Orthopaedic Journal of M. P. Chapter https://ojmpc.com/index.php/ojmpc <h4>P-ISSN: <a href="https://portal.issn.org/resource/ISSN/2320-6993">2320-6993</a> | E-ISSN: <a href="https://portal.issn.org/resource/ISSN/2582-7243">2582-7243</a></h4> <p>Orthopaedic Journal of M P Chapter is official publication of M P Chpater of Indian Orthopaedic Association. Orthopaedic Journal of M P Chapter started in 1980 with Dr. P. K. Rai as first editor. Subsequently Dr. H.K.T. Raza, Dr. Alok C Agrawal, Dr. Sunil Rajan, Dr. A. Mukherjee, Dr. Alok C Agrawal and then again Dr. Ashish Gohiya were elected as editor. Currently Dr. Saurabh Jain is editor of this journal. In year 2013 this journal got P-ISSN 2320-6993 and in the year 2020 this journal got E-ISSN 2582-7243. Currently this journal has both print and online versions and it is an open access journal, it is peer revied and there is no processing fee for authors. It was indexed with Index Copernicus with IC value of 71.64. Currently this journal has both print and online versions and it is an open access journal, it is peer revied and there is no processing fee for authors.</p> M P Chpater of Indian Orthopaedic Association en-US Orthopaedic Journal of M. P. Chapter 2320-6993 Orthopaedic Practices In Post Covid Era https://ojmpc.com/index.php/ojmpc/article/view/118 <p>Today, life of every person in this world can be divided into, BC and AC i.e. before corona and after corona. This is the amount of impact the novel corona virus has made, not only in India, but globally. Reasons are many. The novel corona virus is highly contagious, virulent and lethal especially in high risk groups. Since there is no treatment or vaccine available till date, prevention of spread of infection remains the main stay of treatment. This can be accomplished by stopping the spread of infection from the source via droplets or aerosols, which can be done by covering mouth and nose, social distancing, frequent hand washing and regularly disinfecting surfaces.<br>We the Orthopaedic surgeons working as health workers, due to nature of our work are more susceptible and vulnerable. Furthermore, Orthopaedic surgeries are aerosol generating procedures, which make them further more susceptible to infection. Our practise is further complicated by illiterate and reckless patients, untrained and irresponsible staff, deficient, shortage and unavailability of quality control equipment’s, increased financial burden and daily changing irrational government policies. We have already seen our colleagues getting infected and even some have lost their life. Hence, for protecting ourselves, family members and our patients, we need to evolve, develop strategies and modifications, in our life as well as in orthopaedic practises so as to prepare and prevent rather than repair and rent the mis-happening. Further, we do not know as yet what complications and physiological responses will be encountered in post COVID-19 scenario. Hence with minimal current literature available, a balanced, pragmatic approach should be undertaken. <br>Various papers and articles have suggested guidelines, modifications and standard operative procedures to deal with pandemic situation. Planning is the key factor, in addition to the guidelines and standard operative procedures (SOP) as given by health care organisations. We as Orthopaedicians, also need to plan and modify our practices at each level relating to OPD, admission and surgeries, following all the standard precautions at all the times.<br>Patients visit in OPD or hospitals, should be minimized by favouring telemedicine or emails if possible, and favouring consultation by prior appointment only. Try to make definitive diagnosis and final treatment decision at first consultation only. Patient prioritisation in favour of non-operative strategies be emphasized. Referrals and transfers for investigation and radiology especially multiple times should be minimized and must outweigh the potential benefit of intervention, particularly for patients in vulnerable groups. Alternative resources such as written and web-based information should be used maximally. <br>Guard outside the clinic or hospital, can be trained to screen and isolate the suspected patients by taking fever history or by use of thermal screening. In OPD, clinicians