Aims: Treatment options for proximal humeral fractures are not very clear, specially in osteoporotic bones. Non operative treatment if on one hand leads to unpredicted and poor outcomes, the operative treatment on the other hand leads to... more
Aims: Treatment options for proximal humeral fractures are not very clear, specially in osteoporotic bones. Non operative treatment if on one hand leads to unpredicted and poor outcomes, the operative treatment on the other hand leads to devascularization of fractured fragments and implant failure leading to unacceptable results. Newer interlocking plates, which are applied with minimum soft tissue stripping of fractured fragments and better fixation abilities seems a promising alternative. We present our experience with such plates. Patients and Methods: Over a period of two years 2002 and 2003, we used 50 plates to treat Neer’s two and three parts and surgical neck of humerus fractures. We reviewed our clinical results with PHILOS plates, which is in interlocking plate. Average age was 34 (24–82). 21 Male and 29 Females. We followed them clinically and radiologically for healing. The shoulder function was assesses with DASH scoring system. The DASH system questionnaire was filled by patients before the fracture and after healing of the fractures. We used a regimen of progressive rehabilitation of shoulder from immediate post operative period. All the complications including union issues, shoulder function, wound problems, nerve injuries, infection and implant failure were noted. Two different techniques were used to fix the fracture with the plate. Statistical analysis was performed on the data collected through DASH questionnaires along with multivariate and univariate analysis and t-tests. Results: We were able to follow all the patients who filled the pre fracture and post healing DASH system questioner. X-rays and clinical findings were available for all the patients in the study. All the patients united with average length of 6 weeks (5–12 weeks). All the fractures united. There were no deep infections; however, two patients had to have a week of oral antibiotics for superficial wound infection. There were no permanent nerve injuries. Eight patients had transient axillary nerve paresis, which resolved after 10–15 days. Patient satisfaction with the procedure was high. 48 % of patients showed a rise in DASH scores after the fracture healing, indicating decrease shoulder function. This was statistically analysed and failed to reach any significance p=0.867. There was no difference between the two techniques in terms of complications and union rates. Conclusions: PHILOS interlocking plates in our study showed 100% union rate with no or minimal complications and preservation of shoulder function. They are technically not difficult to apply and allow immediate post operative mobilization. Hence we recommend their use in primary fixation of proximal humerus fractures.
Research Interests:
Research Interests: Decision Making, Polysaccharides, Peer Review, Medicine, Irish medical history, and 13 moreHumans, England and Wales, Pulmonary Embolism, Anticoagulants, Aspirin, Arthroplasty, Lower limb, Lower Extremity, Total Hip, Total Knee Arthroplasty, Outcome measure, Venous Thrombosis, and Medical and Health Sciences
Research Interests: Orthodontics and Medicine
Research Interests:
Research Interests:
Rotating-hinge knee prostheses have low survivorship and high complications except in primary arthroplasties in elderly patients. We retrospectively reviewed 142 single third-generation design, rotating hinge prostheses (11 primary... more
Rotating-hinge knee prostheses have low survivorship and high complications except in primary arthroplasties in elderly patients. We retrospectively reviewed 142 single third-generation design, rotating hinge prostheses (11 primary procedures and 131 revisions) at 57months follow up. Implant survival was 73 %. Successful two-stage reimplantation for prosthetic infection was 78.4% but new infection rate was 22%. The tibial component was durable while the femoral component was problematic. We observed only one patellar maltracking and no polyethylene wear. A third generation rotating-hinge arthroplasty reconstruction was reliable in complex problems. Outcomes in primary situations were excellent. Complications were the rule rather than the exception in revisions. With timely intervention, attention to soft tissue coverage, and realistic expectations, complications were contained and functional benefits were appreciable.
