on early postoperative outcomes after total hip arthroplasty (THA).

Methods.

39 men and 36 women aged 50 to 76 years who underwent cementless THA for osteoarthritis were followed up for at least 2 years. Patients were evaluated pre- and post-operatively (at 6, 12, and 24 months) using the Harris Hip Score (HHS), 36-item Short Form Health Survey (SF-36), and Western Ontario and McMaster University Osteoarthritis Index (WOMAC). Patients were classified into 3 groups based on their preoperative HHS (poor, <45; intermediate, 45–55; good, >55). Differences between and within groups were compared.

Results.

Patients with a poor preoperative HHS had worse early postoperative outcomes in terms of HHS, SF-36, and WOMAC. Postoperative pain and function correlated with preoperative HHS, but postoperative range of motion and deformity did not.

Conclusion.

Poor preoperative function may affect recovery unfavourably and lead to prolonged pain. Earlier THA in the course of functional decline may associate with better outcomes.
Initial Symptoms and Delayed Diagnosis of Osteosarcoma around the Knee Joint
Authors: Pan Kok Long , Chan Wai Hoong , Chia Yin Yin
Published: October 2016

Purpose.

To identify initial symptoms of osteosarcoma around the knee joint.

Methods.

Records of 19 men and 11 women aged 9 to 34 (mean, 17) years with osteosarcoma around the knee joint were reviewed. Each patient was interviewed (for a mean of 1.5 hours), and a detailed history of symptom onset recorded.

Results.

In all patients, the first symptom was pain, which was more pronounced on weight bearing in 16 (53%) of them and was worse at night in 11 (37%). Swelling was noticed in 28 patients (a mean of 7 weeks after pain onset). 16 (53%) of the patients had a history of minor trauma around the time of symptom onset. 20 (67%) of the patients had a limp, in 9 of whom it was not associated with pain on weight bearing; only 2 (7%) had a pathological fracture. The mean interval from the onset of symptoms (pain) to presentation was 10 (range, 0–49) weeks. The mean interval from presentation to radiography was 3 (range, 0–20) weeks; in 8 patients this interval exceeded 3 weeks despite a noticeable swelling. The mean interval from radiography to referral to our hospital was 2 (range, 0–14) weeks. Together with the 2 weeks for diagnostic workup and biopsy, the mean total delay was 17 (range, 4–55) weeks.

Conclusion.

Physicians should be aware of the symptoms of osteosarcoma and promptly refer patients to tumour centres, especially adolescents, those who present with pain that may be worse at night and on weight bearing, and those in whom a swelling and/or a limp is evident.
Radiological and Histological Analysis of Synthetic Bone Grafts in Recurring Giant Cell Tumour of Bone: A Retrospective Study
Authors: Hattori Hiroyuki , Matsuoka Hiroaki , Yamamoto Kengo
Published: October 2016

Purpose.

To review the radiology and histology of synthetic bone grafts resected from patients with recurrent giant cell tumour (GCT) of bone.

Methods.

22 patients underwent curettage and grafting for GCT of bone using autogenous cancellous bone mixed with apatite-wollastonite-containing glass ceramic (AWGC), hydroxyapatite (HA), or a mixture of HA and tricalcium phosphate (TCP). Patients were followed up every 3 to 6 months. Three men and 3 women aged 20 to 33 (mean, 27) years developed local recurrence. The mean interval from surgery to recurrence was 35 (range, 12–89) months. Specimens containing the recurring GCT of bone and the surrounding synthetic bone and new bone were evaluated.

Results.

No complication related to the use of the synthetic bone (such as toxicity, fracture or deformity) occurred. The synthetic bone incorporated well into the surrounding host bone, but was not completely absorbed. HA was more bioactive than AWGC in human bone. HA/TCP were more bioresorbable and osteoconductive in human bone than HA or AWGC. In most areas of AWGC grafts, intervening layers of fibrous connective tissue were seen between the granules and the bone. In most areas of HA grafts, the granules were completely surrounded by viable bone, with bone ingrowth into the pores of the granules, as well as venules and fibrous tissue ingrowth in the pores of portions of the grafts.

Conclusion.

A mixture of synthetic bone and autogenous cancellous bone is safe and useful for grafting after curettage for GCT of bone.
Use of Autologous Fibrin Sealants to Treat Ganglion Cysts: A Report of Two Cases
Authors: Nakama Kenjiro , Gotoh Masafumi , Mitsui Yasuhiro , Shirachi Isao , Higuchi Fujio , Nagata Kensei
Published: October 2016

Two patients underwent arthroscopy-guided injections of autologous fibrin sealants to treat ganglion cysts causing suprascapular nerve palsies. After at least 2 years of follow-up, both patients had no suprascapular nerve symptoms and their external rotation strength had returned to normal. Magnetic resonance imaging revealed no evidence of ganglion cyst recurrence.
Mortality after Vertebral Fractures in a Japanese Population
Authors: Ikeda Yuzo , Sudo Akihiro , Yamada Tomomi , Uchida Atsumasa
Published: October 2016

Purpose.

To assess the association between vertebral fractures and mortality.

Methods.

419 women and 210 men aged 60 to 98 (mean, 73) years participated in an osteoporosis screening exercise. Patient age, gender, comorbidity, lumbar pain, smoking, and alcohol consumption were recorded, as were the number of vertebral fractures and bone mineral density. Vertebral fractures were evaluated using lateral radiographs and quantitative morphometry. Anterior, central, and posterior vertebral heights were measured; vertebral fractures were defined as a decrease of ≥20% in any of these heights.

Results.

