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   Table of Contents - Current issue
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July-December 2020
Volume 6 | Issue 2
Page Nos. 93-165

Online since Thursday, December 31, 2020

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EDITORIAL  

Future directions in deformity correction p. 93
Peter H Thaller
DOI:10.4103/2455-3719.305858  
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ORIGINAL ARTICLES Top

Analysis of different osteotomies used in hallux valgus: A systematic review Highly accessed article p. 96
Sayed Mohamed Elgoyoushi, Mohamed A Omar, Sherif Dabash, Ahmed M Thabet, Yasser Elbatrawy
DOI:10.4103/2455-3719.305859  
Background: A variety of metatarsal (MT) osteotomies have been described for the treatment of hallux valgus (HV) deformity. Many of these techniques were abandoned throughout the years. Because no one procedure has shown to be capable of correcting all types of HV deformities, clinicians have adopted treatment algorithms. Objective: This work aims to review different methods of, as well as indications and contraindications for osteotomies to treat HV in the literature, and provide cumulative data about the intermediate to long-term management of HV. Patients and Methods: An online search was performed using the Medline database on PubMed, Google Scholar, and Science Direct from 2000 to 2019. All English language published studies describing osteotomies in HV were identified and analyzed. Results: Twenty-eight studies were identified from 2000 to 2019. Seventeen of the studies (60.7%) were prospective, whereas 5 studies (17.9%) were retrospective. The most common procedure used were Chevron (10 studies), followed by Reverdin (4 studies), Bosch (4 studies), Magnan (3 studies), Akin (2 studies), and Scarf osteotomy (2 studies). Simple, effective, rapid, inexpensive (SERI), distal linear MT osteotomy, reverse L-shape osteotomy, subcapital osteotomy combined with lateral soft-tissue release, and modified Mitchel were represented by 1 study each. Conclusion: The management of HV involves several procedures. The choice of each patient's procedure depends on the degree and reducibility of deformity, the digital formula used, presence or absence of symptoms from lateral rays. It also depends on the training of the surgeon and the learning curve in his career. Interest in percutaneous surgery has been increasing for both patients and surgeons. The most commonly used procedures were Chevron in 10 studies. Complications occurred in 82.1% of studies, and only 5 (17.9%) had no complications. These studies used SERI, Chevron, Reverdin in one study and Akin in two studies. Chevron was the most commonly used procedure with less complications.
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Curved “K” wires: The covert villain in circular external fixators p. 107
Charles Brian Howard, Eitay Farkash
DOI:10.4103/jllr.jllr_19_20  
Context: Complications associated with “K” wires used in circular external fixators include intraoperative nerve and vessel damage, loss of tension, high rates of pin tract infection, and wire breakage. Aims: To investigate if insertion of “K” wire with a curvature is responsible, in part, for these complications. Settings and Design: This paper is a theoretical analysis of the forces and consequences of a tensioned curved wire on the bone, experimental measurement of the heat produced on inserting a curved compared to a straight (with a guide) wire into a bovine rib bone. Subjects and Methods: 1.8 mm K wires were drilled into two bovine rib bones using a battery-powered hand drill. The temperatures reached were recorded with a thermal camera. Statistical Analysis Used: Student's t-test. Results: (1) A tensioned curved wire would cut through the bone. (2) higher temperatures were reached when inserting a K wire in a curved manner than with a guide. (3) Drilling a curved wire initiates metal fatigue. It is theoretically possible to reach the forces needed to correct the curvature on the wire by “pinching” the wire near its insertion into the bone with the index and thumb of the non-drilling hand, but these forces far exceed the pressure pain threshold. In addition, the constantly changing force and direction would make the necessary proprioceptive changes almost impossible to follow. Conclusions: Theoretically and experimentally a curve on a K wire will increase vessel/nerve damage, thermal necrosis, pin tract infection, loosening, and loss of wire tension. Present-day method of “pinching” the end of the K wire to prevent curvature is probably inefficient and K wires should be inserted using a guide.