should preferably use eye protection shield (face-mask or goggles) and N95 mask which can be re-used again after 5 days of incubation, whereas use of triple layer mask is sufficient for orthopaedic patients attending OPD. Mask dispensers can be installed in OPD and hospitals, so that the no touch mask can be prescribed to the patients coming without mask. The waiting room should be modified to have adequate room ventilation, so that there is at least 1meter distance between the patients allowing limited and restricted patient movement. The risk of infection, in healthcare workers can minimized by use of Personal protective equipment (PPE), which should be used correctly and safely even while donning and doffing. If possible, staff and helpers should work in rota’s so that all are not exposed and you can have a reserve team if needed. In hospitals, surgical workforces are likely to be further depleted, as they might be working in rota in half strength and rest might be reserved, quarantined or isolated, hence in these times, sub-specialty services may be difficult to run. These healthcare workers should be educated, aware and trained so that they change their behaviour in favour of maintaining social distancing, following standard precautions, frequent hand hygiene, refraining touching their eyes, nose, and mouth with potentially contaminated gloved or un-gloved hands, cleaning and disinfection of equipment and environment. If possible, use disposable equipment, if not possible then frequent cleaning and disinfection between each patient, be done. Avoid touching or frequently sanitize contaminated environmental surfaces e.g. door handles and light switches. Television, warnings, banners, disclosures and posters should be installed in OPD’s with instruction to cover nose and mouth, maintaining social distancing and information and other preventive measures which can create awareness among people. Best practices for safely managing health care waste should be followed. Thorough cleaning and disinfection prior, between and after the use of OPD’s as well as the operating theatre facilities should be re-enforced. <br>Dislocations, minor injuries, stab and penetrating non-contaminated wound without neurovascular deficit and minor to moderate abscess can be treated in the emergency department itself without admission. Most paediatric injuries, upper limb fractures and stable lower limb fractures have high rates of union and can be managed non-operatively, recognising that some patients may require late reconstruction. Delayed primary fixation of up to three months following injury may be acceptable if predictable favourable outcomes in delayed surgeries are weighed against the risks of surgeries. Patients with poly-trauma, pelvic, acetabular and hip fractures with major haemorrhage, open fractures, compartment syndrome and exsanguinating injury all require emergent resuscitation and management. Only absolute indication should be taken for surgery, like limb or lifesaving surgery, septic arthritis, prosthetic joint infection, amputations and re-implantation, crush injuries, cauda-equina syndrome, abscess and infections. Joint replacement and ligament reconstruction can be done at a later stage. Plan and facilitate the surgery such that multiple visits of patient to the OT and admission can be avoided. Re-surgery like, flaps, bone grafting, soft tissue reconstruction, skin grafting and amputations can be avoided by proper planning. Non-union, malunion or elective orthopaedic and spinal surgery should be deferred. Emphasize on reducing hospital admission and minimising length of stay by encouraging early discharge or day care surgery, if possible.