131 (21%) of the participants had vertebral fractures. At the 10-year follow-up, 121 (19%) of the participants (55 men and 66 women) had died; 43 of them had vertebral fractures and 78 did not. The respective 10-year survival rates for participants with and without vertebral fractures were 69% and 86% (p<0.0001). The survival rate was lower in those with greater number of vertebral fractures (76% for those with one or 2 fractures and 50% for those with ≥3 fractures). Multiple regression analysis showed that advanced age (p<0.0001), male gender (p=0.003), and presence of vertebral fractures (p=0.013) correlated significantly with survival.

Conclusion.

The presence and number of vertebral fractures were associated with mortality. Prevention of vertebral fractures may be important for improving the prognosis of patients with osteoporosis.
Proximal Femoral Medullary Canal Diameters in Indians: Correlation between Anatomic, Radiographic, and Computed Tomographic Measurements
Authors: Sen Ramesh Kumar , Tripathy Sujit Kumar , Kumar Raj , Kumar Amit , Dhatt Sarvdeep , Dhillon Mandeep Singh , Nagi ON , Gulati Madhu
Published: October 2016

Purpose.

To compare anatomic, radiographic, and computed tomographic (CT) measurements of the proximal femur in an Indian population.

Methods.

26 left and 24 right dried cadaveric femurs were obtained. Each femur was divided into segments at 10 cross-sectional levels from proximal to distal. At each level, anteroposterior (AP), lateral, 45° internal oblique, and 45° external oblique diameters of the medullary canal weremeasured using radiography and CT. To minimise magnification, the femur was placed over the film/board. The neck shaft angle, femoral head offset, neck length, and femoral head diameter were also measured. For anatomic measurements, the cross-sections of the medullary canal at levels 3 to 10 were measured using a calliper. Anatomic measurements were compared with radiographic and CT measurements, and the distortion calculated. Correlation between the 3 modalities was calculated using the Pearson correlation coefficient. Accuracy index of the 2 diagnostic modalities was measured, based on the differences between anatomic and radiographic/CT measurements. Lower accuracy indices indicated higher accuracy.

Results.

On AP radiographs of all femurs, the mean femoral head diameter was 45 mm, the mean neck shaft angle was 132°, the mean femoral head offset was 42 mm, and the mean neck length was 63 mm. With regard to medullary canal diameters, the radiographic and CT measurements were smaller than anatomic measurements at proximal levels, but similar at distal levels. Variations between femurs and between the 4 diameters at the same level were greater at proximal levels.

Conclusions.

Combined use of radiography and CT is recommended for preoperative assessment of implant size, particularly in uncemented arthroplasty where an optimal fit is essential for biological fixation.
Morphology of the Proximal Femur in a Pakistani Population
Authors: Umer Masood , Sepah Yasir Jamal , Khan Afrasyab , Wazir Ali , Ahmed Mahmood , Jawad Muhammad Umar
Published: October 2016

Purpose.

To measure the morphology of the proximal femur in a Pakistani population.

Methods.

Standardised anteroposterior pelvic radiographs of 116 male and 20 female healthy volunteers aged 20 to 50 (mean, 33) years were taken. Morphologic dimensions of the proximal femur were measured, including canal flare index (CFI), morphological cortical index (MCI), femoral head offset, femoral head diameter, and femoral head position.

Results.

Based on the CFI, 67% of the subjects had normal canal shapes (CFI, 3.0–4.7), whereas 1% and 33% of the subjects had stovepipe shapes (CFI, <3) and champagne-flute shapes (CFI, 4.7–6.5), respectively. Based on the MCI, 29% of the subjects had cylindrical shapes (MCI, <2.7) and 71% had trumpet shapes (MCI, >2.7).

Conclusion.

Morphology of the proximal femur in our study population differed significantly from those in western populations, indicating regional variation. It could also be due to the younger age of our population.
Revision Total Hip Arthroplasty with Femoral Impaction Bone Grafting
Authors: Yan Chun Hoi , Chiu Kwong Yuen , Ng Tsz Pui , Ng Fu Yuen
Published: October 2016

Purpose.

To report the radiological and clinical results of revision total hip arthroplasty (THA) with femoral impaction bone grafting (IBG).

Methods.

4 men and 9 women (15 hips) aged 38 to 84 years underwent revision THA with femoral IBG using Elite plus stems for aseptic loosening or infection.

Results.

The mean follow-up duration was 7.7 years. The Harris hip score improved from 61.7 to 83.7. There was no pain in 11 hips and slight pain in 4. The mean subsidence was 5.7 mm. The mean change of alignment was 1.2°. There was no radiological evidence of stem loosening. One stem was revised due to a peri-prosthetic fracture. Cortical healing was noted in 11 hips, and trabecular incorporation in 10.

Conclusion.

Although intra- and post-operative complications were not uncommon, femoral IBG is a safe procedure in carefully selected patients and offers good medium-term results.
Arthroscopic Repair of Rotator Cuff Tears Using Absorbable Anchors with a Single-Row Technique
Authors: Russo Raffele , Cautiero Fabio , Giudice Gerardo , Ciccarelli Michele , Visconti Valeria
Published: October 2016

Purpose.

To review outcomes of arthroscopic repair of rotator cuff tears using absorbable anchors with a single-row technique.

Methods.

66 patients underwent arthroscopic repair for rotator cuff tears using absorbable anchors with a single-row technique. 51 of them aged 37 to 73 (mean, 57) years had been followed up for a mean of 29 (range, 20–37) months. The extent of the tear was classified as large, medium or small. Functional outcome was assessed using the Constant score. Constant scores and re-tear rates in 3 patient groups (classified by patient age and tear size) were compared.

