A Rare Case of Isolated Intra-articular Fracture of Humeral Trochlea: Surgical Management by Posterior Approach

Vol 42 | January 2021 | page: 28-30 | Akshay Mylarappa, Sanket Mishra


Authors: Akshay Mylarappa [1], Sanket Mishra [1]

[1] Department of Orthopaedics, IMS & SUM Hospital, Bhubaneswar, Odisha, India.

Address of Correspondence

Dr. Akshay Mylarappa,
IMS & SUM Hospital, Bhubaneswar, Odisha, India.
E-mail: akshaymylar@gmail.com


Abstract

Isolated fracture of the trochlea is rare and is only recorded approximately 15 times in literature and the surgical management by posterior approach is never described. The rare incidence may be attributed to its position deep inside the elbow joint without any tendinous or ligamentous attachment, thus protected from any injury. We report a rare case of fracture of the trochlea and its surgical management by posterior approach with Chevron’s olecranon osteotomy and also describe the advantages and disadvantages of the approach. Functional outcome at two-year follow-up was satisfactory.

Keywords: Isolated humeral trochlea; Intra-articular fracture; Posterior approach.


References

1. Hotchkiss RN, Green DP. Fractures and Dislocations of the Elbow. In: Rockwood CA, Green DP, Bucholz RW, editors. Rockwood and Green’s Fractures in Adults. 3. Philadelphia: Lippincott; 1991. pp. 739–841
2. Singh AP, Dhammi IK, Jain AK, Jain S. Neglected isolated fracture of the trochlea humeri. Chin J Traumatol. 2010;13(4):247-249.
3. Kaushal R, Bhanot A, Gupta PN, Bahadur R (2005) Isolated shear fracture of humeral trochlea. Inj Extra 36:210–211. https://doi.org/10.1016/j.injury.2004.09.041
4. Abbassi N, Abdeljaouad N, Daoudi A, Yacoubi H (2015) Isolated fracture of the humeral trochlea: a case report and review of the literature. J Med Case Reports 9:. https://doi.org/10.1186/s13256-015-0564-1
5. Nauth A, McKee MD, Ristevski B, et al (2011) Distal humeral fractures in adults. J Bone Joint Surg Am 93:686–700. https://doi.org/10.2106/JBJS.J.00845
6. Chamseddine A, Hamdan H, Obeid B, Zein H (2009) [Articular coronal fractures of the distal humerus]. Chir Main 28:352–362. https://doi.org/10.1016/j.main.2009.08.009
7. Nakatani T, Sawamura S, Imaizumi Y, et al (2005) Isolated fracture of the trochlea: a case report. J Shoulder Elbow Surg 14:340–343. https://doi.org/10.1016/j.jse.2004.07.012
8. Singh R, Singh H, Kanodia N (2019) Olecranon Osteotomy Approach for Complex AO-13C Fractures of Distal Humerus: A Prospective Analysis of 24 Cases. Malays Orthop J 13:30–35. https://doi.org/10.5704/MOJ.1903.005
9. Shahane SA, Stanley D (1999) A posterior approach to the elbow joint. J Bone Joint Surg Br 81:1020–1022. https://doi.org/10.1302/0301-620x.81b6.9696

How to Cite this Article: Mylarappa A, Mishra S | A Rare Case of Isolated Intra-articular Fracture of Humeral Trochlea: Surgical Management by Posterior Approach | Odisha Journal of Orthopaedics & Trauma | January 2021; 42: 28-30.

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Solitary Plasmacytoma of Medial End of Clavicle: A Rare Case Report

Vol 42 | January 2021 | page: 21-23 | Avinash Naik, Saurav N. Nanda, Sourav Kumar Pal, K Srikant, Debashish Mishra


Authors: Avinash Naik [1], Saurav N. Nanda [1], Sourav Kumar Pal [1], K Srikant [1], Debashish Mishra [1]

[1] Department of Orthopaedics, Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha, India.

Address of Correspondence

Dr. Avinash Naik,
Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha, India.
E-mail: dravinashnaik@gmail.com


Abstract

Introduction: Clavicle, an unusual site for an expansile lytic lesion of bone with multiple differential diagnostic possibilities and plasmacytoma being one of them, although reported but very rare. Solitary plasmacytoma of bone(SBP) are a localized bone tumour consisting of plasma cells with no other clinical features that of multiple myeloma. We are presenting such a rare case of solitary plasmacytoma of bone involving the medial end of the clavicle.
Case report: A 40-year female presented with complaints of pain and swelling in the inner aspect of the left clavicle since 2 months. Radiographs showed a lytic expansile lesion involving the medial end of the clavicle and confirmed with CT scan. FNAC was inconclusive and hence excisional biopsy done with a provisional diagnosis of giant cell tumour (GCT). Histopathology features suggestive of plasma cell neoplasm like nodules of plasma cells with an enlarged nucleus and also IHC quantified plasma cells with stains for kappa and lambda. Skeletal survey, serum and urinary electrophoresis, alkaline phosphatase, haemoglobin, renal function test, ESR, CRP, serum calcium and phosphate levels were within normal limits. Bone marrow biopsy also ruled out the possibility of multiple myeloma hence a possible diagnosis of solitary plasmacytosis of bone was made. The patient was further evaluated by oncologists and subsequently, radiotherapy was given. The patient has been in regular follow up for 2 years with no signs of recurrence and multiple myeloma.
Conclusion: Clavicle, although an unusual site of primary bone tumour, should be kept in mind for any swelling around it. Plasmacytoma should also be considered as a differential along with other commoner differentials like GCT, fibrous dysplasia for osteolytic expansile lesions in the clavicle. Multiple myeloma should be ruled at presentation and at long term regular follow-ups to be considered as solitary plasmacytoma of bone after histopathological diagnosis.
Keywords: Plasmacytoma; Clavicle.


