Orthopaedic Outpatient Department Research Articles

Prescription pattern of analgesics in orthopaedics OPD at a tertiary care hospital

Background: Analgesics are the most common class of drugs prescribed for various conditions in the orthopedics outpatient department (OPD). This study is performed for a better understanding of analgesics prescribing pattern in orthopedics and to correlate the use of selective cyclooxygenase-2 (COX-2) inhibitors, conventional non-steroidal anti-inflammatory drugs (NSAIDs), and opioid analgesics in practice in the present scenario. Methods: The prescriptions from the OPD of Orthopedics at Dr. B. R. Ambedkar Medical College was reviewed between June 2013 and November 2013, entered in a pre-designed proforma. Pain was quantified using numeric rating scale. The type of analgesics administered, whether monotherapy or combined therapy and the duration of therapy, was analyzed to obtain an overview of the current prescribing pattern. Results: A total of 300 prescriptions were analyzed. 800 drugs were prescribed with an average of 2.6 drugs per prescription. Of these, 62.3% were NSAIDs, 15.4% were opioid analgesics and 22.3% were gastroprotective agents. 61% of the NSAIDs were prescribed as monotherapy and 39% were prescribed as fixed drug combination (FDC). The ratio of selective to non-selective NSAIDs is 1.3:1. Conclusions: The results of the present study show frequent use of selective COX-2 inhibitors, although non-selective NSAIDs topped the list of various selective NSAIDs, non-selective NSAIDs, and opioid analgesics. This suggests that gastrointestinal safety was an important concern while prescribing these drugs. Many FDCs were found to be irrational.

Necessity of Radiography in Young Adults presenting with Low Back Pain of Short Duration

Background and Objectives: The occurrence of low back pain of short duration and without positive clinical findings is high. 15% and 30% of the population suffer from this condition. Young working adults are most commonly affected by this condition. Aim of this study is to assess the necessity of plain radiography of lumbosacral spine in diagnosing and treating young patients presenting in Orthopaedic outpatient department with low back pain of short duration without history of trauma and no positive clinical findings. Methods: We prospectively studied 500 young patients of age between 25 to 40 years presenting with low back pain of less than 3 months duration without any history of trauma and no positive clinical finding. We excluded patients with history of trauma, fever, patients with radiating pain, neurodeficit, Patients with bladder/bowel complaints and Patients with any other systemic disorder. All these patients received standard treatment in the form of short term medication, postural training and application of ergonomic principles while working. Results: 64% of the patients recovered fully within 2 weeks of treatment. 36% of the patients were not relieved hence Lumbosacral spine radiographs were performed after 2 weeks of treatment. Positive findings on radiographs were early degenerative changes and loss of lumbar lordosis due to para-spinal muscle spasm, seen in 9.7%of the patients in whom radiographs were performed. These radiographic changes were not indicative of different modality of treatment, hence we continued the same treatment and further31% of the patients were recovered fully after 4 weeks of treatment. Interpretation and Conclusions: Performing lumbo-sacral radiographs does not have any influence on treatment or outcome in young patients presenting with low back pain of less than 3 months duration without any history of trauma and no positive clinical finding. Key words: Low back pain, Lumbosacral spine radiograph

Prescribing pattern in orthopedics outpatient department of a medical college in India

Background: Periodic evaluation of drug utilization pattern is necessary to promote rational drug use by. In orthopedics practice, the prescribing pattern needs to be regularly monitored since many of the drugs prescribed carry untoward adverse effects. In this backdrop, the present study was conducted to explore the prescribing pattern in orthopedics outpatient department (OPD) of a medical college in Eastern India. Methods: A cross-sectional study was conducted at a Tertiary Care Medical College in West Bengal. The prescriptions of all consecutive patients attending the orthopedics OPD for the first time (except post-surgical follow-up) were included in the study. Data analysis was done using descriptive statistical methods: frequencies, percentage, mean, and standard deviation. Results: A total of 837 prescriptions were analyzed with an average number of drugs per prescription being 2.57. Among the drugs, non-steroidal anti-inflammatory drugs were most commonly prescribed (64.14% [1383/2156]) followed by anti-ulcer drugs (13.58% [293/2156]), centrally acting muscle relaxants (21.4% [323/1516]), multivitamins and minerals (9.09% [196/2156]), and others (antibiotics, anti-gout drugs, etc.,) (5.12% [110/2156]). Drugs were prescribed in the generic name in 35.72% (770/2156) of prescriptions. A total of 71.56% (1543/2156) of drugs were prescribed from national essential medicine list. Antibiotics were prescribed in 53 encounters (53/2156 [2.46%]) and 93 prescriptions (4.38%) mentioned administration of injectables. The frequency of drug administration and the duration of treatment was mentioned in 87.81% (1893/2156) and 82% (1768/2156) of the prescriptions, respectively. Conclusion: The current piece of work pointed out certain lacunae in the prescribing practices of the orthopedicians of the institute as evidenced by low generic prescribing, inadequate information about the duration of therapy and frequency of administration in many prescriptions.

