IRANIAN JOURNAL OF ORTHOPAEDIC SURGERY
Year:2005 | Volume:3 | Issue:4 (12)|Papers Count:8

Background: The study of functional outcomes following orthopedic procedures, such as joint replacement, has become common in the last decade. To report only on radiographic changes, joint motion range or limb alignment after a knee arthroplasty, without evaluation of changes the patients feel in their general well-being or daily personal or social functions would be futile. The instruments for assessment are usually based on patients’ general health, or on possible post-operative improvement of certain daily functions. The functional outcome assessment instruments for knee replacement have not been validated in Iran. We are trying to show the validity of such instruments in knee arthroplasty performed in a university set-up in Iran. Methods: Sixty patients, 56 women and 4 men, who had undergone total knee arthroplasty by a single surgeon, were recruited for clinical evaluation and for filling out the questionnaires on 3 outcome instrument systems, namely SF-36, WOMAC and MACTAR. Two control groups consisting of 44 cases of similar age from general population with knee discomfort and susceptible to osteoarthritis as well as 26 patients scheduled for knee arihroplasty filled out the same questionnaires.Results: The health status measurement (SF-36), disease-specific outcome measure and patient preference arthritis scores all showed significant improvement in operated cases, in both short and long term follow-up groups. Certain aspects of function like socialization with others, attending religious ceremonies and similar activities, often requiring full knee bending and/or sitting on the carpeted floor, were the main reasons for dissatisfaction with the procedure. Conclusion: The knee arthroplasty increased quality of life, improved function and produced great satisfaction in the majority of cases in our society. This is, however, a viable option for people who could change their lifestyle and household and are able to make the adjustments mentally and financially.

Background: Femoral shaft fracture is one of the most common fractures in high energy trauma patients and can be associated with soft tissue injuries of knee joint. Recognition of ligamentous and meniscal injuries of knee in acute phase is essential for optimum treatment and prognosis. Polytraumatized patients with femur fracture and knee ligament or meniscus damage present a difficult diagnosis challenge.Methods: Twenty two adult patients with closed or open, displaced, diaphyseal femoral fractures and no previous knee injury were prospectively studied to look for possible concomitant ipsilateral knee injury. In all cases the mechanism of injury was high energy car accident. Trauma following open reduction and fixation with nail or plate. All patients had an examination under anaesthesia followed by knee arthroscopy. Results: The results of physical examination showed instability of grade 1 or more in six patients; two positive valgus stress test, one isolated and another with positive anterior drawer test, one positive varus stress test, two positive isolated anterior drawer tests, one isolated positive posterior drawer test. There were also knee effusions in 8 patients. Significant arthroscopic findings consisted of three cases of hemarthrosis; one complete and two partial anterior cruciate ligaments tears and two lateral meniscuses tears. In general, upon physical examination, 6 cases of ligamentous injury were suspected and in knee arthroscopy five patients had positive findings; and similar findings were confirmed by both tests. Therefore high incidences of ipsilatersal knee injuries (36.3%), including those that were occult, occurred in conjunction with femoral shaft fractures. Conclusions: Based on the above findings, it is recommended to have a high index of suspicion for coexisting knee injury with ipsilateral fracture of femur.

Background: The views on treatment of unstable thoracic or lumbar fractures are varied. Relieving the pressure off the neural elements and posterior fusion and instrumentation either one level above and one below the fracture (Short Segment-SS) or two levels above and two below (Long Segment-LS) is one of the treatment options for such fractures. We set up the current study to evaluate the possible difference in outcome between short and long segment instrumentation and fusion.Methods: In a retrospective study from 2000 to 2004, 23 patients who had undergone short-segment instrumentation were compared with 16 long-segment fusion cases. The functional assessment was performed by low back outcome score (LBOS), and radiographic evaluation was performed by movements of anterior- wedge, regional and inter-vertebral angles. The cases with no or with minimal neurologic problem, unstable fractures between T11-L4, with less than 30 percent local kyphosis and less than 50 percent canal encroachment were included.Results: The 39 had 33.4±14.4 years average age at the time of study. The mean follow-up was 40.8±12.5 months. The SS cases had LBO score of 55.9±14.4 and LS group scored 55.4± 13.2. Increased local kyphosis compared to initial post operative angulations was observed in both groups (3.3 degree for LS and 1.5 degree in SS).Conclusions: Both short and long segment posterior instrumentation of unstable lower thoracic or lumbar fractures give reasonably good functional outcomes. The post operative improved local kyphosis deteriorates with time, but to a slightly lesser degree in short segment instrumentation.

