Deepak Joshi

Unreamed interlocking nailing in open fractures of tibia

Purpose. To assess the clinical outcome of unreamed intramedullary interlocking nailing in open fractures of tibia, and to evaluate the incidence of complications in these open fractures as a result of the unreamed intramedullary nailing. Methods. Between June 1999 and May 2000, a total of 60 cases of open tibial shaft fractures were operated on with unreamed interlocking nails at Safdarjung Hospital, New Delhi, India. Records of 56 patients (4 women and 52 men) were available for study. Only injuries associated with the tibial shaft were included. Traffic accidents were the cause of fractures in all patients. All fractures were classified according to Gustilo and Anderson system for open fractures. There were 30 (53.6%) type-I, 18 (32.1%) type-II, 4 (7.1%) type-IIIA, and 4 (7.1%) type-IIIB fractures. After thorough debridement under anaesthesia, an unreamed interlocking nail was inserted with assistance by an image intensifier. All nails were statically locked with one screw each proximally and distally. Results. The patients were followed up for a mean period of 20 months (range, 18–24 months) and were evaluated according to the modified Ketenjians criteria. Results were good to excellent in 85.8% cases, and poor in 10.7% cases. Only 2 of 8 patients with type-III fractures had good results. Two of 4 type-IIIA and all 4 type-IIIB fractures had chronic osteomyelitis. Of 56 patients, 6 had early infection, 6 had delayed union, 6 had infected non-union, 2 had nail breakage, 8 had screw breakage, and 10 had anterior knee pain. Conclusion. Unreamed interlocking tibial nailing can be safely used for type-I and type-II open injuries even with delayed presentation. Use of unreamed nailing in those type-III fractures with delayed presentation was not recommended, because of high incidence of complications.

Arthroscopic fixation for acute acromioclavicular joint disruption using the TightRope device.

Purpose. To review outcome after arthroscopic fixation for acute acromioclavicular (AC) joint dislocation using the TightRope device. Methods. Records of 15 men and 2 women aged 19 to 52 (mean, 35) years who underwent arthroscopic fixation using the TightRope device for acute (<3 weeks) AC joint dislocation of Rockwood type III (n=6), type IV (n=1), and type V (n=10) were reviewed. Outcome was evaluated using the Constant score. The coracoclavicular (CC) distance before and after surgery was compared. Results. The mean follow-up period was 22.1 (range, 12–37) months. The mean time to return to work was 4 (range, 1.5–12) months, excluding one failure. The mean postoperative Constant score was 86.4 (range, 63–96). The CC distance decreased from 21.5±5.2 mm preoperatively to 9.8±3.5 mm at 6 months and to 10±3.2 mm at one year. There was no over-correction. All patients had satisfactory outcome except for one who had rupture of the TightRope suture at 6 months. Two patients had partial loss of reduction (≥2 mm) after 3 to 6 months secondary to osteolysis at the clavicular button site. Conclusion. Arthroscopic fixation using the TightRope device for acute AC joint dislocation achieves satisfactory outcome.

Arthroscopic reconstruction of the anterior cruciate ligament using bone-patellar tendon- bone autograft: Experience of the first 100 cases

Purpose. To review the results of patients who underwent arthroscopic reconstruction of the anterior cruciate ligament (ACL) via a single incision technique using a bone-patellar tendon-bone autograft. Methods. Patients with ACL-deficient knees who were symptomatic and wanted to maintain an active lifestyle or continue sporting activities were included. ACL reconstruction using the bone-patellar tendon-bone graft was performed on 100 patients. One-year follow-up was completed in 78 patients who were then reviewed. The mean age of patients reviewed was 26.8 years (range, 21–39 years), of whom 35 (44.9%) were aged between 26 and 30 years. There were 73 men and 5 women (ratio, 14.6:1). Injuries on the right side outnumbered those on the left (44 versus 34). Sports injuries accounted for 66.7% (n=52) of patients, motor vehicle accidents and household injuries accounted for 30.8% (n=24) and 2.6% (n=2), respectively. Results. Excellent and good-to-excellent results were achieved in 7 (9%) and 61 (78.2%) of patients. Residual anterior knee pain (n=18) was the most common complication, followed by difficulty in regaining full range of motion (n=10) and divergence of femoral screw (n=9). Conclusion. This procedure provides consistent and reproducible results in carefully selected patients and allows them an early return to sporting activities with minimal residual morbidity.