Added advantage of ayurvedic management in a series of 100 cases of osteoarthritis of the knee joint: a shared experience between Orthopaedic and Ayurvedic Faculty

Osteoarthritis of the knee joint is a disease due to the uncoupling of balance between cartilage degeneration and regeneration in the elderly, causing knee joint pain, deformity and limp. About half of the population after the fifth decade of life have symptoms of osteoarthritis of the knee. The treatment of osteoarthritis varies from conservative to operative procedures. As yet, no long-term definitive conservative management has been described. We compared the results of osteoarthritis among 100 patients in the Orthopaedic outpatient department who either underwent (42 patients) or did not undergo (58 patients) added ayurvedic panchakarma (snehan and swedan) therapy. Patients' visual anologue scores and satisfaction scores were assessed before the treatment and after 2 and 4 weeks. Patients with early to moderate grade of osteoarthritis treated with added ayurvedic therapy showed better improvment in terms of pain and mobilization compared with the patients treated with analgesics only.

Long term outcomes of neglected intracapsular fracture neck in young adults managed by modified double angle barrel plate (DABP) with intertrochanteric valgusosteotomy

Introduction: Fracture neck of femur in young adult have relatively higher incidence of complications such as nonunion, avascular necrosis (AVN) of femoral head, loss of fixation, screw cut-out, and delayed secondary osteoarthritis. Delayed presentation of these cases in developing countries such as India further compromises the outcome of these fractures. Situations like this in young adult lead to difficulty in fixation by simple cancellous screw because of lack of compression surface area. Replacement surgeries in these cases are a difficult choice in these patients; it is difficult to restrict squatting for lifelong due to social culture and lack of toilets. Now, days also preferences are given to head sparing surgeries and osteosynthesis. Materials and Methods: Cases were selected from the patients attending orthopedics outpatient department and emergency trauma center from August 2006 to August 2012. During this period, total 56 cases of neglected fracture neck femur came to our department. Of these 56 cases, 36 cases qualify for inclusion into this study. Of 36 cases, 22 were female and 14 were male with an age range from 22 years to 48 years and average age of 42 years. Average duration from injury to operative procedure was 4.9 weeks (34 days) and range from 2 weeks to 18 weeks. These cases were operated by modified double angle barrel plate (DABP) with intertrochanteric valgus osteotomy with one cannulated cancellous screw (CCS). Results: Total 36 cases were operated using DABP and trochanteric osteotomy. Final outcomes were evaluated using modified Askin and Bryan criteria. Of these 36 cases, 32 (88.8%) cases gave good to excellent results and completed their full follow-up. Rest four cases were unable to continue with same implant fixation. These were kept in failure group. These four cases showed failure due to loss of reduction, screw cut-out, and secondary collapse of femoral head after AVN. These cases further managed by replacement surgeries. Discussion: Neglected fracture neck femurs are not rare presentation in developing countries. Various modalities of treatment are fibular graft, iliac bone graft, multiple screws with fibular graft, muscle pedicle graft. In our case series, we had done combination of DABP with trochanteric osteotomy with CCS and achieved excellent to good results and this method can be used a primary method for management of neglected femoral neck fracture.

Congenital pseudoarthrosis of tibia: A rare case report

Congenital pseudoarthrosis (CPT) of the tibia is rare congenital anomaly occurring 1 in 190,000 live births. It is one of the rare causes of limb shortening. A 8-year-old male child born of consanguious marriage came to orthopedic OutPatient Department with history of significant shortening of left leg since birth so much, so that patient cannot use his left leg for walking. His right leg was normal. Family history of neurofibromatosis-I (NF-1) is present. History, photographs and X-rays were taken and patient was diagnosed as a case of CPT of the tibia. Significant association between CPT of tibia and NF-I has been found. The case is of significance to orthopedicians and pediatrician from the management point of view.

