Senthil Nathan Sambandam

Critical analysis of outcome measures used in the assessment of carpal tunnel syndrome.

Clinicians and researchers are confounded by the various outcome measures used for the assessment of carpal tunnel syndrome (CTS). In this study, we critically analysed the conceptual framework, validity, reliability, responsiveness and appropriateness of some of the commonly used CTS outcome measures. Initially, we conducted an extensive literature search to identify all of the outcome measures used in the assessment of CTS patients, which revealed six different carpal tunnel outcome measures [Boston Carpal Tunnel Questionnaire (BCTQ), Michigan Hand Outcome Questionnaire (MHQ), Disability of Arm, Shoulder and Hand (DASH), Patient Evaluation Measure (PEM), clinical rating scale (Historical-Objective (Hi-Ob) scale) and Upper Extremity Functional Scale (UEFS)]. We analysed the construction framework, development process, validation process, reliability, internal consistency (IC), responsiveness and limitations of each of these outcome measures. Our analysis reveals that BCTQ, MHQ and PEM have comprehensive frameworks, good validity, reliability and responsiveness both in the hands of the developers, as well as independent researchers. The UEFS and Hi-Ob scale need validation and reliability testing by independent researchers. Region-specific measures like DASH have good frameworks and, hence, a potential role in the assessment of CTS but they require more validation in exclusive carpal tunnel patients.RésuméLes cliniciens et les chercheurs sont submergés par le nombre de mesures utilisées pour l’évaluation du syndrome du canal carpien (CTS). Nous avons réalisé pour cette étude une étude critique de ces différentes mesures au travers de la littérature. Six différentes mesures sont utilisées : le questionnaire de Boston (BCTQ), le questionnaire de Michigan (MHQ), le score DASH, l’évaluation PEM, le questionnaire Hi-Ob scale et la mesure UEFS. Nous avons étudié sur tous les plans ces différents scores. Les mesures de type BCTQ, MHQ et PEM sont fidèles et utiles aussi bien pour les chirurgiens que pour les chercheurs. Les mesures UEFS et Hi-Ob scale nécessitent une validation par des examinateurs indépendants, la technique DASH nécessite une validation pour les patients présentant une lésion isolée du canal carpien.

“WhatsApp”ening in orthopedic care: a concise report from a 300-bedded tertiary care teaching center

Abstract Smartphones have emerged as essential tools providing assistance in patient care, monitoring, rehabilitation, communication, diagnosis, teaching, research and reference. Among innumerable communication apps, WhatsApp has been widely popular and cost effective. The aim of our study was to report the impact of introduction of a smartphone app “WhatsApp” as an intradepartmental communication tool on (1) awareness of patient-related information, (2) efficiency of the handover process and (3) duration of traditional morning handovers among orthopedic residents in a 300-bedded tertiary care teaching center. Written handovers and paging used for communication at our center led to occasional inefficiencies among residents. Widespread use, low cost, availability and double password protection (phone lock and WhatsApp lock) made WhatsApp’s group conversation feature an ideal tool for intradepartmental patient-related communication. Twenty-five consecutive admissions before and after WhatsApp (BW, AW) were included in the study. Eight orthopedic residents attempted fifty randomly arranged questions based on the twenty-five patients in each study period. A null hypothesis that introduction of WhatsApp group would neither increase the awareness of patient-related information nor improve the efficiency of the handovers among residents was assumed. A significant improvement observed in scores obtained by residents in the AW group led to rejection of the null hypothesis. The residents also reported swifter and efficient handovers after the introduction of WhatsApp. Our results indicate that the introduction of a smartphone app “WhatsApp” as an intradepartmental communication tool can bring about an improvement in patient-related awareness, communication and handovers among orthopedic residents.