Research Interests:
Research Interests:
Treatment options for arthrofibrosis following total knee arthroplasty include manipulation under anesthesia, open or arthroscopic arthrolysis, and revision surgery to correct identifiable problems. We propose preoperative low-dose... more
Treatment options for arthrofibrosis following total knee arthroplasty include manipulation under anesthesia, open or arthroscopic arthrolysis, and revision surgery to correct identifiable problems. We propose preoperative low-dose irradiation and Constrained Condylar or Rotating-hinge revision for severe, idiopathic arthrofibrosis. Irradiation may decrease fibro-osseous proliferation while constrained implants allow femoral shortening and release of contracted collateral ligaments. Fourteen patients underwent fifteen procedures for a mean overall motion of 46° and flexion contracture of 30°. One patient had worsening range of motion while thirteen patients had 57° mean gain in range of motion (range 5°-90°). Flexion contractures decreased by a mean of 28°. There were no significant complications at a mean follow up of 34 months (range 24 to 74 months).
Research Interests:
Research Interests:
Research Interests:
Introduction: Traditionally the fixation of choice as recommended by the AO ASIF group for transverse fractures of the Olecranon and the Patella is the tension band wiring technique. The concept of tension band wiring is based on the fact... more
Introduction: Traditionally the fixation of choice as recommended by the AO ASIF group for transverse fractures of the Olecranon and the Patella is the tension band wiring technique. The concept of tension band wiring is based on the fact that the distractive force applied to one surface of the bone will result in compression on the opposite articular surface. Clinical outcomes of TBW are not equivocal. It is associated with significant morbidity such as non union, failure of fixation, especially in osteoporotic bone and infection which sometimes leads to amputation. Often a second procedure for removal of prominent metal work is required. In our biomechanical study we investigated this concept as we believe that the forces generated by TBW construct do not generate significant compressive forces required for healing of fracture. Materials and Methods: We used 4th generation composite bones (Sawbones ® , Malmoe, Sweden.). These bone analogues have been validated to closely simulate human bone characteristics for fracture toughness, tensile strength, compressive strength, fatigue crack resistance and implant subsidence. The advantage of using 4th generation composite bone model is that it provides uniformity which is not achievable in cadaveric studies. Two different bone models representative of Olecranon and patella were used. Transverse fractures were created in the bones and fixed with TBW technique as described in A.O. manual. Two 0.062-inch Kirschner wires and figure of eight configuration of 18G Stainless steel wire with single knot technique was used. Micro motion transducers (DVRT: MicroStrain, Williston, Vermont) with an accuracy of ± 1μm were placed across the fracture site both anteriorly and posteriorly. Continuous information regarding fracture distraction and compression, as determined by the transducers was recorded from both sites simultaneously during the experiment. The tension band wire construct was loaded up to a maximum force of 4000 Newtons for patella and 500 for the olecranon. The fractures were subjected to cyclic loading at 1Hz using a servo hydraulic materials-testing system (model 8500; Instron, Canton, Massachusetts). The results were analysed on a computer and statistical analysis performed. Results: During the application of cyclical loading, we noted a gap at the articular surface ranging from 1.1± 0.4mm and 2.1± 0.6mm for Olecranon and patella constructs respectively. During most of the duration of the experiment no transducer displacements were recorded at the articular surface. Conclusion: The concept that distractive forces at one end could be converted to compression at the other end through the TBW does not hold true in our biomechanical study. A simpler construct may suffice for fixation of patellar and Olecranon fractures which can reduce the complications associated with TBW fixation.
Research Interests:
Introduction: In clinical practice The Cascade sign is widely used to assess the rotational deformity of the fingers associated with metacarpal and phalangeal fractures. We carried out a scientific study on thirty volunteers to evaluate... more
Introduction: In clinical practice The Cascade sign is widely used to assess the rotational deformity of the fingers associated with metacarpal and phalangeal fractures. We carried out a scientific study on thirty volunteers to evaluate the validity or otherwise of this standard sign. Material and Methods: Metal pointers were attached to the dorsum of the fingers, flexed at MCP and PIP joints. These pointers represented the mid longitudinal axis of the phalanges. Standardised AP radiographs of the closed fist were taken in all cases with the wrist placed in neutral position, in a custom made jig. The radiographs were assessed by two different observers using Picture Archiving and Communication System, software version VA42B, to determine the convergence of the metal pointers towards the scaphoid tubercle, as described in the cascade sign and Lister method.. Statistics: Power of the study was determined with an assumption of a type-2 error of 0.05 and a two sided test. Descriptive statistics and confidence limits were calculated using SPSS 11 software. Results: We observed that the metal pointers did not equivocally converge towards the scaphoid tubercle. The persistent pattern of convergence was within a 2–3cm radius of the scaphoid tubercle. The statistical analysis, two tailed paired t-test of this pattern showed strong association with this latter finding. (p Conclusion: Our study suggests that the cascade sign is sensitive but not specific to access the rotational deformity of the fingers. Radiological there is significant scatter about the scaphoid tubercle.