<br>If surgery is planned, then patients as well as the staff both need to be tested prior, for COVID-19. Isolation prior to surgery will help to reduce transmission further. Surgeries should be planned only when appropriate supportive equipment e.g. ventilators, PPE and intensive care unit beds for post-operative care following surgery are available. Since Orthopaedic surgeries are aerosol-generating procedures use PPE, including gloves, long-sleeved gowns, balaclava, eye protection or face shield and powered air purifier respiratory (PARP) are recommended for all healthcare workers in OT. If PARP is not available then, N95 with goggles and balaclava with additional face shield covering skin to maximum can reduce infection risk. Use of laminar flow, positive pressure, space suits, pulse lavage or powered tools, drills, saw, reamers, suction irrigation reaming and other aerosol generating equipment’s etc is not recommended. Shifting to un-reamed intramedullary nails, hand reamers and hand drills can be helpful. Surgery should be preferentially being done in adequately ventilated room, with negative pressure rooms with minimum of 12 air changes per hour or at least 160 litres/second in facilities with natural ventilation. Surgical theatre capacity is likely to be working with decreased strength, as they are likely to be redeployed to support non-surgical specialties, still then, unnecessary individuals in the room should be avoided. Use of suction with electro-cautery for smoke evacuation is recommended. Use of absorbable sutures, clear visible dressing and removable slabs or splits can reduce patient revisit for suture removal, dressings or cast removal to hospital or clinic and prevent exposure. After surgery, proper donning off of the PPE kit is equally important as proper donning of kit to prevent infection, which needs to be practiced. Post-operative follow-up, dressing, antibiotics should be managed on telemedicine or remote consultations (e.g. telephone or video consultation), so as to avoid their hospital re-visit and face-to-face interaction. Appropriate arrangements to evaluate common post-operative complications at one stop visits be done. Enhanced recovery programmes, targeted video or home based rehabilitation will help in safe and early rehabilitation.<br>Ours is a developing country with limitations and hence we need to use resources judiciously. Proper allocation and optimisation of resources is necessary. One advantage in this time is Ayushman Bharat Yojna, which is world’s largest health insurance scheme fully financed by the government of India, covering 107.4 million poor and vulnerable entitled families for health care hospitalization across public and private empanelled hospitals and involving more than 101 orthopaedic procedures and 12 polytrauma procedures enrolled in this scheme. Testing and treatment of COVID-19 is available for free under this Ayushman Bharat Yojna (scheme). <br>Rest, recuperation and psychological support is equally needed in addition, not only to the surgeon but all the team members. Hence, we Orthopaedic surgeons need to be flexible, dynamic, reactive and collaborative and show leadership in these testing times. Safety of the patients and the staff is foremost important hence conservative or minimal invasion methods with shorter hospital stay and short surgical times should be preferred. We should balance optimum treatment of a patient’s condition against clinical safety and resources. The guidelines are not absolute and are continually evolving and updated; hence we need to be frequently in touch with new updated recommendations via web education and news along with feedback from our patients, till we can resume normalcy approved by the appropriate state health authorities. Possibly a second wave can occur so we must prepare ourselves by strictly following the policies of disinfection of surfaces, regular hand hygiene and social distancing in anticipation. We must seek this time as an experience and opportunity to focus on improving ourselves. </p> Saurabh Jain Copyright (c) 2020 https://creativecommons.org/licenses/by-nc-nd/4.0 2020-12-16 2020-12-16 26 2 49 51 Approach To A Clubfoot Deformity Patient: Ponseti Management https://ojmpc.com/index.php/ojmpc/article/view/119 <p>Clubfoot is among the most common congenital foot deformities, needing correction, which when left untreated can cause severe cosmetic, functional and social issues. Ponseti method has revolutionized the treatment in favour of nonsurgical serial manipulation and casting. Simultaneous correction of cavus, adductus, and varus followed by correction of equinus by percutaneous tenotomy can be achieved in mean 5 weeks. It is based on sound understanding of the functional anatomy of foot (synchronous movements of the tarsal bones at subtalar joint to unlock the deformity) and biological response of young connective tissue and bone to change in direction of mechanical stimuli which can gradually reduce or almost eliminate deformities of clubfeet. This review article describes, approach to a clubfoot patient, its features, classification, assessment, ponseti method of manipulation and casting and errors of treatment and their management. Aim of this review article is to compile the important information pertaining to clubfoot management which will be useful for the basic orthopaedic surgeon in their clinical practice and for post-graduate students.