Indian Journal of Orthopaedics最新文献

Introduction: To study the incidence of bone cement implantation syndrome in elderly patients undergoing cemented stem hip arthroplasty with the use of pulse lavage.

Materials and methods: 40 consecutive patients undergoing cemented stem hip arthroplasty enrolled in the study and intra-operative vitals post induction and post cementing were recorded at 5, 10 and 15 min.

Results: Study depicted an incidence of 32.5%. The incidence of grade 1, 2 ,3 was 22.5%,7.5% and 2.5%, respectively. There was a significant correlation between increased age and those patients suffering from BCIS grade 2 and 3 (p = 0.016). There was no correlation drawn between the comorbidities of the patients and the presence of the condition. However, all the patients with a history of dementia, myocardial infarction and stroke developed the syndrome. A significant correlation was drawn with patients suffering from left ventricular failure (p-value 0.03) pre-operatively. The severity of bone cement implantation syndrome was associated with a significant increase in pre-operative neutrophils (p-value 0.037) and hyponatremia (p-value 0.042) compared to patients with a mild condition, indicated the need for optimisation of the patient. A severe case leading to cardio-pulmonary collapse post cementing was recorded.

Conclusions: BCIS is a commonly occurring under-reported phenomenon in the elderly, leading to significant intra-operative complications. Pre-operative risk assessment along with good coordination between anaesthetist and surgeon is imperative.

Purpose: To characterize various regimens used for surgical antimicrobial prophylaxis (SAP) in patients undergoing orthopedic implant surgeries (OISs).

Method: A prospective observational study was conducted in patients undergoing OISs to identify various antimicrobial regimens used for SAP. Patients were followed up for a month to detect signs of surgical site infections (SSIs). Risk factors that increase the likelihood of SSIs were determined. Adherence to standard guidelines for SAP was evaluated. Cost analysis and adverse drug reaction (ADR) profiling of each of the regimens used were also done.

Results: Among the 264 patients included, 11 regimens for SAP were followed. Ceftriaxone + amikacin given for 1-5 days was the most common regimen employed (37.87%). One-day regimens (< 24 h) were more commonly prescribed (34.84%) than all other durations (2-5 days). SSIs were observed in 2.37% of the included patients. Gender, presence of cardiovascular comorbidities, low preoperative Hb, and the choice of antimicrobial regimen selected for SAP were associated with SSIs. The adherence rate to standard guidelines for SAP was 35.5%. In our study, ceftriaxone given for < 24 h was the most cost-effective regimen, with the lowest cost per patient (0.28 USD) and no infections. Procurement of ceftriaxone and amikacin contributed to > 70% of the total cost of SAP. Vomiting, epigastric pain, and thrombophlebitis were the common ADRs observed.

Conclusion: SAP practices for patients undergoing OISs are highly variable, with low adherence to standard guidelines. Development of evidence-based national and institution-specific guidelines, along with regular antibiotic stewardship activities, could help curb the heterogeneity in SAP practices.

Background: As far as we know, no study has investigated spontaneous postoperative shoulder imbalance (PSI) correction in adolescent idiopathic scoliosis (AIS) patients. The objective is to assess the incidence of and associated factors for spontaneous PSI correction in AIS patients.

Methods: The study evaluated 144 postoperative AIS patients with PSI aged 10-20 years between 2010 and 2018. An analysis included demographic data and radiographic measurements (Risser grading, Lenke type, upper instrumented vertebra [UIV], and lowest instrumented vertebra [LIV]). Preoperative, postoperative, and follow-up radiographs were evaluated for shoulder parameters: radiologic shoulder height (RSH); T1 tilt angle; clavicle angle (CA); proximal thoracic curve (PTC), main thoracic curve (MTC), and lumbar curve (LC) Cobb measurements; and apical vertebral translation (AVT) of the PTC, MTC, and LC.

