Ramesh Kumar Sen

Management of femoral head osteonecrosis: Current concepts

Osteonecrosis of femoral head (ONFH) is a disabling condition of young individuals with ill-defined etiology and pathogenesis. Remains untreated, about 70-80% of the patients progress to secondary hip arthritis. Both operative and nonoperative treatments have been described with variable success rate. Early diagnosis and treatment is the key for success in preserving the hip joint. Once femoral head collapses (>2 mm) or if there is secondary degeneration, hip conservation procedures become ineffective and arthroplasty remains the only better option. We reviewed 157 studies that evaluate different treatment modalities of ONFH and then a final consensus on treatment was made.

Quality of life following total hip arthroplasty in patients with acetabular fractures, previously managed by open reduction and internal fixation.

Purpose Total hip replacement (THR) is one of the most successful and cost-effective surgical procedures and remains the treatment of choice for long-term pain relief and restoration of function for patients with diseased or damaged hips. Acetabular fractures managed either conservatively or operatively by fixation tend to present later with secondary joint changes that require THR. In this study we evaluated the functional outcome and quality of life achieved by such patients. Methods Our study was carried out as a retrospective trial by recruiting patients who underwent THR from June 2006 to May 2012. A total of 32 patients were included with a mean age of 46.08 years ranging from (25–65) years. We evaluated the quality of life in the patients using scoring techniques of Short Musculoskeletal Functional Assessment (SMFA) and the 12-Item Short Form Health Survey (SF-12). Functional outcome was assessed using Harris Hip Score (HHS). Results The mean HHS of the patients was 84.3 with a range from 56 to 100. The SMFA averaged 13.3. The SF-12 score averaged 49.1. The correlation of the HHS with SF-12 was positive (p = 0.001) while with SMFA there was a negative correlation (p = 0.001). Conclusion From this study it is inferred that the functional outcome of THR and quality of life in patients who had acetabular fractures and were initially managed by open reduction and internal fixation is good.

Management of neglected acetabular fractures

Abstract Management of neglected acetabular fractures is a difficult task. Osteosynthesis in such cases may not be an ideal solution because of the femoral head damage due to pressure by the fractured acetabular edge, avascular necrosis, difficulty in mobilizing the fragments due to callus formation, difficulty in indirect reduction of the fracture fragments and macerated acetabular fragments all contributing to inadequate fracture reduction. Majority of such fractures are now treated with total hip replacement. While treating such fractures with THR, problems associated with neglected acetabular fractures such as fracture non-union, hip dislocation, protrusio, cavitary bone defect or peripheral bone defect must be considered. 3D computed tomography scan provides a clear view about the acetabular and periacetabular bony anatomy. Impaction grafting and antiprotrusio cage or ring with a cemented acetabular cup can address most of the hip protrusio and cavitary bone defects. Segmental bone defect needs cortical strut-bone graft fixation and subsequent implantation of a cemented or uncemented acetabular cup implantation. Fracture non-union needs approximate reduction and fixation with plates followed by bone grafting and implantation of an acetabular cup. Despite these efforts, the outcome of THR in neglected acetabular fracture is considerable worse than after conventional hip replacement.

Awareness of osteoporosis in postmenopausal Indian women: An evaluation of Osteoporosis Health Belief Scale

Context: The level of awareness about osteoporosis in postmenopausal women who are the common sufferers. Aims: This study aims to evaluate the level of awareness in postmenopausal women using the Osteoporosis Health Belief Scale (OHBS). Settings and Design: Osteoporosis has emerged as a common health problem in geriatric population. A proactive role needs to be played for preventing its consequences. Before initiating any preventive measures, an evaluation of awareness level of the target population is necessary. The questionnaire-based study design was used for this study. Subjects and Methods: A questionnaire (OHBS)-based study in 100 postmenopausal women in Chandigarh was conducted. The bone mineral density (BMD) was measured in each case by dual energy X-ray absorptiometry. Height, weight, and body mass index (BMI) of the participants were noted. Statistical Analysis Used: Statistical analysis was conducted to evaluate any correlation between the various components of the OHBS and the BMD. Results: No statistically significant difference was noted in the seven component parameters of OHBS among the normal, osteopenic, and osteoporotic women suggesting that the health belief regarding susceptibility is not much different between the three groups of the study population. A statistically significant difference between the mean BMI of normal and osteoporotic population was noted. Conclusions: The results show that there is a great deficit in the awareness level of postmenopausal Indian women regarding osteoporosis. Most of the women were unaware of the condition and the means to prevent it. The study emphasizes that health care professionals have lot of ground to cover to decrease the incidence of osteoporosis and its associated health problem.