Results.

Among the 66 patients, there were 24 large, 29 medium and 13 small cuff tears, and a total of 48, 37, and 18 anchors were used, respectively. Among the 51 patients, the median Constant score improved significantly after arthroscopy (30 vs. 73, p<0.0001). Six shoulders had complete re-tears; their median Constant score was 48 and their adjusted Constant score was 65%. Complete re-tears occurred more often in patients aged >60 years than in those aged 50 to 59 years and <50 years (4/15 vs. 1/22 vs. 1/14), and more often in patients with large tears than in those with medium and small tears (4/24 vs. 2/29 vs. 0/13).

Conclusion.

Arthroscopic repair of rotator cuff tears using absorbable anchors with a single-row technique is reliable in patients aged <60 years with small or medium tears.
Anatomy of L4 to S3 Nerve Roots
Authors: Waikakul Saranatra , Chandraphak Supichya , Sangthongsil Pichet
Published: October 2016

Purpose.

To study the course of L4 to S3 nerve roots and their distance with the ala of the sacrum and the sacroiliac joint.

Methods.

The embalmed left half pelvis of 25 male and 27 female cadavers aged 30 to 91 (mean, 68) years were studied. The ventral rami of the L4, L5, S1, S2, and S3 nerve roots were dissected along their courses from the corresponding intervertebral foramina to the lesser pelvis. The distances between each nerve root and the most anterior and inferior parts of the sacroiliac joint were measured in both coronal and sagittal planes.

Results.

There were 3 locations of fusion of L4 and L5 nerve roots: above, on, or below the level of the most anterior part of the sacroiliac joint. Fusion of S1 and S2 nerve roots at the most inferior part of the sacroiliac joint was encountered in 10% of pelvises. Most S1 and S2 nerve roots lay medial to the sacroiliac joint and closed to the anterior cortex of the ala of the sacrum.

Conclusion.

Sacral nerve roots may fuse at different levels. Most L4 to S3 nerve roots lie close to the anterior surface of the sacroiliac joint and the ala of the sacrum. To prevent nerve root injury, dissection with a sharp instrument should be avoided at such area and 5 to 7 mm medial to the sacroiliac joint.
Pulmonary Cement Embolism during Cement Augmentation of Pedicle Screw Fixation: A Case Report
Authors: Akinola Bolarinwa , Lutchman Lennel , Barker Paul , Rai Am
Published: October 2016

We present a case of pulmonary cement embolism during cement augmentation of pedicle screw fixation for severe degenerative scoliosis. During intra-operative C-arm fluoroscopy, a radio-opaque substance was incidentally noted to pulsate in synchrony with the patient's heartbeat. A diagnosis of pulmonary cement embolism was made. The patient was treated with coumarin for 6 months. He made a good recovery.
Spinal Nerve Root Herniation into a Pseudomeningocele Associated with Lumbar Spondylolysis: A Case Report
Authors: Odate Seiichi , Shikata Jitsuhiko
Published: October 2016

A 38-year-old man presented with low back pain and sciatica on the left side. Magnetic resonance imaging showed spinal nerve root herniation into a pseudomeningocele associated with lumbar spondylolysis. After closure of the dural defect, the sciatic pain was relieved and subsequently the patient was able to return to work.
Microsurgical Resection of Cavernous Haemangioma around the Thoracic Neuroforamen: A Case Report
Authors: Uchida Kenzo , Yayama Takafumi , Nakajima Hideaki , Hirai Takayuki , Kobayashi Shigeru , Chen Kebing , Guerrero Alexander Rodriguez , Baba Hisatoshi
Published: October 2016

Treatment for haemangioma of the spinal cord often results in extensive bony resection that necessitates fusion and/or instrumentation. We report on a 75-year-old man who presented with neuropathic pain and muscle weakness of both lower limbs, secondary to an epidural haemangioma at T11–T12, extending laterally into the neuroforamen. The tumour was resected within the neuroforamen after a partial laminectomy and limited medial foraminotomy at T11–T12, without disruption of the osseous continuity of the pars interarticularis, avoiding spinal stabilisation surgery.
Management of Musculoskeletal Injuries after the 2009 Western Sumatra Earthquake
Authors: Pang Hee-Nee , Lim Wilfred , Chua Wei-Chong , Seet Benjamin
Published: October 2016

Purpose.

To report injury patterns and management of musculoskeletal injuries after an earthquake.

Methods.

94 male and 161 female patients aged 17 to 90 (mean, 53) years underwent surgery for musculoskeletal injuries. Their injury patterns, anaesthesia administered, surgeries undertaken, and development of postoperative complications were reviewed.

Results.

Of the 255 patients, 155 sustained superficial lacerations with minor soft-tissue contusion, whereas 100 sustained injuries that necessitated surgery under anaesthesia. The injuries involved the tibia/ankle (n=90), the hand (n=48), the pelvis/femur (n=41), the radius/ulnar (n=36), the foot (n=20), the humerus (n=10), and the spine (n=10). 30 (12%) of the patients had multiple injuries. The most common procedure performed was debridement (n=58), followed by open reduction and internal fixation with plates and screws for closed fractures (n=20), Kirschner wiring (n=11), external fixation (n=8), and general surgery and others (n=6). Repeated debridements were performed for 19 open fractures; 10 involved the distal tibia. 63 procedures were carried out under anaesthesia or sedation. General anaesthesia involved 2 patients; one had a right hemi-colectomy for an ischaemic bowel and another had an appendicectomy. Regional anaesthesia included sub-arachnoid block for lower-limb surgeries (n=21), axillary brachial plexus block for upper-limb surgeries (n=11), and femoral and sciatic nerve blocks for a lower-limb surgery (n=1). The remaining 28 procedures involved conscious sedation. The mean number of debridements for open fractures was 2.8 (range, 2–5). The mean follow-up duration was 10.4 (range, 7–14) days. Only one patient developed a postoperative wound infection.