Rotator cuff tears: An evidence based approach

Lesions of the rotator cuff (RC) are a common occurrence affecting millions of people across all parts of the globe. RC tears are also rampantly prevalent with an age-dependent increase in numbers. Other associated factors include a history of trauma, limb dominance, contralateral shoulder, smoking-status, hypercholesterolemia, posture and occupational dispositions. The challenge lies in early diagnosis since a high proportion of patients are asymptomatic. Pain and decreasing shoulder power and function should alert the heedful practitioner in recognizing promptly the onset or aggravation of existing RC tears. Partial-thickness tears (PTT) can be bursal-sided or articular-sided tears. Over the course of time, PTT enlarge and propagate into full-thickness tears (FTT) and develop distinct chronic pathological changes due to muscle retraction, fatty infiltration and muscle atrophy. These lead to a reduction in tendon elasticity and viability. Eventually, the glenohumeral joint experiences a series of degenerative alterations - cuff tear arthropathy. To avert this, a vigilant clinician must utilize and corroborate clinical skill and radiological findings to identify tear progression. Modern radio-diagnostic means of ultrasonography and magnetic resonance imaging provide excellent visualization of structural details and are crucial in determining further course of action for these patients. Physical therapy along with activity modifications, anti-inflammatory and analgesic medications form the pillars of nonoperative treatment. Elderly patients with minimal functional demands can be managed conservatively and reassessed at frequent intervals. Regular monitoring helps in isolating patients who require surgical interventions. Early surgery should be considered in younger, active and symptomatic, healthy patients. In addition to being cost-effective, this helps in providing a functional shoulder with a stable cuff. An easily reproducible technique of maximal strength and sturdiness should by chosen among the armamentarium of the shoulder surgeon. Grade 1 PTTs do well with debridement while more severe lesions mandate repair either by trans-tendon technique or repair following conversion into FTT. Early repair of repairable FTT can avoid appearance and progression of disability and weakness. The choice of surgery varies from surgeon-to-surgeon with arthroscopy taking the lead in the current scenario. The double-row repairs have an edge over the single-row technique in some patients especially those with massive tears. Stronger, cost-effective and improved functional scores can be obtained by the former. Both early and delayed postoperative rehabilitation programmes have led to comparable outcomes. Guarded results may be anticipated in patients in extremes of age, presence of comorbidities and severe tear patters. Overall, satisfactory results are obtained with timely diagnosis and execution of the appropriate treatment modality.

Reliability of radiological classifications used in Legg-Calve-Perthes disease.

Radiological assessment is a valuable tool in the assessment, management and prognostication of Perthes disease. Radiological assessment, however, is not an easy task and all classification systems used in Perthes disease have some degree of interrater and intrarater variabilities. In the past, there were some isolated studies to find the reliability of the classifications used in Perthes disease. In this study, we comprehensively studied three most commonly used radiological classifications (Salter–Thompson, lateral pillar and Catterall). We had 44 patients’ radiographs (anteroposterior and lateral) taken in the fragmentation stage, and two experienced observers assessed and classified the radiographs on two separate occasions. In this study, we found that the average interrater reliability of the Salter–Thompson, lateral pillar and Catterall classifications was 0.163 (0.08–0.236), 0.722 (0.581–0.824) and 0.433 (0.280–0.546), respectively. The intrarater reliability was 0.313 and 0.699 for the Salter–Thompson, 0.707 and 0.658 for the lateral pillar and 0.38 and 0.577 for the Catterall classifications. Further, we tried to determine the possible reason for the low reliability associated with the Catterall classification. We think that the quantitative method of lateral pillar has better intrarater and interrater reliabilities than other classification systems, and the reliability of the Catterall classification can be significantly improved if some radiological parameters such as metaphyseal reaction and identification of the junction of involved to uninvolved region can be optimized.

Extended trochanteric osteotomy: current concepts review

BackgroundRevision total hip arthroplasty is a technically demanding procedure which has gained importance for more than two decades. It was a nightmare for revision surgeons during its initial years of inception before the advent of extended trochanteric osteotomy (ETO). This technique gains access to the femoral medullary canal without compromising the bone stock and aids removal of primary implant and cement mantle without further damaging the parent bone. Like any other surgery, ETO does have certain limitations and complications as reported by various authors. Though it has been routinely used by revision surgeons, thorough knowledge of technical details of ETO is still lacking. So this review article is aimed at addressing the indications, surgical procedure, fixation technique, implant selection and complication of ETO which has been presented over a period of years by various authors.MethodsWe searched in the most commonly used portals like MEDLINE (PubMed) and Google scholar using appropriate terminologies for the literature regarding the various preoperative, intraoperative and postoperative clinical scenarios in which revision surgeons utilized ETO.Results and conclusionETO is an important tool in the revision surgeon’s armamentarium and can be used in variety of clinical scenarios and for various intraoperative needs and goals. Awareness about biomechanics of ETO, indications, implants selection, fixation techniques and complications is paramount for good intraoperative and postoperative outcome. ETO by posterior approach continues to be a work horse approach for most revision surgeons all over the world.

