Bhavuk Garg

Outcome of short proximal femoral nail antirotation and dynamic hip screw for fixation of unstable trochanteric fractures. A randomised prospective comparative trial

A prospective, randomised, controlled trial was performed to compare the outcome of treatment of unstable trochanteric fractures with either a short proximal femoral nail antirotation (PFNA) or dynamic hip screw (DHS). Eighty one patients with unstable fracture of the proximal part of the femur were randomised, at the time of admission, for fixation with either a short PFNA (n=42) or DHS (n= 39). The primary outcome measure was reoperation within the first postoperative year and mortality at the end of one year. Operative time, fluoroscopy time, blood loss, and any intra-operative complication were recorded for each patient. Clinical and radiological follow-up was undertaken for a minimum of 36 months. Any changes in the position of the implant or fixation failure were recorded. Hip range of motion, pain in the hip or thigh and return to work were used to compare the outcomes. There was no significant difference between 1 year mortality rates for the two groups. The mean operative time was significantly less in PFNA group (25 min) than in the DHS group (38 min). Patients treated with a PFNA experienced a shorter fluoroscopy time and less blood loss. Six patients in DHS group had implant failure while none experienced this in PFNA group. The PFNA group had a better functional outcome than the DHS group.

Microendoscopic versus Open Discectomy for Lumbar Disc Herniation: A Prospective Randomised Study

Purpose. To compare the outcomes of microendoscopic discectomy (MED) versus open discectomy for lumbar disc herniation. Methods. 80 men and 32 women aged 26 to 57 (mean, 37) years with a single-level disc herniation were randomised to undergo MED (n=55) or open (fenestration/laminotomy) discectomy (n=57). Patients were assessed pre- and post-operatively (at week 6, month 6, and year one). The 2 groups were compared with respect to surgical time, anaesthesia time, duration of hospital stay, intra-operative blood loss, weight of disc material removed, and self-evaluated low back pain and functional outcome (using the Oswestry low back pain disability questionnaire). Results. Surgical and anaesthesia times were significantly longer, but blood loss and hospital stay were significantly reduced in patients having MED than open discectomy. The improvement in the Oswestry score in both groups was significant at week one, but not at other follow-ups. The complication rate was similar in both groups. One patient with MED had a recurrence of disc herniation after 7 months and was treated with open discectomy. Conclusions. Both methods are equally effective in relieving radicular pain. MED entailed shorter hospital stay, less morbidity, and earlier return to work. Nonetheless, it is a demanding technique and should not be attempted without specific instruction and training.

Anterior versus posterior procedure for surgical treatment of thoracolumbar tuberculosis: A retrospective analysis.

Background: Approach for surgical treatment of thoracolumbar tuberculosis has been controversial. The aim of present study is to compare the clinical, radiological and functional outcome of anterior versus posterior debridement and spinal fixation for the surgical treatment of thoracic and thoracolumbar tuberculosis. Materials and Methods: 70 patients with spinal tuberculosis treated surgically between Jan 2001 and Dec 2006 were included in the study. Thirty four patients (group I) with mean age 34.9 years underwent anterior debridement, decompression and instrumentation by anterior transthoracic, transpleural and/or retroperitoneal diaphragm cutting approach. Thirty six patients (group II) with mean age of 33.6 years were operated by posterolateral (extracavitary) decompression and posterior instrumentation. Various parameters like blood loss, surgical time, levels of instrumentation, neurological recovery, and kyphosis improvement were compared. Fusion assessment was done as per Bridwell criteria. Functional outcome was assessed using Prolo scale. Mean followup was 26 months. Results: Mean surgical time in group I was 5 h 10 min versus 4 h 50 min in group II (P>0.05). Average blood loss in group I was 900 ml compared to 1100 ml in group II (P>0.05). In group I, the percentage immediate correction in kyphosis was 52.27% versus 72.80% in group II. Satisfactory bony fusion (grades I and II) was seen in 100% patients in group I versus 97.22% in group II. Three patients in group I needed prolonged immediate postoperative ICU support compared to one in group II. Injury to lung parenchyma was seen in one patient in group I while the anterior procedure had to be abandoned in one case due to pleural adhesions. Functional outcome (Prolo scale) in group II was good in 94.4% patients compared to 88.23% patients in group I. Conclusion: Though the anterior approach is an equally good method for debridement and stabilization, kyphus correction is better with posterior instrumentation and the posterior approach is associated with less morbidity and complications.