Conclusion.

Our team was effective in managing orthopaedic injuries after an earthquake. The postoperative complication rate was low. Regional and spinal anaesthesia are relatively safe alternatives to general anaesthesia when carried out under such austere circumstances. The success of the mission depended on collaboration with the local health care workers and external agencies.
Cervical Spine Injury Recovery Prediction Scale: A Means of Predicting Neurological Recovery in Patients with Acute Subaxial Cervical Spine Injury
Authors: Kumar Ramesh , Arora Sumit , Mohapatra Dattatrey
Published: October 2016

Purpose.

To develop a comprehensive Cervical Spine Injury Recovery Prediction Scale (CSIRPS) to predict outcomes for patients with acute subaxial cervical spine injury (CSI).

Methods.

42 men and 18 women (mean age, 41 years) with acute subaxial (C3–C7) CSI and a neurological deficit were evaluated clinically and radiologically after crutch-field skeletal traction. The comprehensive CSIRPS comprised 5 predictor variables: American Spinal Injury Association (ASIA) impairment scale, maximum cord compression, maximum canal compromise, signal intensity pattern in the cord, and Cervical Spine Injury Severity Score (CSISS). Point values of each predictor were weighted based on consensus and experience, and the total effect was computed using the CSIRPS. A receiver operating characteristic (ROC) curve was plotted with the CSIRPS data to obtain the critical value that can predict walkers from non-walkers.

Results.

The Chi squared value for CSIRPS was 55.771 and the contingency coefficient was 0.694 (p<0.0001), both of which were highest among each predictor's corresponding values. A ROC curve was plotted with the CSIRPS data. With 100% area under the ROC curve, the critical value of 50 was identified with a sensitivity and specificity of 100%. All the patients with CSIRPS above this level regained the useful functions on follow-up, whereas patients with lower scores did not.

Conclusion.

The CSIRPS is a practical and accurate means of predicting outcomes in patients with acute subaxial CSI.
Popliteal Angle as an Indicator for Successful Closed Reduction of Developmental Dysplasia of the Hip
Authors: Molony Diarmuid C , Harty James A , Burke Thomas E , D'Souza Lester G
Published: October 2016

Purpose.

To evaluate the use of the popliteal angle as an indicator for successful closed reduction of developmental dysplasia of the hip (DDH) in children with delayed presentation.

Methods.

29 patients aged 6 to 18 months underwent successful closed reduction for unilateral DDH under general anaesthesia. Using a graduated goniometer, the popliteal angle was measured with the hip abducted within the safe zone (to avoid redislocation and injury to the femoral capital epiphysis) before and after reduction and after 6 weeks of spica casting.

Results.

The mean popliteal angles before and after reduction and after 6 weeks of spica casting were 5.1°, 37.5°, and 17.9°, respectively (p<0.0001, paired t test). Because of discomfort, the spica casts were altered in 3 patients (2 at week 1 and one at week 3).

Conclusion.

Reduction of the hip in DDH results in an increased popliteal angle of >20°. This may be used to indicate the diagnosis and safe closed reduction.
Incidence of Deep Vein Thrombosis following Total Hip Arthroplasty: A Doppler Ultrasonographic Study
Authors: Wong Keng Lin , Daguman Richillo , Lim Kay Hui , Shen Liang , Lingaraj Krishna
Published: October 2016

Purpose.

To investigate the incidence of deep vein thrombosis (DVT) following total hip arthroplasty (THA) in Singaporean patients.

Methods.

197 patients (mean age, 60 years) underwent primary THA (n=155) or revision procedure (n=42) without receiving routine chemoprophylaxis. There were 149 Chinese, 25 Malays, 19 Indians, and 4 Eurasians. Duplex ultrasonography to detect DVT was performed on both lower limbs on postoperative day 5.

Results.

15 (8%) patients developed DVT, which was proximal in 6 and distal in 9. Only one patient had pulmonary embolism. The presence of DVT did not correlate to age, gender, race, presence of diabetes mellitus, history of malignancy, smoking habit, fixation type, primary versus revision type of surgery, or operating time.

Conclusion.

The incidence of DVT following THA in Singaporean patients is low, and routine chemoprophylaxis may not be indicated.
The Efficacy of Patient Information Sheets in Wrist Arthroscopy: A Randomised Controlled Trial
Authors: Makki Daoud , Alameddine Manal , Khateeb Hesham Al , Packer Greg
Published: October 2016

Purpose.

To evaluate the effects of perioperative information for wrist arthroscopy on postoperative pain, return to daily activities, and patient satisfaction.

Methods.

34 women and 21 men aged 19 to 54 (mean, 35) years underwent diagnostic wrist arthroscopy to explore the radiocarpal and midcarpal joints. They were randomised to receive specific preoperative information on the procedure (pictures of the wrist joint anatomy, portal entry sites, and the arthroscope) and written instructions on postoperative care (n=28) or only standard preoperative information and verbal instructions on postoperative care (n=27). The visual analogue score (VAS) for pain and the Quick Dash score for return to daily activities of each patient were recorded before and after wrist arthroscopy. Analgesic intake after wrist arthroscopy was recorded.