Nonvascularized fibular grafting in nonunion of femoral neck fracture: A systematic review

Nonunion of femoral neck fractures following primary fixation and neglected femoral neck fracture in young adults is a challenging task. Every effort should be directed toward hip joint salvage in these patients. Among different available options of hip salvage, nonvascularized fibular graft (NVFG) osteosynthesis is simple, easy to perform, and a successful technique. In this review, the available literature on NVFG in neglected and nonunion femoral neck fractures has been analyzed. After review of 15 articles on NVFG, the average nonunion rate was estimated to be 7.86% (range 0–31%). Six articles that evaluated the preoperative and postoperative osteonecrosis reported improvement in 50% patients. The clinical and/or functional outcome was good to excellent in 56–96% patients following fibular osteosynthesis. Few complications such as coxa vara deformity, limb shortening, and intraarticular penetration of the graft or hardware have been reported. However, there are minimal donor site morbidities such as mild ankle pain, transient loss of toe flexors and extensors and transient lateral popliteal nerve palsy.

Focus on pelvis and acetabulum

et al. [1] discuss the specific characteristics of pelvic non-union and malunion. They collected the data of ten series between 2 and 204 patients. Pain, leg length discrepancy and instability are the predominant symptoms. They pre-sent a three-stage procedure for surgical correction, possi-ble complications and results. Although outcome is unpre-dictable, operative treatment is mostly the only way to improve function.Veerappa et al. [2] zoom in on neglected acetabular frac-tures. In order to decide on the optimal treatment, a thor-ough preoperative analysis of the situation is necessary. Hip dislocation, protrusion, cavitary bone defect and non-union may be present. Open reduction and internal fixation may not be the ideal solution due to the severe damage on the femoral head. Treatment may differ from conservative to total hip arthroplasty. To secure solid cup implantation, bone grafting and anti-protrusio cup implantation may be necessary. Outcome will be considerably worse than after conventional hip replacement.Two articles concentrate on pelvic fractures in the elderly. In their comprehensive article, Wagner et al. [3] review the characteristics of fragility fractures of the sacrum and present the typical distribution of bone den-sity in the sacrum of elderly persons. As a consequence, the morphology of sacral fractures in the elderly is con-sistent, but stability varies from stable to highly unstable. When there is suspicion of a sacral lesion, conventional radiographs must be completed with CT imaging and MRI. Wagner et al. give an overview of possible treatment alter-natives and discuss their advantages and limitations.Dietz et al. [4] present a small but alarming series of fragility fractures of the pelvis with hemodynamic insta-bility. Although seldom, arterial bleeding after pubic rami fractures may occur and there must be a high index of sus-picion in the elderly patient, who suffered a pubic rami Fractures of the pelvic ring and acetabulum remain to be a major challenge. There are diverse reasons for this. Pel-vic and acetabular lesions are relatively seldom, and there is a long learning curve for the orthopedic trauma surgeon. The pelvic ring, especially the innominate bone, is a com-plex three-dimensional structure. Analysis of injuries of this large osteoligamentar construct is demanding. Classi-fication of pelvic and acetabular lesions is also difficult; it requires a thorough assessment of conventional radiographs and CT images with multiplanar reconstructions. Finally, surgery of the pelvis and acetabulum is dangerous, as vital neurovascular structures pass near to the fractures.It therefore is understandable yet problematic that sur-geons delay the decision to operate or not on these lesions. This has several unfavorable consequences. The outcome is worse when pelvic fractures are operated on later than 3 weeks after the accident. In vertically unstable pelvic ring lesions, it becomes very difficult to correct the vertical dis-placement. Also in acetabular injuries, precise reduction in displaced fracture fragments is hard when performed late. Letournel impressively demonstrated in his very large series that delayed surgery of acetabular fractures is connected with more complications and poor long-term outcome.This “focus on” issue deals with late surgery and revi-sion surgery of pelvis and acetabular injuries. Tripathy

Modified Stoppa approach for acetabulum fracture: a review

Fracture acetabulum is a grave injury and a challenge for orthopedic surgeons. Anterior and posterior approaches have been described for fixation of acetabulum fractures. The modified Stoppa approach is considered an alternate to anterior approach, which provides access to pelvis from inside the cavity. The purpose of this article is to review the available literature on use of the modified Stoppa approach in acetabulum fractures. The available data suggest that modified Stoppa approach is useful in anterior acetabulum fractures and some posterior acetabulum fractures, especially where buttressing of medial wall is required.