</p> A Ajmera Saurabh Jain Copyright (c) 2020 https://creativecommons.org/licenses/by-nc-nd/4.0 2020-12-16 2020-12-16 26 2 52 64 Outcome Of Postero-Medial Soft Tissue Release In Congenital Talipes Equino Varus https://ojmpc.com/index.php/ojmpc/article/view/120 <p><strong>Background:</strong> Clubfoot is one of the most common congenital orthopaedic anomalies, first described by Hippocrates in the year 400 BC. However, its treatment still continues to challenge the skills of the paediatric orthopedic surgeon as it has a notorious tendency to relapse, irrespective of whether the foot is treated by conservative or operative means.</p> <p><strong>Material &amp; Methods:</strong> This prospective study was conducted at our center from June 2014 to May 2016 in 39 (31 cases) congenital talipes equinovarus deformities treated by single stage posteromedial soft tissue release and the outcome assessment was done by Pirani score and Green, Lloyd- Roberts criteria.</p> <p><strong>Results:</strong> The mean age was 1.7 years. 21 were male and 10 were female. The mean pre-operative Pirani score improved from 4.8± 0.82 to 1.4± 0.86 postoperatively, which was statistically significant (p &lt; 0.05). As per the Green Lloyd-Roberts criteria 13 (37%) feet had excellent results, 13 (37%) feet had good results and 9 (25%) feet had poor results. 6 feet had superficial infection or wound gaping and plaster sore and skin blisters were seen in 4 feet.</p> <p><strong>Conclusion:</strong> Single stage Postero-Medial Soft Tissue Release produces satisfactory results when done at appropriate age as soft tissues are more resilient to correction and the remodeling capacities of the cartilaginous bone are good.</p> Singh V Yadav A Vyas GS Sharma SK Patidar A Mehta R Bhinde S Jain P Copyright (c) 2020 https://creativecommons.org/licenses/by-nc-nd/4.0 2020-12-16 2020-12-16 26 2 65 69 Ponseti Technique In Children With Idiopathic Club Foot Presenting After 1 Year Of Age: A Retrospective Study https://ojmpc.com/index.php/ojmpc/article/view/121 <p><strong>Background:</strong> Ponseti method is accepted as gold standard treatment for idiopathic clubfoot in infants. However, very few studies are available in literature on use of Ponseti method in older children. The aim of this study is to determine the effectiveness of Ponseti technique in the treatment of late presenting congenital idiopathic club foot (CTEV).</p> <p><strong>Material &amp; Methods:</strong> We retrospectively evaluated the results of ponseti method of serial casting in 23 patients with 32 clubfeet (15 males and 8 females) presenting after the walking age by using Pirani score. Quantitative variables were expressed as mean ± standard deviation and compared between initial and last follow-up scores using the paired t-test.</p> <p><strong>Results:</strong> The mean age at presentation was 3.4 (range 1 to 15) years and mean follow up was 14.2 (range 6 to 21) months. The mean pre-correction Pirani score improved from 4.51 (range 2.5 to 6) to 0.55 (range 0 to 1) after treatment, respectively which was statistically significant (p &lt; .001). In 95% of the feet, satisfactory correction of the deformity was achieved. The mean number of casts applied was 9.2 (range 6 to 16).</p> <p><strong>Conclusion:</strong> The Ponseti technique is an effective method for the management of idiopathic clubfoot, even in older children up to 15 years of age.</p> Singh VB Gawande J Lakhtakia PK Copyright (c) 2020 https://creativecommons.org/licenses/by-nc-nd/4.0 2020-12-16 2020-12-16 26 2 70 74 Philos Plate For Fixation Of Supracondylar Dome Osteotomy https://ojmpc.com/index.php/ojmpc/article/view/122 <p><strong>Background:</strong> Various corrective osteotomies and different modes of fixation have been described to correct genu valgum deformity. We evaluated the results of dome osteotomy for genu valgum which was stabilized with proximal humerus internal locking system (PHILOS) plate.