Results.

The mean post-arthroscopic VAS from days 2 to 6 was significantly lower in the experimental group than controls. This was reflected by the decrease in analgesic intake. The mean post-arthroscopic Quick Dash score was significantly lower in the experimental group than controls (40 vs. 47, p=0.02), indicating earlier return to daily activities.

Conclusion.

Patients who received specific preoperative information on the procedure and written instructions on postoperative care experienced less pain, consumed less analgesics, and had an earlier return to daily activities.
Two-Year Outcomes of Transforaminal Lumbar Interbody Fusion
Authors: Poh Seng-Yew , Yue Wai-Mun , Chen Li-Tat John , Guo Chang-Ming , Yeo William , Tan Seang-Beng
Published: October 2016

Purpose.

To evaluate the outcomes, fusion rates, complications, and adjacent segment degeneration associated with transforaminal lumbar interbody fusion (TLIF).

Methods.

32 men and 80 women aged 15 to 85 (mean, 57) years underwent 141 fusions (84 one-level, 27 2-level, and one 3-level) and were followed up for 24 to 76 (mean, 33) months. 92% of the patients had degenerative lumbar disease, 15 of whom had had previous lumbar surgery. Radiographic and clinical outcomes were assessed at 2 years. The short-form 36 (SF-36) health survey, visual analogue scale (VAS) for pain, and the modified North American Spine Society (NASS) Low Back Pain Outcome Instrument were used.

Results.

Of the 141 levels fused, 110 (78%) were fused with remodelling and trabeculae (grade I), and 31 (22%) had intact grafts but were not fully incorporated (grade II). No patient had pseudoarthroses (grade III or IV). For one-level fusions, poorer radiological fusion grades correlated with higher VAS scores for pain (p<0.01). All components of the SF-36, the VAS scores for pain, and the NASS scores improved significantly after TLIF (p<0.01), except for general health in the SF-36 (p=0.59). Improvement from postoperative 6 months to 2 years was not significant, except for physical function (p<0.01) and role function (physical) [p=0.01] in the SF-36. Two years after TLIF, 50% of the patients reported returning to full function, whereas 72% were satisfied. 26 (23%) of the patients had adjacent segment degeneration, but only 4 of them were symptomatic.

Conclusion.

TLIF is a safe and effective treatment for degenerative lumbar diseases.
Collagen Membranes for Host-Graft Integration: An Animal Study
Authors: Guerzon Edwin Ravanzo , Pereira Barry P , Bhavanam Kishore , Khin Zarchi A , Nathan Saminathan Suresh
Published: October 2016

Purpose.

To evaluate the biocompatibility of collagen membranes for host-graft integration.

Methods.

18 Achilles tendons in 9 rats were used. Five tendons were controls and repaired with prolene 3–0 sutures only. The remaining 13 tendons were cases, and a 10-mm section was excised. A 15×5 mm bovine pericardial collagen membrane (Tutomesh; Tutogen Medical, Germany) was laid circumferentially around the tendon and secured with prolene 3–0 sutures. Tendons were harvested after 4 and 6 weeks. Only the repair interfaces (i.e. cut ends and immediate surrounding tissue) were evaluated. Integration of the membranes to the tendons was evaluated using a semi-quantitative wound maturation scale (1–4) based on the presence of inflammatory cells, vascularisation, fibroblasts, and the amount and alignment of collagen fibrils. The presence of fibroblasts and vascularisation were positive parameters, whereas inflammatory cell ratios were regarded as negative parameters. Immunohistochemical study was also performed.

Results.

There was no host-graft reaction or wound complication (infection, abscess or seroma). Histological and immunohistochemical assessment confirmed re-approximation of the cut tendon ends and incorporation of the membrane onto the tendon as early as week 4. At week 4, the mean maturation scale scores were 2.7 for controls and 3.3 for cases (p=0.11). At week 6, the corresponding values were 3.8 and 3.0 (p=0.004). A reparative process involving formation of blood vessels and invasion by fibroblasts was noted in both control and case tendons. In controls, T- and B-lymphocytes were present. In cases, inflammatory cells were noted at the junction of the host and membrane without invasion of the graft material. There was no lymphocytic infiltration on the graft. The foreign body reaction was localised and minimal.

Conclusion.

The collagen membrane achieved favourable host-graft integration as early as week 4, with a minimal foreign body reaction.
Autologous Blood Reinfusion in Patients Undergoing Bilateral Total Hip Arthroplasty
Authors: Gee Albert O , Garino Jonathan P , Lee Gwo-Chin
Published: October 2016

Purpose.

To compare the rate and unit of allogeneic blood transfusion in one-stage bilateral total hip arthroplasty (THA) in patients with and without autologous blood reinfusion.

Methods.

Records of a consecutive series of 43 men and 33 women aged 25 to 83 (mean, 55) years who underwent one-stage sequential bilateral THA by a single surgeon were reviewed. Their risks of cardiopulmonary complications were minimal. At least 4 weeks prior to surgery, 38 of the patients donated 2 units of autologous blood in 2 stages (one to 2 weeks apart). The remaining 38 patients did not donate blood owing to personal preferences or logistical reasons. All pre-donated autologous blood was transfused back to the patients in the recovery room. Estimated blood loss volume, blood salvaged volume, and complications were recorded, as were pre- and post-operative haemoglobin levels. The 2 groups were compared with respect to the rate and unit of allogeneic blood transfusion.

Results.

