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   Table of Contents - Current issue
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January-June 2022
Volume 10 | Issue 1
Page Nos. 1-48

Online since Thursday, November 24, 2022

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ORIGINAL ARTICLES  

Blood flow restriction therapy to restore quadriceps wasting persistent after anterior cruciate ligament reconstruction p. 1
Hemant Jain, Shubham Agarwal, Kishore Raichandani, Arun Vaishy
DOI:10.4103/JOASP.JOASP_58_21  
INTRODUCTION: Anterior cruciate ligament (ACL) is the most commonly injured ligament in the knee that requires surgical intervention. After ACL reconstruction, it has been reported that quadriceps wasting can persist for years even after complete rehabilitation and aggressive physiotherapy. Blood flow restriction (BFR) therapy is proposed to induce muscle growth and improve strength in chronic muscle atrophy. But the data on the efficacy of BFR therapy are controversial and lacking in the existing literature. AIMS/OBJECTIVES: In this study, we focus on identifying the patients having chronic quadriceps wasting after ACL reconstruction and intervene to restore the quadriceps wasting using BFR therapy. MATERIALS AND METHODS: All the participants had unilateral reconstruction of ACL tear >1 year back and completed the standard postoperative rehabilitation protocol but had >10% of difference in quadriceps thickness in the involved limb as compared to contra-lateral limb measured by ultrasonography. They were then proceeded further with BFR therapy and were re-examined after 6 weeks of BFR therapy. RESULTS: It was observed that 64% of the participants had persistent quadriceps muscle atrophy even after 1 year of completing standard post-rehabilitation protocol after ACL reconstruction with more than 10% deficit. The quadriceps thickness observed after the BFR therapy increased by 10 ± 7% at one-third of femur length from knee joint and 16.6 ± 4% at two-thirds of femur length in the involved extremity but did not show any change in uninvolved extremity. Post-training quadriceps femoris symmetry index also increased in the involved extremity compared to the baseline (87 ± 5% pre-procedure to 96 ± 4% post-procedure, P <0.01). CONCLUSION: This study concludes that BFR therapy after knee surgery may be a viable modality for the treatment of residual atrophy of quadriceps after years of ACLR. This can be used in patients who require extra assistance in resisting muscle atrophy or building muscle strength.
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Functional outcome of proximal tibia fractures (Shatzker’s type V and VI) fixed with open reduction and internal fixation with dual plate osteosynthesis p. 6
Jagdish Singh Charan, Vishal Singh, Avinash Gundavarapu, Shashi Kumar H K
DOI:10.4103/JOASP.JOASP_4_22  
INTRODUCTION: Tibial plateau fractures occur when the proximal tibia bears an excessive axial load and commonly occur in road Traffic accidents and sports injuries. It constitutes 1% of all orthopedic fractures and 8% of fractures in the elderly. The treatment of tibial plateau fractures is continuously evolving. Various techniques have emerged over the last few decades. Many people have studied these fractures and their management modalities and no single consensus has been reached regarding the superiority of any modality. MATERIALS AND METHODS: Following institutional scientific and ethical committee approval, this study was undertaken in the patients with proximal tibia fractures (Shatzker’s type V and VI) reporting to the Department of Orthopedics at Apollo Hospital Bannerghatta Road, Bengaluru during the study period. This was a prospective observational study. A total of 30 consecutive patients were followed up as per the inclusion criteria. They were followed up for 6 months. RESULTS: There were a total of 30 cases of proximal tibia Shatzker type V and VI fractures followed up during the study period. The demographics constituted 73.33% males and 26.67% females with an age range of 23–64 years and a mean age of 41.66 years. The most common mode of injury was road traffic accidents amounting to 73.33% of fractures. The majority of patients were in the age group less than 40 years and men were involved more than women. The functional outcome measured via the Modified Rasmussen Score showed good to excellent results in 93.33% of cases in the postop period at 6 months. CONCLUSION: This study shows fixation with dual anatomical locking plate and screws for proximal tibia Shatzker type V and VI fractures gives good to excellent functional outcomes in the early postop period.