Autologous Conditioned Serum as a Novel Alternative Option in the Treatment of Unilateral Lumbar Radiculopathy: A Prospective Study.

Study DesignThe study was conducted on patients who received autologous conditioned serum (ACS) as a line of treatment at the Orthopedics outpatient department of Post Graduate Institute of Medical Education and Research (PGIMER, Chandigarh) from January 2011 to June 2012. Of the 1,224 patients, 20 males or females were included in the study based on the inclusion and exclusion criteria. The institutional board of PGIMER approved the study before it was initiated.PurposeTo study the efficacy of ACS in the treatment of unilateral lumbar radiculopathy.Overview of LiteratureInterleukin (IL)-1 appears to be of special importance among the cytokines identified in orthopedic diseases. ACS contains high concentrations of IL-1 receptor antagonist, antagonist to IL-1 in that is a biochemical 'sensitizer' of nerve roots in radiculopathy.MethodsWe included 20 patients with unilateral lumbar radiculopathy after obtaining informed consent. We prepared ACS as described by Meijer et al. Under bi-planar fluoroscopic imaging in anterior-posterior and lateral views, ACS was administered via epidural perineural technique. Patients in both groups were evaluated by quadruple visual analogue scale, straight leg raising test, revised Oswestry disability index, and 12-Item Short Form of Health Survey before and after epidural injections at 3 weeks, 3 months, and 6 months.ResultsThere was a statistically significant change in all parameters from pre-injection to first, second, and third follow-up (p<0.001).ConclusionsACS can modify the disease course in addition to reducing pain, disability and improving general health.

Medical student dress code in the orthopaedic out-patient department.

Currently, medical students are not given specific guidance on how to dress, which allows them to wear what they interpret as being appropriate, which may not always be optimal. Many studies have shown that a doctor's attire can greatly affect the consultation; however, no studies have been carried out for patient response to medical student attire. A patient questionnaire was issued, based on pictures of medical students in various clothing styles: with a white coat; without a white coat but smartly dressed; and without a white coat and dressed in smart casual attire. This was followed by a second live phase, where patients were seen by medical students dressed with or without white coats and were asked to complete a survey assessing their response to the student and consultation, based solely on their mode of dress. Patients favour medical students wearing white coats. White coats scored highest in trust and confidence, cleanliness, and professionalism; they were not more intimidating. Ninety per cent of respondents thought that it was important how medical students dressed, and 78 per cent would like to be able to distinguish medical students from doctors. Currently, medical students are not given specific guidance on how to dress The results show that medical student attire is an important issue for patients. It has been shown that patients did not find students dressed in white coats intimidating, and that white coats make students come across as more professional, thereby enhancing the patient experience. We recommend that medical students should be given more direction in how to dress so as to help instill higher levels of satisfaction in patients. Furthermore, the opinions on white coats should be further explored and their reinstitution considered.

OP0081-HPR Physiotherapist's Accuracy in Recognising and Diagnosing Inflammatory Joint Disease While Working in A New Patient Rheumatology Clinic

BackgroundPhysiotherapists working in triage roles are well established in orthopaedic and spinal clinics, but there is less literature available on their role in rheumatology. Physiotherapy clinical specialist posts were established...

Understanding the pain status of the patient: a survey of pain status and pain treatment in an orthopedic outpatient department