</p> <p><strong>Material &amp; Methods:</strong> 39 cases of Genu Valgum deformity in 24 patients treated by dome osteotomy and fixed with PHILOS plate (15 patients had bilateral deformities and 9 patients had unilateral deformity) were evaluated clinically (intermalleolar distance and tibio-femoral angle) and radiologically (tibio-femoral angle).</p> <p><strong>Results:</strong> Pre-operative mean intermalleolar distance, clinical tibio-femoral angle and radiological tibio-femoral angle pre-operatively improved from 17.5 cm (range 11 to 24), 19.250 (range 140 to 240) and 20.90 (range 150 to 260) to postoperative 2.25 cm (range 0 to 4 cm), 7.750 (range 40 to 100) and 8.950 (range 50 to 110) respectively. The mean pre-operative LDFA was 74.850 (range 670 to 830) whereas post-operative mean value was 86.90 (range 830 to 900). The mean Bostman knee score improved significantly from 20.8 (range 18 to 22) to 29.1 (range 27 to 30). 2 patients (2 limbs) had good score i.e. between 20 to 27, while rest all the patients had excellent score between 28 to 30. Improvement in intermalleolar distance, tibio-femoral angle and LDFA was statistically significant (P&lt; 0.001)</p> <p><strong>Conclusion:</strong> Dome osteotomy with PHILOS plate fixation is reasonable cost effective, easy, available and viable option for treatment of genu valgum with excellent short to midterm results and without complication as seen by wedge osteotomy.</p> Mohindra M Gautam VK Meena A Gupta N Desai J Saikia S Copyright (c) 2020 https://creativecommons.org/licenses/by-nc-nd/4.0 2020-12-16 2020-12-16 26 2 75 80 A Comparative Study Of Efficacy Of Intra-lesional Dry Needling, Platelet Rich Plasma And Corticosteroid In Lateral Epicondylitis https://ojmpc.com/index.php/ojmpc/article/view/123 <p><strong>Background:</strong> Lateral epicondylitis (LE) or Tennis Elbow (TE) is a common cause of musculoskeletal pain involving common extensor origin of the forearm with various treatment options available ranging from conservative, intra-lesional injection to surgical.</p> <p><strong>Material &amp; Methods:</strong> 147 cases of recalcitrant Lateral Epicondylitis treated with intra-lesional dry needling (n=50), platelet rich plasma (PRP) (n=49) or corticosteroid (n=48) injections were compared for VAS and DASH score.</p> <p><strong>Results:</strong> The mean pre-injection VAS score in needling, PRP and steroid group improved from 67.48, 68.00 and 67.39 to 38.50, 36.37 and 36.85 at 24 weeks’ post-injection respectively which was statistically significant (p&lt;0.05). The mean pre-injection DASH score in needling, PRP and steroid group improved from 57.72, 56.96 and 56.19 to 32.04, 31.37 and 31.17 24 weeks’ post-injection respectively, which was statistically significant with paired t test p value &lt; 0.05.</p> <p><strong>Conclusion:</strong> All three procedures, intra-lesional dry needling, PRP and corticosteroid were equally effective in treating lateral epicondylitis, with improvement in both the functional as well as pain scores in long term, but immediate post procedural relief was found better in the corticosteroid group.</p> Jain P Maheshwari M Jain RK Prajapati R Copyright (c) 2020 https://creativecommons.org/licenses/by-nc-nd/4.0 2020-12-16 2020-12-16 26 2 81 85 Functional Outcome of Comminuted Clavicle Fracture Treated With LCP: A Prospective Study https://ojmpc.com/index.php/ojmpc/article/view/124 <p><strong>Background:</strong> Fractures of clavicle are very common injuries, which have been traditionally treated non-operatively but has shown increased rate of malunion and nonunion. Operative fixation of clavicle fracture prevents these complications. Hence to validate this we evaluated the outcome of locking compression plate in treatment of comminuted middle third clavicular fractures.</p> <p><strong>Material &amp; Methods:</strong> 25 cases of closed comminuted middle third clavicular fracture between 18 to 60 years were treated surgically with open reduction and internal fixation with locking compression plate and were assessed radiologically for union and functionally by Constant and Muller score.