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Does a complete loss of articular cartilage of patella warrant a patellar resurfacing when combined with patellar denervation in primary total knee arthroplasty? Results of a randomized prospective trial p. 13
Shakti Swaroop, Shivji Prajapati, Smarajit Patnaik, Akshaya Sahoo, Swati Patnaik
DOI:10.4103/JOASP.JOASP_16_22  
BACKGROUND: Complete cartilage loss and incomplete cartilage loss of the patella both have been reported to give good results with both resurfacing and nonresurfacing. We have tried to combine patellar denervation (PD) with the procedure and to compare the results of resurfacing or not resurfacing patella in posterior stabilized (PS) total knee arthroplasty (TKA). MATERIALS AND METHODS: A prospective single-center randomized prospective trial was done, including 68 patients undergoing unilateral TKA who were divided into patellar nonresurfacing (PNR) and patellar resurfacing (PR) groups. The patients underwent PS TKA. A blinded observer followed up the patients for 2 years, and visual analog scale at stairs (VAS-stairs), Knee Society Score (KSS), and range of motion were noted. RESULTS: The difference in VAS-stairs score from the baseline to the end of 1 month was significantly improved in the PR group, PNR = 4.4 ± 0.8 and PR = 5.5 ± 0.6, P = 0.0001. The difference in VAS-stairs score was significantly improved in the PR group again at 6 months, PNR = 5.9 ± 0.8 and PR = 7.1 ± 0.7, P = 0.0001. A comparison within the two groups at 1-month postop resulted in significantly better KSS 1 scores in the PR group (Chi-square value = 43.2, P < 0.001). When KSS 2 was compared between the two groups, we found no statistical significance in their preoperative scores and at postoperative time intervals of 1 month, 6 months, 1 year, and 2 years. CONCLUSIONS: Resurfacing patella with PD in an Outerbridge grade 4 patella yields better pain relief on stairs within the first 6 months. Also, resurfacing patella with PD in an Outerbridge grade 4 patella does not improve the functional outcomes at 2 years, and further long-term follow-up needs to be reported in the future.
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Ulnar nerve injury post Cubitus varus correction by lateral closing wedge osteotomy: Lessons learnt p. 19
Nikhil Challawar, Shubham Siddheshwar Zade, Vishwesh D Chudasama
DOI:10.4103/JOASP.JOASP_7_21  
BACKGROUND: Supracondylar fractures of the humerus are the most common elbow injuries in skeletally immature children between 5 and 15 years of age. Managed conservatively or treated inadequately these fractures result in malunion-producing Cubitus varus deformity. MATERIALS AND METHODS: We retrospectively studied a 9-year-old male patient who presented to us with cubitus varus deformity owing to the conservative management of previous Supracondylar humerus fracture. Patient was operated by Lateral closing wedge osteotomy. Pre operative and post operative assessment was done clinically and with the help of radiographs. RESULT: Patient developed ulnar nerve palsy owing to the overcorrection of deformity which ultimately required ulnar nerve release and anterior transposition. Complete functional recovery was achieved 6 months post index surgery. CONCLUSION: Lateral closing wedge osteotomy provides an effective and relatively simple way for correcting cubitus varus deformity yet can result in ulnar nerve palsy in the event of overcorrection.