Abstract Background: Pain assessments help clinicians to evaluate their patients’ symptoms. However, patients’ satisfaction with pain management is difficult to interpret and may mislead the clinician into being satisfied with inadequate pain management. Objective: We described and explored patients’ pain status, patients’ satisfaction with their pain management, the impact of pain on sleep habit and routine activities of daily living (ADLs), and the proportion of patients who had undertreatment of pain in the Orthopaedic Outpatient Department, Ramathibodi Hospital. Methods: A prospective, cross-sectional survey study of pain characteristics and pain management of Orthopaedic outpatients aged over 18 years in the Orthopaedics Department, Ramathibodi Hospital using two parts of a verified questionnaire. Results: In all, 863 patients were studied. Numbers of patients with acute or chronic pain were in similar proportions and mainly diagnosed as nociceptive pain (83.7%). Most of them suffered from moderate or severe pain (42.6% vs. 39.1%). Severity of symptoms was correlated with sleep disturbance and disturbance in ADLs. However, no correlation was revealed between satisfaction with pain management and the intensity of pain and there was also no correlation between satisfaction with pain management and sleep disturbance or disturbance in ADLs. Most commonly prescribed medications were nonsteroidal antiinflammatory drugs (NSAIDs) (58.8%). However, 93.4% of returning patients who suffered from severe pain were still treated with nonopioid analgesics. Conclusion: Patients suffered from moderate to severe pain and had disturbances in their sleep habit and ADLs. Most of them were satisfied with previous pain management, which was usually with nonopioid analgesics including NSAIDs and muscle relaxants. This group included some patients who experienced a high intensity of pain. We recommend clinicians pay more attention to the pain intensity of individual patients and justify appropriate medication by using a step-up approach and multimodal analgesics

Clinical observation of traumatic ankle arthritis with orthopedics lotion on 60 cases

Observing the clinical curative effect of orthopedics lotion to treat traumatic ankle arthritis, the outpatient department of orthopedics in Guang'anmen Hospital collected 60 cases who were diagnosed as traumatic ankle arthritis. The cases who already met the inclusion criteria, were randomly divided into the treatment group (30 cases) and control group (30 cases). Thirty patients in treatment group were received fumigation treatment with orthopedics lotion; 30 patients in control group were treated by intra-articular injection of sodium hyaluronate. After 5 weeks treatment, the effects on the both groups would be observed and analysed. Baird-Jackson scoring system was used to assess the overall curative effect. Visual analogue scales (VAS) was used to assess analgesic effect. BJ scores of pre-treatment and post-treatment in both the treatment group and the control group were compared, P <0O. 01, significantly different; and the BJ scores after treatment of two groups were compared by paired t-test, the t value is 1. 76, there was no significant difference between two groups. Both of the treatments were effective, but there was no significant difference in overall curative effect between the two kinds of treatment. The VAS scores after treatment of two groups were compared by paired t-test, the t value was 2. 282, and there was a significant difference between two groups (P <0. 05). The analgesic effect shown in treatment group was better than the control group. The results suggest that: orthopedics lotion is a effective way to treat traumatic ankle arthritis, and it has significant effect on analgesic.

Radiological Estimation of Age from Hand Bone in Sudanese Infants and Toddlers

Age determination is one of the most important factors for identification. Unfortunately, births are not recorded regularly in Sudan, especially in rural areas. However, identification of age is very important for a variety of reasons, including identifying legal and criminal responsibility, and for many other social events such as beginning a job, marriage, retirement and joining the army. The study aimed to find the reliability of using international methods to estimate bone age of people through hand bone radiograph in Sudanese people by studying the reliability of using hand bone age “the digital atlas of hand age” which depended on Greulich and Pyle (GP) and Tanner and Whitehouse (TW2/3) methods in Sudanese people in exact group of age, and to compare the hand and wrist bone development between Caucasian and Sudanese people. The study was conducted on 48 samples (26 males and 22 females) from the center of Sudan. The study was made by conventional X-Ray taken from Sudanese newborn babies to 2 and 3 years old for males and females respectively. Those images were taken mostly from the emergency and orthopedic outpatient departments. The ages were grouped in the same ways and periods used in the atlas. So the criteria were tested, and the outcomes were compared with international standards in the atlas of hand bone age. There is evidence that skeletal maturation may vary between difference ethnic and socioeconomic groups of children or among children living in various geographical locations. It is found that there is reliability and applicability of using the atlas in Sudanese people with considering that there might be mild variations between Sudanese and Caucasian people’s hand and wrist bone development in which Caucasian people bone growth was earlier than the Sudanese people bones about 1 - 2 months.

Is Renal Osteodystrophy a Neglected Entity?