Comparison of Soap and Antibiotic Solutions for Irrigation of Lower-Limb Open Fracture Wounds

To The Editor: We would like to comment on the article entitled, “Comparison of Soap and Antibiotic Solutions for Irrigation of Lower-Limb Open Fracture Wounds. A Prospective, Randomized Study” (2005;87:1415-22), by Anglen. First, we would like to congratulate the author for this excellent prospective, randomized study. The author even stratified the confounding variables, such as the grade of open injury, before randomizing. Hence, we think that this article provides important scientific evidence regarding the wound irrigation of open fractures. However, we would like to ask the author to clarify some areas in the article so that readers will acquire even more valuable information. The study compared patients who had been randomized to irrigation with either a bacitracin solution (group B) or a castile soap solution (group C) and demonstrated that there was no significant difference between the groups with regard to most of the variables that can possibly contribute to poor wound-healing. The author also compared the cohort of patients who had poor wound-healing in group B with the cohort of patients who …

Extra-articular deformities in arthritic knees-a grueling challenge for arthroplasty surgeons: An evidence-based update

Critical to the success of a total knee arthroplasty (TKA) is the anatomical alignment. This may appear as a challenge in an extra-articular deformity (EAD) that may be inherent in certain people or result from fracture malunion, congenital disorders, nutritional, metabolic and infective causes. This appraisal aimed at providing the reader with an up-todate overview of the research carried out on, and existent evidence of EAD correction while planning a TKA. We reviewed the current English literature on TKA in extra-articular knee deformities. Among the published data, a common initial approach of mandatory clinical and radiological assessment emerges as an obligatory step while handling cases with EAD. While several methods of managing the deformity and arthritis have been described, a broad division into intra-articular and extra-articular means can be deciphered. The relatively old-school, yet reliable thought process of extra-articular correction allows an all-inclusive restoration of alignment with the inherent complications related to the necessary osteotomy. A cohort of younger and more venturesome surgeons seem inclined towards performing navigated, intra-articular correction for mild to moderate and sometimes, severe deformities. The crux of the matter lies is obtaining a well-balanced knee without violating the all-important cruciates. Restoring the patient’s ambulatory status seems sooner with the intra-articular methods which are also more precise in determining the axes and while removing minimum bone. Greatest satisfaction is accomplished in those with less grotesque, rotationallyaligned knees while meticulously balancing soft-tissues and encouraging earlier weightbearing.

Rationale of Cruciate Retaining Design in Rheumatoid Arthritis: A Review of Clinical Analysis and its Role in Rheumatoid Arthritis

Background: Over the years, proponents of total knee designs (cruciate retaining and posterior stabilised) have conducted several long-term studies to claim the potential of these designs in several subsets of patients. Total knee arthroplasty (TKA) in patients with rheumatoid arthritis has also been one such domain where numerous studies were conducted in the past. A general perception among majority of arthroplasty surgeons is that, posterior stabilised (PS) is the implanted design of choice among patients with Rheumatoid arthritis (RA). However, with the available literature there is a significant disparity related to the selection of implants in patients with rheumatoid RA. In this review of literature, an attempt is made to identify the clinical performance and role of one such implant design, the cruciate retaining (CR) prosthesis in rheumatoid arthritis. Method: The review was conducted after a series of advanced search in the following medical databases; Pub med, Biomed central, Cochrane and Google scholar for articles related to long term follow up studies of cruciate retaining total knee arthroplasty in rheumatoid arthritis using the keywords cruciate retaining prosthesis, total knee arthroplasty, rheumatoid arthritis. Results: The available data demonstrate that the CR design is attributed with an excellent long term survivorship and functional outcome even in follow up studies up to twenty-five years. Conclusion: The advantages of using a CR design are long term survivorship, controlled femoral roll back and preservation of bone stock. Thus, the data gathered in this review lead to a consideration that the CR design is an implant design on par with PS design in patients with RA.

Total Knee Arthroplasty In Patients With Parkinson's Disease- A Critical Analysis of Available Evidence

Background: In this era of modern medicine, there is an increase in life expectancy and thereby an ageing population. Among this group one of the most common neurological disorder is Parkinson disease and one of the most common operation done in elderly population is a total joint arthroplasty. But total joint arthroplasty in Parkinson disease is a relatively uncommon entity. There is sparse literature available with regards to total knee arthroplasty (TKA) in Parkinson disease. This review focusses on the necessity, complications and previous experiences on TKA in PD based on the literature available. Method: The review was conducted after a series of advanced search in the following medical databases; Pub med, Biomed central, Cochrane and Google scholar for articles related to total knee replacement in patients with Parkinson’s disease. The following keywords were used; Total knee arthroplasty, Parkinson’s disease, Hoehn and Yahr, Flexion Contracture. Results: The review indicates that the functional outcome is comparable to that of controls in immediate post-operative phase, one year and three-year phase, but the long term functional outcome seems to deteriorate significantly. Conclusion: Total knee arthroplasty can serve as an effective tool in alleviating pain in short term as well as long term periods, whereas the functional outcome seems to deteriorate post operatively on a long-term basis. Nevertheless, TKA in PD is a challenging situation, thereby necessitating a holistic approach with the efforts from various specialists needed at each stage to ensure a successful operation.