Background. Although there are frequent studies about normal range of thoracic kyphosis, there is still a controversy about the exact values of this curve. In nine reported studies on 10 to 20 years of age boys, the value ranged from 25.1° to 53.3°. Objective for the Study. The aim of the present research was investigation of normal ranges of thoracic kyphosis in school children in Kermanshah, western Iran. Methods. 582 male students aged 13 to 18 years old using cluster random sampling were recruited from schools in Kermanshah city, 97 students for each age. Thoracic curves were measured using the flexicurve method. Results. Mean thoracic kyphosis for whole population was 35.49° SD 7.83 and plus or minus two standard deviations ranged from 19.83° to 51.15°. It increased gradually from 13 to 16 and then there was a little decrease to 18 years. Mean values for each age (13–16) were 13 (34.41 SD 7.47°), 14 (34.86 SD 8.29°), 15 (35.79 SD 7.93°), 16 (36.49 SD 7.85°), 17 (35.84 SD 8.33°), and 18 (35.55 SD 7.07°). Conclusions. Our results are in agreement with previous reports and can be used as normal values for local and regional purposes.
Purpose. The purpose of this paper is to present our technique for the treatment of periplate fractures. Methods. From 2009 to 2012 we treated three patients. In all cases the existing plate was left and the new one placed over the existing. Locking screws were placed through both plates. The other screws in the new plate were used as best suited the fracture. Results. In all cases less than 6 months had passed between fractures. None of the original fractures had healed. Mean followup was 2 years. All fractures proceeded to union within 7 months. No complications were recorded. All the patients returned to their normal activities and were satisfied with the results of their treatment. Conclusion. Our plate on plate technique is effective for the treatment of periplate fractures. A solid fusion can be achieved at the new fracture site without disturbing the previous fixation.
Hip fractures are common and the incidence is expected to increase. Systemic analgesics, often prescribed to relieve pain after hip fractures, have huge side effects and can delay surgery. We analyse the role and efficacy of alternative forms of analgesia like fascia-iliac blocks (FIB) and assess the feasibility of a service delivered by junior doctors. 104 consecutive hip fracture patients were prospectively recruited and equally divided into cases (patients receiving FIB) and controls (patients receiving systemic analgesia). Outcome measures included time of initial analgesia, total preoperative dose of analgesia, pain scores from admission to 24 hours preoperatively, and complications. The pain scores were significantly lower (P ≤ 0.05) in patients receiving FIB at 2 and 8 hours preoperatively. The timing of initial analgesia was also quicker in patients with FIB (25 compared to 40 minutes). FIB patients required fewer doses of systemic analgesia. The block was successful in 67% of patients. There were no complications. The implementation of EWTD, HAN, and shift-system and the reduction in the number of medical staff have increased the burden on emergency departments. This study demonstrates that FIB performed by junior doctors are not only safe and effective analgesia but also provide an opportunity for junior doctors to improve current clinical practice.
Purpose. The management of unstable distal radial fractures in the superelderly (≥80 years old) remains controversial. The aim of this study was to compare the functional outcome of super-elderly patients with and without malunion after a distal radial fracture.Methods. We identified 51 superelderly patients living independently with displaced fractures from a prospective database of 4024 patients with distal radial fractures. Activities of daily living, presence of wrist pain, whether the wrist had returned to its normal level function, grip strength and ROM were recorded. The dorsal angulation was measured radiographically.Results. There were 17 (33.3%) patients defined to have a malunion. The outcomes of the independent patients with and without malunion were compared at a mean follow-up of 15 months. No difference was observed in activities of daily livingP=0.28, wrist painP=0.14, whether the wrist had returned to its normal level functionP=0.25, grip strengthP=0.31, or ROMP=0.41. An increasing degree of dorsal angulation correlated with diminished ROM (P=0.038), but did not correlate with activities of daily living (P=0.10).Conclusions. Malunion of the distal radius does not influence the functional outcome of independent superelderly patients.