Results: Spontaneous PSI correction was observed in 99 (68.75%) patients. The spontaneous correction and nonspontaneous correction groups differed significantly in terms of Lenke-type preoperative LC (23° vs 26°; P = 0.091), postoperative LC (11° vs 8°; P = 0.013), LC at follow-up (13.5° vs 9°; P = 0.028), postoperative AVT of LC (- 0.8° vs - 0.4°; P = 0.033), AVT of LC at follow-up (- 0.7° vs - 0.1°; P = 0.091), PTC at follow-up (16° vs 20°; P = 0.019), and AVT of PTC at follow-up (0° vs -0.3°; P = 0.029). Multivariate analysis identified postoperative T1 tilt and postoperative LC as significantly associated with PSI correction.

Conclusions: The incidence of spontaneous PSI correction is high. Postoperative T1 tilt and postoperative LC are significantly associated with spontaneous PSI correction.

Aseptic nonunion is prevalent in orthopedic practice, causing persistent pain and functional impairment. Humeral shaft fractures, accounting for 3-5% of all fractures, have nonunion rates of 2-33% in nonoperative and 5-10% in surgical management. This study, the largest case series on operative management of humeral shaft nonunion, examines surgical techniques and outcomes. This retrospective study, conducted at a referral center in eastern India, included 132 patients with aseptic humeral shaft nonunion from 2002 to 2020. Cases were from May 2002 to April 2012 and May 2015 to December 2020. Patients aged 20-70 years with nonunion more than 6 months post-trauma were included. Exclusions were open fractures, infections, gap nonunions, pathological fractures, and concomitant upper limb injuries. Surgical techniques involved excising fibrous and unhealthy tissue, compressing the nonunion site, decorticating, shingling, autologous bone grafting, and stable fixation with dynamic or locking compression plates. Outcomes were assessed using DASH, VAS, and constant shoulder score scores at a minimum follow-up of 24 months. The study included 132 patients, 84 males and 48 females, with a mean age of 42.3 years. Fractures were due to high-energy trauma in 78 cases and low-energy trauma in 54 cases. All patients received autologous bone grafts and plating techniques. Quick DASH scores improved from 77 to 5 on average. Union was achieved in 21 weeks on average, with minimal complications. Despite variations in time intervals, treatments, and follow-up durations, consistent management strategies emphasize stable fixation, bone grafts, and careful complication management to achieve high union rates and satisfactory outcomes. Complications included seven infections, one failure needed refixation and one case of transient radial nerve palsy. Absolute stability using a plate with or without autologous bone grafting for aseptic humeral shaft nonunion results in high union rates and satisfactory radiological and functional outcome.

Introduction: The Steinberg classification system is commonly used by orthopedic surgeons to stage the severity of patients with osteonecrosis of the femoral head (ONFH), and it includes mild, moderate, and severe grading of each stage based on the area of the femoral head affected. However, clinicians mostly grade approximately by visual assessment or not at all. To accurately distinguish the mild, moderate, or severe grade of early stage ONFH, we propose a convolutional neural network (CNN) based on magnetic resonance imaging (MRI) of the hip joint of patients to accurately grade and aid diagnosis of ONFH.

Materials and methods: T1-MRI images of patients diagnosed with early stage ONFH were collected. Three orthopedic surgeons selected 261 slices containing images of the femoral head and labeled each case with the femoral head necrosis classification. Our CNN model learned, trained, and segmented the regions of femoral head necrosis in all the data.

Results: The accuracy of the proposed CNN for femoral head segmentation is 97.73%, sensitivity is 91.17%, specificity is 99.40%, and positive predictive value is 96.98%. The diagnostic accuracy of the overall framework is 90.80%.

Conclusions: Our proposed CNN model can effectively segment the region where the femoral head is in MRI and can identify the region of early stage femoral head necrosis for the purpose of aiding diagnosis.

Objective: This study aims to enhance our understanding of the morphological pattern, causes and pathogenesis of meniscal root injuries in the Indian population.