The mean estimated blood loss was 939 (SD, 448; range, 200–2500) ml. The mean volume of blood salvaged was 302 (SD, 196; range, 0–850) ml, representing a collection rate of 32%. In patients with and without autologous blood reinfusion, 16 (42%) and 33 (87%) patients received allogeneic blood transfusion of 0.9 and 2.4 units, respectively (p<0.0001). Four patients developed major cardiopulmonary complications. None had deep venous thrombosis or pulmonary embolism. No complications resulted from blood transfusion. The 2 groups were not significantly different in complication rate (13% vs. 18%, p=0.54) and discharge haemoglobin levels.

Conclusion.

Autologous blood reinfusion was effective in reducing the rate and unit of allogeneic blood transfusion in patients undergoing one-stage bilateral THA.
Tuberculosis of the Foot and Ankle in Children
Authors: Agarwal Anil , Qureshi Nadeem Akhtar , Khan Shariq Azam , Kumar Pawan , Samaiya Sachin
Published: October 2016

Purpose.

To report manifestations and management of tuberculosis of the foot and ankle in 21 children.

Methods.

Records of 12 girls and 9 boys aged 3 to 14 (mean, 7) years with tuberculosis of the foot and ankle were reviewed. The mean delay in presentation was 4.7 (range, 0.5–14) months. All the patients had local swelling, tenderness, and antalgic gait; 16 were limping; 5 had an antecedent trauma; 11 had an abscess; and 6 had a discharging sinus. The diagnosis was based on a smear positive for acid-fast bacilli (n=2), histopathology (n=15), or clinicoradiological findings (n=4). Nine patients had osteoarticular tuberculosis in other parts of the body. None had evidence of pulmonary tuberculosis. Lesions were classified into synovial (articular) and osseous. All 3 synovial lesions occurred in the ankle, 2 of which were at an advanced stage. Osseous lesions occurred in the calcaneus (n=5), metatarsal (n=5), talus (n=3), cuboid (n=3), medial cuneiform (n=1), and phalanx (n=1), and were sub-classified into stages 1 (n=3), 2 (n=5), and 3 (n=10) according to disease progression. All the patients were treated conservatively with splintage and chemotherapy.

Results.

The mean follow-up period was 21 (range, 7–51) months. All the 3 patients with stage 1 osseous lesions showed healing within 6 weeks and had complete recovery of function. Four of the 5 patients with stage 2 lesions also showed complete recovery of function and reformation of bony trabeculations; radiological incorporation of sequestrum was obvious by 6 months in most patients. In patients with stage 3 lesions, healing was delayed and there was residual alteration in bony architecture and joint changes. Sclerotic changes and joint involvement also increased the likelihood of poor outcomes. However, none of our patients had any residual tenderness or foot deformity at the final follow-up.

Conclusion.

Outcome after non-operative treatment is good, provided the lesions are treated early.
Sterile Surgical Helmet System in Elective Total Hip and Knee Arthroplasty
Authors: Singh Vinay Kumar , Hussain Shazeena , Javed Sadaf , Singh Ivor , Mulla Rohinton , Kalairajah Yegappan
Published: October 2016

Purpose.

To evaluate the sterility of the sterile surgical helmet system (SSHS) during elective total hip and knee arthroplasty in theatres with (n=20) and without (n=20) laminar flow.

Methods.

Three surgeons performed 14 total knee arthroplasties (TKAs) and 6 total hip arthroplasties (THAs) in a laminar flow theatre and 15 TKAs and 5 THAs in a non-laminar flow theatre. An SSHS was used in all the procedures. Samples were taken from the hood at 30-minute intervals during surgery. Swabs were then broken into cooked meat broths for cultivation of organisms. The broths were then directly inoculated onto blood agar and fastidious anaerobic agar for culture of aerobic and anaerobic bacteria, respectively. After 24 hours, these plates were reinoculated with broths that had been incubated for 24 hours. Microbial growth was quantified as 0 (none), 1 (mild), 2 (moderate) and 3 (heavy). Bacterial contamination in the 2 groups at 30, 60 and 90 minutes was compared.

Results.

Respectively in the laminar and non-laminar flow theatres, 0 and 9 of the SSHSs showed bacterial growth after direct inoculation, and 14 and 18 of the SSHSs grew 18 and 24 types of organisms in the swab cultures after 24 hours of incubation. Respectively at 30, 60, and 90 minutes, the degree of contamination from direct incubation was significant, but the degree of contamination on swabs after 24 hours of inoculation was not significant. The mean time-dependent contamination after direct inoculation was 0 for the laminar flow group and 0.5, 0.75, and 1.0 for the non-laminar flow group, whereas the corresponding values after 24 hours of incubation were 1.8, 1.8, and 2.6, and 2, 2.75, and 2.95. Coagulase negative Staphylococcus aureus was the most common organism in both groups.

Conclusion.

80% of SSHSs used were contaminated intra-operatively. Direct contact with the SSHS should be avoided by the operating team during surgery. Routine changing of gloves in case of contact with the SSHS should be practised.
Exeter Small Femoral Stem for Patients with Small Femurs
Authors: Chiu Kwok-Hing , Cheung Kin-Wing , Chung Kwong-Yin , Shen Wan-Yiu
Published: October 2016

Purpose.

To report the long-term results of total hip arthroplasty (THA) using small size Exeter femoral stems.

Methods.

Eight men and 34 women aged 60 to 83 (mean, 70) years underwent 45 THAs using the Exeter small stem with offsets of 30 mm (n=3), 33 mm (n=15), and 35.5 mm (n=27). The Harris hip score was assessed pre- and post-operatively. Stem alignment and axial subsidence of the stem were measured. Radiolucent lines around the femur were recorded at 14 Gruen zones. Completeness and thickness of the cement mantle and cement fractures were also noted. Ectopic ossification, if present, was graded. Stem loosening was based on the Olsson definitions.