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Effect of ultrasound-guided pes anserine bursa injection on knee scores: A comparative study p. 24
Mahesh Choudhary, Richa , Shefali Gupta, Anil Kumar Gaur
DOI:10.4103/JOASP.JOASP_19_21  
INTRODUCTION: Pes anserine bursitis is a common clinical finding in patients with knee osteoarthritis. This causes significant disability and functional hindrance. Management includes medication, physiotherapy, and local steroid injection. Though many studies have been done in relation to the management of pes anserine bursitis, a comparative study for two techniques of giving local steroid injection is the first of its kind. AIM: The aim of this study was to compare the effect of ultrasound-guided versus blind corticosteroid injection in pes anserine bursa. MATERIALS AND METHODS: A total of 84 patients (comprising 100 injection limbs) attending the outpatient department of Physical Medicine and Rehabilitation at a tertiary care center were selected. Detailed demographic data were collected and each patient was examined clinically. American College of Radiology clinical classification criteria for knee osteoarthritis were used to diagnose knee osteoarthritis. All the patients were injected with methylprednisolone 80 mg (2 mL), half of them under ultrasound guidance and the other half by clinical judgment. All the study participants were evaluated using a visual analog scale (VAS) score and knee injury and osteoarthritis outcome score (KOOS), pre-procedure and post-procedure at 1 week, 1 month, and 3 months, to assess pain and the functional improvement using paired t test for intra-group and unpaired t test for inter-group comparison. RESULTS: Both the groups with comparable baseline assessment showed a significant improvement in the VAS score after the injection at 1 week, 1 month, and 3 months duration. Also, there was a significant improvement in the functional status in patients of both groups as indicated by the KOOS after the injection at 1 week, 1 month, and 3 months duration. However, there was no statistically significant difference in the outcome measured on VAS score with the two techniques. This implies that both techniques led to comparable VAS outcomes statistically. However, the functional outcome as indicated by KOOS score was significantly higher in the group injected under ultrasound guidance. CONCLUSION: KOOS assessment indicated that ultrasound-guided injection technique is superior to the blind technique. On the basis of the VAS score, no statistically significant difference was found in outcomes using the two different techniques.
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Corona mortis—A south Indian cadaveric study p. 30
Vetrivel Chezian Sengodan, Marimuthu Sivagnanam, Ranjithkumar Selvaraj, Surendhar Rathinasamy
DOI:10.4103/JOASP.JOASP_15_22  
BACKGROUND: “Corona mortis” is an abnormal arterial or venous connection between the obturator and the inferior epigastric or external iliac arteries or veins, which can cause torrential bleeding leading to the death of the individual. It may be encountered during acetabular surgeries, hernia surgeries, and gynecological procedures. The purpose of our study is to determine the incidence and variations of corona mortis in the south Indian population. MATERIALS AND METHODS: Forty hemipelves of 20 cadavers were in our study group. With the cadaver in the supine position, dissection was done using Stoppa’s approach. After dissection, data about the presence or absence of corona mortis, the nature of corona mortis (arterial/venous/arteriovenous variant), and the distance between corona mortis and pubic symphysis were collected. RESULTS: Corona mortis was present in 33 (82.5%) hemipelves. It was bilateral in 13 (65%) cadavers. It was present in all the female cadavers on both sides, whereas it was present in 21 (75%) out of the 28 male hemipelves. Venous variant was present in 26 (78.78%), followed by arteriovenous variant in five (15.16%), and arterial variant in two (6.06%) hemipelves. The mean distance of corona mortis from pubic symphysis was 55.65 mm. CONCLUSIONS: The incidence of corona mortis was 82.5% in our study. Our study was dominated by the venous variant compared with the arterial and arteriovenous variants. Corona mortis had gender variations: it was present in all the females in our study, whereas it was not so among males as per our study.