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Reference values of the femur and tibia mechanical axes and angles in the sagittal plane, determined on the basis of three-dimensional modeling p. 116
Leonid Nikolaevich Solomin, Alexander Igorevitch Utekhin, Victor A Vilenskiy
DOI:10.4103/2455-3719.305861  
Background: The reference values of the anatomical, mechanical lines and angles of the femur and tibia in the frontal plane have been sufficiently studied. At the same time, the data concerning the mechanical axis and angles in the sagittal plane are rather contradictory. Aims and objectives. The aim of this study was to determine the 3D reference values of the mechanical axes and angles of the femur and tibia in the sagittal plane. Materials and Methods: The study included data of 23 adult volunteers for whom computer tomography (CT) was done. The inclusion criteria were: absence of the deformity confirmed by long-leg films (using known reference lines and angles (RLA) assessment), absence of torsional deformity confirmed by CT and extended position of the limb. Results: It was found that the mechanical axis of the lower limb in the sagittal plane divides the distal joint line of the femur into two segments: anteriorly - 43.8+7.9%, posteriorly - 56.2+7.9%. The proximal joint line of the tibia, correspondingly, is divided into 23.3+8.8% anteriorly and 76.7+8.8% posteriorly. The found values of mechanical angles were the following: mechanical Posterior Proximal Femoral Angle (mPPFA) - 84.7 + 8.8 °, mechanical Posterior Distal Femoral Angle (mPDFA) - 81.1 + 3.95 °, mechanical Posterior Proximal Tibial Angle (mPPTA) - 81.6 + 2.8 °, mechanical Anterior Distal Tibial Angle (mADTA) - 79.9 + 2.98°. Conclusion: The obtained data on the mechanical axis of the lower limb for the sagittal plane can be used both for deformity assessing, planning and estimating the accuracy of deformity correction.
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Defining the anatomic axis joint center distance and anatomic axis joint center ratio of the distal femur in the coronal plane p. 121
Nando Ferreira, Andries Johannes Cornelissen, Marilize Burger, Aaron Kumar Saini
DOI:10.4103/2455-3719.305862  
Background: The aim of this radiographic study was to define the anatomic axis joint center distance (aJCD) and anatomic axis joint center ratio (aJCR) of the distal femur in the coronal plane for skeletally mature individuals. Methods: A cross-sectional radiographic study was conducted to calculate the horizontal distances between the anatomical axis and the center of the knee at the level of the intercondylar notch and the joint line. Ratios relating these points to the width of the femur were then calculated. Results: A total of 164 radiographs were included: 91 male (55.5%) and 73 female patients (44.5%) with a mean age of 44.9 ± 18.1 years, with 79 right (48.2%) and 85 left (51.8%). The mean intercondylar width was 75.6 ± 6.6 mm, the mean aJCD at the notch was 3.6 ± 1.8 mm, the mean aJCD at the joint line was 4.9 ± 1.8 mm, the mean aJCR at the notch was 45.2 ± 2.4, and the mean aJCR at the joint line was 43.5 ± 2.4. The intercondylar width was significantly different (P < 0.001) between males (79.5 ± 4.8 mm) and females (70.6 ± 5.0 mm). A significant difference between the aJCR at the notch (P = 0.004) and the aJCR at the joint line (P = 0.003) was observed in males and females. No differences between the aJCD at the notch and/or aJCD at the joint line were observed between males versus females, left versus right, and those younger versus those older than 65 years. Conclusion: This is the first objective description of the aJCR of the distal femur in the coronal plane. This ratio can be used to aid the planning and execution of distal femoral deformity correction, retrograde femoral nailing, and total knee arthroplasty. Level of Evidence: IV
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Acute ulnar osteotomy versus gradual distraction by external fixator to correct missed monteggia type 1 fracture-dislocation; A comparative study Highly accessed article p. 126
Abdelhakim Ezzat Marei, Mahmoud A El-Rosasy
DOI:10.4103/2455-3719.305864  
Background: Monteggia fracture-dislocations are complex injuries. These injuries, especially neglected ones, remain a challenge for orthopedic surgeons. The aim of this study is to compare the results of acute and gradual ulnar lengthening osteotomies in treating chronic Monteggia fractures in children. Patients and Methods: The study includes two groups of patients, treated at our institution in the period from April 2014 to September 2018. The first group (Group A) included nine patients who were treated by an overcorrective ulnar osteotomy with acute lengthening with bone grafting. The second group (B) includes 11 children who were treated by Ilizarov distraction osteogenesis for differential lengthening of forearm bones. There were 14 boys and 6 girls. The left elbow was involved in five patients and the right elbow 15 patients. All fractures were classified as Bado type I with anterior radial head dislocation. The average age at the time of surgery was 7 years and 4 months. Results: The mean interval from the injury to surgical interference was 8.6 months. There was a significant improvement of the elbow range of motion and Mayo elbow performance score. In group B, the mean external fixation time was 9.7 weeks (range from 9 to 15 weeks). The mean total treatment time was 12.3 weeks (ranged from 12 to 16 weeks). Superficial pin-tract infection occurred in all cases and was managed without further sequelae. Conclusions: Both approaches yielded equally good results. The open surgery approach entails a more invasive procedure, but more convenient to the patient and no arduous postoperative follow-up is needed. On the contrary, differential lengthening of forearm bones is a percutaneous procedure with the application of Ilizarov principles in a controlled biological manner; with no graft materials needed. Both techniques effectively reduced the radial head.