Objectives. To study the correlation between avascular necrosis and the demographics, time elapsed from fracture to surgery, quality of reduction, Garden classification, and the position of the screw following use of the dynamic hip screw (DHS) in the treatment of subcapital neck fractures. Methods. A prospective study of 96 patients with subcapital neck fractures was carried out in a faculty hospital. Patients underwent surgery with closed reduction and internal fixation with DHS. Results. There were 58% male and 42% female patients, with a mean age of 53 years (+/−14). In terms of Garden classification, 60% were Garden IV, 26% were Garden III, and 14% were Garden II. Nonunion was observed in three cases (3%) and was treated with valgus intertrochanteric osteotomy, in all cases leading to successful healing. Avascular necrosis was observed in 16% of patients. The positioning of the screw into the femoral head showed a significant correlation with necrosis. Conclusions. The incidence of necrosis in patients under the age of 50 years is twice as high as that in older patients. Displacement is a predictive factor regarding osteonecrosis and is associated with a high and anterior position of the screw in the femoral head. Level II of evidence. Study Type: therapeutic study.
Aim. To evaluate the clinical use of blocking screws as a supplement to stability in distal tibial metaphyseal fractures treated with statically locked intramedullary nail. Main Outcome Measurement. Alignment and reduction preoperatively, postoperatively, and at healing were the main outcome measured with an emphasis on maintenance of initial reduction on followup. Patients and Methods. This was a prospective study of 20 consecutive cases of distal tibial metaphyseal fractures treated with statically locked intramedullary nailing with supplementary blocking screw between August 2006 and September 2007 with a maximum followup of 3 years. Medullary canal diameter was measured at the levels of fracture and isthmus. Results. The mean diameter of tibia at the level of isthmus was 11.9 mm and at the fracture site was 22.9 mm. Mean length of distal fracture segment was 4.6 cm. Mean varus/valgus alignment was 10.3 degrees preoperatively and 1.7 degrees immediatly postoperatively and was maintained till union. Using Karlstrom-Olerud score the outcome was excellent to good in 90%. Conclusion. We conclude that the use of blocking screw as a supplement will aid in achieving and maintaining the reduction of distal tibial metaphyseal fractures when treated with intramedullary nailing thereby extending the indication of intramedullary nailing.
Aim . In these case series which are about type 3 open tibial fractures formed with three different high energy trauma etiologies in different parts of tibia. We aimed to assess our three-stage treatment approach and discuss final results of our elective surgery management with three different fixation methods. Patients and Methods . We assessed 19 patients with type 3 open tibial fractures between 2009 and 2012. Our treatment protocol consisted of three stages. Early intervention in operating room, which including vascular repairs or soft tissue closure, was done if necessary. Definitive surgery was performed using internal or external fixation in the first 15 days. Patients were followed up for at least one year. Last conditions of all our cases were evaluated according to modified Johner and Wruhs criteria. Results . Nine cases were type 3A, seven cases were type 3B, and three cases were type 3C in terms of fracture typing. All patients were followed up for at least one year and mean follow up time was 15 months. In terms of functional and clinical outcome, six cases were evaluated as excellent, eight cases as good, two cases as fair, and three cases as poor. Discussion . Staged treatment option in type 3 open tibial fractures seems to be a good method in reducing complication and achieving the best result. We think that definitive staged treatment protocol including internal fixation with plating or intramedullary nailing (IMN) of the fractures is a reliable method, especially to avoid complications as a result of external fixator and to provide patient rapport.
Fixation of tibial plateau fractures with plate has been widely used. This prospective study was planned to compare locking plate fixation of tibial plateau fracture with nonlocking methods in terms of their functional outcomes. The subjects of the study were selected from consecutive patients suffering from tibial plateau fractures referred to Kashani Hospital in Isfahan, Iran, between 2012 and 2013 and were candidate for surgery. The final included patients were assigned to two groups, those who were treated with locking plate (n = 20) and those who were treated with nonlocking plates (N = 21). The mean duration of follow-up was 13.4 months (ranging between 10 and 17 months). The mean of knee scores was significantly higher in locking plate group than in nonlocking plate group at the follow-up time (80.20 ± 10.21 versus 72.52 ± 14.75, P = 0.039). Also, the mean VAS pain severity score was significantly lower in locking plate group compared with nonlocking plate group (4.45 ± 2.50 versus 6.00 ± 2.59, P = 0.046). This study confirmed superiority of the locking plate method over nonlocking plate method with regard to knee score as well as VAS pain score.