Results.

The mean follow-up was 9 (range, 5–12) years. The mean Harris hip score improved from 37 (range, 13–61) to 80 (range, 47–96) [p<0.001]. At the latest follow-up, the score was excellent (90–100) in 8 (18%) of the hips, good (80–89) in 21 (47%), fair (70–79) in 9 (20%), and poor (<70) in 7 (16%). All hips had a complete cement mantle of ≥2 mm. All stems were inserted without intramedullary reaming. 11 (24%) of the hips developed stem subsidence of <2 mm; all stabilised within 2 years. None of these patients had pain or other radiological signs of loosening. Six stems showed radiolucent lines of <1 mm in the upper zones, which were not progressive. No cement fracture or subsidence was noted. Using revision for any cause as an endpoint, the overall survival rate of Exeter small femoral stem was 100% at 10 years and 89% at 12 years.

Conclusion.

The results of Exeter small stems for patients with small femurs are good.
Displaced Tibial Intercondylar Eminence Fractures
Authors: Kieser David Christopher , Gwynne-Jones David , Dreyer Stephan
Published: October 2016

Purpose.

To review outcomes of 19 patients with tibial eminence fractures.

Methods.

Records of 10 female and 9 male patients with type II (n=3) and type III (n=16) displaced tibial intercondylar eminence fractures were reviewed. Nine of whom were skeletally immature aged 6 to 15 (mean, 12) years; the remaining 10 patients were aged 19 to 55 (mean, 32) years. 14 involved the left knee. All patients presented with a painful haemarthrosis and reduced range of movement.

Results.

The most common activity causing this injury was skiing (n=7, primarily in adult females [n=5]), followed by cycling or motocrossing (n=6) and falling or other sporting activities (n=6). The injury mechanisms entailed forced flexion with rotation (n=7), hyperextension with rotation (n=7, primarily in skeletally immature males [n=4]), and direct trauma (n=5, primarily in adult males [n=4]). Eight patients (60% of adults and 22% of children) had associated injuries of the knee, which commonly occurred after direct trauma. Two patients were treated in a cast or brace after closed or open reduction without fixation. Two patients underwent arthroscopic reduction and internal fixation, and 15 underwent open reduction and internal fixation (2 after failed arthroscopic reduction and 11 proceeded directly). Postoperatively, 7 patients had a positive Lachman test, but none complained of subjective instability. Ten patients had knee stiffness; all except one had been immobilised for 4 to 6 weeks. Seven patients had extension impingement; 6 of them had been treated with open reduction and internal fixation. Two patients underwent further surgery for debridement and screw removal at years 1 and 3. One patient developed arthrofibrosis and underwent arthrolysis at month 6, but knee stiffness remained. No patient underwent subsequent anterior cruciate ligament reconstruction.

Conclusion.

Tibial eminence fractures are as common in adults as in children. Female skiers are at higher risk. Stiffness is a more common complication than laxity. Early range-of-motion exercise may reduce stiffness and extension impingement.
Staged Arthroscopic Reconstructive Surgery for Multiple Ligament Injuries of the Knee
Authors: Subbiah M , Pandey Vivek , Rao Sharath K , Rao Sripathi
Published: October 2016

Purpose.

To review treatment outcome of our staged protocol for multiple ligament injuries of the knee.

Methods.

21 men who were treated for multiple ligament injuries of the knee and had completed at least one year of rehabilitation were evaluated. Patients were examined under anaesthesia and then by diagnostic arthroscopy. Arthroscopic reconstructive procedures for injured cruciate ligaments were performed after a minimum 110° flexion and full extension were regained. Collateral ligaments injuries were treated first, followed by posterior cruciate ligament (PCL) and then anterior cruciate ligament (ACL) tears. Outcome was evaluated using the Lysholm knee score and International Knee Documentation Committee (IKDC) knee ligament evaluation form.

Results.

19 patients aged 24 to 55 (mean, 36) years were followed up for a mean of 22 (range, 14–33) months. The mean Lysholm score was 92. The mean scores for patients treated within and after 3 weeks were 93 and 90, respectively. The overall IKDC grading was B in 15 knees and C and D each in 2 knees. For the 2 patients with grade D, one presented 19 months after the injury and had persistent posterior sag (secondary to capsular contracture). His Lysholm score was 82. The second patient developed a deep infection and endured a flexion loss of 30° but had a satisfactory Lysholm score of 94. There was no significant difference between early and delayed treatments and between low- and high-velocity injuries in terms of the Lysholm score, the IKDC grade, the range of movement, and the functional outcome.

Conclusion.