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One-week accelerated PONSETI method in the management of idiopathic clubfeet p. 131
Yasser Ali Elbatrawy
DOI:10.4103/2455-3719.305871  
Purpose: This study aims to evaluate the results of the 1-week accelerated PONSETI method in the management of idiopathic clubfeet implemented by Ahmad and Aker in which manipulations, five castings, and Achilles tendon tenotomy are done in a week. Methods: We studied 15 patients with 22 moderate-to-severe congenital idiopathic clubfeet treated by the 1-week accelerated PONSETI method. The method involves the manipulation of the deformed foot and the first casting in the 1st day, with the second, third, fourth, and fifth castings (if the foot is not fully corrected, additional casting is done till reaching fully initial correction) in the 4th, 5th, 6th, and 7th day postmanipulation. After removal of the last cast, Achilles tenotomy was performed with subsequent 3-week casting in all patients. The Pirani scores were used for comparing the results before starting the treatment and after removal of the final cast. Results: We had 15 patients (7 bilateral and 8 unilateral) of clubfoot. The average age at the treatment was 15.2 days (range = 1–90 days). All patients, who had moderate-to-severe congenital idiopathic clubfeet with a Pirani score of 4–6 (mean = 5.61), underwent the 1-week accelerated PONSETI technique. After removal of the 3-week cast, the scores were 0 for all cases (except 3 feet with Pirani score of 0.5), which was an indication for deformity correction to achieve acceptable feet in all patients without the experience of any short-term complications. Conclusions: Our study of the 1-week accelerated PONSETI technique was found to be safe and effective for the initial correction of severe idiopathic clubfoot deformity in children less than 3 months of age and confirmed the results reported by Ahmad and Aker's study but still needs more follow-up of the patients to confirm the results on the long term.
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An external fixator and limited release in the treatment of neglected, recurrent, relapsed and resistant talipes equinovarus deformity of the feet p. 137
Aditya K Agrawal, Manish R Shah, Malkesh D Shah, Neel H Patel, Takshay Gandhi, Sarvang M Desai, Jagdish J Patwa
DOI:10.4103/2455-3719.305868  
Introduction: The existence of resistant and neglected talipes equinovarus deformity of the foot is still prevalent in many parts of the world, serving as a challenge to an orthopedic surgeon to convert this complex deformity into a normal functioning foot. Our study aims to evaluate the results of our mid-path treatment in neglected, resistant, relapsed, and rigid clubfoot. Our treatment protocol's objectiveswere (1) the foot must become plantigrade at the end of the treatment. (2) Patient must be able to wear normal shoes. Patients and Methods: Our study included 35 feet belonging to 29 patients (six cases of bilateral congenital talipes equinovarus) aged between 2 years and 8 years with an average age of 4.8 ± 2.5 years. Our protocol includes soft-tissue release and frame fixation using a mini external fixator at the same time. After frame removal, an above-knee cast was given for 3 weeks. The average follow-up period was 3.8 ± 1.2 years. Results: We achieved excellent results in 30 cases, 3 cases had a fair result, and 2 cases had a poor result using Pirani score. Two cases had superficial infection and two cases required additional procedures. The average fixator duration was 10 weeks. Conclusion: Our mid-path protocol for managing neglected and rigid talipes equinocavovarus deformity has excellent outcomes with satisfactory patient compliance to the treatment with added advantages of rapid correction and decreased pain during and reduced external fixator duration. Level of Evidence: Level IV.
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Infected regenerate in ilizarov surgery p. 142
Barakat Sayed El-Alfy, Mohamed Fahmy Abdelaziz, Abdallah Ibrahim Elazanki
DOI:10.4103/jllr.jllr_16_20  
Background: The regenerate is the newborn of the distraction process, and it passes by many changes during its growth and maturation. Many complications can take place at the regenerate site. The aim of this study is to highlight infection as a possible complication that may affect the regenerate during bone lengthening. Patients and Methods: In this study, we present three cases who were complicated by infection of the regenerate. The diagnosis and management were described in details. Results: The predisposing factors for this complication may be patient-related or technically related factors. The isolated organisms were Escherichia coli, Staphylococcus epidermidis, and Staphylococcus aureus. Infection was controlled in all cases. The desired length was achieved in two cases, and one case was left with residual shortening of 2 cm. Conclusion: Infection of the regenerate is a rare but serious complication. A high index of suspicion is required for its diagnosis, and few options are available for its management.