References

1. Dr. Chinmay Biswas, Dr. Chinmay Biswas, Dr. Abhradip Mukherjee, Dr. Soumen Roy, 2016. “Solitary Plasmacytoma of clavicle: A rare case report”, International Journal of Current Research, 8, (01), 25387-25389.
2. Jaffe ES, Harris NL, Stein H, Vardiman JW (2001) World Health Organization Classification of Tumours: Pathology and Genetics, Tumours of Haematopoietic and Lymphoid Tissues. Ann Oncol 13: 490-491.
3. Panagopoulas A,Megas P,Kaisidis A,Dimakopoulos P(2006)Radiotherapy Resistant Solitary Bone Plasmacytoma of clavicle.European journal of Trauma 32:190-193.
4. Nirmalesh M & Indranil C & Palash K M & Bidyut K G.(2018).Cytohistopathological Diagnosis of Solitary Plasmacytoma of Clavicle: A Rare Site for a Rare Tumor. Biomed Journal of Scientific & Technical Research. 2. 10.26717/BJSTR.2018.02.000660.
5. Kleins, Kuppers R (1999) The New England Journal of Medicine. 341: 1520.
6. Shahid M,Hali NZ,Mubeen A,Zaheer S,Julfiqar(2010)Solitary Plasmacytoma of Clavicle-A rare case presentation.J Cytol Histol 1:103.doi:10.4172/2157-7099.1000103.
7. Dimopoulos, M.A., Moulopoulos, L.A., Maniatis, A., et al. 2000. Solitary plasmacytoma of bone and asymptomatic multiple myeloma. Blood, 96:20372044

How to Cite this Article: Naik A, Nanda SN, Pal SK, Srikant K, Mishra D| Solitary Plasmacytoma of Medial End of Clavicle: A Rare Case Report | Odisha Journal of Orthopaedics & Trauma | January 2021; 42: 21-23.

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Analysis of the Results of Titanium Elastic Nails (TENS) in Paediatric Femur Fractures

Vol 42 | January 2021 | page: 02-07 | Manoranjan Mallick, Pramod Sahoo, Debi Prasad Nanda


Authors: Manoranjan Mallick [1], Pramod Sahoo [1], Debi Prasad Nanda [1]

[1] Department of Orthopaedics, SCB Medical College, Cuttack, Odisha, India.

Address of Correspondence

Dr. Debi Prasad Nanda,
SCB Medical College, Cuttack, Odisha, India.
E-mail: drdebiortho@gmail.com


Abstract

Background: Pediatric femur fracture management is a controversial issue even today. Because of the spontaneous healing power of this age group, one school of thought believes in hip spica cast while the other group of orthopedicians prefer surgical management of this fracture.
Aims and objective: Aim of this study was to analyze the results of pediatric femur fractures treated with Titanium elastic nails (TENS).
Material and methods: This is a prospective study of 30 cases of pediatric femur fracture treated with TENS in the Department of Orthopedic, SCBMCH, from July 2017 to December 2019 and functional results are analyzed with 10 scoring criteria devised by Flynn et al i.e. Flynn criteria. Radiological assessment was done by Anthony et al scale for grading callus formation.
Result: Excellent results achieved in 24 (79%), satisfactory in 4 (15%) and poor in 2(6%) cases as per Flynn criteria. All fractures healed in a mean period of 7.9 weeks (6-12 weeks). The most common complication was entry site irritation in 6 (20%) that subside after nail removal.
Conclusion: TENS is an effective modality of a surgical method for pediatric femoral shaft fracture with precise technique and proper aftercare.
Keywords: TENS; Adolescent femur; Fracture.


References

1. Anderson Randolph L. Conservative Treatment of Fractures of the Femur, Journal of Bone and Joint Surgery, 1967; 49:1371-1375.
2. Dameron Thomas B and Thompson Hugh A. Femoral-Shaft Fractures in Children: Treatment by Closed Reduction and Double Spica Cast Immobilization, J Bone Joint Surg Am. 1959; 41:1201-1212.
3. Irani RN, Nicholson JT, Chung SMK. Long-term results in the treatment of femoral-shaft fractures in young children by immediate spica immobilisation. J Bone Joint Surg [Am] 1976; 58-A :945-51.
4. Ligier J N , Metaizeau J P , Prevot J , Lascombes P. Elastic stable intramedullary nailing of femoral shaft fractures in children,J Bone Joint Surg [Br] l988;70-B :74-7.
5. Lee Z L, Chang C H,Yang W E,Hung S S. Rush Pin Fixation Versus Traction and Casting for Femoral Fracture in Children Older than Seven years, Chang Gung Med J 2005;28:9-15.
6. Splain, SH, Denno, JJ.Immediate double hip spica immobilization as the treatment for femoral shaft fractures in children.J Trauma ;1985, 25: 994-6.
7. Bar-On E, Sagiv S, Porat S. External fixation or flexible intramedullary nailing for femoral shaft fractures in children. A prospective, randomised study. J Bone Joint Surg Br. 1997 Nov; 79(6): 975-978.
8. Slongo TF. Complication and failures of the ESIN technique. Injury. 2005; 36: S-A78-S-A85.
9. Gonzalez-Herranz P, Burgos-Flores J, Rapariz JM, et al. Intramedullary nailing of the femur in children. J Bone Joint Surg Br 1995; 77:262–6.
10. Anil Shiha, Hisham H, Rifaie, Mohamed Alam. Elastic stable intramedullary nailing of femoral shaft fractures in children,Pan Arab J. Ortho, Trauma 2004,Vol 8(1);11-16
11. Lee YHD, Lim KBL,Gao GX,Mahadev A,Lam KS,Tan SB,Lee EH. Traction and spica casting for closed femoral shaft fractures in children, Journal of Orthopaedic Surgery 2007; 15(1):37-40.
12. Hassan Al-Sayed. Titanium Elastic Nail Fixation for Paediatric Femoral Shaft Fractures, Pan Arab J. Orth. Trauma – Vol. (10) No. (I)/ January 2006:7-15.
13. Houshian S, Buch G C, Pedersen N W and Harving S. Femoral shaft fractures in children-Elastic stable intramedullary nailing in 31 cases, Acta Orthop Scand 2004; 75 (3): 249–251.
14. Till H, Huttl B, Knorr P and Dietz HG. Elastic stable intramedullary nailing (ESIN) provides good long-term results in pediatric long-bone fractures,Eur J Pediatr Surg, Oct 2000; 10(5): 319-22.
15. Singh R, Sharma SC, Magu NK, Singla A. Titanium elastic nailing in pediatric femoral diaphyseal fractures. Indian J Orthop 2006; 40:29-34.
16. Memduh HEYBELI , Hassan Hilmi MURATLI, Levent CELEBI, Serap GULCEK, Ali BICIMOGLU. The results of intramedullary fixation with titanium elastic nails in children with femoral fractures, Acta Orthop Traumatol Turc 2004; 38(3): 178-187
17. Flynn JM, Hresko T, Reynolds RA, Blasier RD, Davidson R, Kasser J.Titanium elastic nails for pediatric femur fractures: a multicenter study of early results with analysis of complications. J Pediatr Orthop. 2001; 21:4-8.
18. Saikia KC, Bhuyan SK, Bhattacharya TD, Saikia SP. Titanium elastic nailing in femoral diaphyseal fractures of children in 6-16 years of age, Indian Journal of Orthopaedics,2007;vol-41:(4) 381-385.
19. Rockwood and Wilkin’s Fracture in Children, 6th Edition (page-896)
20. Basant Kumar Bhuyan, Suryansh Mohan Singh.Titanium elastic nailing in pediatric femoral diaphyseal fractures in the age group of 5-16 years – A short term study; journal of clinical orthop aedics and trauma 5 (2014) 203-210.
21. Abhijit Kawalkar, C.M. Badole. Percutaneous titanium elastic nail for femoral shaft fracture in patient between 5 and 15 years. Journal of Orthopaedics 15 (2018) 695–700