Research Interests:
Pelvic insufficiency fracture (PIF) occurs when the quality of the bone is compromised due to various reasons. A trivial injury can lead to a pathological fracture. These fractures are usually stable and are managed by conservative means.... more
Pelvic insufficiency fracture (PIF) occurs when the quality of the bone is compromised due to various reasons. A trivial injury can lead to a pathological fracture. These fractures are usually stable and are managed by conservative means. If the fracture pattern is unstable, it mandates some form of surgical fixation. An appropriate method of fixation in rheumatoid patient’s is not
Research Interests:
Research Interests:
Research Interests:
Research Interests:
Research Interests:
Research Interests:
Purpose: Trapezium excision and arthroplasty combined with ligament reconstruction as a treatment for first carpometacarpal joint arthritis is known to be associated with synovitis, prosthesis subluxation /dislocation and proximal... more
Purpose: Trapezium excision and arthroplasty combined with ligament reconstruction as a treatment for first carpometacarpal joint arthritis is known to be associated with synovitis, prosthesis subluxation /dislocation and proximal migration of the metacarpal. To determine the effectiveness of our technique we used the objective and subjective outcome scores to assess the long term results Methods: Ten patients (11 thumbs) underwent trapezium arthroplasty and ligament reconstruction procedure for grade III/ IV Eaton and Glickel arthritis. The FCR tendon was harvested split into half from proximal to its insertion site. The insertion site was left intact, the split tendon was passed through the first metacarpal base, passed along the radial side of the implant, through scaphoid and back to the 1st metacarpal as an entrapment technique. 7 female and 3 male patients with mean age of 53.9 comprised our series. Off the 10 patients 60% had surgery on their dominant hands. Results: All the ...
Research Interests:
We retrospectively reviewed medical records and radiographs of 82 children who presented within 12 months of their birth, with unilateral dislocated/subluxed hips and required treatment in from of traction, closed/open reduction, pelvic... more
We retrospectively reviewed medical records and radiographs of 82 children who presented within 12 months of their birth, with unilateral dislocated/subluxed hips and required treatment in from of traction, closed/open reduction, pelvic osteotomy and maintenance. The purpose of the study was to assess if HE angle could be utilized as a prognostic indicator fro assessing reduction of the affected hip. Hilgenreiner epiphyseal angle was measured by two observers for the normal as well as the abnormal side and differences noted. The measurements of the primary presentation and follow-up films were then correlated. Two groups of patients emerged, those in who the difference between the normal and abnormal hips was less than 10 degrees and those in whom was greater than or equal to 10 degrees, on initial presentation. Their management transpired to be quite different (p=0.000), with open reduction/pelvic osteotomy being required in all cases in the latter group.
Research Interests:
Introduction: Weber B fractures are one of the most common fractures of the ankle. Unstable fractures are treated with lateral plating and a lag screw. Another method of fixation is antiglide plating, this concept was first introduced by... more
Introduction: Weber B fractures are one of the most common fractures of the ankle. Unstable fractures are treated with lateral plating and a lag screw. Another method of fixation is antiglide plating, this concept was first introduced by Brunner and Weber in 1982. Manoli and Schaeffer in 1987, showed that fixation by antiglide plate demonstrated superior static biomechanical properties compared to lateral plating. However there are some shortcomings in their study and hence we decided to perform our biomechanical study. The shortcomings of the Manoli study are. They did not use an interfragmentary lag screw for lateral plate fixation. It was a cadaveric study where the bone does not accurately represent the live bone. The quality of the bone ranging from normal to osteoporotic bone varies from cadaver to cadaver and hence there is no uniformity between the samples. Materials and Methods: We used 4th generation composite bone models validated to closely simulate human bone characteri...