Sir, Renal Osteodystrophy (ROD) is the term given to the bone changes which accompany chronic renal failure [1]. We here by present a case of a middle aged female who was suffering from renal disease from more than eight years and was being treated for Ankylosing Spondylitis as co morbidity. Thirty two- year-old, female presented to our orthopedic outpatient department with chronic backache and stiffness of back and hip joints from eight years. She had many prescriptions of various physicians to show she is chronically ill. HLA-B27 report was negative. Her family history was not significant and menstrual history was normal. There was no history of trauma, fever, night sweats, night pains, loss of appetite, loss of weight, morning stiffness, involvement of smaller joints of hand and feet, bowel disturbances, recurrent UTI’s, jaundice, breathlessness, cough with haemoptysis. On examination, all movements of her back were restricted, especially flexion. Both hips had fixed flexion deformity of 15 degrees and all movements were restricted. She was unable to sit cross legged and squat. Her cardiovascular, respiratory and abdominal examinations were normal. Subsequently she was admitted for evaluation. Patient was investigated for–hemoglobin, total and differential leukocyte counts, ESR, random blood sugar, S.G.P.T., RA- Factor, C-reactive protein, serum uric acid, blood urea, serum creatinine, serum calcium, serum phosphorus, serum alkaline phosphatase, urine calcium and phosphorus estimation. She was found to have deranged renal function, as blood urea and serum creatinine were raised to 168 mg% and 4.0mg% .Her serum alkaline phosphatase was raised to 311 I.U. /LIT. Her serum calcium was low 7.0 mg% and phosphate normal 6.0 mg%. Her X-ray dorsolumbar spine AP/Lateral views revealed generalized increase in density (osteosclerosis) with calcification of anterior longitudinal ligament [Table/Fig-1]. X-ray Pelvis showed triradiate pelvis with protrusio acetabuli [Table/Fig-2]. Clinicoradiological diagnosis of Renal Osteodystrophy was made. Patient was then made to undergo ultrasound of KUB region which revealed conjoined kidneys. [Table/Fig-1]: X-ray Dorsolumbar spine AP and lateral views showing generalized increase in density with calcification of anterior longitudinal ligament [Table/Fig-2]: X-ray pelvis AP view showing triradiate pelvis with bilateral protrusio acetabuli Moriniere P, et al., in their study on disappearance of aluminic bone disease in a long term asymptomatic dialysis population have stated that Osteomalacia is a common component of bone disease in patients with end stage renal disease, although its prevalence is decreasing [2]. The disorder is characterized by low rates of bone turnover, a mineralization defect, and an accumulation of unmineralized osteoid (bone matrix). The type of Osteomalacia differs from that caused by Vitamin D deficiency, and the role of 1, 25-dihydroxy-cholecalciferol deficiency in Osteomalacia associated with end stage renal disease is unclear [3]. X-ray pelvis AP view in our patient revealed triradiate pelvis with bilateral protrusio acetabuli changes which are commonly seen in Osteomalacia. According to the study of Lewis C, et al., Osteoslerosis is seen in 20% of patients because the bony trabeculae look prominent in relation to decreased mineralization [4]. X-ray spine AP and lateral views of our patient revealed dense vertebrae. ROD is classified as osteitis fibrosa, osteomalacia, or mixed, mild, or a dynamic disease; according to the histological features. The frequency at the start of therapy for end stage renal disease has been reported by Hutchison AJ, et al., [5]. On review we have placed our case in variety of mixed disease according to this classification as features of Osteitis fibrosa were coexisting with Osteomalacia. In our opinion whenever there is a Chronic Renal Disease and the patient has positive radiological findings – should be referred to Orthopedician as they are more aware about ROD. In this case prescriptions revealed that HLA-B27 has also been done assuming Ankylosing Spondylitis.

Correlation of magnetic resonance imaging findings in low back pain patients with daily travel time and mode

Background: Low back pain (LBP) is the major worldwide cause of pain and it is caused mainly due to long day sedentary work style in office and long hours of travelling in metro cities. The aim was to correlate the association of LBP with increase in time of travel and different modes of travel in metro cities.Methods: Of all the LBP patients referred from orthopedic outpatient department to Radiology Department for magnetic resonance imaging (MRI) spine, 200 cases of those who travelled minimum 2 h daily and more were considered for this study.Results: The results showed correlation of increase in incidence of degenerative changes in spine and changes in disc with increase in travelling time and also the different modes of travel. The changes increased with time significantly in younger population.Conclusions: In our study of 200 patients complaining of LBP and having changes is spine reported on MRI showed reliable association of the LBP to the daily travelling of minimum 2 h and more, and associated with mode of travel, particularly two wheelers followed by public transport.