The increased incidence of motor vehicle accidents during the past century has been associated with a significant increase in brachial plexus injuries. New imaging studies are currently available for the evaluation of brachial plexus injuries. Myelography, CT myelography, and magnetic resonance imaging (MRI) are indicated in the evaluation of brachial plexus. Moreover, a series of specialized electrodiagnostic and nerve conduction studies in association with the clinical findings during the neurologic examination can provide information regarding the location of the lesion, the severity of trauma, and expected clinical outcome. Improvements in diagnostic approaches and microsurgical techniques have dramatically changed the prognosis and functional outcome of these types of injuries.
The incidence of brachial plexus injuries is rapidly growing due to the increasing number of high-speed motor-vehicle accidents. These are devastating injuries leading to significant functional impairment of the patients. The purpose of this review paper is to present the available options for conservative and operative treatment and discuss the correct timing of intervention. Reported outcomes of current management and future prospects are also analysed.
Background. The objective of the present study was to compare mechanical strength and stability of the newly designed spacer plate with the gold standard plate for the treatment of medial knee joint osteoarthritis. Materials and Methods. Ten fourth-generation tibial bone composites underwent a medial open-wedge high tibial osteotomy (HTO) according to standard techniques, using five TomoFix plates and five Contour Lock plates. Static compression load to failure and load-controlled cyclical fatigue failure tests were performed. Forces and horizontal displacements were measured; plastic deformations and dynamic stiffness were determined. Results and Discussion. In all samples, rotation of the tibial head and fracture of the opposite cortex were observed. Behaviors of the specimens under static loading were comparable between groups. Cyclic testing revealed lateral significant higher stiffness until failure for the Contour Lock compared to the TomoFix plate. No visible implant failure was observed in any group. Conclusion. Considering the static analysis, both plates offered sufficient stability under physiologic loads of up to 3000 N. The Contour Lock plate-fixated specimens showed a higher stability during the cyclic testing, supposedly due to the wider distance between the fixation screws.
Introduction . A method for the determination of safe angles for screws placed in the posterior acetabular wall based on preoperative computed tomography (CT) is described. It defines a retroacetabular angle and determines its variation in the population. Methods . The retroacetabular angle is the angle between the retroacetabular surface and the tangent to the posterior acetabular articular surface. Screws placed through the marginal posterior wall at an angle equal to the retroacetabular angle are extraarticular. Medial screws can be placed at larger angles whose difference from the retroacetabular angle is defined as the allowance angles. CT scans of all patients with acetabular fractures treated in our institute between September 2002 to July 2007 were used to measure the retroacetabular angle and tangent. Results . Two hundred thirty one patients were included. The average (range) age was 42 (15–74) years. The average (range) retroacetabular angle was 39 (30–47) degrees. The average (range) retroacetabular tangent was 36 (30–45) mm. Conclusions . Placing the screws at an average (range) angle of 39 (33–47) degrees of anterior inclination with the retroacetabular surface makes them extraarticular. Angles for medial screws are larger. Safe angles can be calculated preoperatively with a computer program.
Developmental hip dysplasia (DDH) presents considerable technical challenges to the primary arthroplasty surgeon. Autogenous bulk grafting using the femoral head has been utilised to achieve anatomic cup placement and superolateral bone coverage in these patients, but reported outcomes on this technique have been mixed with the lack of graft integration and subsequent collapse, an early cause of failures. We describe a novel technique combining the use of bulk autograft with an iliac osteotomy, which provides primary stability and direct cancellous-cancellous bone contact, optimising the environment for early osseointegration. Twenty-one hips in 21 patients with DDH underwent this technique and were followed for a mean of 8.1 years. The preoperative radiographic classification was Crowe type I in 12 hips (57%), type II in 4 hips, and type III in 5 hips, and the mean Sharp angle was 49.6° (range 42°–60°). All grafts united by year. At time of followup, there was no radiographic evidence of graft collapse or loosening. There were no reoperations. Our study has shown that this technique variation combining an iliac osteotomy with bulk autograft in cases of developmental hip dysplasia provides early stability and reliable graft incorporation, together with satisfactory clinical and radiological outcomes in the medium term. Longer term study is necessary to confirm the clinical success of this procedure.