Research Interests:
Summary Long-term follow-up studies on the effects of glucosamine preparations are still awaited. At present, only short-term results are available. They are known to relieve pain and decrease the rate of joint space narrowing clinically... more
Summary Long-term follow-up studies on the effects of glucosamine preparations are still awaited. At present, only short-term results are available. They are known to relieve pain and decrease the rate of joint space narrowing clinically in osteoarthritis of knee, whilst the side effects are less when compared to the anti-inflammatory drugs and even placebos. It is probably safe – but there is no good evidence that it works. It would be ideal to have a medication that is a normal constituent of the human cartilage, which modifies the natural history of the disease. It is possible that long-term clinical studies with glucosamine may result in modifications to the indications for joint surgery or the time patients can live with osteoarthritis before developing substantial disability.
Research Interests:
Research Interests:
Research Interests:
Research Interests:
Research Interests:
BACKGROUND Increased body mass index (BMI) is considered as an important factor that affects the need for total knee and hip arthroplasty (TKA/THA) and the rate of perioperative complications. Previous investigations have not fully... more
BACKGROUND Increased body mass index (BMI) is considered as an important factor that affects the need for total knee and hip arthroplasty (TKA/THA) and the rate of perioperative complications. Previous investigations have not fully established the relationship of BMI and perioperative transfusion with surgical site infection (SSI) or the relationship of BMI and perioperative transfusion after TKA or THA. METHODS The National Surgical Quality Improvement Program database was used to perform a retrospective cohort study involving 333,223 TKA and 41,157 THA cases between 2011 and 2018. Multivariable regression assessed the associations of BMI (5 standard categories) and transfusion with SSI. Odds ratio (OR) of SSI was calculated relative to a normal BMI (18.5-24.9 kg/m2) after adjustment of potential confounding factors. RESULTS Perioperative transfusion decreased significantly over time for both TKA and THA; however, SSI rates remained steady at just under 1% for TKA and 3% for THA. In TKA, a higher OR for SSI was associated only with a BMI of 40+ (OR, 1.86; 95% confidence interval [CI], 1.60-2.18) compared to a referent BMI. In THA, increased ORs of SSI were seen for all BMI levels above normal and were highest for a BMI 40+ (OR, 3.08; 95% CI, 2.47-3.83). In TKA, ORs of transfusion decreased with increasing BMI and were lowest for a BMI 40+ (OR, 0.51; 95% CI, 0.47-0.54). In THA, ORs of transfusion began to increase slightly in overweight patients, reaching an OR of 1.36 (95% CI, 1.21-1.54) for a BMI 40+. CONCLUSIONS SSI incidence remained unchanged despite continuous reductions in blood transfusion in TKA and THA patients over 8 years. In TKA, ORs for SSI increased, but ORs for transfusion decreased with increasing BMI above normal. Conversely, in THA, ORs for SSI and transfusion both increased for a BMI 40+, but only OR for transfusion increased in underweight patients. These findings suggest the importance of controlling obesity in reducing SSI following TKA and THA.
Research Interests:
Background: The objective of this study was to evaluate the functional outcome after lumbar discectomy in Cauda equina syndrome—retention type (CESR) patients with delayed presentation. Materials and Methods: Fourteen patients with CESR... more
Background: The objective of this study was to evaluate the functional outcome after lumbar discectomy in Cauda equina syndrome—retention type (CESR) patients with delayed presentation. Materials and Methods: Fourteen patients with CESR presenting after 48 h (i.e., 2–42 days) from the onset of symptoms were included in the study. Acute lumbar disc prolapse was the cause of CESR in all patients. A detailed history including age, sex, onset of back pain, bladder and bowel symptoms, neurological signs, level of lesion, timing of surgery, and neurologic recovery (resolution of pain, sensory and motor deficits, and urinary, rectal, and sexual dysfunction [SD]) were recorded and analyzed. Bladder dysfunction was assessed using the urinary symptom profile (USP) questionnaire. Bowel dysfunction was assessed using the neurogenic bowel dysfunction (NBD) questionnaire. SD in men was analyzed using the international index of erectile function (IIEF) questionnaire and Female SD was analyzed usin...