How to Cite this Article: Mallick M, Sahoo P, Nanda  D| Analysis of the Results of Titanium Elastic Nails (TENS) in Paediatric Femur Fractures | Odisha Journal of Orthopaedics & Trauma | January 2021; 42: 02-07.

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Open fractures of Tibia treated by unreamed interlocking nailing

Vol 41| January 2020 | page: 3-6 | Nirmal Chandra Mohapatra, Udit Saurav Sahoo


Authors: Nirmal Chandra Mohapatra [1], Udit Saurav Sahoo [1]

[1] Department of Orthopaedics, SCB Medical College, Cuttack, Odisha, India.

Address of Correspondence

Dr. Udit Sourav Sahoo
SCB Medical College, Cuttack, Odisha, India.
E-mail: uditsouravsahoo@gmail.com


Abstract

Objective: To assess the clinical outcome of unreamed intramedullary interlocking nailing in open fractures of tibia, and to evaluate the incidence of complications in these open fractures as a result of the same.
Methods: Between June 2018 and May 2019, a total of 56 cases of open tibial shaft fractures were operated on with unreamed interlocking nails at SCB MCH, Cuttack, India. Records of 52 patients (18 women and 34 men) were available for study. Only injuries associated with the tibial shaft were included. Traffic accidents were the cause of fractures. All fractures were classified according to Gustilo and Anderson classification for open fractures. There were 28(53.8%) type-I, 16 (30.7%) type-II, 8 (15.3%) type- IIIA fractures. After thorough debridement under anaesthesia, an unreamed interlocking nail was inserted. All nails were locked proximally and distally.
Results: The patients were followed up for a mean period of 19 months (range, 18–24 months) and were evaluated according to the modified Ketenjian’s criteria. Results were good to excellent in 85.8% cases, and poor in 10.7% cases. Only 2 of 8 patients with type-III fractures had good results. Of 56 patients, 6 had superficial infection, 4 had deep infection, 6 had delayed union, 1 had infected non-union, 3 had malunion, 6 had screw breakage, and 10 had anterior knee pain.
Conclusion: Unreamed interlocking tibial nailing can be safely used for type-I and type-II open injuries even with delayed presentation. Use of unreamed nailing in type-III fractures with delayed presentation has high incidence of complications in this study.
Keywords: Unreamed interlocking nail, Open tibial fractures.


References

1. Bach AW, Hansen Jr ST (1989) Plates versus external fixation in severe open tibial shaft fractures: a randomized trial. Clin Orthop 241:89–94
2. Bonatus T, Olson SA, Lee S, Chapman MW (1997) Non- reamed locking intramedullary nailing for open fractures of the tibia. Clin Orthop 339:58–64
3. Court-Brown CM, McQueen MM, Quaba AA, Christie J (1991) Locked intramedullary nailing of open tibial fractures. J Bone Joint Surg Br 73:959–964
4. Gustilo RB, Anderson JT (1976) Prevention of infection in the treatment of one-thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg Am 58:453–458
5. Hasenhuttl K (1981) The treatment of unstable fractures of the tibia and fibula with flexible medullary wires. A review of two-hundred and thirty-five fractures. J Bone Joint Surg Am 63:921–931
6. Henley MB, Chapman JR, Agel J, Harvey J, Whorton AM, Swiontkowski MF (1998) Treatment of type II, IIIA, and IIIB open fractures of tibial shaft. A prospective comparison of un- reamed interlocking intramedullary nails and half-pin external fixators. J Orthop Trauma 12:1–7
7. Holbrook JL, Swiontkowski MF, Sanders R (1989) Treatment of open fractures of the tibial shaft: ender nailing versus exter- nal fixation. A randomized prospective comparison. J Bone Joint Surg Am 71:1231–1238
8. Klein MP, Rahn BA, Frigg R, Kessler S, Perren SM (1989) Reaming versus non-reaming in medullary nailing: inter- ference with cortical circulation of the canine tibia. Arch Orthop Trauma Surg 109:314–316
9. Klemm KW, Borner M (1986) Interlocking nailing of complex fractures of the femur and tibia. Clin Orthop 212:89–100
10. Lottes JO (1974) Medullary nailing of the tibia with triflange nail. Clin Orthop 105:53–66
11. Melcher GA, Metzdorf A, Schegel U, Ziegler WJ, Perren SM, Printzen G (1995) Influence of reaming versus nonreaming in intramedullary nailing on local infection rate: experimental investigation in rabbits. J Trauma 39:1123–1128
12. Schandelmaier P, Krettek C, Rudolf J, Kohl A, Katz BE, Tscherne H (1997) Superior results of tibial rodding versus ex- ternal fixation in grade 3B fractures. Clin Orthop 342:164–172
13. Stegemann P, Lorio M, Soriano R, Bone L (1995) Manage- ment protocol for unreamed interlocking tibial nails for open tibial fractures. J Orthop Trauma 9:117–120
14. Tornetta P 3rd, Bergman M, Watnik N, Berlowitz G, Steuer J (1994) Treatment of grade-IIIb open tibial fractures. A pro- spective randomised comparison of external fixation and non- reamed locked nailing. J Bone Joint Surg Br 76:13–19
15. Whittle AP, Russel TA, Taylor JC, Lavelle DG (1992) Treatment of open fractures of the tibial shaft with the use of interlocking nailing without reaming. J Bone Joint Surg Am 74:1162–1171
16. KneifelT, Buckley R. A comparison of one versus two distal locking screws in tibial fractures treated with unreamed tibial nails: a prospective randomized clinical trial. Injury 1996;27:271–3.