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Evaluating the accuracy of the orthopedic eye p. 147
Gerhard Thiart, Marilize Burger, Nando Ferreira
DOI:10.4103/jllr.jllr_20_20  
Purpose: Orthopedic surgeries are still dependent on the human factor and more specifically the human eye to gauge the end result. Thus, the planned result and the final surgical result may differ at times. Our hypothesis was that the human eye would not be able to distinguish any angulational difference <3° from the planned trajectory. Materials and Methods: A cross-sectional study in the form of an online survey was conducted. Five clinical scenarios (each with seven variations) that require judgment of angles were recreated. Thirty-five yes or no statements were tested. Results were collected and analyzed statistically. Results: Seventy-four respondents completed the survey. The mean responded age was 42.8 years (standard deviation [SD]: 11.2, range: 28–80). The average of years in practice as a doctor (but not yet a specialist) was 8.3 years (SD: 2.1, range: 4–11), and the median number of years after qualifying as an orthopedic surgeon was 9.0 years (interquartile range, 5.0–17.5). The highest frequencies of inaccuracies occurred around the 1° error margin for all scenarios. Although specialists appeared to score higher (66.6 ± 7.3%) than trainees (62.9 ± 11.4%), this difference was not significantly different (P = 0.107). Conclusion: Orthopedic surgeons can distinguish alignment differences of <3° if the reference framework is perfectly orthogonal and parallel. If the reference framework is rhomboid (skewed) then gauging angles of <3 degrees off it, especially if the angle being gauged is on the same side as one of the acute angles formed by the reference framework.
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Limb lengthening in down syndrome p. 153
Christopher A Iobst
DOI:10.4103/2455-3719.305872  
Introduction: The average life expectancy for Down syndrome patients has markedly improved. Musculoskeletal disorders occur in 20%–27% of patients with Down syndrome, with hip or knee instability among the most common presentations. Leg length discrepancy has rarely been reported in Down syndrome but can occur as the result of previous lower extremity surgery. This case report presents our experience with the first documented use of an intramedullary lengthening nail to correct a 4.5 cm iatrogenic leg length discrepancy in a skeletally mature Down syndrome patient. Materials and Methods: A single patient surgically treated for leg length discrepancy was followed over a 1-year period and retrospectively reviewed. Results: An 17-year-old male with Down syndrome presented with a 4.5 cm leg length discrepancy secondary to a previously attempted hip fusion. He had been treated with a shoe lift but had difficulty walking with the lift and resorted to toe walking whenever the lift was not being used. His mother, who was his full-time caregiver, was interested in surgical options for permanently correcting his discrepancy. After long discussions over multiple visits covering the risks and benefits of the various choices, the decision to proceed with lengthening of the short limb using a retrograde femoral intramedullary lengthening nail was made. Distraction osteogenesis of 4.5 cm with full consolidation was achieved in this patient without complications. He was able to return to full independent ambulation without a lift by 4 months. Conclusion: Limb lengthening requires a detailed postoperative protocol that may appear to be difficult for a Down syndrome patient with cognitive developmental delay to manage. However, this report documents that if the patient has a reliable caregiver and close postoperative monitoring is maintained, a successful outcome is possible. This represents the first published case of limb lengthening in a Down syndrome patient.
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CASE REPORTS Top

Saphenous nerve entrapment during bone transport in an ilizarov frame p. 159
Prateek Behera, Vishal Champawat, Vivek Tiwari, Vikas Gupta
DOI:10.4103/jllr.jllr_13_20  
Ilizarov fixator system plays an important role in modern orthopedics due to its multiple uses. Complications related to its use are well documented and have been classified by many authors in the past. In this case report, we describe a rare complication of saphenous nerve dysfunction secondary to it getting entrapped in its course by a transfixation wire during the process of bone transport. The diagnosis and management of this complication has been discussed with an intention to make the surgeons aware of similar situation in their own practice.
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Adult pseudo-tumor-like subacute osteomyelitis p. 163
Teka Maher, Zaier Akram Yassine, Ben Hnia Majdi, Ben GHozlen Hazem, Abid Faouzi
DOI:10.4103/2455-3719.305874  
Hematogenous osteomyelitis in adults is rare, and its subacute form is exceptional after the age of 20. It' is usually clinically latent which explains the difficulty of the diagnosis. The first differential diagnosis is bone tumors. It is known for its poor clinical and biological presentation despite a rich radiological aspect. Magnetic resonance imaging (MRI) is the examination of choice to confirm the diagnosis. The main differential diagnosis are primary and secondary bone tumors. The treatment is based on surgery and precise antibiotic therapy. Our patient is 52 years old who had pain in his left thigh, a discrete inflammatory syndrome without fever. He underwent standard X-ray, scintigraphy, and MRI, leading to finding an intraosseous lytic process with rupture of the cortical bone. The diagnosis of staphylococcal osteomyelitis was confirmed thanks to surgical biopsy and bacteriological sample, and his treatment was completed with specific antibiotic therapy.
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