Outcome of double bundle anterior cruciate ligament reconstruction using crosspin and aperture fixation.

Background: Double bundle anterior cruciate ligament (DBACL) reconstruction is said to reproduce the native anterior cruciate ligament (ACL) anatomy better than single bundle anterior cruciate ligament, whether it leads to better functional results is debatable. Different fixation methods have been used for DBACL reconstruction, the most common being aperture fixation on tibial side and cortical suspensory fixation on the femoral side. We present the results of DBACL reconstruction technique, wherein on the femoral side anteromedial (AM) bundle is fixed with a crosspin and aperture fixation was done for the posterolateral (PL) bundle. Materials and Methods: Out of 157 isolated ACL injury patients who underwent ACL reconstruction, 100 were included in the prospective study. Arthroscopic DBACL reconstruction was done using ipsilateral hamstring autograft. AM bundle was fixed using Transfix (Arthrex, Naples, FL, USA) on the femoral side and bio interference screw (Arthrex, Naples, FL, USA) on the tibial side. PL bundle was fixed on femoral as well as on tibial side with a biointerference screw. Patients were evaluated using KT-1000 arthrometer, Lysholm score, International Knee Documentation Committee (IKDC) Score and isokinetic muscle strength testing. Methods: Out of 157 isolated ACL injury patients who underwent ACL reconstruction, 100 were included in the prospective study. Arthroscopic DBACL reconstruction was done using ipsilateral hamstring autograft. AM bundle was fixed using Transfix (Arthrex, Naples, FL, USA) on the femoral side and bio interference screw (Arthrex, Naples, FL, USA) on the tibial side. PL bundle was fixed on femoral as well as on tibial side with a biointerference screw. Patients were evaluated using KT-1000 arthrometer, Lysholm score, International Knee Documentation Committee (IKDC) Score and isokinetic muscle strength testing. Results: The KT-1000 results were evaluated using paired t test with the P value set at 0.001. At the end of 1 year, the anteroposterior side to side translation difference (KT-1000 manual maximum) showed mean improvement from 5.1 mm ± 1.5 preoperatively to 1.6 mm ± 1.2 (P < 0.001) postoperatively. The Lysholm score too showed statistically significant (P < 0.001) improvement from 52.4 ± 15.2 (range: 32-76) preoperatively to a postoperative score of 89.1 ± 3.2 (range 67-100). According to the IKDC score 90% patients had normal results (Category A and B). The AM femoral tunnel initial posterior blow out was seen in 4 patients and confluence in the intraarticular part of the femoral tunnels was seen in 6 patients intraoperatively. The quadriceps strength on isokinetic testing had an average deficit of 10.3% while the hamstrings had a 5.2% deficit at the end of 1 year as compared with the normal side. Conclusion: Our study revealed that the DBACL reconstruction using crosspin fixation for AM bundle and aperture fixation for PL bundle on the femoral side resulted in significant improvement in KT 1000, Lysholm and IKDC scores.

A six months old neglected anterior shoulder dislocation managed by closed reduction and Latarjet procedure

A neglected shoulder dislocation is a rarer entity and only few cases are reported in the literature. An anterior dislocation of the shoulder is rarely missed as patients present with limb in abduction and external rotation, an attitude very familiar to orthopaedic surgeon. Occasionally such cases are missed when they present with fracture of proximal humerus or when they receive treatment from unqualified practitioners who commonly practise in rural areas. Owing to very few reports there is paucity of literature and no standard treatment protocol exists for neglected anterior dislocation of the shoulder, though most such chronic cases are managed by open reduction. This case report describes a six months old neglected anterior dislocation with a significant Hill Sachs lesion, which was managed by closed reduction and Latarjet procedure.