A Study to Compare effectiveness of Closed Kinetic Chain Exercises Verus Open Kinetic Chain Exercises in Patients with Osteoarthritic Knee Joints

Introduction : The goal of individualized programme requires critical analysis of potential benefits and limitations between Open kinetic chain(OKC) and Closed kinetic chain(CKC) in Osteoarthritis knee .OKC exercises involve motions where the distal segment is free to move in space, without causing simultaneous motions at adjacent joints while in CKC exercise distal segment is fixed or stabilized on a support surface. Aim of Study : To study the effects of Closed Kinetic Chain Exercise and Open Kinetic Chain Exercise in Osteoarthritis Knee. Methodology : A Clinical trial consisted of 30 patients, diagnosed with tibiofemoral OA, as per the Inclusion&Exclusion Criteria were recruited from orthopedic Out-patient Department to Physiotherapy Department, Civil Hospital, Ahmedabad. Patients were divided into two,one group was given OKC and other group CKC exercises. The functional outcome were pain measured on visual analogue scale (VAS)&Function by Western Ontario and McMaster universities Osteoarthritis Index (WOMAC) taken on the 1st day&after 8 weeks. Results : There is no significant difference as per Wilcoxen Signed Rank and Wilcoxen Sum rank test between CKC and OKC Exercises along with conventional therapy in reducing pain and improving Physical Function in patients with Osteoarthritis Knee. Discussion : CKC exercises, in acute phase was painful compared to OKC exercises due to weightbearing position. But later on as patients always want improvement in their activity like squatting, walking, stair climbing, CKC help them in their functional rehabilitation. So ultimate rehabilitation programme of Osteoarthritis Knee patient should include both OKC exercises and CKC exercises. Conclusion : CKC exercise along with conventional therapy as effective as OKC exercise for improving the pain and functional disability

A rare case of Goldenhar syndrome with radial aplasia

Goldenhar syndrome (GS) is a well-recognised condition characterised by variable degree of uni- or bilateral involvement of craniofacial structures involving first and second branchial arches manifesting ocular and auricular anomalies and also vertebral defect. This syndrome presents at birth and its exact aetiology is still unknown. The affections of the neural crest cells may have some role in the multiple malformations of the GS. We present a teenaged female case who attended the Orthopaedic Outpatient Department to receive handicapped certificate in Bankura Sammilani Medical College and Hospital. She had multiple skeletal abnormalities, which included hemifacial microsomia, vertebral malformations in the form of scoliosis, distorted pelvis, but the most striking feature was the absence of thumb and aplasia of radius of left side. She did not suffer from any ocular or auricular abnormalities, neither from any cardiological, urogenital or gastroenteric ones. Radial defects associated with GS might represent a subset within this spectrum. Our case probably belongs to this subset, therefore is a very rare one.

Young man with knee pain

A 22-year old male patient from rural background presented to our tertiary care orthopedics outpatient department after being referred from the primary health care center. The patient had a gradually increasing, non-radiating, dull pain in the left knee for the past 3 months. The pain worsened after exercise and walking, and was relieved on taking nonsteroidal anti-inflammatory drugs. There was no history of swelling, fever, loss of appetite, trauma, malaise, weight loss, pain, or swelling at any other site. On examination, the general condition of the patient was fair except for mild pallor and slight limp on walking. On local examination, the patient had tenderness in the left knee joint, centered in the region of tibial condyle, without any other sign of inflammation or adjacent lymphadenopathy. The active range of motion was limited and the passive range of motion was full in all directions but painful. The rest of the orthopedic examination was normal. The patient was advised plain radiographs of the knee (Figure 1) followed by contrast-enhanced magnetic resonance imaging (MRI) (Figures 2 and 3).

Elbow Reconstruction Following an Extensive Resection of the Proximal Part of the Ulna in a Patient with Ewing Sarcoma: A Case Report.