Staged management of multiple ligament injuries of the knee enabled satisfactory restoration of function, stability, and range of movement in most of our patients. By staging the procedures, the need for subsequent ACL reconstruction can be better evaluated, as ACL reconstruction is not necessary in patients not undertaking strenuous activities.
Ipsilateral Tibial Shaft Fracture and Distal Tibial Triplane Fracture with an Intact Fibula: A Case Report
Authors: De Rover Walter B Sprenger , Alazzawi Sulaiman , Hallam Peter J , Walton Neil P
Published: October 2016

We present a case of an ipsilateral tibial shaft fracture and a distal tibial triplane fracture with an intact fibula in a 14-year-old boy. Computed tomography revealed the distal tibial triplane fracture with a 2.6-mm displaced Tillaux fragment and a posterior malleolar shear fragment. Open reduction and internal fixation was performed to optimise healing and outcome. This is a rare injury, for which a high index of suspicion is needed for diagnosis. Missing the intra-articular distal tibial triplane fracture could result in a disabling angular deformity (mostly varus) or limb-length discrepancy secondary to premature partial closure of the distal physis.
Alendronate-Associated Ulnar and Tibial Fractures: A Case Report
Authors: Tang Zhi Hao , Kumar Veerasingam Prem
Published: October 2016

Bisphosphonates are widely used to prevent osteoporotic fractures. Long-term use has resulted in unexpected subtrochanteric fractures in some elderly patients. We report a patient on long-term alendronate therapy who sustained fractures of the ulna and tibia sequentially over a 7-month period, without any trauma or fall.
Arthroscopic Keyhole Proximal Biceps Tenodesis: A Technical Note
Authors: Amaravathi Rajkumar S , Pankappilly Biju , Kany Jean
Published: October 2016

We describe an arthroscopic keyhole technique for proximal biceps tenodesis. The technique is safe, easy to reproduce, cost-effective, and less time consuming. It does not need any special instrumentation and is suitable especially for use in the developing countries. It enables examination of the biceps sheath and distal biceps tendon for unidentified tears, synovitis, and fibrosis.
Closed Reduction and Percutaneous Screw Fixation for Tibial Plateau Fractures
Authors: Sament Radheshyam , Mayanger JC , Tripathy Sujit Kumar , Sen Ramesh Kumar
Published: October 2016

Purpose.

To evaluate treatment outcomes of closed reduction and percutaneous screw fixation for tibial plateau fractures.

Methods.

48 men and 8 women aged 19 to 61 (mean, 36) years underwent closed reduction and percutaneous screw fixation for closed tibial plateau fractures with <5 mm depression. According to the Schatzker classification, patients were classified into type I (n=9), type II (n=22), type IV (n=5), and type V (n=20). Closed reduction was achieved using manual ligamentotaxis with traction in extension under image intensifier control. Reduction was fixed percutaneously with cancellous screws (6.5 mm) and washers. Functional outcome (pain, walking capacity, extension lag, range of motion, and stability) was evaluated using the Rasmussen score. A total score of 28 to 36 was considered as excellent, 20 to 27 as good, 10 to 20 as fair, and >10 as poor.

Results.

Patients were followed up for a mean of 2.8 (range, 1–4) years. The mean length of hospital stay was 5 (range, 2–15) days. All the fracture united radiographically after a mean of 3 (range, 2.5–4.2) months. Respectively in Schatzker types-I, -II, -IV, and -V fractures, outcomes were excellent in 6, 10, 2, and 2 patients, good in 2, 9, 3, and 14 patients, fair in 1, 3, 0, and 2 patients, and poor in 0, 0, 0, and 2 patients. Outcome was satisfactory (good-to-excellent) in 89%, 86%, 100%, and 80% of the respective fracture types of patients. The mean Rasmussen score was 25.7 for all patients; it was 27.7 for type I, 26.3 for type II, 28.6 for type IV, and 23.4 for type V fractures. The mean Rasmussen score was significantly lower in 12 patients with ligament injury than in 44 patients without ligament injury (19.8 vs. 27.3, p<0.001). No patient had any complication (infection, wound dehiscence or hardware problem).

Conclusion.

Closed reduction and percutaneous screw fixation for tibial plateau fractures is minimally invasive. It reduces the length of hospital stay and costs, enables early mobilisation with minimal instrumentation, and achieves satisfactory outcomes.
Antegrade Interlocking Nailing for Distal Femoral Fractures
Authors: Kulkarni Sunil Govind , Varshneya Ankit , Kulkarni Govind Shivram , Kulkarni Milind Govind , Kulkarni Vidisha Sunil , Kulkarni Ruta Milind
Published: October 2016

Purpose.

To assess outcomes of antegrade interlocking nailing for supracondylar or intercondylar fractures of the distal femur.

Methods.

Records of 10 women and 20 men aged 20 to 70 (mean, 48.7) years who underwent antegrade interlocking nailing for distal femoral fractures were reviewed. 23 patients had closed fractures and 7 had open fractures; 6 had associated fractures of the forearm or tibia. According to the AO/ASIF system, fractures were classified as types A1 (n=13), A2 (n=6), A3 (n=3), and C1 (n=8). The affected leg was put in an extension shoe for traction, and reduction was achieved with the help of percutaneous lag screws. The nail was inserted from the tip of the greater trochanter and centred in both anteroposterior and lateral planes. The nail was modified to have 3 screw slots in the mediolateral plane and one screw slot in the anteroposterior plane distally for stability in multiple directions. Postoperatively early mobilisation and partial weight bearing were allowed. Patients were assessed using the modified knee-rating scale of the Hospital for Special Surgery.

Results.

The mean time to bone union was 13.1 (range, 10–18) weeks. The mean follow-up period was 18.8 (range, 11–30) months. Three patients were lost to follow-up; outcomes in the remaining patients were excellent in 20 and good in 7. The mean range of knee flexion was 106° (range, 90°–120°). One patient developed a flexion deformity of 10°. All patients attained full quadriceps strength. No patient had ligamentous instability, nerve injuries, superficial or deep infections, or implant failure. Three patients had malunion, which was located in the meta-diaphyseal segment and not in the intra-articular segment. Hence, there was no functional problem or shortening. The mechanical axis was not deviated.

Conclusion.

Antegrade interlocking nailing achieved good-to-excellent outcomes for distal femoral fractures