Materials and methods: Sixty-four patients with meniscus root tears were included in the study. The patients were categorized into two groups based on the location of the meniscus tear: Group 1 (n = 41) comprised patients with lateral meniscus root injury (LMRI), and Group 2 (n = 23) included patients with medial meniscus root injury (MMRI). Demographic and patient-specific data, such as age, gender, BMI, history of injury, and injury type, were recorded. All patients underwent surgical treatment, and intraoperative findings (chondral damage grade, type of root injury, associated ligamentous injuries) were documented. Meniscus root tears are further classified into 5 categories depending upon their morphological types. A minimum 12-month follow-up assessed functional outcomes using the Lysholm and IKDC knee scores.

Results: The mean age for MMRI and LMRI was 50.3 years and 29.4 years, respectively. In the MMRI group, 48% (11/23) were female compared to only 15% (6/41) in the LMRI group. The mean BMI in the MMRI and LMRI groups was 30.1 and 25.4, respectively. Nine patients in MMRI and 4 patients in LMRI group exhibited grade 3 or higher chondral damage. Type 2 meniscus root tear was most common type in both the groups (51% in MMRI vs. 74% in LMRI). Both LMRI and MMRI groups demonstrated significant improvement in functional outcomes.

Conclusions: Medial meniscus root injuries predominantly occur in the elderly without a significant history of trauma, often associated with a high grade of medial femoral chondral damage, suggesting a degenerative etiology. In contrast, lateral meniscus root injuries tend to occur in younger patients with a notable history of knee injury, indicative of a traumatic etiology for LMRI.

Introduction: Interspace defects after osteochondral autograft transfer (OATS) are filled only with fibrocartilage. Attempts have been made to address these issues in OATS with procedures like mega OATS and Hexagonal Osteochondral Graft System. We have described the functional outcomes of a hybrid technique combining a regeneration and a restoration modality to address the interspace defect in OATS.

Methods: Consecutive cases of full-thickness focal chondral defects of the knee were treated using the nuts-in-jelly mosaicplasty technique. Patients with less than 1 cm lesions, ligament insufficiency, and alignment abnormalities were excluded. Bone marrow aspirate concentrate (BMAC) with fibrin glue has been used to fill the defect remaining after the osteochondral cylinders are transferred, resulting in a configuration like nuts dispersed in a jelly.

Results: We had a total of 12 cases-4 cases of osteochondritis dessicans (OCD) and 8 cases of traumatic chondral defects. The mean age of the patients was 32 years (range 19 - 44 years). 4 were female patients. The available cartilage was fixed in all the OCD cases. The remaining defect was filled with one or two osteochondral cylinders and the BMAC-fibrin glue or only with BMAC-fibrin glue. In traumatic defect cases, the space remaining after the OATS cylinder transfer was filled with BMAC-fibrin glue. The mean follow-up period was 3 years (range 2 - 5 years). All cases had good to excellent Tegner-Lysholm scores with a mean score of 92 (range 85 - 96).

Conclusion: Nuts in jelly mosaicplasty may address the issue of fibrous cartilage formation after OATS in the interspace. Further prospective comparative studies are necessary to validate the findings of this study.

Background: Bone marrow aspirate concentrate (BMAC) is considered one of the biological treatments for knee osteoarthritis (KOA). Patient selection remains a key factor to ensure that optimal treatment benefit and body mass index (BMI) are one of the key factors to be considered. This study aims to evaluate the influence of obesity on the duration of treatment benefit of BMAC for KOA.

Methods: This prospective cohort study enrolled 68 patients who underwent a single BMAC injection for early stage KOA. The patients were categorized based on their BMI into normal, overweight, and obese groups. Visual Analog Scale (VAS) for pain and Knee Injury and Osteoarthritis Outcome Score (KOOS) were the outcomes analysed. The duration of treatment benefit is estimated by Kaplan-Meier survival analysis.

Results: Sixty-eight patients (normal BMI = 43, overweight BMI = 15, obese BMI = 10) were enrolled in the study for analysis. While significant improvement in the outcome scores was noted compared to the baseline throughout the study period in the normal BMI and overweight group, the obese group returned to baseline parameters at 3 months follow-up. Patients in the normal BMI group demonstrated significant improvement in VAS (p < 0.001) and KOOS (p < 0.001) outcomes compared to the overweight and obese group. Survival analysis demonstrated a significant decline in the mean treatment benefit of 9.8 (95%CI [6.151-13.431], p = 0.027) months in normal BMI group to 6.6 (95%CI [3.473-9.727]) months and 4.1 (95%CI [2.760-5.440]) months in overweight and obese groups, respectively.