Management of Extensor Mechanism Deficit as a Consequence of Patellar Tendon Loss in Total Knee Arthroplasty A New Surgical Technique

Extensor mechanism disruption is an uncommon but devastating complication of total knee arthroplasty. A new technique of extensor mechanism reconstruction for patellar tendon loss, after total knee arthroplasty, with the help of extensor mechanism composite allograft is described. Four patients with chronic extensor mechanism-deficient total knee arthroplasty were undertaken for revision surgery along with reconstruction of extensor mechanism with an innovative technique using an extensor mechanism composite allograft consisting of a patella-patellar tendon-tibial tubercle. On final follow-up, none of the patients had extensor lag but for 10 degrees of extensor lag in 1 patient only. Providing an environment for bone-to-bone healing both proximally as well as distally and supervised postoperative rehabilitation led to encouraging results in the management of a failed extensor mechanism after total knee arthroplasty.

Giant cell tumour of the tendon sheath of the hand

Purpose. To review outcomes of 106 patients after complete excision of the giant cell tumour of the tendon sheath of the hand, with or without postoperative radiotherapy. Methods. Records of 77 women and 29 men aged 11 to 61 (mean, 31) years who underwent excision of giant cell tumours of the tendon sheath of the hand were reviewed. All patients presented with gradually progressive swelling; only 3 of them also presented with pain. The lesions were located on the dorsal aspect (n=11), the palmar aspect (n=66), both aspects (n=10), or circumferentially (n=14). No patient had multiple lesions. Five patients had bony erosion and 3 had neurovascular bundle involvement. Results. The mean follow-up period was 12 (range, 4–22) years. 56 patients with well-encapsulated giant cell tumour in the palmer and/or dorsal aspects were classified as at low risk of recurrence. The remaining 50 patients were classified as at high risk of recurrence and underwent postoperative radiotherapy. None of the patients at low risk had any recurrence; 4 of those at high risk had recurrence despite radiotherapy. No complication was attributable to the irradiation, except that 3 patients had some dark pigmentation around the wound scar. Conclusion. Postoperative radiotherapy may have a role in reducing recurrence of the giant cell tumour of the tendon sheath of the hand.

Staged reduction of neglected transscaphoid perilunate fracture dislocation: A report of 16 cases

BackgroundTransscaphoid perilunate fracture dislocation is a rare injury and can be easily missed at the initial treatment. Once ignored, late reduction is not possible and needs extensive dissection. An alternative treatment such as proximal row carpectomy may be required for neglected injuries, but surgical outcome is not as good as that of an early reduction. We aim to present an alternative technique of staged reduction and fixation in patients of neglected transscaphoid perilunate dislocations and study its outcome.Material & Methods16 cases (14 males & 2 females) with neglected transscaphoid perilunate fracture dislocation (> 3 month old) were treated with staged reduction. Mean duration between injury and surgery was 4.5 months. In first stage an external fixator was applied across the wrist and distraction was done at 1 mm/day. Second surgery was done through dorsal approach and we were able to reduce all the fractures & dislocations. Herbert screws and K wires were used for fixation.ResultsThe mean duration between two surgeries was 2.4 weeks (range 2–4 weeks). 9 cases had excellent results, 5 had good result. Two patients developed reflex sympathetic dystrophy and had fair results.ConclusionStaged reduction should be considered for neglected transscaphoid perilunate dislocations. If properly executed, a good functional pain free range of motion is the usual outcome.

Treatment of flexion-type supracondylar humeral fracture in children

Purpose. To assess the results of treatment for flexion-type supracondylar humeral fracture in children. Methods. The treatment of 14 children with flexion-type supracondylar humeral fracture was reviewed. Severity was classified according to the Gartland system for extension-type fractures. Type-I fractures were treated with immobilisation in an extension cast. For type-II and -III fractures, closed reduction was first attempted followed by percutaneous pinning. If closed reduction failed, open reduction and internal fixation was performed. Results. Patients were followed up for at least one year (range, 14–36 months). Treatment results were excellent in 7 patients, good in 4, fair in 3, and poor in none. Patients were pain-free and satisfied and none suffered any activity restriction. Conclusion. Closed reduction and percutaneous pinning is a good treatment option for type-II and -III flexion-type supracondylar humeral fractures.