Malignant bone tumors are usually located in the lower extremities. Malignant bone tumors in the upper extremities, especially in the forearm, are rare1. Current treatment of this type of tumor consists of chemotherapy and limb-sparing, radical resection of the tumor. The most frequently applied reconstructive procedures involve the implantation of endoprostheses, autogenous bone grafts, allografts, and other forms of reconstruction2-6. This case report describes a patient with a tumor of the ulna; the operative treatment and its results are also presented. The patient and his parents were informed that data concerning the case would be submitted for publication, and they provided consent. A seven-year-old boy presented to the hospital emergency department with pain in the left elbow that had been ongoing for several days. Clinical examination revealed left elbow distension, reddening of the skin over the olecranon, and tenderness of this region to palpation. Laboratory tests showed mild elevation of the inflammation indicators, including erythrocyte sedimentation rate, C-reactive protein level, and white blood-cell count. A radiograph of the forearm failed to reveal any pathology. The patient was discharged with recommended antibiotic therapy, and a follow-up visit was scheduled for two weeks later. Two months after the first visit, the patient reported to the Orthopaedic Outpatient Department at the University Children’s Hospital with persistent pain in the left elbow. Clinical examination revealed edema of the entire elbow with mild erythema and tenderness to palpation, especially prominent in the olecranon region. A radiograph of the forearm demonstrated advanced osteolytic lesions within the proximal part of the ulna, with concomitant reactive osteogenesis and a periosteal reaction (Fig. 1). Radiographs also showed a pathological fracture within the involved region of the bone. The radiographs raised unequivocal suspicion of a malignant neoplastic lesion; therefore, the patient was hospitalized for …

A randomised controlled trial to evaluate the efficacy of a health maintenance clinic intervention for patients undergoing elective primary total hip and knee replacement surgery

AimThis paper is the report of a study exploring the efficacy of a health maintenance clinic intervention for patients with severe osteoarthritis of the hip and knee whilst awaiting primary joint replacement surgery. BackgroundHistorically in the UK patients with severe osteoarthritis waited many months for their hip and knee replacement surgery. The waiting time was often in the absence of support and advice relating to symptom management. A health maintenance intervention was developed to provide support to patients whilst awaiting their joint replacement and to optimise their health status ahead of the procedure. MethodsA randomised control trial (RCT) compared usual care (pre-operative assessment only) to a new intervention (health maintenance clinic plus pre-operative assessment). A sample of 250 people with osteoarthritis waiting for joint replacement were recruited via an orthopaedic out-patient department between 2005 and 2006. To assess the effectiveness of the intervention outcome, measures were recorded at two points in time (on referral to the waiting list and at 2weeks prior to surgery). ResultsNo significant difference between the total score on the disease specific outcome measure was found (p=0.69). However, participants in the experimental group were significantly more satisfied with their care (p=0.001) and had fewer incidences of postponement of surgery (p=0.002). ConclusionA tailored intervention for symptom management in the pre-operative period increases patient satisfaction which may have a positive impact on concordance and postoperative recovery. Also, reducing the number of surgical postponements has a positive economic value for health care providers.

Does excessive flatfoot deformity affect function? A comparison between symptomatic and asymptomatic flatfeet using the Oxford Foot Model

Treatment of asymptomatic flexible flatfeet is a subject of great controversy. The purpose of this study was to examine foot function during walking in symptomatic (SFF) and asymptomatic (ASFF) flexible flatfeet. Thirty-five paediatric and juvenile patients with idiopathic flexible flatfeet were recruited from an orthopaedic outpatient department (14 SFF and 21 ASFF). Eleven age-matched participants with typically developing feet served as controls (TDF). To study foot function, 3D multi-segment foot kinematics and ankle joint kinetics were captured during barefoot gait analysis. Overall, alterations in foot kinematics in flatfeet were pronounced but differences between SFF and ASFF were not observed. Largest discriminatory effects between flatfeet and TDF were noticed in reduced hindfoot dorsiflexion as well as in increased forefoot supination and abduction. Upon clinical examination, restrictions in passive dorsiflexion in ASFF and SFF were significant. During gait, the hindfoot in flatfeet (both ASFF and SFF) was more everted, but less flexible. In sagittal plane, limited hindfoot dorsiflexion of ASFF and SFF was compensated for by increased forefoot mobility and a hypermobile hallux. Concerning ankle kinetics, SFF lacked positive joint energy for propulsion while ASFF needed to absorb more negative ankle joint energy during loading response. This may risk fatigue and overuse syndrome of anterior shank muscles in ASFF. Hence, despite a lack of symptoms flatfoot deformity in ASFF affected function. Yet, contrary to what was expected, SFF did not show greater deviations in 3D foot kinematics than ASFF. Symptoms may rather depend on tissue wear and subjective pain thresholds.