Background: Comminuted distal metaphyseal fractures of tibia, often pose major treatment problems. Closed reduction, leads to high rate of malunion, while open reduction is associated with high risk of wound problems, joint stiffness, and nonunion. Biological fixation of these fractures by locking compression plates (LCP) is another alternative for fixation of this difficult fracture.Methods: 22 patients with comminuted fracture of distal metaphysic, in a two-year period were treated with percutaneous application of LCP. The cases were evaluated clinically and rediographically with an average follow-up of 11 months. Results: Union was achieved in 19.2 (15-28) weeks in all cases. No skin breakdown and no malunion were observed. Full ankle motion was observed in all but 3 patients who had restricted dorsiflexion. One case of superficial wound infection was observed. Plate prominency was seen in 3 patients that caused skin irritation in one case. All swellings subsided and blisters healed within two weeks. Conclusions: With better preservation of blood-supply in biological application of LCP plates in distal tibial metaphyseal fractures, fast healing potential with fewer complications is to be expected.

Background: Talus has unique anatomical, biomechanical and vascular-supply features. Talar neck fracture is not common, but when it happens, would be associated with high complication rate, resulting in significant disability. We would like report our experience with a small group of such fractures.Methods: 11 cases of talar neck fractures who had referred to our center in 3 years period (2002-4) were retrospectively studied. The mean age was 23 years old. There were 9 types II and 2 types III (Hawkins classification). All the cases had undergone open reduction and inertial fixation. The result of treatment was evaluated with a mean follow-up of 17 months.Results: All fractures healed. Varus malunion was observed in two cases, one of whom required repeat surgery, and one with superficial infection. Avascular necrosis of the talar body was seen after the 2 type III and 3 of type II cases. Degenerative arthritis of subtalar joint was evident in 8, and ankle arthritis in 5 patients. Conclusions: Talar neck fractures are associated with high complication rates. Post traumatic arthritis and stiffness are more common, especially in those who develop avascular necrosis. Prompt accurate reduction, rigid fixation and early motion can reduce the complications to some extent.

Background: The anesthesiologist has a key role in reducing post-operative pain, who could achieve this goal by different techniques to reduce patient discomforts and stresses. This study compared the analgesic effects of meperidine (an opioid drug) in reducing post-operative pain in the IVRA (intravenous regional anesthesia) technique. Methods: In a descriptive-analytical cross-sectional clinical trial which is a randomized, single blinded and controlled study, 30 cases were divided into 3 groups, all undergoing IVRA. All the patients were similar regarding anesthetic technique except for this fact that 30 mg local meperidine was administered in one group, 30 mg systemic (intravenous) meperidine was injected in the second group and the third group received placebo. A visual analogue scale was administered for pain measurement and comparison. VAS pain scores and possible required analgesic dosage and complications were compared during the intra-operative and post-operative periods. Student-t test, ANOVA and Chi square tests were used for data analysis with a p-value less than 0.05 considered significant. Results: The results denoted that both intravenous and local meperidine could decrease pain scores and required analgesic dose (including systemic opioids and oral acetaminophen tablets); with no statistically difference between the two groups.Conclusions: The results suggested that additive meperidine can decrease intraoperative and postoperative pain when administered locally in IVRA technique.

Nonunion of tibial stress fracture has been reported in athletes and only in proximal and midshaft of tibia. We have found no report of nonunion of a stress fracture in distal tibiofibula. Report of this lesion, especially in a non-athlete adolescent, is interesting and important.

Clubfoot is one of the most common congenital deformities in children. Several different methods of manipulation and casting have been used over the years for the primary treatment. These, however, resulted into surgery in 50-80% of cases, often requiring extensive soft tissue release for correction of residual or recurrent deformities. Long term follow-up of patients who underwent surgery has shown several outstanding complications such as pain, stiffness, early arthritis, unsightly feet, etc. Because of such unsatisfying outcomes, the orthopaedic surgeons started thinking about non-surgical treatment once more.Dr Ponseti introduced his technique of manipulation and casting since nearly 50 years ago, but it was not accepted by the orthopaedic community, and nobody took him seriously. It was not until he published his long- term follow-ups with more than 90% excellent and good results that his technique was popularized, and is now considered the best approach to the primary treatment of clubfoot.