How to Cite this Article: Mohapatra N, Sahoo U S. | Open fractures of tibia treated by unreamed interlocking nailing. | Odisha Journal of Orthopaedics & Trauma | January 2020; 41: 3-6 .

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Split hand foot malformation: Presentation of a rare case and description of a novel technique in management of split hand Study design: Case report

Vol 41 | January 2020 | page: 28-30 | Sudhir Kumar Mahapatra


Authors: Sudhir Kumar Mahapatra [1]

[1] Department of Orthopaedics, IMS & SUM Hospital, Bhubaneswar, Odisha India.

Address of Correspondence

Dr. Anurag Singh,
IMS & SUM Hospital, Bhubaneswar, Odisha India.
E-mail: goanurag007@gmail.com


Abstract

Introduction: High-energy musculoskeletal trauma with extensive soft tissue loss is difficult to treat and underlying fracture makes it more cumbersome. This prolongs hospitalization and regular conventional dressings increase socio-economic burden. Vacuum assisted closure (VAC) was developed to prepare wound for early definitive management. It acts by decreasing edema, exudates, bacterial counts and promotes granulation tissue formation, neovascularization, approximates wound edges.
Aim: To evaluate outcomes, efficacy and limitations of low-cost VAC for management of extensive soft tissue loss and infected wounds.
Materials and Methods: This study was conducted in Dept. Of Orthopedics of a tertiary care hospital from December 2018 to July 2019 on 53 patients, either with extensive soft tissue injury following acute trauma or those with infected-necrotic wound. Forty two patients had acute trauma history while remaining 11 had infected non healing wound. Cultures were sent pre and post VAC application and antibiotic coverage was administered. Low cost VAC was applied after debridement and changed after every 3 – 4 days.
Results: Forty eight cases treated with low-cost VAC were ready for skin graft/flap/secondary suture after 1 to 3 cycles (4 to 12 days) of therapy. Another two cases developed spontaneous re-epithelization. The wound infection was controlled in 70% of the cases. Three patients did not achieve desired result due to limitations of the procedure.
Conclusion: Low-cost VAC has proved to be effective while being substantially cheaper (1/16th of conventional VAC). Its role is limited when the depth of wound is far greater than its length.
Keywords: Low cost VAC, Vacuum assisted closure, wound management, Negative pressure wound therapy, Soft tissue loss, Compound fracture.


References

1. Morykwas, M. J., L. C. Argenta, E. I. Shelton-Brown, and W. McGuirt. “Vacuum-Assisted Closure: A New Method for Wound Control and Treatment: Animal Studies and Basic Foundation.” Annals of Plastic Surgery 38, no. 6 (June 1997): 553–62. https://doi.org/10.1097/00000637-199706000-00001.
2. Morykwas, M. J., and L. C. Argenta. “Nonsurgical Modalities to Enhance Healing and Care of Soft Tissue Wounds.” Journal of the Southern Orthopaedic Association 6, no. 4 (1997): 279–88.
3. Morykwas, M. J., L. C. Argenta, E. I. Shelton-Brown, and W. McGuirt. “Vacuum-Assisted Closure: A New Method for Wound Control and Treatment: Animal Studies and Basic Foundation.” Annals of Plastic Surgery 38, no. 6 (June 1997): 553–62. https://doi.org/10.1097/00000637-199706000-00001.
4. Argenta, L. C., and M. J. Morykwas. “Vacuum-Assisted Closure: A New Method for Wound Control and Treatment: Clinical Experience.” Annals of Plastic Surgery 38, no. 6 (June 1997): 563–76; discussion 577.
5. Genecov, D. G., A. M. Schneider, M. J. Morykwas, D. Parker, W. L. White, and L. C. Argenta. “A Controlled Subatmospheric Pressure Dressing Increases the Rate of Skin Graft Donor Site Reepithelialization.” Annals of Plastic Surgery 40, no. 3 (March 1998): 219–25. https://doi.org/10.1097/00000637-199803000-00004.
6. McCallon, S. K., C. A. Knight, J. P. Valiulus, M. W. Cunningham, J. M. McCulloch, and L. P. Farinas. “Vacuum-Assisted Closure versus Saline-Moistened Gauze in the Healing of Postoperative Diabetic Foot Wounds.” Ostomy/Wound Management 46, no. 8 (August 2000): 28–32, 34.
7. Philbeck, T. E., K. T. Whittington, M. H. Millsap, R. B. Briones, D. G. Wight, and W. J. Schroeder. “The Clinical and Cost Effectiveness of Externally Applied Negative Pressure Wound Therapy in the Treatment of Wounds in Home Healthcare Medicare Patients.” Ostomy/Wound Management 45, no. 11 (November 1999): 41–50.
8. Eginton, M. T., K. R. Brown, G. R. Seabrook, J. B. Towne, and R. A. Cambria. “A Prospective Randomized Evaluation of Negative-Pressure Wound Dressings for Diabetic Foot Wounds.” Annals of Vascular Surgery 17, no. 6 (November 2003): 645–49. https://doi.org/10.1007/s10016-003-0065-3.
9. Herscovici, Dolfi, Roy W. Sanders, Julia M. Scaduto, Anthony Infante, and Thomas DiPasquale. “Vacuum-Assisted Wound Closure (VAC Therapy) for the Management of Patients with High-Energy Soft Tissue Injuries.” Journal of Orthopaedic Trauma 17, no. 10 (December 2003): 683–88. https://doi.org/10.1097/00005131-200311000-00004.
10. Song, D. H., Wu, L. C., Lohman, R. F., Gottlieb, L. J., & Franczyk, M. (2003). Vacuum Assisted Closure for the Treatment of Sternal Wounds: The Bridge between Débridement and Definitive Closure. Plastic and Reconstructive Surgery, 111(1), 92–97. doi:10.1097/01.prs.0000037686.14278.6a
11. Mouës, C. M., G. J. C. M. van den Bemd, F. Heule, and S. E. R. Hovius. “Comparing Conventional Gauze Therapy to Vacuum-Assisted Closure Wound Therapy: A Prospective Randomised Trial.” Journal of Plastic, Reconstructive & Aesthetic Surgery: JPRAS 60, no. 6 (2007): 672–81. https://doi.org/10.1016/j.bjps.2006.01.041.
12. Armstrong, David G., Lawrence A. Lavery, and Diabetic Foot Study Consortium. “Negative Pressure Wound Therapy after Partial Diabetic Foot Amputation: A Multicentre, Randomised Controlled Trial.” Lancet (London, England) 366, no. 9498 (November 12, 2005): 1704–10. https://doi.org/10.1016/S0140-6736(05)67695-7.
13. Vuerstaek, J. D. D., Vainas, T., Wuite, J., Nelemans, P., Neumann, M. H. A., & Veraart, J. C. J. M. (2006). State-of-the-art treatment of chronic leg ulcers: A randomized controlled trial comparing vacuum-assisted closure (V.A.C.) with modern wound dressings. Journal of Vascular Surgery, 44(5), 1029–1037. doi:10.1016/j.jvs.2006.07.030
14. Llanos, S., Danilla, S., Barraza, C., Armijo, E., Pi??eros, J. L., Quintas, M., … Calderon, W. (2006). Effectiveness of Negative Pressure Closure in the Integration of Split Thickness Skin Grafts. Annals of Surgery, 244(5), 700–705. doi:10.1097/01.sla.0000217745.56657.e5
15. Vuerstaek, Jeroen D. D., Tryfon Vainas, Jan Wuite, Patty Nelemans, Martino H. A. Neumann, and Joep C. J. M. Veraart. “State-of-the-Art Treatment of Chronic Leg Ulcers: A Randomized Controlled Trial Comparing Vacuum-Assisted Closure (V.A.C.) with Modern Wound Dressings.” Journal of Vascular Surgery 44, no. 5 (November 2006): 1029–37; discussion 1038. https://doi.org/10.1016/j.jvs.2006.07.030.
16. “Tools to Compare the Cost of NPWT with Advanced Wound Care: An Aid to Clinical Decision-Making – Wounds International.” https://www.woundsinternational.com/resources/details/tools-to-compare-the-cost-of-npwt-with-advanced-wound-care-an-aid-to-clinical-decision-making.
17. Eginton, Mark T., Kellie R. Brown, Gary R. Seabrook, Jonathan B. Towne, and Robert A. Cambria. “A Prospective Randomized Evaluation of Negative-Pressure Wound Dressings for Diabetic Foot Wounds.” Annals of Vascular Surgery 17, no. 6 (November 2003): 645–49. https://doi.org/10.1007/s10016-003-0065-3.
18. Isago, Tsukasa, Motohiro Nozaki, Yuji Kikuchi, Takashi Honda, and Hiroaki Nakazawa. “Negative-Pressure Dressings in the Treatment of Pressure Ulcers.” The Journal of Dermatology 30, no. 4 (April 2003): 299–305. https://doi.org/10.1111/j.1346-8138.2003.tb00391.x.