</p> <p><strong>Results:</strong> All 25 patients of comminuted midshaft clavicle fracture with mean age 28.3 years united in mean duration of 13.2 weeks. As per Constant and Muller score, 18 patients (72%) had excellent functional outcome, good in 5 patients (20%), fair in 2 patients (8%) and none of the patients had poor outcome. 3 patients developed hypertrophic skin scar, 2 patients had plate prominence and in 1 patient superficial infection occurred.</p> <p><strong>Conclusion:</strong> Mid third clavicle fractures treated by locking plate achieve reliable bony union and provides a more rigid stable fixation which does not require immobilization for longer periods. It results in earlier return to functional outcome and improved patient and surgeon results, with decreased rates of nonunion and malunion.</p> Bhinde S Jain P Singh V Copyright (c) 2020 https://creativecommons.org/licenses/by-nc-nd/4.0 2020-12-16 2020-12-16 26 2 86 89 Etiology Of Avascular Necrosis Of Femoral Head In Population Of Malwa Region In Madhya Pradesh https://ojmpc.com/index.php/ojmpc/article/view/125 <p><strong>Background:</strong> Osteonecrosis is characterized by bone cell death following, decrease in blood supply to the bone due to traumatic or non-traumatic cause. We evaluated the etiology of osteonecrosis of femoral head in population of Malwa region of Madhya Pradesh.</p> <p><strong>Material and Methods:</strong> This longitudinal study was conducted from January 2018 to Jan 2020 in patients diagnosed with avascular necrosis of femoral head, which were evaluated, examined and investigated to know the etiology of the disease.</p> <p><strong>Results:</strong> 70 cases with mean age of 39 years (55 males and 15 females) were included. Bilateral involvement was seen in 20 (29%) cases, whereas 50 (71%) cases had unilateral involvement. Idiopathic AVN was most common cause of the osteonecrosis as seen in 27 (39%) cases followed by steroid induced AVN in 12 (17%), post traumatic in 13 (19%) cases, alcohol induced in 8 cases (11%), both alcohol and steroid induced in 2 (3%) cases and sickle cell anaemia was seen in 8 (11%) cases.</p> <p><strong>Conclusion:</strong> Our results showed that most common cause of osteonecrosis of femoral head in population of Malwa region of Madhya Pradesh is idiopathic followed by trauma, steroid induced and then alcoholism or sickle cell anemia. Most commonly affected people are in age group of 26-40 years with male preponderance. Appearance of disease is more, unilateral as compared to bilateral.</p> Choudhari P Deshpande M Jain N Prajapati R Copyright (c) 2020 https://creativecommons.org/licenses/by-nc-nd/4.0 2020-12-16 2020-12-16 26 2 90 94 Tillaux Fracture In Adult: A Case Report https://ojmpc.com/index.php/ojmpc/article/view/126 <p>We report a rare case of Tillaux fracture of the ankle in a 36-year-old man. He sustained the injury in a football tackle and presented to us with pain and swelling of the left ankle. After preliminary X-rays, a CT scan was done which showed a Tillaux type fracture which is a rare injury after epiphyseal fusion. The ankle was treated with open reduction and internal fixation with screws and plaster for 6 weeks. At 3 months the patient had no pain in the ankle and able to mobilize full weight bearing on that side.</p> Syed T Storey P Rocha R Kocheta A Singhai S Copyright (c) 2020 https://creativecommons.org/licenses/by-nc-nd/4.0 2020-12-16 2020-12-16 26 2 95 98 Loss Of Swallowing Reflex Lasting For 42 Days After Anterior Cervical Decompression And Fixation Done For Traumatic Cervical Spine Injury: A Case Report https://ojmpc.com/index.php/ojmpc/article/view/127 <p>Post-operative dysphagia is a common complication seen after anterior approach to cervical spine, which is usually mild and recovers well over a period of four weeks. We present a rare case of severe dysphagia with inability to swallow, lasting 6 weeks after anterior cervical decompression and fixation, in a case of post traumatic cervical spine injury, which was treated conservatively. The causes, types and management strategies are discussed with aim to familiarize the surgeon with the complication.</p> Gawande J Verma PK Mishra C Lakhtakia PK Copyright (c) 2020 https://creativecommons.org/licenses/by-nc-nd/4.0 2020-12-16 2020-12-16 26 2 99 103