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Comparison between fluoroscopy-guided radiofrequency ablation of genicular nerves and intra-articular injection of steroid in relieving pain and improving function among candidates of knee replacement surgery: A randomized controlled trial p. 35
Margaret Chabungbam, Akoijam J Singh, Longjam N Singh, Chandrakant Pilania, Sreejith Choorapra, Tripti Swami, Kanti Rajkumari
DOI:10.4103/JOASP.JOASP_20_22  
BACKGROUND: Osteoarthritis (OA) is the second most common rheumatologic problem in India. Prevalence of OA in India is 22–39% and knee OA alone contributes to 80% of OA burden. Despite the immense impact of this disease, very few effective non-surgical treatment options are available. The present study aims to compare fluoroscopy-guided radiofrequency ablation (RFA) of genicular nerves with intra-articular (IA) injection of methylprednisolone acetate in relieving pain and improving function in Grade 3 and 4 OA of knee. MATERIALS AND METHODS: A randomized controlled trial was done in the Department of Physical Medicine and Rehabilitation, Regional Institute of Medical Sciences for a period of 1 year on 76 patients with knee OA Kellgren–Lawrence (KL) grade 3 and 4. They were divided into two groups: study and control groups. The study group underwent RFA of genicular nerves of knee, whereas the control group received IA knee injection with methylprednisolone acetate 80 mg. Assessments of Visual Analog Scale (VAS) and Western Ontario McMaster University Osteoarthritis Index (WOMAC) were done at 1, 4, and 12 weeks. RESULTS: The study group showed a decrease in VAS score from 6.84 ± 0.638 at baseline to 2.61 ± 0.718 at 1 week and 2.97 ± 0.885 at 12 weeks. The control group showed a decrease in VAS score from 5.82 ± 0.563 at baseline to 2.18 ± 0.393 at 1 week and 4.03 ± 0.545 at 12 weeks. WOMAC function score improved from 44.79 ± 7.185 at baseline to 26.79 ± 4.375 at 12 weeks in the RFA group, whereas in the steroid group it improved from 41.26 ± 5.310 at baseline 24.89 ± 3.431 at 12 weeks (P<0.05). CONCLUSION: RFA of genicular nerve can be used as an effective modality for providing cost-effective and long-standing pain relief in patients with KL Grade 3 and 4 OA knee who are unable to undergo knee replacement surgery.
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CASE REPORTS Top

Klippel–Trénaunay Syndrome (KTS or KT) is a rare clinical syndrome p. 40
Mahendra Kumar Gosaliya, Jitendra Aloria, Rajesh Goel, Dinesh Kumar Bairwa, Mohit Maheshwari, Sachin Pachori
DOI:10.4103/JOASP.JOASP_53_21  
Klippel Trenaunay syndrome is a congenital illness that affects capillary abnormalities, varicosities, and musculoskeletal hypertrophy. That condition incorporates a range of pathology, comprising haemorrhage, venous thromboembolism, embolic consequences, with, in exceptional situations, appendage elongation, which may necessitate surgery. Venous aberrations are divided into the following but never pass the centreline. Nevertheless, we encountered a scenario of an 8-year-old kid that manifested having varicosity of vasculature or deformation of the right lower extremity, as well as cavernous haemangiomas distributed everywhere in his chest, back, gluteal area, and legs since new. Due to the involvement of neurofibromatosis, several paravertebral soft tissue masses and bladder hypertrophy were also seen. In clinical practise, the coexistence of KTS with neurofibromatosis is uncommon.
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Tracheoesophageal fistula in a case of Pott’s spine: Unusual presentation amid COVID pandemic p. 44
Anita T Anokar, Samruddhi Dhanaji Chougale, Medha Bargaje, Ram B Deoskar, Ashish Dhotre, Amarnath Prasad, Avani Rajput
DOI:10.4103/JOASP.JOASP_18_22  
Acquired tracheoesophageal fistula (TOF) is a rare entity. We present a case of a 49-year male, non-smoker, with no known comorbidities admitted with acute respiratory symptoms and desaturation to a COVID hospital during the first peak of the pandemic. Initial workup showed all raised inflammatory markers, deranged liver function, and poor ejection fraction of 20%. COVID RT-PCR was negative. Early high-resolution computed tomography done as COVID suspect, peaked up the tracheoesophageal fistula with aspiration pneumonia. On magnetic resonance imaging spine, paradiscal, prevertebral involvement at the D1-D2 level suggesting Pott’s spine, with mediastinal irregular cavity formation, ruptured in trachea and esophagus. A detailed history revealed neck pain for 3 months and increased cough while swallowing for 10 days. Neck pain was not evaluated due to fear of COVID and lockdown. On esophagoscopy, anterior wall of the upper esophagus had fistula with smooth clear margins. Diagnosis of tubercular TOF confirmed on endotracheal inflamed fistulous track secretions. The patient was treated conservatively with initial nasogastric tube feeding and antitubercular treatment achieving complete resolution.
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