How to Cite this Article: Singh A, Panda D, Mishra J, Dash A. | Low-cost vacuum assisted closure therapy for extensive musculoskeletal trauma and infection: Outcomes, efficacy and limitations . | Odisha Journal of Orthopaedics & Trauma | January 2020; 41: 28-30.

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Low-cost vacuum assisted closure therapy for extensive musculoskeletal trauma and infection: Outcomes, efficacy and limitations

Vol 41 | January 2020 | page: 21-25 | Anurag Singh, Damodar Panda, Jitendra Mishra, Aniruddh Dash


Authors: Anurag Singh [1], Damodar Panda [1], Jitendra Mishra [1], Aniruddh Dash [1]

[1] Department of Orthopaedics, IMS & SUM Hospital, Bhubaneswar, Odisha India.

Address of Correspondence

Dr. Anurag Singh,
IMS & SUM Hospital, Bhubaneswar, Odisha India.
E-mail: goanurag007@gmail.com


Abstract

Introduction: High-energy musculoskeletal trauma with extensive soft tissue loss is difficult to treat and underlying fracture makes it more cumbersome. This prolongs hospitalization and regular conventional dressings increase socio-economic burden. Vacuum assisted closure (VAC) was developed to prepare wound for early definitive management. It acts by decreasing edema, exudates, bacterial counts and promotes granulation tissue formation, neovascularization, approximates wound edges.
Aim: To evaluate outcomes, efficacy and limitations of low-cost VAC for management of extensive soft tissue loss and infected wounds.
Materials and Methods: This study was conducted in Dept. Of Orthopedics of a tertiary care hospital from December 2018 to July 2019 on 53 patients, either with extensive soft tissue injury following acute trauma or those with infected-necrotic wound. Forty two patients had acute trauma history while remaining 11 had infected non healing wound. Cultures were sent pre and post VAC application and antibiotic coverage was administered. Low cost VAC was applied after debridement and changed after every 3 – 4 days.
Results: Forty eight cases treated with low-cost VAC were ready for skin graft/flap/secondary suture after 1 to 3 cycles (4 to 12 days) of therapy. Another two cases developed spontaneous re-epithelization. The wound infection was controlled in 70% of the cases. Three patients did not achieve desired result due to limitations of the procedure.
Conclusion: Low-cost VAC has proved to be effective while being substantially cheaper (1/16th of conventional VAC). Its role is limited when the depth of wound is far greater than its length.
Keywords: Low cost VAC, Vacuum assisted closure, wound management, Negative pressure wound therapy, Soft tissue loss, Compound fracture.