Research Interests:
Research Interests:
Research Interests:
Positioning for primary and revision total knee arthroplasty in patients with ipsilateral below knee amputation requires special consideration. Prior case reports have described various strategies, each having their own limitations. Here... more
Positioning for primary and revision total knee arthroplasty in patients with ipsilateral below knee amputation requires special consideration. Prior case reports have described various strategies, each having their own limitations. Here we describe a novel technique flexing the amputated extremity over a radiolucent triangle. All equipment for this technique is readily available in most operating rooms and does not require the need for a second assistant to help stabilize the extremity during the procedure.
Research Interests:
Rotating-hinge knee prostheses have low survivorship and high complications except in primary arthroplasties in elderly patients. We retrospectively reviewed 142 single third-generation design, rotating hinge prostheses (11 primary... more
Rotating-hinge knee prostheses have low survivorship and high complications except in primary arthroplasties in elderly patients. We retrospectively reviewed 142 single third-generation design, rotating hinge prostheses (11 primary procedures and 131 revisions) at 57months follow up. Implant survival was 73 %. Successful two-stage reimplantation for prosthetic infection was 78.4% but new infection rate was 22%. The tibial component was durable while the femoral component was problematic. We observed only one patellar maltracking and no polyethylene wear. A third generation rotating-hinge arthroplasty reconstruction was reliable in complex problems. Outcomes in primary situations were excellent. Complications were the rule rather than the exception in revisions. With timely intervention, attention to soft tissue coverage, and realistic expectations, complications were contained and functional benefits were appreciable.
Research Interests:
The use of hip arthroscopy is gaining popularity for diagnostic and therapeutic purposes. With our increasing understanding of hip biomechanics and pathophysiology, our techniques for treatment are evolving as well. The main aim is to... more
The use of hip arthroscopy is gaining popularity for diagnostic and therapeutic purposes. With our increasing understanding of hip biomechanics and pathophysiology, our techniques for treatment are evolving as well. The main aim is to preserve the joint and prolong the degenerative process associated with femoroacetabular impingement (FAI). In general, combined pathology is encountered when a diagnosis of FAI is established. In our experience, we have seen large number of patients with a combination of cam and pincer lesions with or without associated labral tears. It is optimal to address all symptomatic pathology with one surgical intervention. The described technique shows the feasibility of dealing with the hip FAI pathology by using traction sutures on the capsule through a 2-portal technique.
Research Interests:
Research Interests: Orthodontics and Medicine
Research Interests:
Treatment options for arthrofibrosis following total knee arthroplasty include manipulation under anesthesia, open or arthroscopic arthrolysis, and revision surgery to correct identifiable problems. We propose preoperative low-dose... more
Treatment options for arthrofibrosis following total knee arthroplasty include manipulation under anesthesia, open or arthroscopic arthrolysis, and revision surgery to correct identifiable problems. We propose preoperative low-dose irradiation and Constrained Condylar or Rotating-hinge revision for severe, idiopathic arthrofibrosis. Irradiation may decrease fibro-osseous proliferation while constrained implants allow femoral shortening and release of contracted collateral ligaments. Fourteen patients underwent fifteen procedures for a mean overall motion of 46° and flexion contracture of 30°. One patient had worsening range of motion while thirteen patients had 57° mean gain in range of motion (range 5°-90°). Flexion contractures decreased by a mean of 28°. There were no significant complications at a mean follow up of 34 months (range 24 to 74 months).
Research Interests:
Research Interests:
Research Interests:
Pelvic insufficiency fracture (PIF) occurs when the quality of the bone is compromised due to various reasons. A trivial injury can lead to a pathological fracture. These fractures are usually stable and are managed by conservative means.... more
Pelvic insufficiency fracture (PIF) occurs when the quality of the bone is compromised due to various reasons. A trivial injury can lead to a pathological fracture. These fractures are usually stable and are managed by conservative means. If the fracture pattern is unstable, it mandates some form of surgical fixation. An appropriate method of fixation in rheumatoid patient’s is not