This is a retrospective review of 243 hip arthroplasties treated with either hemiarthroplasty (61 surgeries-Group 1) or total hip arthroplasty (182 surgeries-Group 2). The mid- to long-term results of relatively similar, predominately young patient cohorts were assessed annually via radiographs and the Harris Hip Scores for pain and clinical function. Groin pain persisted in 16.4% of Group 1 and 5.5% of Group 2 (P = 0.0159). Thigh pain persisted in 11.5% of Group 1 and 2.2% of Group 2 (P = 0.0078). Complications in Group 1 were 4/61 including 2 revisions with an overall survival rate of 96.7% versus Group 2 complication rate of 29/182 with 15 revisions and an overall survival rate of 91.8%. There were no cases of acetabular protrusio in Group 1, but 2 cases (1%) in Group 2 had cup loosening or osteolysis. Two cases were revised in Group 1 (3.2%). Both were undersized femoral stems. The fifteen revisions (8.2%) in Group 2 included loose stem (1), instability (8), infections (3), cup loosening (2), and accelerated polyethylene wear (1). Hemiarthroplasty has a higher incidence of thigh and groin pain but fewer complications compared with total hip arthroplasty.
Background. Traditionally, osteolysis around total knee replacements (TKRs) is treated with complete revision. In certain subsets, polyethylene insert exchange and bone grafting may be applicable. This study reports the clinical outcomes for selective bone grafting in patients with osteolysis without complete revision of the TKR. Methods. This retrospective study analyzes 10 TKRs (9 patients, 66.5 ± 6.1 years old) presenting with osteolysis and revised after 8.7 ± 1.9 years of in vivo function. At index TKR, all patients were implanted with uncemented prosthesis and modular polyethylene insert with anteroposterior articular constraint (Ultracongruent, Natural Knee II, Sulzer Medica). The surgical technique for treating the osteolysis included removal of necrotic bone tissue using curettage, filling of the defect with bone graft materials, and polyethylene insert exchange. Results. Patients have not exhibited any further complications associated with osteolysis after 5.1 ± 2.4 years of followup. Routine radiographic exams show total incorporation of the graft material into the previously lytic regions in all patients. Conclusion. In some TKRs with osteolysis and firmly fixed components, the removal of lytic tissue and subsequent defect filling with bone graft materials can be a viable solution. This case series shows complete resolution of osteolysis in all patients with no complications.
Background. Intertrochanteric fractures of the proximal femur are one of the most common fractures encountered, and dynamic hip screw with a side plate is the standard treatment. We compared a minimally invasive surgical technique with the conventional surgical technique used in the fixation of intertrochanteric fractures with the dynamic hip screw (DHS) device. Methods. Thirty patients with such fractures were treated with the conventional open technique and 30 with a new minimally invasive technique. Patients in both groups were followed up for 1 year. Results. There was less blood loss, minimal soft tissue destruction, shorter hospital stay, and early mobilization with the minimally invasive technique. Conclusion. The present study finds minimally invasive technique superior to conventional (open) DHS.