References

1. Morykwas, M. J., L. C. Argenta, E. I. Shelton-Brown, and W. McGuirt. “Vacuum-Assisted Closure: A New Method for Wound Control and Treatment: Animal Studies and Basic Foundation.” Annals of Plastic Surgery 38, no. 6 (June 1997): 553–62. https://doi.org/10.1097/00000637-199706000-00001.
2. Morykwas, M. J., and L. C. Argenta. “Nonsurgical Modalities to Enhance Healing and Care of Soft Tissue Wounds.” Journal of the Southern Orthopaedic Association 6, no. 4 (1997): 279–88.
3. Morykwas, M. J., L. C. Argenta, E. I. Shelton-Brown, and W. McGuirt. “Vacuum-Assisted Closure: A New Method for Wound Control and Treatment: Animal Studies and Basic Foundation.” Annals of Plastic Surgery 38, no. 6 (June 1997): 553–62. https://doi.org/10.1097/00000637-199706000-00001.
4. Argenta, L. C., and M. J. Morykwas. “Vacuum-Assisted Closure: A New Method for Wound Control and Treatment: Clinical Experience.” Annals of Plastic Surgery 38, no. 6 (June 1997): 563–76; discussion 577.
5. Genecov, D. G., A. M. Schneider, M. J. Morykwas, D. Parker, W. L. White, and L. C. Argenta. “A Controlled Subatmospheric Pressure Dressing Increases the Rate of Skin Graft Donor Site Reepithelialization.” Annals of Plastic Surgery 40, no. 3 (March 1998): 219–25. https://doi.org/10.1097/00000637-199803000-00004.
6. McCallon, S. K., C. A. Knight, J. P. Valiulus, M. W. Cunningham, J. M. McCulloch, and L. P. Farinas. “Vacuum-Assisted Closure versus Saline-Moistened Gauze in the Healing of Postoperative Diabetic Foot Wounds.” Ostomy/Wound Management 46, no. 8 (August 2000): 28–32, 34.
7. Philbeck, T. E., K. T. Whittington, M. H. Millsap, R. B. Briones, D. G. Wight, and W. J. Schroeder. “The Clinical and Cost Effectiveness of Externally Applied Negative Pressure Wound Therapy in the Treatment of Wounds in Home Healthcare Medicare Patients.” Ostomy/Wound Management 45, no. 11 (November 1999): 41–50.
8. Eginton, M. T., K. R. Brown, G. R. Seabrook, J. B. Towne, and R. A. Cambria. “A Prospective Randomized Evaluation of Negative-Pressure Wound Dressings for Diabetic Foot Wounds.” Annals of Vascular Surgery 17, no. 6 (November 2003): 645–49. https://doi.org/10.1007/s10016-003-0065-3.
9. Herscovici, Dolfi, Roy W. Sanders, Julia M. Scaduto, Anthony Infante, and Thomas DiPasquale. “Vacuum-Assisted Wound Closure (VAC Therapy) for the Management of Patients with High-Energy Soft Tissue Injuries.” Journal of Orthopaedic Trauma 17, no. 10 (December 2003): 683–88. https://doi.org/10.1097/00005131-200311000-00004.
10. Song, D. H., Wu, L. C., Lohman, R. F., Gottlieb, L. J., & Franczyk, M. (2003). Vacuum Assisted Closure for the Treatment of Sternal Wounds: The Bridge between Débridement and Definitive Closure. Plastic and Reconstructive Surgery, 111(1), 92–97. doi:10.1097/01.prs.0000037686.14278.6a
11. Mouës, C. M., G. J. C. M. van den Bemd, F. Heule, and S. E. R. Hovius. “Comparing Conventional Gauze Therapy to Vacuum-Assisted Closure Wound Therapy: A Prospective Randomised Trial.” Journal of Plastic, Reconstructive & Aesthetic Surgery: JPRAS 60, no. 6 (2007): 672–81. https://doi.org/10.1016/j.bjps.2006.01.041.
12. Armstrong, David G., Lawrence A. Lavery, and Diabetic Foot Study Consortium. “Negative Pressure Wound Therapy after Partial Diabetic Foot Amputation: A Multicentre, Randomised Controlled Trial.” Lancet (London, England) 366, no. 9498 (November 12, 2005): 1704–10. https://doi.org/10.1016/S0140-6736(05)67695-7.
13. Vuerstaek, J. D. D., Vainas, T., Wuite, J., Nelemans, P., Neumann, M. H. A., & Veraart, J. C. J. M. (2006). State-of-the-art treatment of chronic leg ulcers: A randomized controlled trial comparing vacuum-assisted closure (V.A.C.) with modern wound dressings. Journal of Vascular Surgery, 44(5), 1029–1037. doi:10.1016/j.jvs.2006.07.030
14. Llanos, S., Danilla, S., Barraza, C., Armijo, E., Pi??eros, J. L., Quintas, M., … Calderon, W. (2006). Effectiveness of Negative Pressure Closure in the Integration of Split Thickness Skin Grafts. Annals of Surgery, 244(5), 700–705. doi:10.1097/01.sla.0000217745.56657.e5
15. Vuerstaek, Jeroen D. D., Tryfon Vainas, Jan Wuite, Patty Nelemans, Martino H. A. Neumann, and Joep C. J. M. Veraart. “State-of-the-Art Treatment of Chronic Leg Ulcers: A Randomized Controlled Trial Comparing Vacuum-Assisted Closure (V.A.C.) with Modern Wound Dressings.” Journal of Vascular Surgery 44, no. 5 (November 2006): 1029–37; discussion 1038. https://doi.org/10.1016/j.jvs.2006.07.030.
16. “Tools to Compare the Cost of NPWT with Advanced Wound Care: An Aid to Clinical Decision-Making – Wounds International.” https://www.woundsinternational.com/resources/details/tools-to-compare-the-cost-of-npwt-with-advanced-wound-care-an-aid-to-clinical-decision-making.
17. Eginton, Mark T., Kellie R. Brown, Gary R. Seabrook, Jonathan B. Towne, and Robert A. Cambria. “A Prospective Randomized Evaluation of Negative-Pressure Wound Dressings for Diabetic Foot Wounds.” Annals of Vascular Surgery 17, no. 6 (November 2003): 645–49. https://doi.org/10.1007/s10016-003-0065-3.
18. Isago, Tsukasa, Motohiro Nozaki, Yuji Kikuchi, Takashi Honda, and Hiroaki Nakazawa. “Negative-Pressure Dressings in the Treatment of Pressure Ulcers.” The Journal of Dermatology 30, no. 4 (April 2003): 299–305. https://doi.org/10.1111/j.1346-8138.2003.tb00391.x.

How to Cite this Article: Singh A, Panda D, Mishra J, Dash A. | Low-cost vacuum assisted closure therapy for extensive musculoskeletal trauma and infection: Outcomes, efficacy and limitations . | Odisha Journal of Orthopaedics & Trauma | January 2020; 41: 21-25.

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A prospective study of clinical outcomes of management of arthroscopic assisted tibial plateau fractures fixation

Vol 41 | Issue 1 | Jan-Jun 2020 | page: 17-20 | Bibhudutta Mall, Sunil Kumar Dash, Aurobindo Das, Sanket Mishra,
Harekrushna Sahu


Authors: Bibhudutta Mall [1], Sunil Kumar Dash [1], Aurobindo Das [1], Sanket Mishra [1], Harekrushna Sahu [1]

[1] Department of Orthopaedics, Hi-Tech Medical College & Hospital, Bhubaneswar, Odisha India.