Anthropometric and Radiologic Measurements of Coracoid Dimensions and Clinical Implications in an Indian Population

Background: Recurrent shoulder dislocation and anterior instability are most commonly attributed to pathology of the capsulolabral complex with the presence of bony loss at the humeral and glenoid surfaces. Unassessed bone loss has been a cause of failure of primary soft tissue procedures or recurrence of symptoms, despite adequate address of soft tissue pathology. Purpose: To study the anthropometric and radiologic dimensions of the coracoid in relation to glenoid bone loss, its adequacy in filling glenoid defects in an Indian population, and whether the choice of surgical technique (congruent arc vs classical) and graft positioning alters the surgical results. This study also intended to establish whether computed tomography measurements correlate with actual anthropometric measurements. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A total of 64 participants with 108 healthy shoulders were included in this study. Additionally, 100 skeletally mature bone specimens of the scapula were measured to assess glenoid diameter as well as coracoid width and length in 2 perpendicular planes with a humeral subtraction 3-dimensional en face glenoid view. Results: Specimen and participant measurements proved that the congruent arc technique was able to fill up to 50% more glenoid bone loss than the classical technique in an Indian population (mean ± SD, 13.45 ± 6.97 vs 7.96 ± 4.89 mm, respectively), with computed tomography being the best and most accurate modality to study it. The mean difference in the bone block length restoration of the glenoid bony arc was 5.41 ± 2.08 mm. Radii of curvature were congruent in populations of the Indian subcontinent. Conclusion: The congruent arc technique can be performed in an Indian population but with caution and careful presurgical assessment of bone loss. However, adequate coracoid dimension to accommodate the implant for fixation without failure must be ensured, as anthropometry suggests the existence of a subset of the population in whom the graft may have compromised width for accommodating standard implants for fixation.

Practice guidelines for the management of multiligamentous injuries of the knee

Background: Multiligamentous injuries of knee remain a gray area as far as guidelines for management are concerned due to absence of large-scale, prospective controlled trials. This article reviews the recent evidence-based literature and trends in treatment of multiligamentous injuries and establishes the needful protocol, keeping in view the current concepts. Materials and Methods: Two reviewers individually assessed the available data indexed on PubMed and Medline and compiled data on incidence, surgical versus nonsurgical treatment, timing of surgery, and repair versus reconstruction of multiligamentous injury. Results: Evolving trends do not clearly describe treatment, but most studies have shown increasing inclination toward an early, staged/single surgical procedure for multiligamentous injuries involving cruciate and collateral ligaments. Medial complex injuries have shown better results with conservative treatment with surgical reconstruction of concomitant injuries. Conclusion: Multiligamentous injury still remains a gray area due to unavailability of a formal guideline to treatment in the absence of large-scale, blinded prospective controlled trials. Any in multiligamentous injuries any intervention needs to be individualized by the presence of any life- or limb-threatening complication. The risks and guarded prognosis with both surgical and non-surgical modalities of treatment should be explained to patient and relations.

Outcome of repair of chronic tear of the pectoralis major using corkscrew suture anchors by box suture sliding technique

AIM To assess the functional and clinical results of repair of chronic tears of pectoralis major using corkscrew and sliding suture technique. METHODS In this retrospective study, we reviewed the results of pectoralis major repair in 11 chronic cases (> 6 wk) done between September 2011 and December 2014 at our institute. In all cases repair was done by same surgeon using corkscrew suture anchors and box suture sliding technique. At 6 mo, after surgery magnetic resonance imaging was done to see the integrity of the repair. Functional evaluation was done using Penn and ASES scores. Pre and postoperative Isokinetic strength was measured. RESULTS Average follow-up was 48.27 ± 21.0 mo. The Wilcoxon signed rank test was used to evaluate the outcome scores. The average ASES score increased from an average of 54.63 ± 13.0 preoperatively to 95.09 ± 2.60 after surgery at their last follow-up. The average Penn score also increased from 5.72 ± 0.78, 2.81 ± 1.32 and 45.81 ± 1.72 to 9.36 ± 0.80, 8.27 ± 0.90 and 59 ± 1.34 for pain, satisfaction and function respectively. Follow up magnetic resonance imaging (MRI) (at 6 mo) showed continuity and the bulk of pectoralis major muscle in all cases. Average isokinetic strength deficiency in horizontal adduction at 60° was 13.63% ± 6.93% and at 120° was 10.18% ± 4.93% and in flexion at 60° was 10.72% ± 5.08% and at 120° was 6.63% + 3.74%. Results showed that both ASES and Penn score improved significantly (2 tailed P value = 0.0036). CONCLUSION We could conclude from this series that pectoralis major repair even in chronic cases using 5.5 mm corkscrew anchors give excellent functional and cosmetic results. In chronic cases the repairable length of the tendon is not available and sliding suture technique allows for fixation of worn out tendomuscular junction to bone without letting cutting through the muscle.