Background. Septic arthritis is a true orthopaedic emergency. Important factors determining outcome are rapid diagnosis and timely intervention. Changing trends in microbiological spectrum and emerging drug resistance poses big challenge. Present study evaluates bacterial strains and their sensitivity pattern in septic arthritis of North Indian children. Methods. Fifty children with septic arthritis of any joint were evaluated. Joint was aspirated and 2 cc of aspirated fluid was sent for gram stain and culture. Blood cultures were also sent for bacteriological evaluation. Results. Fifty percent cases had definite radiological evidence of septic arthritis whereas ultrasound revealed fluid in 98% cases. Aspirated fluid showed isolates in 72% cases. The most common organism was Staphylococcus aureus (62%) followed by Streptococcus pneumoniae and Gr. B Streptococcus. Blood culture could grow the organism in 34% cases only. The bacterial strain showed significant resistance to common antibiotic cocktail in routine practice. Resistance to cloxacillin and ceftriaxone was 62% and 14% respectively. No organisms were resistant to vancomycin and linezolid. Conclusion. S. aureus is still the most common organism in septic arthritis. Though a significant resistance to common antibiotic cocktail is noticed, the strain is susceptible to higher antibiotics. We recommend using these antibiotics as an empirical therapy till culture and sensitivity report is available.
Background. In orthopedics, there is no instrument specifically designed to assess patients’ expectations of their final surgery outcome in general trauma populations. We developed the Trauma Expectation Factor Trauma Outcome Measure (TEFTOM) to investigate the fulfilment of patients’ expectations one year after surgery as a measure of general trauma surgical outcomes. The aim of this paper was to assess the psychometric characteristics of this new general trauma outcome measure. Methods. The questionnaire was tested in 201 ankle and distal tibia fracture patients scheduled for surgery. Patients were followed up for twelve months. The TEFTOM questionnaire was evaluated for its criterion validity, internal consistency, reproducibility, and responsiveness. Results. TOM showed good criterion validity against the American Academy of Orthopaedic Surgeons Foot and Ankle Scale (Pearson’s correlation coefficient = 0.69–0.77). Internal consistency was acceptable for TEF (Cronbach’s alpha = 0.65–0.76) and excellent for TOM (Cronbach’s alpha = 0.76–0.85). Reproducibility was moderate to very good (intraclass coefficient correlation (ICC) ≥0.67) for TEF and very good (ICC ≥0.92) for TOM. TOM also proved to be responsive to changes in patients’ condition over time (Wald test; P<0.001). Conclusions. TEFTOM is a promising tool for measuring general trauma outcomes in terms of patients’ expectation fulfilment that proved to be valid, internally consistent, reproducible, and responsive to change.
Dynamic systems in the lumbar spine are believed to reduce main fusion drawbacks such as pseudarthrosis, bone rarefaction, and mechanical failure. Compared to fusion achieved with rigid constructs, biomechanical studies underlined some advantages of dynamic instrumentation including increased load sharing between the instrumentation and interbody bone graft and stresses reduction at bone-to-screw interface. These advantages may result in increased fusion rates, limitation of bone rarefaction, and reduction of mechanical complications with the ultimate objective to reduce reoperations rates. However published clinical evidence for dynamic systems remains limited. In addition to providing biomechanical evaluation of a pedicle-screw-based dynamic system, the present study offers a long-term (average 10.2 years) insight view of the clinical outcomes of 18 patients treated by fusion with dynamic systems for degenerative lumbar spine diseases. The findings outline significant and stable symptoms relief, absence of implant-related complications, no revision surgery, and few adjacent segment degenerative changes. In spite of sample limitations, this is the first long-term report of outcomes of dynamic fusion that opens an interesting perspective for clinical outcomes of dynamic systems that need to be explored at larger scale.
Autologous platelet rich plasma preparations, commonly referred to as platelet gel, have been reported to have benefits when used in total knee replacement of less blood loss and better motion, with few reported complications. This retrospective review of 268 consecutive primary total knee arthroplasty cases compares postsurgical range of motion at 2, 8, and 12 weeks, knee manipulation rates, change in hemoglobin, and complications between one group receiving a platelet gel preparation (135 cases), and an equivalent group receiving no platelet gel preparation (133 control cases). No difference was found between groups in manipulation rates, knee range of motion, or changes in hemoglobin (P > 0.05). The use of platelet gel in this study did not have a significant effect on hemoglobin at 72 hours postoperatively, knee range of motion, or manipulation rates up to 3 months post-op in this patient cohort.