Address of Correspondence

Dr. Bibhudutta Mall,
Hi-Tech Medical College & Hospital, Bhubaneswar, Odisha India
E-mail: bibhuduttamail_013@live.com


Abstract

This is a prospective case study about tibia plateau fractures in 28 patients which was managed with arthroscopic assisted internal fixation with plating and with or without bone grafting. In our study we saw domestic fall was a cause of fracture in about 60 yrs age patient with osteoporosis . Intra operative findings showed lateral meniscal tear in 6 patients medial meniscal tear in 1 patient which were repaired or menisectomy was done accordingly. In most of the patient fracture union seen by 4 to 6 months. Radiological Rasmussen score was Excellent in 53.5% in 3 months of follow up where as it improved to 75% by 6 months and 1 year follow up. Clinical Rasmussen score was Excellent in 50% of patients in 3 months where as it was improved to 71.4% by 6 months and 75% by 1 year follow up. Complications like infection in 3 patients , malunion in 2 patients, wound dehiscence in 2 patients. Arthroscopic assisted tibial plateau fixation is a preferred treatment for tibial plateau fracture because arthroscopy gives a precise visualization of pathology in the knee joint which can be meticulously addressed which gives early mobility and excellent range of movements.
Keywords: Intra-articular fracture , Tibial plateau , Arthroscopy-assisted internal fixation.


References

1. Hohl M. Part I: Fractures of the proximal tibia and fibula. In: Rockwood C, Green D, Bucholz R, eds. Rockwood and Green’s Fractures in Adults. Vol 2. 3rd ed. Philadel¬phia, PA: JB Lippincott; 1992:1725-1757.
2. Caspari RB, Hutton PM, Whipple TL, Mey¬ers JF. The role of arthroscopy in the manage¬ment of tibial plateau fractures. Arthroscopy. 1985; 1(2):76-82.
3. Jennings JE. Arthroscopic management of tibial plateau fractures. Arthroscopy. 1985; 1(3):160-168.
4. Schatzker J, McBroom R, Bruce D. The tib¬ial plateau fracture: the Toronto experience 1968-1975. Clin Orthop Relat Res. 1979; 138:.94-104.
5. Caspari RB,Hutton PMJ,Whiplle,Meyers JF.The Role of arthroscopy in the management of tibial plateau fracture
6. Rasmussen PS (1973) Tibial condylarfractures: impairment of knee joint stability as an indication for surgical treatment. J Bone Joint Surg Am 55:1331–1350.
7. Arthroscopic-Assisted Fixation of Tibial Plateau Fractures: Patient-Reported Postoperative Activity Levels John Kampa, MD; Ryan Dunlay, MD; Robby Sikka, MD; Marc Swiontkowski, MD
8. Fowble CD, Zimmer JW, Schepsis AA. The role of arthroscopy in the assessment and treatment of tibial plateau fractures. Arthroscopy 1993;9:584-90.
9. Arthroscopy-assisted operative management of tibial plateau fractures. Mehmet Asik Ozgur Cetik Ufuk Talu Yunus V. Sozen.
10. Roerdick WH,Oskam J,Vierhout Pam.Arthroscopically assisted osteosynthesis of tibial plateau fracture in patients older than 77 years.Arthroscopy2001;17:826-831
11. Medium-term results of percutaneous, arthroscopically-assisted osteosynthesis of fractures of the tibial plateau T. Scheerlinck, C. S. Ng, F. Handelberg, P. P. Casteleyn.
12. arthroscopic assisted management of tibial plateau fractures; a novel technique Younis kamal
13. Yi-Sheng Chan et al: Arthroscopy assisted surgery for tibial plateau fractures. Chang Gung Med j 2011;34:239-47.

How to Cite this Article: Mall B, Dash S, Das A, Mishra S, Sahu H. | A prospective study of clinical outcomes of management of arthroscopic assisted tibial plateau fractures fixation | Odisha Journal of Orthopaedics & Trauma | Jan-June 2020; 41(1): 17-20.

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Outcome of Differential period of immobilization (4 weeks Vs 6 weeks ) of Colles’ Type Fractures of the Distal Radius in Geriatric population: A prospective study

Vol 41 | January 2020 | page: 11-16 | Nirmal Chandra Mohapatra, Ramesh Chandra Maharaj, Jugaratna Khatua, Debi Prasad Nanda


Authors: Nirmal Chandra Mahapatra [1], Ramesh Chandra Maharaj [1], Jugaratna Khatua [1], Debi Prasad Nanda [1]

[1] Dept Of Orthopedics, SCB Medical College & Hospitals, Cuttack, Odisha India.

Address of Correspondence

Dr. Debi Prasad Nanda,
SCB Medical College & Hospitals, Cuttack, Odisha India
E-mail: drdebiortho@gmail.com


Abstract

Background: Perkin-Colles’ fracture however may leave behind a deformed wrist.
Aim: To evaluate how the period of immobilization in conservative treatment of extra-articular Colle’s type fractures of the distal radius affects functional outcome.
Objective: One group was immobilized for 4 week another group for 6 weeks.
Null Hypothesis: There is no difference between two groups in terms of functional outcome.
Methods: This prospective study included 70 patients and was carried in S.C.B. Medical College in Department of Orthopedics from 2017-19.One group was immobilized for 4 week another group for 6 weeks. Standard radiographs were made of both wrists in two directions after the fracture, then of the injured side on day 11 following repositioning, and at 3month and 6 month. Anatomical results were assessed by evaluating the dorsal angulation, loss of radial inclination, and loss of radial length. Functional results were assessed by the evaluation of pain, range of active motion, grip strength, and appearance of the wrist joint.
Results: 1-No Statistically significant difference between two groups in terms of functional outcome in 6 months 2- Statistically significant difference between two groups in terms of functional outcome in 3 months.
Conclusion: In long term follow up there is no difference in functional outcome with respect to period of immobilization rather it is more related to the radiological (anatomical) outcome.
Keywords: Casts, Conservative, Mayo score, Colles’ fracture, hand strength, prospective studies, radiography, range of motion, articular; treatment failure.