Sacroiliitis caused by Salmonella typhi: a case report

Sacroiliitis caused by Salmonella typhi is rare. In India, unilateral sacroiliitis is usually caused by tuberculosis. We report a 22-year-old man who presented with a high-grade fever and positive blood culture for Salmonella typhi. The patient was treated with intravenous vancomycin and levofloxacin for 15 days and then oral levofloxacin for 6 weeks.

Integrity of the Lateral Femoral Wall in Intertrochanteric Hip Fractures

To The Editor: With regard to the article, “Integrity of the Lateral Femoral Wall in Intertrochanteric Hip Fractures. An Important Predictor of a Reoperation” (2007;89:470-5), by Palm et al., we first would like to congratulate the authors for emphasizing that the integrity of the lateral femoral wall is a predictor of success of open reduction and internal fixation of …

Outcome and safety analysis of 3D-printed patient-specific pedicle screw jigs for complex spinal deformities: a comparative study

BACKGROUND CONTEXT Spinal deformities are very challenging to treat and have a great risk of neurologic complications because of hardware placement during corrective surgery. Various techniques have been introduced to ensure safe and accurate placement of pedicle screws. Patient-specific screw guides with predrawn and prevalidated trajectory seem to be an attractive option. PURPOSE We have focused on developing three-dimensional (3D) printing technique for complex spinal deformities in India. This study also aimed to compare the placement of pedicle screw with 3D printing and freehand technique. STUDY DESIGN/SETTINGS This is a retrospective comparative clinical study in an academic institutional setting. PATIENT SAMPLE A total of 20 patients were enrolled during the study: 10 were operated on with the help of 3D printing (Group 1) and 10 were operated on with freehand technique (Group 2). Group 1 included six patients with congenital scoliosis, three patients with adolescent idiopathic scoliosis (AIS), and one patient with post-tubercular kyphosis, and Group 2 included five patients with congenital scoliosis, four patients with AIS, and one patient with post-tubercular kyphosis. OUTCOME MEASURES Primary outcomes were measured in terms of screw violation, and secondary outcomes were measured in terms of surgical time, blood loss, radiation exposure (number of shoots required), and complications. MATERIALS AND METHODS MIMICS Base v18.0 software was used for 3D reconstruction from computed tomography scan images of all the patients. 3-Matic software was used to create a drill guide. A 3D printer from Stratasys Mojo with ABS P430 model material cartilage (a thermoplastic material) was used for the printing of the vertebra model and jigs. A two-sample test of proportion was used to compare correctly and wrongly placed pedicle screws with 3D printing and freehand technique. t Test with equal variance was used for operating surgical time and blood loss. RESULTS No superior or inferior screw violation was observed in any of our patients in either group. We found a significant difference (p=.03) between the two groups regarding perfect screw placement in favor of 3D printing. There were 13 Grade 2 medial perforations in the freehand group and 3 in the 3D printing group. There was no Grade 3 medial perforation in either group. Six Grade 2 lateral perforations in the freehand group and seven in the 3D printing group were observed. Three Grade 3 lateral perforations in the freehand group and two in 3D printing group were observed. Analysis showed a statistically significant (p=.005) medial violation in the freehand group. Surgical time was significantly less (p=.03) in the 3D printing group compared with the freehand group. Mean blood loss was higher in the freehand group but was not statistically significant (p=.3) in the 3D printing group. Fluoroscopic shots required were less in number in the 3D printing group compared with the freehand group. There was no neurologic deficit in any of the patients in the two groups. CONCLUSIONS In our study, focusing on spinal deformities with statistically significant higher rates of accurate screw positioning and higher numbers of inserted screws with 3D printing was possible because of enhanced safety, particularly at apical levels. As such, spinal deformities are difficult to treat worldwide. In India, these deformities are often neglected and present at a very late and a much more deformed state when their treatment becomes even more challenging. Developing these patient-specific drill templates will enable an average spine surgeon to treat these patients with much ease and safety.