Conclusion: BMI is a significant factor that influences the benefit of BMAC injection for early knee OA. Hence, BMAC injection must be used with caution in individuals with high BMI.

Background: Ultracongruent (UC) total knee replacement (TKR) designs, serving as alternatives to posterior stabilized (PS) and cruciate retaining (CR) designs, lack conclusive evidence regarding posterior femoral rollback. This study aimed to compare intraoperative posterior femoral rollback and maximal knee flexion between UC and PS inserts, addressing the paucity of literature on femoral rollback achieved with UC designs in total knee replacement.

Methods: A consecutive cohort of 20 patients undergoing robotic-assisted primary total knee replacement, posterior femoral rollback and maximal intraoperative knee flexion were assessed. Robotic imaging at varying flexion angles (0°, 45°, 90°, and 120°) was conducted after implanting femoral and tibial components with Ultracongruent and Posterior-Stabilized trial inserts. Femoral contact on the tibia was estimated as a percentage of the sagittal dimension of the tibial component with 0 representing the anterior edge and 100 representing the posterior edge of the tibial component.

Results: In extension, UC inserts exhibited a statistically significant posterior contact point versus PS inserts (56.3 + 4.3 vs 53.5 + 5.3, p = 0.003). Between 0 and 45° flexion, 13 of 20 UC inserts showed a paradoxical anterior translation exceeding 5%, unlike the PS group. At 90° flexion, both displayed consistent posterior femoral rollback, with PS inserts having a more posterior contact point (63.5 + 6.2 vs 67.2 + 5.1, p = .008). At 120° flexion, rollback was similar (70.1 + 8.4 vs 71.3 + 8.4, p = 0.128). Mean maximal flexion was 130° (SD = 6.87) and 133° (SD = 6.72) for UC and PS inserts, respectively (p = 0.0001).

Conclusions: The study indicates UC inserts achieve comparable posterior femoral rollback in deep flexion, supporting their alternative use, despite minor intraoperative flexion differences. However, paradoxical anterior translation in mid-flexion with UC inserts warrants further investigation into wear and clinical outcomes.

Distal femur physeal fractures in children, particularly Hoffa fractures, are rare and prone to complications. This study aims to evaluate the outcomes of surgical intervention in children presenting with delayed intra-articular distal femur physeal fractures. A multicentric retrospective study involved six pediatric patients with delayed presentation of distal femur physeal fractures. Five patients underwent surgical intervention involving osteotomy and anatomical re-fixation of the malunited fragments. One patient opted for conservative management. The age at presentation, time since injury, surgical procedures, and clinical and radiological outcomes were evaluated at the final follow-up. Fixation with lag screws was sufficient in three patients, while two required additional plate stabilization. The mean age of patients was 12.2 years, comprising four boys and two girls. The average delay in presentation was 30.8 months (ranging from 3 months to 8 years). For the surgical group (n = 5), the knee range of motion improved from an average of 16°-66° preoperatively to 6°-128° post-operatively at a mean follow-up of 60 months. The mean limb shortening was 3 cm (range 0.5-5 cm). Two patients required additional procedures for distal femur varus malalignment. The conservatively managed patient showed no improvement in knee movements at the 12-month follow-up, serving as a control. Surgical intervention involving osteotomy and anatomical reduction for malunited intra-articular Salter-Harris-type III and IV fractures of the distal femur in children yields good to excellent outcomes. Limb length discrepancy and malalignment, if present, can be addressed separately. Longer follow-up until skeletal maturity is necessary to evaluate final outcomes in these patients. Level of evidence: Level IV (case series). Therapeutic.

Supplementary information: The online version contains supplementary material available at 10.1007/s43465-024-01291-4.