References

1-Ark J, Jupiter JB. The rationale for precise management of distal radius fractures. Orthop Clin North Am 1993;24:205-10.
2-Jupiter JB. Fractures of the distal end of the radius. J Bone Joint Surg Am 1991;73:461-9.
3-Alfram PA, Bauer GC. Epidemiology of fractures of the forearm: a biomechanical investigation of bone strength. J Bone Joint Surg Am 1962;44:105-14.
4-Hesp R, Klenerman L, Page L. Decreased radial bone mass in Colles’ fracture. Acta Orthop Scand 1984;55:573-5.
5-Cassebaum WH. Colles’ fracture: a study of end results. JAMA 1950;143:963-5.
6-Golden GN. Treatment and prognosis of Colles’ fracture. Lancet 1963;1:511-5.
7-Bacorn RW, KurtkZeJF. Colles’ fracture : a study of two thousand cases from the New York State Workman’s Compensation Board. IBone Joint Surg (Am] 1953;35-A:643-58.
8-Gartland JJ Jr, Werley CW Evaluation of healed Colles’ fractures. I Bone Joint Surg [Am] 1951 ;33-A:895-907.
9-Golden GN. Treatment and prognosis of Colles’ fracture. Lancet 1963;i:51 1-5.
10-Pool C. Colles’ fracture: a prospective study of treatment. I Bone Joint Surg [Br] 1973;55-B:540-4.
11-Sarmiento A, Pratt GW, Berry NC, Sinclair WF. Colles’ fractures: functional bracing in supination. I Bone Join: Surg [Am] 1975;57-A :311-7.
12-van der Linden W, Erlcson R. Colles’ fracture : how should its displacement be measured and how should it be immobilized? I Bone Joint Surg [Am] 1981 ;63-A :1285-8.
13-Coosiey WP Ill, Dobyns JH, LInscbeld RL Complications of Colles’ fractures. I Bone Joint Surg (Am] l980;62-A :613-9.
14-Lidstrom A. Fractures of the distal end of the radius: a clinical and statistical study of end results. Ada Orthop ıcand 1959; Suppl 41.
15-Muller ME, Allgower M, Schneider R, Willenegger H. Manual of internalfixation: techniques recommendedby the AO Group. 2nd ed. Berlin etc : Springer-Verlag, 1979.
16-Salter RB, Slmnioiids DF, Malcolm BW, Rumble U, Macmichael D, aemeiits ND. The biological effect ofcontinous passive motion on the healing of full-thickness defects in articular cartilage: anexperimental investigation in the rabbit. J Bone Joint Surg [Am] 1980;62-A:1232-5l.
17-Stewart HD, Innes AR, Burke FD. Functional cast-bracing for Colles’ fractures : a comparison between cast-bracing and conventional plaster casts. J Bone Joint Surg (Br] l984;66-B :749-53.
18-Müller ME. The comprehensive classification of fractures of long bones. In:Müller ME, Allgöwer M, Schneider R, Willenegger H, editors. Manual of internal fixation. 3rd ed. Heidelberg-New York: Springer-Verlag; 1991. p. 134-5.
19-Bilic R, Ruzic L, Zdravkovic V, Boljevic Z, Kovjanic J. Reliability of different methods of determination of radial shortening. Influence of ulnar and palmar tilt. J Hand Surg Br1995;20:97-101.
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21-Altissimi M, Antenucci R, Fiacca C, Mancini GB. Long term results of conservative treatment of fractures of the distal radius. Clin Orthop 1986;(206):202-10.
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transfixation with Kirschner wires and cast. Am J Orthop 1962;44-A:337-51.
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low-demand patients older than 60 years. J Hand Surg Am2000;25:19-28.
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How to Cite this Article: Mahapatra N C, Maharaj R C, Khatua J, Nanda D P. | Outcome of Differential period of immobilization (4 weeks Vs 6 weeks ) of Colles’ Type Fractures of the Distal Radius in Geriatric population: A prospective study. | Odisha Journal of Orthopaedics & Trauma | January 2020; 41: 11-16 .

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From Editors Desk

Vol 41 | January 2020 | page: 1 | Nirmal Chandra Mohapatra


Authors: Nirmal Chandra Mohapatra [1]

[1] Department of Orthopaedics, SCB Medical College, Cuttack, Odisha, India

Address of Correspondence

Dr. Nirmal Chandra Mohapatra,
SCB Medical College, Cuttack, Odisha, India.
E-mail: ojot.editor@gmail.com


From Editors Desk

The purpose of our journal has been to serve as a permanent, transparent and open platform for the presentation, scrutiny, and discussion of Orthopaedic research in our state. This we have endeavoured since the very inception of our journal in 19–. Despite the multitude of impressive articles and sustained enthusiasm with which the previous editors and authors carried on, we realised that a massive change was needed in order to maintain our utility and contribute to our goals in this everchanging changing world. We had to sit down, introspect and decide how we could do things better. The shortcomings were glaring. We lacked indexing in any major form. In this technologically savvy age, our online presence and article submission system was archaic. Despite having such a senior and talented pool of orthopaedic surgeons our peer-review system was abysmal. Our editorial/reviewer teams have to be moulded in order to solve the problems of deprecation into the journals working methods. All this requires not only a coordinated effort on the part of the editors & reviewers but it also needs the sustained support of the authors and the entire orthopaedic community of the state. There are many issues that need to be tackled. We lack subspeciality focus, an online submission system, a proper peer review system, our articles are submitted just in the nick of time and yet it is expected to be published early (without a proper peer-review or constructive criticism) and finally, we lacked a professional vetting system for the submitted articles. We decided to rope in professional publishers and approached the Indian Orthopaedic Research Group. The changes that we attempt to bring in will require long term planning, patience (for the results will require a lot of time to present) and probably also require cajoling for acceptance by our whole fraternity. But these changes are absolutely mandatory and this piece of the editorial is probably akin to Nokia CEOs infamous “burning platform” memo (before Nokia/Symbian sank in 2011), except that we envision a very successful transition. The effect of these changes will be apparent over the next 2 to 3 volumes and we hope these will set in motion improvements that last a foreseeable future.

Professor (Dr) Nirmal Chandra Mohapatra
Editor-in-Chief
The Odisha Journal of Orthopaedics and Trauma


How to Cite this Article: Mohapatra N C |From Editors Desk | Odisha Journal of Orthopaedics & Trauma | January 2020; 41: 1.  


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